Every finding on record at The Manor Healthcare Residence

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #6) of three residents reviewed for PASRR Level 1 screenings. The facility failed to refer Resident #6 to the appropriate state designated MH/ID authority for evaluation. Resident #6 was diagnosed with a mental illness prior to admission. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a Face Sheet dated 12/11/25 for Resident #6 revealed an [AGE] year-old male admitted initially to the facility on [DATE] and readmitted on [DATE]. His diagnoses included schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia (psychosis like hallucinations/delusions) major mood disorder (depression or mania); vascular dementia, moderate, with anxiety (a stage of dementia due to blood flow issues in the brain where thinking/memory problems are significant (moderate), and the person experiences significant worry, nervousness, or fear (anxiety)). Review of Resident #6's quarterly MDS assessment dated [DATE], reflected a BIMS score of 9 which indicated moderately impaired cognition. No neurological diagnoses (disease that affects the brain or nerves), including non-Alzheimer's dementia, were identified. Review of Resident #6's comprehensive care plan, revised 11/25/2025, reflected in part, Focus - [Resident #6] has Impaired cognitive function/dementia or impaired thought process r/t Dementia. Goals - The resident will maintain current level of cognitive function . Interventions - Administer medications as ordered. Monitor/document side effects and effectiveness . Review of Resident #6's PASRR Level 1 Screening completed on 01/18/22 by the referring nursing facility reflected Resident #6 had a diagnosis of dementia and schizoaffective disorder. Interview on 12/11/25 at 4:02 PM, the MDS Coordinator stated the PASSR was to determine if an individual had a mental disease or illness or IDD and required resources that they were not receiving in the community. The referring entity (hospital, group home, hospice/home health or family) is responsible for completing the PASSR. The MDS Coordinator stated the facility has 72 hours to upload into electronic system. If it's negative, it pretty much stops there. If it is positive, it sends an alert to local authority and it is then determined if it is truly positive. If the PASSR is incorrect, the regulation is to put it as it was provided to the facility. The MDS Coordinator stated if the PASSR is not completed accurately, someone could miss services that they need or can benefit from. Interview on 12/11/25 at 4:08 PM, the ADM stated the PASSR is showing if they have MHMR and if they need services. The people who are discharging the patient are responsible for completing the PASSR. Once the facility receives the PASSR paperwork, it is given to the MDS Coordinator, and she processes the information on it. She then sets up the services based on their needs. If the PASSR is filled out incorrectly, the MDS Coordinator corrects it. If the PASSR is filled out incorrectly, the residents might miss out on services they may need (wheelchairs and things like that). The ADM stated her expectations are for the PASSR to be filled out accurately coming from the hospital and they will look over it. They will make sure to follow through to make sure it is correct so the residents can get the services they need. Interview on 12/11/25 at 4:13 PM, the DON stated the PASSR is to screen people for intellectual disabilities. The referral comes from the hospital or wherever they are coming from. Once they receive the PASSR it goes to the MDS Coordinator, and it is uploaded into their electronic system. If it triggers positive, then she lets IDT the team know. If the PASRR is filled out incorrectly, there is a form they can fill out to correct the mistake. If the PASSR is not filled out accurately, people with special needs and intellectual disabilities may not have their needs met. The facility's PASRR policy was requested from the ADM, 12/11/2025 at 4:15 pm and the facility did not have a related policy. Review of the facility's policy admission Criteria revised March 2019 reflected the following: 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.a. The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for an MD, ID, or RD.b. If the level I screen indicates that the individual may meet the criteria for an MD, ID, or RD, he or she is referred to as the state PASARR representative for the Level II (evaluation and determination) screening process.(1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD.(2) The social worker is responsible for making referrals to the appropriate state-designated authority.c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.d. The state PASARR representative provides a copy of the report to the facility.e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential residents that are outlined in the evaluation.f. Once a decision is made, the state PASARR representative, the potential resident and his or her representative are notified.10. The preadmission screening program requirements do not apply to residents who, after being admitted to the facility, were transferred to a hospital.11. The state may choose not to apply the preadmission screening requirement if:a. the individual is admitted directly to the facility from a hospital where he or she received acute inpatient care.b. the individual requires facility services for the condition for which he or she received care in the hospital; andc. the attending physician has certified (prior to admission) that the individual will need less than 30 days of care at the facility.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. Upon observation of medication pass on 12/09/2025 beginning at 9:18AM, the medication error rate was 100% based on 31 out of 31 medications being administered late for 2 of 2 residents (15 and #17) by MA #A. The medication error rate was 100% based on 31 out of 31 medications being administered late for 2 of 2 residents (#15 and #17) by MA A. The failure could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. 1. Record review of Resident #15's face sheet dated 12/09/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include Vitamin D Deficiency, Hypokalemia (a condition where the blood's potassium level drops too low), Hypothyroidism (abnormally low activity of the thyroid gland), Essential Hypertension (high blood pressure with no single identifiable cause), Unspecified Asthma (chronic lung condition where airways narrow), Gastro-esophageal Reflux (chronic condition where stomach acid flows back into the esophagus), Epilepsy (condition characterized by recurrent, unprovoked seizures), Chronic Right Heart Failure (occurs when the right side of the heart cannot pump enough blood to the lungs), COPD (a condition involving the constriction of the airways and difficulty or discomfort in breathing), and Schizoaffective Disorder (mental illness blending symptoms of schizophrenia and those of a mood disorder).Record review of resident #15's admission MDS dated [DATE] revealed a BIMS of 15 (indicated cognitively intact of normal thinking and memory). Record review Resident #15's physician's orders for 8:00AM medications reveal the following:Aspirin 81 Oral Tablet 1 by mouth one time a day for DVT prophylaxisCalcium + vitamin D3 Oral Tablet 500-5mg 1 tablet by mouth one time a day related to Vitamin D DeficiencyCholecalciferol Tablet 1000 units 1 tablet by mouth one time a day related to Vitamin D DeficiencyCyanocobalamin Tablet 1000mcg 1 tablet by mouth one time a day for supplementFarxiga oral tablet 10mg 1 tablet by mouth one time a day related to Chronic Right Heart Failure (hold for SBP<100, DBP<60)Ferrous sulfate Tablet 325mg give 1 tablet by moth one time a day related to AnemiaFolic Acid 1mg give 1 tablet by mouth one time a dayFurosemide Oral Tablet 40mg give 1 tablet by mouth one time a day related to Chronic Right Heart FailureGuaifenesin Oral Tablet 400mg give 1 tablet by mouth three times a day for chronic Cough/congestionHydrochlorothiazide oral Table 12.5mg give 1 tablet by mouth one time a day related to Chronic Right Heart Failure (hold for SBP<100, DBP<60)Keppra Oral Tablet 500mg give 1 tablet by mouth 2 times a day related to EpilepsyPotassium Chloride ER Tablet 20 Meq give 2 tablets by mouth two times a day.Sertraline 50mg Oral Tablet give 1 tablet by mouth one time a day related to Major Depressive DisorderBased on observation of medication administration for Resident #15, on 12/09/2025, by MA A began at 9:18AM included the following medications:Aspirin 81 Oral 1 Tablet Calcium + vitamin D3 Oral Tablet 500-5mg 1 tablet Cholecalciferol Tablet 1000 units 1 tablet Cyanocobalamin Tablet 1000mcg 1 tablet Farxiga oral tablet 10mg 1 tablet Ferrous sulfate Tablet 325mg 1 tablet Folic Acid 1mg give 1 tablet Furosemide Oral Tablet 40mg 1 tablet Guaifenesin Oral Tablet 400mg 1 tablet Hydrochlorothiazide oral Tablet 12.5mg 1 tablet Keppra Oral Tablet 500mg 1 Potassium Chloride ER Tablet 20 Meq 2 tablets Sertraline 50mg 1 TabletRecord Review of Resident #15's Medication Administration Audit Report, the following medications were administered MA A at the following times:09:19AM Aspirin 81 Oral Tablet 1 09:19AM Calcium + Vitamin D3 Oral Tablet 500-5mg 1 tablet 09:29AM Cholecalciferol Tablet 1000 units 1 tablet 09:20AM Cyanocobalamin Tablet 1000mcg 1 tablet 09:23AM Farxiga oral tablet 10mg 1 tablet 09:21AM Ferrous sulfate Tablet 325mg 1 tablet 09:30AM Folic Acid 1mg give 1 tablet 10:06AM Furosemide Oral Tablet 40mg give 1 tablet 09:21AM Guaifenesin Oral Tablet 400mg give 1 tablet 09:30AM Hydrochlorothiazide oral Table 12.5mg give 1 tablet 09:25AM Keppra Oral Tablet 500mg give 1 09:25AM Potassium Chloride ER Tablet 20 Meq 2 tablets 09:26AM Sertraline 50mg Oral Tablet 1 tablet 2. Record review of Resident #17's face sheet dated 12/09/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include Bipolar Disorder (brain disorder causing extreme shifts in mood, energy, activity levels, and concentration, cycling between highs and lows), Dry Eye Syndrome (eyes do not produce enough quality tears), Acute Systolic Heart Failure (heat's left ventricle cant squeeze forcefully enough), Gastro-esophageal Reflux Disease (chronic digestive disorder where stomach acid frequently flows back into the esophagus), Vitamin D Deficiency, Chronic Kidney Disease (long term condition where kidneys are damaged and cannot flite blood well), Hyperlipidemia (too many fats in the blood), Essential Hypertension (high blood pressure with no single identifiable cause). Record review of resident #17's Quarterly MDS dated [DATE] revealed a BIMS of 15 (indicates cognitively intact of normal thinking and memory). Record review Resident #17's physician orders for morning medications on 12/09/2025 reveal the following:Calcium 500 + D oral tablet 500 milligram dash 5 milligram dash MCG one tablet by mouth two times a day for supplementCarboxymethylcellulose sodium ophthalmic solution instill one drop in both eyes one time a day related to dry eye syndromeCymbalta oral capsule delayed release particles 30 milligrams give one capsule by mouth one time a day Related to major depressive disorderAspirin delayed release 81 milligrams 1 tablet by mouth once a day for preventativeFerrous sulfate tablet 325 milligrams give one tablet by mouth two times a day related to chronic kidney diseaseFolic acid tablet 1 milligram one tablet by mouth one time a day Headed to severe obesityFurosemide tablet 20 milligrams give one tablet by mouth one time a day related to acute systolic heart failureGabapentin tablet 300 milligrams give one tablet by mouth everyday multivitamin mineral tablet give one tablet by mouth once a day for supplement Potassium chloride ER tablet extended release 10 milliequivalents give one tablet by mouth one time a day for acute potassium depletionSodium chloride tablet 1g give one tablet by mouth one time a day for electrolyte supplement Topamax 50 milligrams orally 2 times a day related to migraine Tricore tablet 145 milligrams give one tablet by mouth one time a day related to hyperlipidemia Trileptal 300 milligrams give one tablet by mouth two times a day related to bipolar disorder Vitamin D3 tablet 125 micrograms give one tablet by mouth two times a day related to vitamin D deficiencyBased on observation of medication administration on 12/09/2025, administration by MA A began at 9:31AM included the following medications:Calcium 500 + D oral tablet 500 milligram dash 5 milligram dash MCG Carboxymethylcellulose sodium ophthalmic solution Cymbalta oral capsule delayed release particles 30 milligrams Aspirin delayed release 81 milligrams 1 tablet Ferrous sulfate tablet 325 milligrams give one tablet Folic acid tablet 1 milligram give one tablet Furosemide tablet 20 milligram give one tablet Gabapentin tablet 300 milligrams give one tablet Potassium chloride ER tablet extended release 10 milliequivalents 1 tabletSodium chloride tablet 1g 1 tabletTopamax give 50 milligrams 1 tablet Tricore tablet 145 milligram 1tablet Trileptal 300 milligrams 1 tablet Vitamin D3 tablet 125 micrograms 1 tablet Record Review of Resident #17's Medication Administration Audit Report, the following medications were administered at the following times:09:39 AM Calcium 500 + D oral tablet 500 milligram dash 5 milligram dash MCG 09:52 AM Carboxymethylcellulose sodium ophthalmic solution 09:42 AM Cymbalta oral capsule delayed release particles 30 milligrams 09:39 AM Aspirin delayed release 81 milligrams 1 tablet 09:40 AM Ferrous sulfate tablet 325 milligrams give one tablet 09:42 AM Folic acid tablet 1 milligram give one tablet 09:45 AM Furosemide tablet 20 milligram give one tablet 09:43 AM Gabapentin tablet 300 milligrams give one tablet 09:43 AM potassium chloride ER tablet extended release 10 milliequivalents 1 tablet09:40 AM sodium chloride tablet 1g 1 tablet09:40 AM S Sodium chloride tablet 1g 1 tablet 09:45 AM Topamax gives 50 milligrams 1 tablet 09:42 AM Tricore tablet 145 milligram 1tablet 09:44 AM Trileptal 300 milligrams 1 tablet 09:41 AM Vitamin D3 tablet 125 micrograms 1 tabletOn 12/09/2025 at 10:00 AM an interview was conducted with MA A. She stated the medications were late being given because she was running late today. She stated the policy was to give medications anywhere from an hour before the scheduled time to an hour after the scheduled time. On 12/09/2025 at 1:15PM, an interview was conducted with the DON. She stated the timeframe for giving medications would be from one hour before they were scheduled until one hour after they were scheduled to be given. Anything given any later than that would be considered a medication error. She stated they did not have a liberalized medication administration policy. On 12/11/2025 at 11:08AM, an interview was conducted with LVN B. She stated that the facility policy for the timeframe for medication administration was one hour before until one hour after the scheduled time. On 12/11/2025 at 11:11AM, an interview was conducted with MA C. She stated the policy had recently been changed but prior to the change, the timeframe for giving medications in a timely manner was to give them during the hour before until an hour after they were due. On 12/11/2025 at 11:30AM, an interview was conducted with LVN D. She stated the facility policy stated that medications were to be given anywhere from one hour before they are due until one hour after the scheduled time. On 12/11/2025 at 4:12PM, an interview was conducted with the Administrator. She stated the policy was to give scheduled medications from one hour before they are due to one hour after they were due. She stated her expectation was that the medications be delivered at the appropriate time. Record review of the policy entitled, Administering Medications dated as revised April 2019 item #7 revealed Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Record review of the policy entitled, Medication Administration Schedule dated as revised in November of 2020 item #3 revealed Scheduled medications are administered within one (1) hour of their prescribed time, unless otherwise specified.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for foods safety for 1 of 1 kitchen reviewed for food safety and sanitation. The facility failed to ensure food items were sealed and not exposed to air in the freezer and in the dry storage area. This failure placed residents at risk of foodborne illness. Findings included: Observation of the kitchen freezer on [DATE] at 9:05 am revealed that a bag of sausage patties was torn open and exposed to air, a box of cinnamon rolls was open and exposed to air, and a box of cookie dough was open and exposed to air. Observation of the dry storage area on [DATE] at 9:09 am revealed that a bag of grits, a bag of corn tortillas, a bag of powder nonfat dry milk and a bag of corn muffin mix were not sealed, and all were exposed to air. An interview with the DM on [DATE] at 2:34 pm revealed that the policy for storing food was all food items were to be labeled, dated, and sealed. She said that all kitchen staff were responsible for ensuring that all food that had been opened or prepped was labeled, dated and sealed. She said if food were not sealed in the freezer, it could get frost bitten. She also said if food were not sealed in the dry storage area, bugs could get into the food, or it could become stale. She said that residents could get sick if food was not sealed. She said that she was responsible for monitoring to ensure that items were labeled, dated, and sealed. She said she monitors by doing a walk through every morning. She said she did not know why the food was not sealed. An interview with CK C on [DATE] at 2:41 pm revealed that the policy on food storage was that all food should be in an airtight container with the date opened and the date the food had expired . He said staff are to follow the first in first out method. He said all kitchen staff were responsible for ensuring that items are labeled, dated and sealed. He said if items are not sealed it could put the residents at risk of getting sick. He said that items were not sealed in the freezer possibly because the bag was not big enough or could not be sealed. He said if the bag were not too small that he did not know why the food would not be sealed. An interview with the ADM on [DATE] at 9:00 am revealed all food in the kitchen needed to be labeled, dated, and sealed. She also said that the food items were supposed to also be labeled with the expiration date. She said the DM was responsible for ensuring food was labeled, dated, and sealed. She said if food were not labeled, dated, and sealed, it could put the residents at risk of getting sick. She said that she monitor ed that the food items are labeled, dated and sealed monthly. She said does a walk through the kitchen every month to ensure that food is labeled, dated and sealed. She said she was not sure why the food was not sealed. Record review of the facility's Dietary Services Policy and Procedures dated 2012 revealed all unused food must be securely covered. Food must be covered when stored, with the date label identifying what was in the container.

Based on observations, interviews, and record review, the facility failed to ensure resident right for personal privacy for 5 of 5 residents (Resident #3, Resident #17, Resident #19, Resident #21 and Resident #40) reviewed for resident rights. The facility failed to knock on Residents #3, #17, #19, #21 and #40's rooms when going into the residents' rooms. This failure could affect all residents right to privacy in the facility and cause the resident to feel like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #3's Face Sheet dated 09/10/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included lack of coordination, muscle wasting, low back pain, skin cancer, solitary pulmonary nodule (small single mass in the lungs), tinea unguium (fungal nail infection), contact with COVID 19, pressure ulcer, abnormal weight loss, vitamin B12 deficiency, vitamin D deficiency, chronic obstructive pulmonary disease (chronic progressive lung disease), colostomy status (has a colostomy bag), need for assistance with personal hygiene, hyperlipidemia (high cholesterol), hypokalemia (low potassium levels), hyperthyroidism (excessive production of thyroid hormones), atrial fibrillation (abnormal heart rhythm), constipation, and calculus of bile duct (stones in the bile duct). Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed Resident #3 had a BIMS score of 15 indicating intact cognitive response. Review of Resident #17's Face Sheet dated 09/10/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17's diagnoses included macular degeneration (blurred vision), chronic pain, ovary cancer, gout (swollen arthritis), pacemaker, anemia (not enough healthy red blood cells), hypothyroidism (excessive production of thyroid hormones), type 2 diabetes mellitus without complications (high blood sugar), morbid obesity, hyperlipidemia (high cholesterol), insomnia (difficulty sleeping), hypertension (high blood pressure), artery dissection (tears in the layers of the artery), heart failure, muscle wasting, lack of coordination, and need for assistance with personal care. Record review of Resident #17's Quarterly MDS dated [DATE] revealed Resident #17 had a BIMS score of 15 indicating intact cognitive response. Review of Resident #19's Face Sheet dated 09/10/2024 revealed she was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #19's diagnoses included cerebral infarction (long term effects of a stroke), upper respiratory infection, muscle wasting, idiopathic neuropathy (nerve damage with unclear cause), personal history of COVID, hypertension (high blood pressure), contact and exposure to other viral communicable diseases, pressure ulcer on right heel, and buttocks, insomnia (difficulty sleeping), dysphagia (difficulty swallowing), major depressive disorder, retention of urine, paraphilia (intense sexual arousal), heart failure, difficulty in walking, muscle wasting, hyperlipidemia (high cholesterol), hypokalemia (low potassium levels), alcohol use with intoxication, cocaine abuse, and gastroesophageal reflux disease without esophagitis (reflux). Record review of Resident #19's Quarterly MDS dated [DATE] revealed Resident #19 had a BIMS score of 6 indicating severe cognitive impairment. Review of Resident #21's Face Sheet dated 09/10/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #21's diagnoses included chronic pulmonary disease (lung disease), lack of coordination, muscle wasting, dysphagia (difficulty swallowing), cognitive communication deficit (problems with communication), dysuria (painful or uncomfortable urination), rectal prolapse (when part of the large intestines slips outside the anus), hemorrhoids, major depressive disorder, tachycardia (fast heart rate), otalgia (earache), urticaria (bumps on the skin like a rash), ascites (accumulation of fluid in the abdomen), abnormal results of liver function, poly osteoarthritis (arthritis that affects multiple joints), urgency of urination, gastritis (swelling of the lining of the stomach), other stimulant dependence, critical illness myopathy (rapid evolving muscle weakness), type 2 diabetes mellitus with diabetic neuropathy (nerve damage due to diabetes), hypokalemia (low potassium levels), hypertension (high blood pressure), hyperlipidemia (high cholesterol), psychoactive substance dependency (need for psychoactive medication), cerebral infraction (stroke), tobacco use, and need for assistance with personal care. Record review of Resident #21's Quarterly MDS dated [DATE] revealed Resident #21 had a BIMS score of 12 indicating moderate impairment. Review of Resident #40's Face Sheet dated 09/10/2024 revealed she was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #40's diagnoses included ocular hypertension , constipation, pain, abscess of liver (pus filled cyst found in the liver) , anemia (not enough healthy red blood cells), hyperlipidemia (high cholesterol), cannabis abuse with psychotic disorder with delusions, delusional disorder, depression, anxiety, repeated falls, retention of urine, headaches, abnormal finding of the skull and head, prostate cancer, muscle wasting, muscle weakness, lack of coordination, insomnia (difficulty sleeping), adjustment disorder, and gastroesophageal reflux disease without esophagitis (reflux). Record review of Resident #40's Quarterly MDS dated [DATE] revealed Resident #40 had a BIMS score of 99 indicating resident was unable to complete the interview. Observation of lunch hall trays being passed on 09/10/2024 at 12:05 pm revealed that CNA A did not knock on Resident #3, Resident #21 and Resident #40's doors before entering. Observation of lunch hall trays being passed on 09/10/2024 at 12:13 pm revealed that CNA B did not knock on Resident #17 and Resident 19's door before entering. An interview with Resident #17 on 09/11/2024 at 8:01 am revealed that staff knock on the door most of the time. She said she does not get upset when staff do not knock. She said she would like staff to knock all the time because it is a good habit. She also said that it also lets her know someone is coming in her room. An interview with Resident #40 on 09/11/2024 at 8:12 am revealed that staff just walk into his room because his door was open. He said it does not bother him because they are like his family. He said he does not care if staff knock or not, it does not bother him. An interview with Resident #3 on 09/11/2024 at 8:23 am revealed that staff knock on her door sometimes. She said most of the time staff did not knock. She also said she does not get upset and that it does not bother her if they know what they are doing. She said she would like staff to knock so it does not startle her. An interview with Resident #21on 09/11/2024 at 8:50 is revealed that staff d id not always knock on her door. She said she is asleep most of the time and that it does not make her upset if staff do not knock. She also stated that she would like staff to knock so she will know when someone is in her room. An attempted interview with Resident #19 on 09/11/2024 at 9:00 am revealed it was unsuccessful. The resident did not want to answer any questions. An interview with the ADON on 09/11/2024 at 2:47 pm revealed staff had been trained on resident rights. He stated that the policy for knocking on the resident's door was to knock on the door, introduce themselves, and ask to come in. He said that everyone was required to knock on the resident's door because the facility was their home. He said that the resident may feel like staff were invading their privacy if they do not knock on the door. He stated he did not know why staff were not knocking on residents' doors. He also said that staff know that they were supposed to knock before entering. An interview with CNA A on 09/11/2024 at 3:15 pm revealed she had been trained on resident rights. She stated the policy for knocking on the resident door was to knock before entering. She also said that if the resident was not able to speak, staff were to knock again and announce themselves and then enter. She said everybody was supposed to knock before entering the resident's room. She said that some residents might think that their privacy was being invaded. She stated she was not paying attention and was just focused on getting the residents their food and it slipped her mind. An interview with CNA B on 09/11/2024 at 3:19 pm revealed she had been trained on resident rights. She stated the policy for knocking on the resident's door was to knock before entering and ask to come in. She said all staff were supposed to knock before entering. She said if staff were not knocking before entering, the resident might feel uncomfortable especially if they were on the toilet. She said she did not know why she did not knock before entering the residents' rooms. An interview with the ADM on 09/12/2024 at 8:57 am revealed staff had been trained on resident rights. She stated the policy was to knock on the resident's door before entering. She said all staff were to knock before entering. She said residents could feel like staff were disrespecting them if they do not knock on the door. She said that herself, the DON, and ADON were responsible for monitoring staff knocking on the door. She said that the facility monitors staff knocking on the door by observations. She said that staff have gotten relaxed. Record review of the facility's Dignity Policy dated 2/2021 revealed that residents are treated with dignity and respect at all times. Staff are expected to knock and request permission before entering the residents' rooms.

Based on observation, interview, and record review, the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during survey for seven of seven anonymous residents reviewed for resident council. The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in private without uninvited staff being present. Findings Included: In a Resident Council interview on 9/11/24 at 2:00 pm, the AT Director gathered several residents and brought them to the Dining Room. In the Dining Room, there were several residents watching TV and several staff in and about the area attending to their daily duties. When asked if there was a more private space, the AT Director remarked that there was no space large enough. He then suggested to move the meeting to the front lobby area where it would be a bit quieter. This space was not private and there was no provision to have staff avoid the area. In an interview on 9/12/24 at 8:25 AM with the AT Director, he stated he was trained on Resident Rights via the company's online training forum. He stated he was trained on how to educate the residents about their rights by another AT Director. He added the purpose for Resident Council was for the residents to be able to discuss their concerns and the meeting should take place once a month. He did not disclose any training around the issue of privacy. When questioned about the issue of privacy and redirecting staff away from the area, he stated, I can't stop nothing. In an interview on 9/12/24 at 8:48 AM with the ADM she stated that the Resident Council meetings should be held monthly, the residents had the right to privacy, and to invite staff to assist. She stated that a negative outcome of not having privacy during resident council meetings could be that they may not feel comfortable disclosing their concerns. She stated that it was her responsibility to ensure Resident Council meetings were held in a location that would ensure privacy for the residents. Record review of Resident Rights Policy, not dated, revealed residents had the right to personal privacy including accommodations, medical treatment, written and telephone communications, personal care, visits and meeting of family and resident groups.

Based on observation, interview, and record review the facility failed to ensure the residents environment remained free of accident hazards for 1 of 3 residents (Resident #92) reviewed for transfers. The facility failed to ensure Resident #92 was transferred using a gait belt . This failure could place residents at risk for injuries and falls. Findings included: Record review of an undated face sheet indicated Resident #92 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of left sided weakness following a stroke, fracture of the nose, and post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). Record review of the rehabilitation hospital physician's progress note on 6/02/2023 indicated Resident #92 had impaired mobility and ADLs. The physician's progress note indicated Resident #92 was dependent and required substantial maximal assistance with transfers from chair, bed to chair transfers. Record review of a rehabilitation hospital physical therapy note dated 06/05/2023 indicated the physical therapist documented with standing Resident #92 required max imum assistance due to Resident #92 leans very heavily to the left side and was unable to actively use the left side of the body and she stood for 30 seconds - 2 minutes per attempt. The note also indicated the therapist documented Resident #92 was able to perform sit-stands with maximum assistance within the therapy bars. The note indicated Resident #92 was not actively moving or using her left lower extremity at this time to progress with gait safely. The note indicated Resident #92 would continue to benefit from physical therapy due to being max assist for transfers and poor mobility at that time. Record review of the base line care plan dated 06/12/2023 indicated the DON documented in functional abilities and goals: mobility Resident #92 required transfer assistance of two plus persons physical assistance. The baseline care plan indicated Resident #92's was cognitively intact. The baseline care plan indicated Resident #92 had a history of falls in the last month prior to admission. The baseline care plan indicated in skin risk current skin issues was not marked nor was a history of skin integrity issues. Record review of the comprehensive care plan dated 06/12/2023 and revised on 07/03/2023 indicated Resident #92 had an ADL self-care deficit related to the stroke and left sided weakness. The care plan interventions indicated on 06/12/2023 with a revision date of 07/03/2023 Resident #92 required extensive assistance of 2 staff and may use a Hoyer (mechanical lift) for transfers. The care plan indicated Resident #92 was at risk for falls related to gait/balance problems, incontinence, use of psychoactive drugs, and vision/hearing problems. The interventions included to anticipate and meet the resident's needs, follow fall protocol, and review past falls and determine the cause. The care plan in the skin integrity section failed to address any abnormal bruising on admission. Record review of aResident #92's skin assessment opened on 06/12/2023 and locked on 06/14/2023 (after the hospital visit ) indicated the previous ADON documented 3 faded bruises to left lateral distallower side of the thigh, 1 light bruise to lateral left lower extremity and 1 bruise to the right forearm. Record review of a fall assessment dated [DATE] indicted indicated Resident #92 had no history of falls in the past three months, and she was alert and oriented. Section E of the assessment assessed gait, balance, muscular coordination, and use of assistive devices. Section E indicated Resident #92 was unable to stand to participate in the assessment. In the area of the assessment predisposing conditions indicated Resident #92 had 1-2 conditions such as stroke, and fractures. Record review of an incident report dated 06/13/2023 at 8:00 a.m., indicated the DON documented during routine resident rounds Resident #92 reported she fell last night. The report indicated Resident #92 stated CNA D went to get her out of bed, grabbed her by the shirt and dropped her on the floor. Resident #92 said she landed on her left side (weak side) and hit her left knee, left wrist, and left elbow. The report indicated the DON wrote Resident #92 said after she fell , CNA D grabbed her by the shirt and threw her back to bed. Resident #92 told the DON that CNA D did not notify anyone that she was dropped. The report indicated Resident #92 indicated she reported this to the night nurse at 1:00 a.m. because she did not want to get anyone in trouble. The incident report indicated Resident #92 demanded to be seen by a doctor. The note indicated the DON notified the nurse practitioner and Resident #92 was transferred to the emergency room and the abuse coordinator was notified of the allegation. The incident report indicated Resident #92 was oriented to person, place, time, and situation. Record review of a hospital discharge record dated 6/13/2023 indicated Resident #92's diagnoses included: contusion of the left thigh; contusion (bruise) of the left upper arm, contusion (bruise) of left hand, contusion (bruise) of left lower leg, contusion (bruise) of forearm and contusion of left foot. Special notes included: SalonPas Patches (10%) apply to tender area 3 times daily for pain. Record review of a hospital acquired left humerus (upper arm) x-ray dated 6/13/2023 indicated soft tissue swelling. Record review of a hospital acquired left forearm x-ray dated 6/13/2023 indicated soft tissue swelling posterior back [NAME] the olecranon (boney area of the elbow). Record review of the consolidated physician orders dated 7/11/2023 indicated Resident #92's physician ordered may use a Hoyer lift (mechanical) for transfers on 06/14/2023 after the fall Record review of a witness statement dated 06/14/2023 indicated, CNA D wrote the incident occurred on 06/12/2023 at 11:36 a.m., Resident #92 wanted to be assisted up to attend the 8:00 p.m . smoke break. CNA D wrote she and CNA C began to struggle to get Resident #92 in her chair. The witness statement indicated Resident #92 began sliding but still was on the bed and never touched the floor. The note indicated Resident #92 was pulled up with their arms under her armpits while holding on to Resident #92's brief. Record review of a witness statement dated 06/13/2023 indicated CNA C wrote the incident occurred on 06/12/2023 at 8:00 p.m. CNA C wrote Resident #92 wanted to get up for the 8:00 p.m. smoke break. CNA C wrote Resident #92 said she could help transfer with her other leg. CNA C said they proceed to stand Resident #92 up and turn her but realized Resident #92 could not help at all. CNA C wrote Resident #92 was still on the bed but was sliding off. CNA C wrote Resident #92 was assisted back up on the bed, but her body did not touch the ground. CNA C indicated the nurse would be notified. CNA C wrote Resident #92 was yelling and cursing saying, we dropped her. CNA C wrote she explained to Resident #92 she did not fall, and Resident #92 responded okay. Record review of an undated witness statement written by the previous ADON indicated the incident occurred on 6/13/2023 at 8:45 a.m. The ADON wrote Resident #92 reported CNA D came into her room to assist her up for a smoke break. The ADON wrote Resident #92 said she informed CNA D she needed two people to help with the transfer, but CNA D transferred her by herself. Record review of an email included in the provider investigation report from RN E dated 6/15/2023 at 10:02 a.m., indicated RN E indicated on or about 06/12/2023 LVN F discussed with her the newly admitted Resident #92 reported a fall occurring earlier that day. The email indicated Resident #92 made the allegation she was dropped by a CNA D. RN E completed a physical assessment and Resident #92 was found to have no obvious injuries but had three circular bruise marks not on the left lateral thigh each similar in size approximately 3-4 centimeters. The email indicated Resident #92 reported pain to her left knee. During an observation on 7/10/2023 at 9:20 a.m., Resident #92 was lying in her bed. Resident #92 said she had been dropped by CNA D on the day she admitted . Resident #92 said she had a stroke, and she cannot use her left side yet. Resident #92 said she was assisted up using her arms and pants. During an interview and observation on 7/10/2023 at 3:59 p.m., CNA D said she went to assist Resident #92 up on 6/12/2023 to smoke at around 3:40 p.m. for the 4:00 p.m. smoke break. CNA D said CNA C assisted her with transferring Resident #92. CNA D said Resident #92 was a new resident and they did not know much about Resident #92. During the interview CNA D demonstrated to the surveyors the transfer technique used by herselfherself, and CNA C. CNA D demonstrated they both put their arm's underneath Resident #92's arm pits one on each side. CNA D indicated the transfer was initiated and Resident #92 was unable to help, and she was heavy. CNA D said both struggled to get Resident #92 back on the bed. CNA D said then she went to obtain a gait belt to assist with the transfer. CNA D said she does not use a gait belt with transfers. CNA D said she feels as though she can hold them better under their armpits. CNA D said she had been in-serviced recently on use of the gait belt and gait belts were available for use. During an interview on 7/10/2023 at 10:15 a.m., RN E said LVN F on 6/12/2023 around 11:00 p.m., came and informed her Resident #92 had made an allegation she had been dropped being transferred for the smoke break. RN E said Resident #92 said her body did not hit the floor but said she slid to the floor. RN E said she texted CNAs C and D. RN E said both CNAs responded and indicated Resident #92's body never touched the floor. RN E said she completed an assessment and the left lateral thigh had three round bruises, in a linear pattern, and not new looking, no swelling and her skin was intact. RN E said she did report the allegation the next morning at 7:00 a.m. to the DON. RN E said she did not report immediately because there were no injuries and there was not a fall. RN E said she did not ask CNAs C and D if they used a gait belt while transferring Resident #92. RN E said if resources were available, and a staff member failed to use the resources to care for a resident safely this was neglect. RN E said she was unsure if the CNAs could access the transfer needs of Resident #92 or other residents. RN E said she informs the nursing staff of the resident care needs by verbal method in a huddle. During an interview on 7/11/2023 at 10:38 a.m., CNA C said she was informed to assist Resident #92 up at 3:30 p.m. to smoke at 4:00 p.m. CNA C said Resident #92 said she could assist with the transfer. CNA C said she and CNA D raised Resident #92 to the sitting position, they placed their arms under Resident #92's arms, grabbed hold of her pants and attempted the transfer. CNA C said she thought Resident #92 could help them with the transfer by shuffling. CNA C said they moved Resident #92 back to the center of the bed and tried a second time. CNA C said this time they used more strength with the transfer. CNA C said they were able to get her in the chair but Resident #92's left leg did not rotate with the transfer. CNA C said when Resident #92 was transferred to bed after smoking a gait belt was used. CNA C said she did not use a gait belt on the initial transfer because it slipped her mind. CNA C said Resident #92 did not attend the 8:00 p.m. smoke break, she said she was never interviewed about the incident. CNA C said she only wrote a statement. CNA C said she did not know the care needs of Resident #92 and her nurse was on break. CNA C said she had been trained on the use of a gait belt prior to this incident. CNA C said neglect could be not giving a resident the care they need. During an observation and interview on 7/11/2023 at 4:07 p.m., CNA G said she had been employed for almost 2 years. CNA G said she had provided care for Resident #92. CNA G demonstrated on the computerized documentation center for the CNAs how she would know how Resident #92 transferred. CNA G said she follows what the previous shift documents in the transfer area. CNA G said she was not computer efficient and was unsure where to find the Kardex (computerized resident care tasks) or care plan for resident care needs. During an interview on 7/11/2023 at 5:49 p.m., LVN F said CNA H reported to her on 6/12/2023 around 11:00 p.m., that Resident #92 made an allegation CNA D dropped her. LVN F said she went immediately and reported to her supervisor RN E. LVN F said she received in report Resident #92 required two staff for transfers. Record review of a Certified Nurse Aide Competency Verification form indicated CNA C was check off on transfers on 7/31/2022. The competency indicated on #11 to put gait belt on resident and securely fasten, 14. Grasp the belt on both sides, 25. Report any changes to the nurse. Record review of a Certified Nurse Aide Competency Verification form indicated CNA D was check off on transfers on 9/24/2022. The competency indicated on #11 to put gait belt on resident and securely fasten, 14. Grasp the belt on both sides, 25. Report any changes to the nurse. During an interview on 7/12/2023 at 1:56 p.m., the Administrator said she expected the CNAs to follow the what the nurse said the level of the safest transfer was for the residents. The Administrator said transferring the residents underneath their armpits could cause harm to them. The Administrator said the DON, therapy staff, and she had the responsibility to ensure nursing staff were checked off for transferring properly. The Administrator said the nursing staff could find how a resident should be transferred on the kiosk, and the care plan. The Administrator said the DON was responsible for weekly random transfer checkoffs and annual skills checkoff including transfers. During an interview on 7/12/2023 at 2:33 p.m., the DON said she said she expected transfers to occur according to the facility policy. The DON said with transfers requiring 2 persons assist a gait belt should be used. The DON said she was responsible for skills check offs in transferring yearly and randomly. The DON said mechanical lift transfers were completed weekly at random with nursing staff. The DON said she monitors transfers with daily rounds. The DON said she was unaware there were CNAs who did not know how to access the kiosk Kardex section for resident care needs. During an interview on 07/12/2023 at 5:03 PM, the Administrator said the incident with Resident #92 had not had a project improvement plan or a QAPI plan put in place. Record review of a Moving A Resident, Bed to Chair/Chair to Bed policy dated 2003 indicated the procedure may involve potential and/or direct exposure to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals. The purpose of this procedure are to allow the resident to be out of his other bed as much as possible to provide for a safe transferring of the resident Steps to Procedure .12. J. Support the resident by placing a gait belt around the resident's waist for you to hold and steady the resident.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: *The deep roasting pan was clean *The sheet pans were clean *The muffin pans were clean *The roasting pans were clean *The skillets were clean *The stock pot was clean These failures could place residents at risk for foodborne illness. Findings included: During an observation and interview on 07/10/23 at 08:25 AM, the following items had carbon buildup inside and outside: *one deep roasting pan *four large sheet pans *three muffin pans *one small sheet pan *two small roasting pans *four skillets *one stock pot One of the skillets was on top of the stove and had yellow residue stuck to the sides of it. The Dietary Cook M said she had cooked eggs in the skillet that morning. During an interview on 07/11/23 at 04:53, the Dietary Manager said the pans, pots and skillets with carbon buildup were not thoroughly clean. The Dietary Manager said they scraped the pots, pans, and skillets when they were washed. The Dietary Manger said since the pot, skillets and pans were not thoroughly clean it placed the residents at risk for getting sick. The Dietary Manger said the skillets were in the process of being replaced. The Dietary Manager said the Administrator was to have ordered them a month ago. The Dietary Manager said the kitchen equipment was monitored every time they were cleaned. The Dietary Manager said the cook and herself were responsible for ensuring the kitchen equipment was in proper condition to be used. During an interview on 07/12/23 at 01:56 PM, the Administrator said she had looked at the pot, pans and skillets and they did not appear to have been thoroughly clean and should not have been used. The Administrator said she told the kitchen staff to throw them away and had ordered new ones. The Administrator said the carbon on the pots, pans and skillets could cake off onto the food. The Administrator said the Dietary Manager and herself were responsible for monitoring kitchen equipment. The Administrator said the Dietician had mentioned a few months back to have them cleaned but no one had told her that they could not clean them. The Administrator said if they had told her they could not clean them she could have replaced them. Record review of the facility's Equipment Sanitation policy dated 2012, indicated .We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. 1. Equipment must be thoroughly sanitized between use in different food preparation tasks .

Based on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for 1 of 2 shower chairs (East shower chair) reviewed for cleanliness. The facility failed to ensure the East shower chair was free from slime like pink, brown, and black material. This failure could place the residents at risk for a diminished quality of life and a diminished clean well-kept environment. Findings included: Record review of an undated face sheet indicated Resident #92 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of left sided weakness following a stroke, fracture of the nose, and post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). During an observation, and interview on 07/10/2023 at 9:20 a.m., Resident #92 was lying in bed when she said the shower chairs were despicable and had what she believed was fecal material. Resident #92 said she could hardly make herself sit on the shower chair. Resident #92 said she had complained to the nurse aides and was told the material on the chair was rust. Resident #92 said she responded with plastic does not rust. Resident #92 said the shower chair had been dirty since she arrived one month ago. During an observation on 7/10/2023 at 10:36 a.m., the shower chair in the East side shower had pink, brown, and black material underneath the toilet seat of the shower chair, and on the plastic pipe frame. During an observation on 7/11/2023 at 9:15 a.m., the shower chair in the east shower room had pink, brown, and black colored material on the plastic underneath the toilet type ring, and the frame of the shower chair. During an interview on 07/11/2023 at 9:21 a.m., Resident #92 said when she showered yesterday, she felt disgusting having sat on a dirty shower chair. Resident #92 said she did not feel clean. During an observation on 7/12/2023 at 9:33 a.m., the east shower chair continued to have brown, pink, and black colored material on the undersurfaces of the shower chair. During an observation and interview on 7/12/2023 at 9:35 a.m., CNA C said the east shower chair did not look very clean when she looked at the pink, brown, and black material on the shower chair. CNA C said the nurse aides were responsible for cleaning of the shower chairs. CNA C said even though the shower chair was dirty she would shower using the shower chair because the dirty material was on the undersurface areas of the shower chair. During an observation, and interview on 7/12/2023 at 9:45 a.m., LVN B said after looking at the shower chair having pink, brown, and black material on the chair said the east shower chair was disgusting. LVN B said the east shower chair should be taken out of use. LVN B said the nurse aides were responsible for ensuring the east shower chair was clean after each use. During an observation, and interview on 7/12/2023 at 10:50 a.m., the DON looked at the chair and she said immediately she would get the east shower chair removed. The DON said she had removed this shower chair and put it out back for disposal but somehow someone returned the chair inside. The DON said using the chair with the pink, black, and brown material on it could cause infections to the residents and she said she would not use the east shower chair for bathing. During an interview on 7/12/2023 at 1:56 p.m., the Administrator said she had not seen the east shower chair. The Administrator said the chair should have been removed and placed in the trash. The Administrator said all resident equipment should be clean and in good working order. The Administrator said this was monitored by rounds. The Administrator said the CNAs and housekeepers were responsible for ensuring the equipment was clean. The Administrator said infections could occur from use of dirty equipment with residents. Record review of an Infection Control Policy and Procedure dated 2010 indicated a variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions .6. Resident care equipment and articles: 3. Routine cleaning and disinfection of resident care equipment. 5. Any resident care equipment/article that is visibly contaminated with blood or body fluids will immediately be cleaned with an approved disinfectant.

Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: During an observation and interview on [DATE] at 11:20 AM, the following medications were observed in the controlled medication storage cabinet awaiting to be disposed: *Hydrocodone/APAP ,d+[DATE]mg- 45 tablets RX# 20606171 *Tramadol 50mg- 5 tablets RX# 4590947 *Tramadol 50mg- 2 tablets RX# 20713619 *Tramadol 50mg- 30 tablets RX# 20714677 *Tramadol 50mg- 10 tablets RX# 20378517 *Tramadol 50mg- 47 tablets RX# 4491885 *Tramadol 50mg- 20 tablets RX# 4540348 *APAP/Codeine ,d+[DATE]mg- 2 tablets RX# 13749007 *Tramadol 50mg- 30 tablets RX# 20737101 The DON said the controlled medications awaiting to be disposed were kept in the locked cabinet behind a locked door. The DON said she was the only one with the key to the door and the cabinet. The DON said her process when she reconciled medications that need to be disposed of was as follows: when medications were brought to her, she checked the narcotic medication count and verified the count with the nurse, the nurse and herself sign the narcotic sheet, she then logged the medication on the destruction log that was kept in a binder, and then placed the medication in the locked cabinet. The DON was not able to find the current log of the medications to be disposed and said she must have misplaced it. The DON said the pharmacy consultant and herself were responsible for reconciling the narcotic medications. The DON said the medications would not come up missing as she does not leave the cabinet, or the door unlocked. Record review of the facility's medication destruction binder on [DATE], indicated the last medication destruction was completed on [DATE]. During an interview on [DATE] at 1:56 PM, the Administrator said when narcotic medications were discontinued, they were given to the DON with the narcotic count sheet and kept locked. The Administrator said the medications were logged when they did medication destruction. The Administrator said ideally the narcotic medication should be logged as the DON received them, but the count was verified on the narcotic count sheet. The Administrator said she did not feel as what they were doing was wrong. The Administrator said if the narcotic medications were not reconciled then medications could come up missing. The Administrator said keeping the controlled medications reconciled could help protect the DON from allegations of drug diversion. The Administrator said the DON and the pharmacy consultant were responsible for ensuring the narcotic medications were accurately reconciled. Record review of the facility's policy Drug Destruction Policy revised [DATE], indicated . It is the policy of this facility to destroy dangerous and controlled medications according to the State of Texas law .4. The nurse submitting the discontinued medication will verify along with the Director of Nursing that the amount of medication remaining matches the log. After verification, both the nurse and the Director of Nursing will sign the log. 6. The Director of Nursing will log medications submitted for destruction. All medications submitted to the Director of Nursing will be kept under double lock system .

Based on observations, interviews and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 14 residents (Resident #9, Resident #11, and Resident #92) reviewed for care plans. 1. The facility failed to follow the care plan for health shakes on Resident #9 and Resident #11. 2. The facility failed to ensure Resident #92's care plan reflected she had PTSD (post-traumatic stress disorder-a disorder that develops in some people who have experienced a shocking, scary, or dangerous event). These failures could place residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: 1.Record review of Resident #9's face sheet, dated 07/12/23, indicated Resident #9 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included diabetes (excess sugar in the blood), high blood pressure, heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs.) and peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm). Record review of Resident #9's quarterly MDS assessment, dated 06/17/23, indicated Resident #9 was understood and understood others. Resident #9's BIMs score was 10, which indicated he was cognitively moderately impaired. Resident #9 required extensive assistance with transfer, toilet use, dressing, bathing, bed mobility, limited assist with personal hygiene and supervision with eating. The MDS indicated Resident #9 had weight loss with no swallowing concerns. Record review of Resident #9's physician orders, dated 04/23/23, revealed an order for health shakes to be given with each meal. Record review of Resident #9's comprehensive care plan, dated 04/23/23 indicated Resident #9 had an unplanned weight loss related to poor food intake. The interventions of the care plan were for staff to monitor weights, to give supplements as ordered, place red napkin on resident's meal tray to identify the resident to staff as possibly needing assistance, encouragement, or substitutes. During an observation on 07/11/23 at 12:34pm, Resident #9 was in his bed eating lunch. No health shake was noted on the lunch tray. Resident #9 had consumed about 75% of his lunch. During an observation and interview on 07/12/23 at 1:00p.m., Resident #9 was sitting up in bed eating lunch with no health shake noted on the tray. Resident #9had consumed about 75% of his lunch. Resident #9 said he receives health shakes on his meal trays most times. Resident # 11 said he sometimes drinks them and other times he was full. Resident #11 said he could not say how often he did or did not receive health shakes. During an interview on 07/12/23 at 1:30 p.m., CNA A said Resident #9 usually receives his health shake and she overlooked it when serving his lunch tray. CNA A said she would go to the kitchen and get Resident #9 a health shake and would look at all resident's tray cards better when serving trays. 2. Record review of Resident #11's face sheet, dated 07/12/23, indicated Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes (excess sugar in the blood), high blood pressure, dementia, and heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs). Record review of Resident #11s quarterly MDS assessment, dated 05/20/23, indicated Resident #11 was understood and understood others. Resident #11's BIMs score was 06, which indicated he was cognitively severely impaired. Resident #11 required extensive assistance with transfer, toilet use, dressing, bathing, bed mobility, personal hygiene, and limited assist with eating. The MDS indicated Resident #11 had weight loss with no swallowing concerns. Record review of Resident #11's physician orders, dated 03/23/23, revealed an order for health shakes to be given with each meal. Record review of Resident 11's comprehensive care plan, dated 01/18/23, indicated Resident #11 had potential nutritional problems related to dysphagia (difficulty swallowing). The interventions of the care plan were for staff to provide diet as ordered, serve supplements as ordered such as health shakes and med pass, and dietitian to evaluate and make diet change recommendations as needed. During an observation on 07/11/23 at 8:26 a.m., Resident #11 was sitting up in bed eating breakfast with no health shake noted on the tray. Resident #11 had consumed 100% of his breakfast. During an interview on 07/11/23 at 4:10 p.m., Resident #11 was unable to say if he received health shakes with each meal. During an observation and interview on 07/11/23 at 5:53 p.m., Resident #11 was in bed assisted by CNA A with no health shake noted on the meal tray. Resident #11 had consumed about 75% of his supper. CNA A said Resident #11 usually received health shakes with most meals but she did not know why he did not receive one on his supper tray. CNA A said she would go to the kitchen and get him a health shake. CNA A said residents could lose weight if they did not receive the health shake. During an observation and interview on 07/12/23 at 9:47 a.m., Dishwasher N, said they had a list of residents who received health shakes on a board in the kitchen. Dishwasher N went into the kitchen and read Resident #9 and Resident #11 names off the board. Dishwasher N said she was responsible to ensure health shakes were on each resident's tray before they left the kitchen. Dishwasher N said she was unaware Resident #9 or Resident #11 did not receive their health shakes on their meal tray. Dishwasher N said she knew Resident # 9 and Resident #11 required health shakes since their names were on the board but could not say why they needed them. During an interview on 07/12/23 at 1:35 p.m., LVN B said physicians orders should be followed. LVN B said nursing staff were responsible to read the tray cards to ensure all residents were served the correct diet and supplements as ordered. She said she was unaware Resident #9 and Resident #11 did not receive their health shakes. LVN B said failure to serve health shakes could lead to weight loss or skin issues. During an interview on 07/12/23 at 4:30 p.m., the DON said she expected physician orders to be followed. She said the charge nurses were responsible to ensure residents received supplements if ordered on their meal tray. The DON said she was not aware Resident #9 and Resident #11 did not receive health shakes on some of their meal trays as ordered. She said failure to receive supplements could lead to weight loss. During an interview on 07/12/23 at 4:40 p.m., the DON and Corporate Nurse said they did not have a policy on physician orders. During an interview on 07/12/23 at 5:22 p.m., the administrator said all physician orders should be followed because orders direct resident care. She said the nurses are the overseer of physician's orders and the DON and ADON should follow up. The administrator said failure to give health shakes as ordered could lead to weight loss and poor health. 33249 3. Record review of an undated face sheet indicated Resident #92 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of left sided weakness following a stroke, fracture of the nose, and post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). Record review of an Admission MDS dated [DATE] indicated Resident #92 understood and was understood. Resident #92's cognition was intact. The MDS indicated Resident #92 required extensive assistance of two staff for bed mobility, transfers, locomotion, dressing and toilet use. The MDS in the area of Psychiatric/Mood Disorder failed to have marked Post Traumatic Stress Disorder (PTSD). Record review of the comprehensive care plan dated 7/03/2023 and updated on 7/11/2023 reflected it failed to indicate Resident #92 had a diagnosis of PTSD (post-traumatic stress disorder) until after surveyor intervention. During an interview on 7/11/2023 at 9:24 a.m., the MDS coordinator said she failed to mark Resident #92's PTSD on the MDS assessment. The MDS coordinator said the CAA did not trigger for a care plan as a result of not marking the MDS correctly. The MDS coordinator said knowing the triggers and care for Resident #92's PTSD would help the staff to know how to respond to her needs. The MDS coordinator said the comprehensive care plan was completed on 7/03/2023. During an interview on 7/12/2023 at 10:55 a.m., the SW indicated said he was unaware of Resident #92's diagnosis of PTSD (post-traumatic stress disorder). The SW said he and other staff should know what the triggers were for Resident #92 in order to ensure how to care for her during those times. During an interview on 7/12/2023 at 10:59 a.m., LVN B said she was the nurse for Resident #92. LVN B said she was unaware of any details related to Resident #92's diagnosis of PTSD or the triggers involved. During an interview on 7/12/2023 at 1:56 p.m., the Administrator said she expected the care plan to reflect the PTSD care Resident #92 required. The Administrator said knowing Resident #92's triggers would help the staff to help to not illicitelicit flare up of memories. The Administrator said anyone could initiate or update a care plan. The Administrator said the MDS coordinator, and the DON monitor the care plans for accuracy. During an interview on 7/12/2023 at 2:33 p.m., the DON said not care planning Resident #92's PTSD would cause the care plan not to be person-centered. The DON said staff should be aware Resident #92 had PTSD, what triggered negative responses, and how the staff should respond to the episodes. Record review of the facility's policy titled, Care Plan, dated 10/04/22, indicated The facility will develop a Comprehensive- care plan for each resident that includes measurable short-term and long-term objectives and timetables to meet a resident(s) medical, nursing, and mental and psycho-social needs that were identified in the comprehensive assessment. 2. The care plan must describe the following: a. Services/Interventions that were to be furnished to attain or maintain the resident=s highest practicable physical, mental, and psychosocial well-being. b. Problem statements to identify services that were required to maintain the resident=s highest practicable physical, mental, and psychosocial well-being, be culturally competent and trauma informed. c. Short- and long-term goals to identify reassessment parameters for the resident=s maintenance of well-being. d. Evaluation of the interventions and goals to maintain the resident=s well-being. 3.The comprehensive care plan must be developed within seven days after completion of the comprehensive assessment. It will be prepared by a care plan team that includes a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and with the resident, resident's family, or legal representative. Documentation will be maintained in the resident's clinical record of the Care Plan meeting. 4.The comprehensive plan will be reviewed regularly, as per guideline, and/or with significant change and revised by a team of qualified persons after each assessment. Documentation will be maintained in the resident's clinical record.

Based on interview, and record review the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations, for 1 of 15 residents reviewed for abuse. (Resident #92) The facility failed to follow their policy when they did not report timely to the state agency Resident #92's allegation of neglect on 06/12/2023. This failure could cause residents to have continued neglect. Findings included: Record review of an abuse policy dated 2003 with a revision date of 10/04/2022 indicated the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subparagraph. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraints not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . The Abuse Preventionist will be responsible for receiving, leading the appropriate investigation, assure that required reporting is completed timely, assures that any additional staff training is assigned, and reports the above and any other measures indicated to the Quality Assurance program. Record review of an undated face sheet indicated Resident #92 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of left sided weakness following a stroke, fracture of the nose, and post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). Record review of the base line care plan dated 06/12/2023 indicated the DON documented in functional abilities and goals: mobility Resident #92 required transfer assistance of two plus persons physical assistance. The baseline care plan indicated Resident #92 was cognitively intact. The baseline care plan indicated Resident #92 had a history of falls in the last month prior to admission. The baseline care plan indicated in skin risk current skin issues was not marked nor was a history of skin integrity issues. Record review of the comprehensive care plan dated 06/12/2023 and revised on 07/03/2023 indicated Resident #92 had an ADL self-care deficit related to the stroke and left sided weakness. The care plan interventions indicated on 06/12/2023 with a revision date of 07/03/2023 Resident #92 required extensive assistance of 2 staff and may use a Hoyer (mechanical lift) for transfers. The care plan indicated Resident #92 was at risk for falls related to gait/balance problems, incontinence, use of psychoactive drugs, and vision/hearing problems. The interventions included to anticipate and meet the resident's needs, follow fall protocol, and review past falls and determine the cause. The care plan in the skin integrity section failed to address any abnormal bruising on admission. Record review of the rehabilitation hospital physician's progress note dated 6/02/2023 indicated Resident #92 had impaired mobility and ADLs. The physician's progress note indicated Resident #92 was dependent and required substantial maximal assistance with transfers from chair, bed to chair transfers. Record review of a rehabilitation hospital physical therapy note dated 06/05/2023 indicated the physical therapist documented with standing Resident #92 required maximum due to Resident #92 leans very heavily to the left side and was unable to actively use the left side of the body and she stood for 30 seconds - 2 minutes per attempt. The note also indicated the therapist documented Resident #92 was able to perform sit-stands with maximum assistance within the therapy bars. The note indicated Resident #92 was not actively moving or using her left lower extremity at this time to progress with gait safely. The note indicated Resident #92 would continue to benefit from physical therapy due to being max assist for transfers and poor mobility at that time. Record review of Resident #92's skin assessment opened on 06/12/2023 and locked on 06/14/2023 (after the hospital visit) indicated the previous ADON documented 3 faded bruises to left lateral distal thigh, 1 light bruise to lateral left lower extremity and 1 bruise to the right forearm. Record review of a fall assessment dated [DATE] indicated Resident #92 had no history of falls in the past three months, and she was alert and oriented. Section E of the assessment assessed gait, balance, muscular coordination, and use of assistive devices. Section E indicated Resident #92 was unable to stand to participate in the assessment. In the area of the assessment predisposing conditions indicated Resident #92 had 1-2 conditions such as stroke, and fractures. Record review of an incident report dated 06/13/2023 at 8:00 a.m., reflected the DON documented during routine resident rounds Resident #92 reported she fell last night. The report indicated Resident #92 stated CNA D went to get her out of bed, grabbed her by the shirt and dropped her on the floor. Resident #92 said she landed on her left side (weak side) and hit her left knee, left wrist, and left elbow. The report indicated the DON wrote Resident #92 said after she fell , CNA D grabbed her by the shirt and threw her back to bed. Resident #92 told the DON that CNA D did not notify anyone that she was dropped. The report indicated Resident #92 indicated she reported this to the night nurse at 1:00 a.m. because she did not want to get anyone in trouble. The incident report indicated Resident #92 demanded to be seen by a doctor. The note indicated the DON notified the nurse practitioner and Resident #92 was transferred to the emergency room and the abuse coordinator was notified of the allegation. The incident report indicated Resident #92 was oriented to person, place, time, and situation. Record review of the consolidated physician orders dated 7/11/2023 indicated Resident #92's physician ordered may use a Hoyer lift (mechanical) for transfers on 06/14/2023. Record review of an email received by HHSC complaint mailbox indicated the administrator sent the initial self-report of Resident #92's allegation of neglect on 6/14/2023 at 10:54 a.m. Record review of a witness statement dated 06/14/2023 indicated, CNA D wrote the incident occurred on 06/12/2023 at 11:36 a.m., Resident #92 wanted to be assisted up to attend the 8:00 p.m. smoke break. CNA D wrote she and CNA C began to struggle to get Resident #92 in her chair. The witness statement indicated Resident #92 began sliding but still was on the bed and never touched the floor. The note indicated Resident #92 was pulled up with their arms under her armpits while holding on to Resident #92's brief. Record review of a witness statement dated 06/13/2023 indicated CNA C wrote the incident occurred on 06/12/2023 at 8:00 p.m. CNA C wrote Resident #92 wanted to get up for the 8:00 p.m. smoke break. CNA C wrote Resident #92 said she could help transfer with her other leg. CNA C said they proceed to stand Resident #92 up and turn her but realized Resident #92 could not help at all. CNA C wrote Resident #92 was still on the bed but was sliding off. CNA C wrote Resident #92 was assisted back up on the bed, but her body did not touch the ground. CNA C indicated the nurse would be notified. CNA C wrote Resident #92 was yelling and cursing saying, we dropped her. CNA C wrote she explained to Resident #92 she did not fall and Resident #92 responded okay. Record review of an undated witness statement written by the previous ADON indicated the incident occurred on 6/13/2023 at 8:45 a.m. The ADON wrote Resident #92 reported CNA D came into her room to assist her up for a smoke break. The ADON wrote Resident #92 said she informed CNA D she needed two people to help with the transfer, but CNA D transferred her by herself. Record review of an email included in the provider investigation report from RN dated 6/15/2023 at 10:02 a.m., RN E indicated on or about 06/12/2023 LVN F discussed with her the newly admitted Resident #92 reported a fall occurring earlier that day. The email indicated Resident #92 made the allegation she was dropped by a CNA D. RN E completed a physical assessment and Resident #92 was found to have no obvious injuries but had three circular bruise marks noted on the left lateral thigh each similar in size approximately 3-4 centimeters. The email indicated Resident #92 reported pain to her left knee. During an observation on 7/10/2023 at 9:20 a.m., Resident #92 was lying in her bed. Resident #92 said she had been dropped by CNA D on the day she admitted . Resident #92 said she had a stroke, and she cannot use her left side yet. Resident #92 said the incident occurred on the first day she arrived as a resident of the facility in June 2023. During an observation and interview on 7/10/2023 at 3:59 p.m., CNA D said she went to assist Resident #92 up on 6/12/2023 to smoke at around 3:40 p.m. for the 4:00 p.m. smoke break. CNA D said CNA C assisted her with transferring Resident #92. CNA D said Resident #92 was a new resident and they did not know much about Resident #92. During the interview CNA D demonstrated to the surveyors the transfer technique used by herself and CNA C. CNA D demonstrated they both put their arms underneath Resident #92's arm pits one on each side. CNA D indicated the transfer was initiated and Resident #92 was unable to help, and she was heavy. CNA D said both struggled to get Resident #92 back on the bed. CNA D said then she went to obtain a gait belt to assist with the transfer. CNA D said she does not use a gait belt with transfers. CNA D said she feels as though she can hold them better under their armpits. CNA D said she had been in-serviced recently on use of the gait belt and gait belts were available for use. During an interview on 7/10/2023 at 10:15 a.m., RN E said LVN F on 6/12/2023 around 11:00 p.m., came and informed her Resident #92 had made an allegation she had been dropped being transferred for the smoke break. RN E said Resident #92 said her body did not hit the floor but said she slid to the floor. RN E said she texted CNAs C and D. RN E said both CNAs responded and indicated Resident #92's body never touched the floor. RN E said she completed an assessment and the left lateral thigh had three round bruises, in a linear pattern, and not new looking, no swelling and her skin was intact. RN E said she did report the allegation the next morning at 7:00 a.m. to the DON. RN E said she did not report immediately because there were no injuries and there was not a fall. RN E said she did not ask CNAs C and D if they used a gait belt while transferring Resident #92. RN E said if resources were available, and a staff member failed to use the resources to care for a resident safely this was neglect. RN E said she was unsure if the CNAs could access the transfer needs of Resident #92 or other residents. RN E said she informs the nursing staff of the resident care needs by verbal method in a huddle. During an interview on 7/11/2023 at 10:38 a.m., CNA C said she was informed to assist Resident #92 up at 3:30 p.m. to smoke at 4:00 p.m. CNA C said Resident #92 said she could assist with the transfer. CNA C said she and CNA D raised Resident #92 to the sitting position, they placed their arms under Resident #92's arms, grabbed hold of her pants and attempted the transfer. CNA C said she thought Resident #92 could help them with the transfer by shuffling. CNA C said they moved Resident #92 back to the center of the bed and tried a second time. CNA C said this time they used more strength with the transfer. CNA C said they were able to get her in the chair but Resident #92's left leg did not rotate with the transfer. CNA C said when Resident #92 was transferred to bed after smoking a gait belt was used. CNA C said she did not use a gait belt on the initial transfer because it slipped her mind. CNA C said Resident #92 did not attend the 8:00 p.m. smoke break, she said she was never interviewed about the incident. CNA C said she only wrote a statement. CNA C said she did not know the care needs of Resident #92 and her nurse was on break. CNA C said she had been trained on the use of a gait belt prior to this incident. CNA C said neglect could be not giving a resident the care they need. During an observation and interview on 7/11/2023 at 4:07 p.m., CNA G said she had been employed for almost 2 years. CNA G said she had provided care for Resident #92. CNA G demonstrated on the computerized documentation center for the CNAs how she would know how Resident #92 transferred. CNA G said she follows what the previous shift documents in the transfer area. CNA G said she was not computer efficient and was unsure where to find the Kardex (computerized care tasks) or care plan for resident care needs. During an interview on 7/11/2023 at 5:49 p.m., LVN F said CNA H reported to her on 6/12/2023 around 11:00 p.m., that Resident #92 made an allegation CNA D dropped her. LVN F said she went immediately and reported to her supervisor RN E. LVN F said she did not report the allegation herself to the DON or the Administrator. LVN F said abuse should be reported immediately to the Administrator. LVN F said she received in report Resident #92 required two staff for transfers. During an interview on 7/12/2023 at 1:56 p.m., the Administrator said she was the abuse coordinator. The Administrator said she reported the allegation of Resident #92's abuse as soon as she learned of the abuse. The Administrator said she was aware Resident #92 made the allegation of abuse on 6/12/2023. The Administrator said she reported the allegation even though she knew the reporting was late. The Administrator said she was just a few hours late with the reporting of Resident #92's allegation to the state agency. The Administrator indicated she had 24 hours to report the allegation of abuse. During an interview on 7/12/2023 at 2:33 p.m., the DON said she notified the Administrator as soon as she was notified of Resident #92's allegations of abuse. The DON said she believed Resident #92's story had inconsistencies, but she reported immediately to the Administrator. The DON said when allegations were not reported promptly then abuse could continue to occur and residents could be in danger if the abuse was continuing.

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 15 residents (Resident #92) reviewed for abuse and neglect. The facility failed to follow their policy when they did not report timely to the state agency Resident #92's allegation of neglect on 06/12/2023. This failure could cause residents to have continued neglect. Findings included: Record review of an undated face sheet indicated Resident #92 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of left sided weakness following a stroke, fracture of the nose, and post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). Record review of the base line care plan dated 06/12/2023 indicated the DON documented in functional abilities and goals: mobility Resident #92 required transfer assistance of two plus persons physical assistance. The baseline care plan indicated Resident #92's was cognitively intact. The baseline care plan indicated Resident #92 had a history of falls in the last month prior to admission. The baseline care plan indicated in skin risk current skin issues was not marked nor was a history of skin integrity issues. Record review of the comprehensive care plan dated 06/12/2023 and revised on 07/03/2023 indicated Resident #92 had an ADL self-care deficit related to the stroke and left sided weakness. The care plan interventions indicated on 06/12/2023 with a revision date of 07/03/2023 Resident #92 required extensive assistance of 2 staff and may use a Hoyer (mechanical lift) for transfers. The care plan indicated Resident #92 was at risk for falls related to gait/balance problems, incontinence, use of psychoactive drugs, and vision/hearing problems. The interventions included to anticipate and meet the resident's needs, follow fall protocol, and review past falls and determine the cause. The care plan in the skin integrity section failed to address any abnormal bruising on admission. Record review of an email received by HHSC complaint mailbox indicated the administrator sent the initial self-report of Resident #92's allegation of neglect on 6/14/2023 at 10:54 a.m. Record review of aResident #92's skin assessment opened on 06/12/2023 and locked on 06/14/2023 (after the hospital visit) indicated the previous ADON documented 3 faded bruises to left lateral distal thigh, 1 light bruise to lateral left lower extremity and 1 bruise to the right forearm. Record review of a fall assessment dated [DATE] indicted indicated Resident #92 had no history of falls in the past three months, and she was alert and oriented. Section E of the assessment assessed gait, balance, muscular coordination, and use of assistive devices. Section E indicated Resident #92 was unable to stand to participate in the assessment. In the area of the assessment predisposing conditions indicated Resident #92 had 1-2 conditions such as stroke, and fractures. Record review of a rehabilitation hospital physical therapy note dated 06/05/2023 indicated the physical therapist documented with standing Resident #92 required max due to Resident #92 leans very heavily to the left side and was unable to actively use the left side of the body and she stood for 30 seconds - 2 minutes per attempt. The note also indicated the therapist documented Resident #92 was able to perform sit-stands with maximum assistance within the therapy bars. The note indicated Resident #92 was not actively moving or using her left lower extremity at this time to progress with gait safely. The note indicated Resident #92 would continue to benefit from physical therapy due to being max assist for transfers and poor mobility at that time. Record review of the rehabilitation hospital physician's progress note on dated 6/02/2023 indicated Resident #92 had impaired mobility and ADLs. The physician's progress note indicated Resident #92 was dependent and required substantial maximal assistance with transfers from chair, bed to chair transfers. Record review of an incident report dated 06/13/2023 at 8:00 a.m., indicated the DON documented during routine resident rounds Resident #92 reported she fell last night. The report indicated Resident #92 stated CNA D went to get her out of bed, grabbed her by the shirt and dropped her on the floor. Resident #92 said she landed on her left side (weak side) and hit her left knee, left wrist, and left elbow. The report indicated the DON wrote Resident #92 said after she fell , CNA D grabbed her by the shirt and threw her back to bed. Resident #92 told the DON that CNA D did not notify anyone that she was dropped. The report indicated Resident #92 indicated she reported this to the night nurse at 1:00 a.m. because she did not want to get anyone in trouble. The incident report indicated Resident #92 demanded to be seen by a doctor. The note indicated the DON notified the nurse practitioner and Resident #92 was transferred to the emergency room and the abuse coordinator was notified of the allegation. The incident report indicated Resident #92 was oriented to person, place, time, and situation. Record review of a witness statement dated 06/13/2023 indicated CNA C wrote the incident occurred on 06/12/2023 at 8:00 p.m. CNA C wrote Resident #92 wanted to get up for the 8:00 p.m. smoke break. CNA C wrote Resident #92 said she could help transfer with her other leg. CNA C said they proceed to stand Resident #92 up and turn her but realized Resident #92 could not help at all. CNA C wrote Resident #92 was still on the bed but was sliding off. CNA C wrote Resident #92 was assisted back up on the bed, but her body did not touch the ground. CNA C indicated the nurse would be notified. CNA C wrote Resident #92 was yelling and cursing saying, we dropped her. CNA C wrote she explained to Resident #92 she did not fall and Resident #92 responded okay. Record review of an undated witness statement written by the previous ADON indicated the incident occurred on 6/13/2023 at 8:45 a.m. The ADON wrote Resident #92 reported CNA D came into her room to assist her up for a smoke break. The ADON wrote Resident #92 said she informed CNA D she needed two people to help with the transfer, but CNA D transferred her by herself. Record review of an email received by HHSC complaint mailbox indicated the administrator sent the initial self-report of Resident #92's allegation of neglect on 6/14/2023 at 10:54 a.m. Record review of the consolidated physician orders dated 7/11/2023 indicated Resident #92's physician ordered may use a Hoyer lift (mechanical) for transfers on 06/14/2023. Record review of a witness statement dated 06/14/2023 indicated, CNA D wrote the incident occurred on 06/12/2023 at 11:36 a.m., Resident #92 wanted to be assisted up to attend the 8:00 p.m. smoke break. CNA D wrote she and CNA C began to struggle to get Resident #92 in her chair. The witness statement indicated Resident #92 began sliding but still was on the bed and never touched the floor. The note indicated Resident #92 was pulled up with their arms under her armpits while holding on to Resident #92's brief. Record review of a witness statement dated 06/13/2023 indicated CNA C wrote the incident occurred on 06/12/2023 at 8:00 p.m. CNA C wrote Resident #92 wanted to get up for the 8:00 p.m. smoke break. CNA C wrote Resident #92 said she could help transfer with her other leg. CNA C said they proceed to stand Resident #92 up and turn her but realized Resident #92 could not help at all. CNA C wrote Resident #92 was still on the bed but was sliding off. CNA C wrote Resident #92 was assisted back up on the bed, but her body did not touch the ground. CNA C indicated the nurse would be notified. CNA C wrote Resident #92 was yelling and cursing saying, we dropped her. CNA C wrote she explained to Resident #92 she did not fall and Resident #92 responded okay. Record review of an undated witness statement written by the previous ADON indicated the incident occurred on 6/13/2023 at 8:45 a.m. The ADON wrote Resident #92 reported CNA D came into her room to assist her up for a smoke break. The ADON wrote Resident #92 said she informed CNA D she needed two people to help with the transfer, but CNA D transferred her by herself. Record review of an email included in the provider investigation report from RN dated 6/15/2023 at 10:02 a.m., RN E indicated on or about 06/12/2023 LVN F discussed with her the newly admitted Resident #92 reported a fall occurring earlier that day. The email indicated Resident #92 made the allegation she was dropped by a CNA D. RN E completed a physical assessment and Resident #92 was found to have no obvious injuries but had three circular bruise marks noted on the left lateral thigh each similar in size approximately 3-4 centimeters. The email indicated Resident #92 reported pain to her left knee. During an observation on 7/10/2023 at 9:20 a.m., Resident #92 was lying in her bed. Resident #92 said she had been dropped by CNA D on the day she admitted . Resident #92 said she had a stroke, and she cannot use her left side yet. Resident #92 said she reported the incident on the same night she admitted . During an observation and interview on 7/10/2023 at 3:59 p.m., CNA D said she went to assist Resident #92 up on 6/12/2023 to smoke at around 3:40 p.m. for the 4:00 p.m. smoke break. CNA D said CNA C assisted her with transferring Resident #92. CNA D said Resident #92 was a new resident and they did not know much about Resident #92. During the interview CNA D demonstrated to the surveyors the transfer technique used by herself and CNA C. CNA D demonstrated they both put their arm's underneath Resident #92's arm pits one on each side. CNA D indicated the transfer was initiated and Resident #92 was unable to help, and she was heavy. CNA D said both struggled to get Resident #92 back on the bed. CNA D said then she went to obtain a gait belt to assist with the transfer. CNA D said she does not use a gait belt with transfers. CNA D said she feels as though she can hold them better under their armpits. CNA D said she had been in-serviced recently on use of the gait belt and gait belts were available for use. During an interview on 7/10/2023 at 10:15 a.m., RN E said LVN F on 6/12/2023 around 11:00 p.m., came and informed her Resident #92 had made an allegation she had been dropped being transferred for the smoke break. RN E said Resident #92 said her body did not hit the floor but said she slid to the floor. RN E said she texted CNAs C and D. RN E said both CNAs responded and indicated Resident #92's body never touched the floor. RN E said she completed an assessment and the left lateral thigh had three round bruises, in a linear pattern, and not new looking, no swelling and her skin was intact. RN E said she did report the allegation the next morning at 7:00 a.m. to the DON. RN E said she did not report immediately because there were no injuries and there was not a fall. RN E said she did not ask CNAs C and D if they used a gait belt while transferring Resident #92. RN E said if resources were available, and a staff member failed to use the resources to care for a resident safely this was neglect. RN E said she was unsure if the CNAs could access the transfer needs of Resident #92 or other residents. RN E said she informs the nursing staff of the resident care needs by verbal method in a huddle. Record review of the consolidated physician orders dated 7/11/2023 indicated Resident #92's physician ordered may use a Hoyer lift (mechanical) for transfers on 06/14/2023. During an interview on 7/11/2023 at 10:38 a.m., CNA C said she was informed to assist Resident #92 up at 3:30 p.m. to smoke at 4:00 p.m. CNA C said Resident #92 said she could assist with the transfer. CNA C said she and CNA D raised Resident #92 to the sitting position, they placed their arms under Resident #92's arms, grabbed hold of her pants and attempted the transfer. CNA C said she thought Resident #92 could help them with the transfer by shuffling. CNA C said they moved Resident #92 back to the center of the bed and tried a second time. CNA C said this time they used more strength with the transfer. CNA C said they were able to get her in the chair but Resident #92's left leg did not rotate with the transfer. CNA C said when Resident #92 was transferred to bed after smoking a gait belt was used. CNA C said she did not use a gait belt on the initial transfer because it slipped her mind. CNA C said Resident #92 did not attend the 8:00 p.m. smoke break, she said she was never interviewed about the incident. CNA C said she only wrote a statement. CNA C said she did not know the care needs of Resident #92 and her nurse was on break. CNA C said she had been trained on the use of a gait belt prior to this incident. CNA C said neglect could be not giving a resident the care they need. During an observation and interview on 7/11/2023 at 4:07 p.m., CNA G said she had been employed for almost 2 years. CNA G said she had provided care for Resident #92. CNA G demonstrated on the computerized documentation center for the CNAs how she would know how Resident #92 transferred. CNA G said she follows what the previous shift documents in the transfer area. CNA G said she was not computer efficient and was unsure where to find the Kardex (computerized care tasks) or care plan for resident care needs. During an interview on 7/11/2023 at 5:49 p.m., LVN F said CNA H reported to her on 6/12/2023 around 11:00 p.m., that Resident #92 made an allegation CNA D dropped her. LVN F said she went immediately and reported to her supervisor RN E. LVN F said she did not report the allegation herself to the DON or the Administrator. LVN F said abuse should be reported immediately to the Administrator. LVN F said she received in report Resident #92 required two staff for transfers. During an interview on 7/12/2023 at 1:56 p.m., the Administrator said she was the abuse coordinator. The Administrator said she reported the allegation of Resident #92's abuse as soon as she learned of the abuse. The Administrator said she was aware Resident #92 made the allegation of abuse on 6/12/2023. The Administrator said she reported the allegation even though she knew the reporting was late. The Administrator said she was just a few hours late with the reporting of Resident #92's allegation to the state agency. The Administrator said she had 24 hours to report the allegation. During an interview on 7/12/2023 at 2:33 p.m., the DON said she notified the Administrator as soon as she was notified of Resident #92's allegations of abuse. The DON said she believed Resident #92's story had inconsistencies, but she reported immediately to the Administrator. The DON said when allegations were not reported promptly then abuse could continue to occur and residents could be in danger if the abuse was continuing. Record review of an abuse policy dated 2003 with a revision date of 10/04/2022 indicated the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpar agrah. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraints not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . The Abuse Preventionist will be responsible for receiving, leading the appropriate investigation, assure that required reporting is completed timely, assures that any additional staff training is assigned, and reports the above and any other measures indicated to the Quality Assurance program. Record review of a Reporting Incidents: State and Home Office policy and procedure dated 2003 and revised 1/08/2007 indicated the following guidelines will be followed by all facilities regarding reporting incidents and variances that occur at the facility. The home office risk management and legal team will assist the facility with appropriate responses to the event/occurrence. The team approach and early intervention may prevent an event form from becoming a claim or lawsuit. The guidelines for state reporting are the guidelines issued by the Texas Department of Aging and Disability Services. Reporting Guidelines to the State of Texas: .All incidents must be reported to the state office, [NAME] Texas within 24 hours of learning of the incident. A written investigation report must be sent no later than the fifth working day after the oral report.

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 Residents (Resident #34) reviewed for transmitting assessments. 1. Resident #34's Annual-5-day MDS assessment had an Assessment Reference date of 03/13/23 and was completed on 03/23/23 but was not transmitted within 14 days of completion 2. Resident #34's Quarterly MDS assessment had an Assessment Reference date of 05/26/23 and was completed on 06/05/23 but was not transmitted within 14 days of completion. This failure could put residents at risk of state and federal monitors having inadequate information about the care residents require and receive. The findings included: Record review of Resident #34's face sheet dated 07/12/23 indicated that resident was a 64year old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of heart failure (impaired blood pumping function), respiratory failure (inadequate gas exchange by respiratory system), hyperglycemia (excessive amounts of glucose in blood system), high blood pressure, and ventral hernia (bulge of tissues in weak abdominal wall). Record review of Resident #34's electronic MDS SUMMARY dated 07/11/23 indicated the Annual 5-day MDS had an ARD date of 03/13/23 and was completed on 03/23/23 but was not transmitted until 07/11/23. Record review of Resident #34's electronic MDS SUMMARY dated 07/11/23 indicated the Quarterly MDS had an ARD date of 05/26/23 and was completed on 06/05/23 but was not transmitted until 07/11/23. During an interview on 07/11/23 at 3:45 PM the MDS Nurse said the MDSs dates 03/13/23 and 05/26/23 were not submitted by accident. She said Resident # 34's prior MDSs did not have to be transmitted related to resident had a Medicare replacement plan. She said when she completed Resident #34's MDSs dated 03/13/23 and 05/26/23 she had forgotten to change the option to transmit after locking the MDSs. She said she was responsible for ensuring all MDSs at the facility were transmitted in a timely manner. The MDS Nurse said she had a Corporate MDS Nurse who oversaw her work as well. The MDS Nurse said that by her not transmitting in a timely manner it could have caused billing problems. During an interview on 07/11/23 at 4:50 PM the Corporate MDS Nurse said that she did not check behind the MDS Nurse to ensure transmissions were completed because the MDS Nurse knew what she was supposed to do and had been completing MDSs for a long time. She said it was an oversight. The Corporate MDS Nurse said by the MDS Nurse not transmitting timely it could have caused CMS to not receive accurate information. During an interview on 07/12/23 at 3:02 PM the DON said that MDSs should be submitted per regulations and in a timely manner. She said the MDS nurse was responsible for ensuring they were completed and transmitted. The DON said the failure could have caused payment issues or inaccurate information in the system for CMS. During an interview on 07/12/23 at 3:55 PM the Administrator said that she expected the MDSs to be completed and transmitted timely and the MDS Nurse was responsible. She said with the failure, the facility could have problems with payment or CMS not having accurate information on Resident #34. Record review of the policy for MDS assessment Data Accuracy dated 10/01/17 indicated Purpose/Policy The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being . Procedures . 10. For Submitting/Transmitting the MDS Please refer to CMS's RAI 3.0 Version Manual for submitting/transmitting the MDS.

Based on interviews, and record review the facility failed to ensure an accurate MDS assessment was completed for 1 of 15 residents (Resident #92) reviewed for MDS assessment accuracy. The facility failed to accurately code Resident #92's PTSD on the MDS. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of an undated face sheet indicated Resident #92 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of left sided weakness following a stroke, fracture of the nose, and post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). Record review of an Admission MDS dated [DATE] indicated Resident #92 understood and was understood. Resident #92's cognition was intact. The MDS indicated Resident #92 required extensive assistance of two staff for bed mobility, transfers, locomotion, dressing and toilet use. The MDS in the area of Psychiatric/Mood Disorder failed to have marked Post Traumatic Stress Disorder (PTSD). Record review of the comprehensive care plan dated 7/03/2023 and updated on 7/11/2023 failed to indicate Resident #92 had a diagnosis of PTSD (post-traumatic stress disorder ) until after surveyor intervention. During an interview on 7/11/2023 at 9:24 a.m., the MDS coordinator said she failed to mark Resident #92's PTSD on the MDS. The MDS coordinator said the CAA did not trigger for a care plan as a result of not marking the MDS correctly. The MDS coordinator said knowing the triggers and care for Resident #92's PTSD would help the staff to know how to respond to her needs. During an interview on 7/12/2023 at 10:55 a.m., the SW said he was unaware Resident #92 had the diagnosis of PTSD. The SW said the staff would need to know Resident #92's triggers to determine the care Resident #92 required during the times she had recollections of her traumatizing event. During an interview on 7/12/2023 at 10:59 a.m., LVN B said she was the nurse for Resident #92. LVN B said she was unaware of any details related to Resident #92's diagnosis of PTSD or the triggers involved. During an interview on 7/12/2023 at 1:56 p.m., the Administrator said she expected the MDS to reflect the PTSD for Resident #92. The Administrator said the MDS coordinator was responsible for ensuring the accuracy of the MDS. The Administrator said the PTSD should have been found on the initial psychosocial assessment. During an interview on 7/12/2023 at 2:33 p.m., the DON said she expected the MDS coordinator to code the MDS accurately. The DON said not coding the MDS accurately could cause the resident not to receive the correct services. Record review of a MDS assessment data accuracy policy dated 10/01/2017 indicated the purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified to staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being .Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g) and (h) require that: 1. The assessment accurately reflects the resident's status. 8. Once the assessment is completed, the RN signs certifying that the assessment is completed. By signing the assessment, the RN is certifying that each section was completed by the appropriate person and that the individual is qualified to determine the accuracy of the portion of the resident's assessment he/she completed.

Based on observations, and interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 1 of 1 maintenance building grounds. The facility failed to ensure the maintenance building grounds were free of broken furniture, mop buckets, mattresses, fall mat, window screens, privacy fencing, gutters, televisions, metal sidings, shop vacuum, shower chairs, pvc piping, and pallets. These failures could place residents at risk for a diminished clean, and well-kept environment. Findings included: During an observation on 7/11/2023 at 11:45 p.m., outside grounds of the maintenance building were: *6 weathered mattresses *6 pallets and pieces of pallets *2 bedside tables *1 over the bed table *2 mop buckets *1 shop vacuum *1 fall mat *2 shower chairs *Numerous pieces of pvc (polyvinylchloride) pipe *Metal siding *2 televisions * Pieces of gutter material * Privacy fencing *Window screens * A barbeque grill During an interview on 7/11/2023 at 12:01 p.m., the maintenance supervisor said the items should have been discarded. The maintenance supervisor said he does not have a way to haul the discarded items away. The maintenance supervisor said he puts what he can in the trash dumpster twice a week when the amount in the dumpster allows for more items. The maintenance supervisor said he was responsible for keeping the grounds clean. The maintenance supervisor said a resident could get in the area and possibly get injured. During an interview on 7/11/2023 at 1:56 p.m., the Administrator said all the broken and unusable items should be discarded. The Administrator said she was unable to find anyone to come and haul off the items. The Administrator said getting an extra dumpster was costly. Record review of an Environment of Care Policy and Procedure dated 2003 indicated .4. Environmental audits will include the following areas: processing receiving, shipping, and storage; building grounds and conditions; housekeeping program, electricity; lighting; heating and ventilation; personnel; chemicals; environment; PPE; and documentation review. 7. Reports of environmental audits will be forwarded to the Governing Board via meetings minutes.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (east nurse/treatment cart) observed for medication storage. The facility failed to ensure the east nurse/treatment cart contained properly labeled medication. These failures could place residents at risk for not receiving drugs and biologicals as needed and medications being used passed their effective or expiration date. Findings included: During an observation and interview on [DATE] at 10:19 AM the east side nurse/treatment cart was reviewed and inside the cart were two clear containers, which were the size of denture cups, that contained pink with white cream. Both containers were not labeled or dated. LVN L said she was unsure of what the containers contained as they were not labeled. LVN L said they appeared to be calazime (skin protectant that helps prevent skin irritation) ointment. LVN L said the DON told her it was barrier cream. LVN L said the containers should have been dated and labeled. LVN L said someone could use it without knowing what it contained since it was not labeled. LVN L said the nurses were responsible for ensuring the containers were labeled and dated. During an interview on [DATE] at 01:56 PM, the Administrator said she expected the carts to have the medications labeled, dated and in the original container. The Administrator said if the medications required to be mixed, to only be done per physician's orders. The Administrator said not having the containers labeled placed the resident at risk for receiving the wrong medication. The Administrator said the nurses were responsible for labeling the containers. The Administrator said the pharmacy consultant checked the carts monthly and the DON randomly checked them. During an interview on [DATE] at 02:46 PM the DON said the containers containing the pink and white cream should have been labeled. The DON said what had happened was the barrier cream tube had ruptured and they had transferred it to a different container. The DON said she was aware they were not supposed to do that. The DON said the cream should have been thrown away. The DON said the cream could have been used on someone else not intended for. The DON said the nurse was responsible for checking the carts daily for expired and unlabeled medications and the pharmacy consultant checked it monthly. Record review of the facility's policy Storage of Medication dated 2003, indicated .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier . The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. Only a pharmacist completes transfer of medications for one container to another .

Based on observation, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety for 1 of 1 kitchen (Kitchen A) reviewed for food storage. The facility did not label or date all foods after it was removed from its original packaging in Kitchen A. This failure could place 38 residents who ate from the 1 kitchen at risk for foodborne illness. Findings include During an observation of Kitchen, A on 6/01/2022 at 9:30 a.m. All foods that were removed from its original packaging did not have labels or dates. Those items were milk, butter, cottage cheese, yellow mustard, relish, cheese, lunch meat, salad, whip cream, tea, and pudding. During an interview on 06/01/2022 at 11:35 a.m. Dietary Manager said she was unaware the labels were needing to be placed on each opened food item as she was placing the date the food items came off the truck. Placing the labels on each item were failed due lack of miscommunication and knowledge of labeling correctly. All kitchen staff are responsible for labeling open food items. Inservice was conducted 6-1-2022 educating staff on the correct way to label. She said not labeling open food items cause residents to become ill. During interview on 06/01/2022 at 11:40 am. Head Cook said the labeling was done incorrectly due to lack of knowledge. All food items were being dated the date received off the truck and not when the food items were opened. Placing the labels on each item were failed due lack of miscommunication and knowledge of labeling correctly. She said all staff are responsible for labeling but was doing incorrectly. Dietary Manager conducted an Inservice 6-1 educating on the correct way to label. Labeling food items is very important for the health and safety of the residents. During an interview on 06/01/2022 at 10:50 AM. Kitchen Staff A said she has been with the facility for 1 month and she was not aware of labeling and dating opened food items. States the labeling and dating of unopened food items was never explained and it was failed due to lack of knowledge. Everyone is responsible for labeling and it is important to label food items, so residents won't become ill. Inservice was conducted 6-1 to educate on labeling. During an interview 06/02/2022 at 10:10 AM Kitchen Staff B said she has been with the facility for 8 months and states the labeling and dating of unopened food items was never explained and it was failed due to lack of knowledge. She knows labeling is important for the health and safety or residents. All staff responsible for labeling and in service was conducted 6-1 on educating. During an interview 06/02/2022 at 10:10 AM Kitchen Staff C said she has been with the facility almost a year and states the labeling and dating of unopened items was never explained and it was failed due to lack of knowledge. All staff responsible for educating and in service conducted 6-1 on labeling. Labeling is important so the residents won't get sick. Dietary Services policy and procedure updated 2012. Food must be covered when stored, with a date label identifying what is in the container. Record review of the Texas Food Establishment Handbook, dated October 2016 revealed: S228.79 Labeling. (a) Food labels. (1) Food packaged in a food establishment, shall be labeled as specified in law, including 21 CFR 101, Food Labeling, 9 CFR 317, Labeling, Marking Devices, and Containers, and 9 CFR 381, Subpart N, Labeling and Containers. [24] (2) Label information shall include: (A) the common name of the food, or absent a common name, an adequately descriptive identity statement; [24] (B) if made from two or more ingredients, a list of ingredients and sub ingredients in descending order of predominance by weight, including a declaration of artificial color or flavor and chemical preservatives, if contained in the food; [24] (C) an accurate declaration of the quantity of contents; [24]

Based on interview and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorders, or a related condition for level II residents review upon a significant change in status assessment for 2 of 3 residents (Residents #20 and #34) reviewed for PASRR services. Resident #20 and #34 had diagnosis of Major Depressive Disorder without level II evaluation. This deficient practice could place residents at risk of not receiving appropriate services to meet their needs. Findings include: Review of the Face sheet for Resident #34 reflected he was admitted on [DATE] with diagnosis of: Dementia, Pain in right hand, Muscle Wasting and Atrophy, Cirrhosis of Liver, left femur (thigh bone) fracture, Alcohol dependence, Major Depressive Disorder (12/3/2020), Multiple rib fractures and difficulty walking. Review of the Care Plan for Resident #34 reflected interventions were in place for: Impaired Cognitive function, Risk of Falls with femur fracture 3/21., full code, History of UTI, Dental related to broken teeth, Inability to Understand words r/t Dementia, Antidepressant Medication, ADL self-performance deficit, Hx of weight loss. Review of the MDS assessment for Resident #34 dated 5/11/22 reflected a BIMS score of 7 indicating cognitive impairment was severe. The Resident's functional assessment reflected he required extensive assistance for all ADLs except eating. He was assessed as always incontinent of bowel and bladder. Review of Physician's orders for Resident #34 dated 6/02/22 reflected orders for: -Antidepressant Medication monitoring -Behavior Monitoring, In an interview on 6/03/22 at 9:20 AM Resident #34 stated he was unaware he took Zoloft for Depression. In an interview on 6/03/22 at 9:54 AM LVN G stated Resident #34 was receiving medication for Depression. She stated there was a period of time when he was really depressed, he would not eat or get out of bed and began losing weight. She felt he had since improved. In an interview on 6/03/22 at 10:05 AM the MDS Coordinator stated a new PASRR evaluation should be done after a new diagnosis of Mental Illness was added to a resident. The MDS Coordinator stated Resident #34 should have been re-evaluated after the diagnosis of Major Depressive Disorder was added. She stated she was the person who determined when a new PASRR was needed and she would also inform the DON. The Coordinator stated she did not know why the Resident was not re-evaluated. Review of the PASRR Level 1 assessment for Resident #20 dated 1/13/21 reflected Resident was negative for any Mental Illness or Developmental Disability. Review of Records reflected a Psych Services referral was made on 1/21/21 Review of the Face sheet for Resident #20 reflected he was admitted on [DATE] with Diagnosis of: Chronic Obstructive Pulmonary Disease, Jaw Pain, Repeated Falls, Type 2 Diabetes, Intestinal obstruction, Neoplasm (abnormal mass of tissue) of left Kidney, Dementia, Major Depressive Disorder, Dysphagia , Chronic Kidney disease. Review of the Care Plan for Resident #20 reflected interventions were in place for: Depression/Anxiety, COPD, Diabetes, Actual falls with no injury, Antidepressant Medication for diagnosis of Anxiety (Celexa), Full Code. Review of the MDS assessment for Resident #20 dated 4/24/22 reflected a BIMS score of 07 indicating severe cognitive impairment. His functional assessment reflected he was ambulating with supervision in his wheelchair and required extensive assistance for dressing, bathing and toileting. He was assessed as occasionally incontinent of bowel and bladder. Review of the Physician's orders for Resident #20 dated 6/01/22 reflected he was to be monitored for side effects of Antidepressant medication and Behaviors. He was referred to Psych Services on 1/21/21. He was prescribed Celexa 20 mg one tablet once a day for Anxiety r/t Major Depressive Disorder. In an interview on 6/03/22 at 9 :40 AM Resident #20 stated he had no problems with any of his medications. He stated he did not know how many pills he took or what they were for. In an interview on 6/03/22 at 9:50 AM LVN E stated Resident #20 was taking Celexa for Depression. She stated he had no current symptoms of Depression, but when he was first admitted he was depressed, missing his girlfriend and independence. In an interview and record review on 6/03/22 at 10:05 AM, the MDS coordinator stated Resident #20 should have had a new PASRR evaluation after his diagnosis of Major Depressive Disorder was added and it should have been positive for mental illness. Records reflected he had PASRR evaluations done on 8/20/2020 and 1/13/21. She stated the 1/13/21 evaluation should have been positive for mental illness. She stated during the PASRR II or PASRR evaluation if Dementia is determined to be a Resident's primary diagnosis they can be deemed ineligible for further services. In an interview on 6/03/22 at 10:40 AM the Administrator stated the MDS coordinator was responsible for updating and reassessing residents when a new PASRR evaluation was needed. She stated when a Resident had a new diagnosis of Mental Illness she would expect a new PASRR evaluation to be done. She stated the facility was reviewing files but had not gotten to all. In an interview on 6/03/22 at 10 :45 AM the DON stated she expected a new PASRR evaluation to be completed whenever a Resident had a new diagnosis concerning mental illness. She stated the facility would do an evaluation for a diagnosis of Major Depressive Disorder. She stated the facility had been reviewing PASRR assessments but not all reviews where completed.

Based on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice and failed to ensure necessary treatment and services to promote healing for one of one residents reviewed for pressure ulcers. (Resident # 32) The ADON/Treatment Nurse failed to ensure the tray table was cleaned prior to providing wound care to Resident #32. She failed to sanitize her hands during the procedure. She applied collagen to Resident #32's wound with a soiled glove. This failure could placed the residents at risk for developing worsening pressure ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe and pain or death. Findings Include: Record review of Resident # 32's Face Sheet dated 06/02/2022 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses include Acute Respiratory Failure with Hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) Muscle weakness, Hypertension (high blood pressure), Pressure Ulcer of right buttock, Stage 2 (ulcer has broken through the top layer of skin and part of the layer below) and Pressure Ulcer of sacral region (portion of spine between lower back and tailbone), Stage 3 (Full thickness tissue loss) Subcutaneous fat (fat just under the skin) may be visible but bone, tendon or muscle are not exposed. Record review of Resident # 32's Quarterly MDS dated [DATE] reflected he was unable to complete a BIMS interview. Record review of Resident # 32's Care Plan dated 05/05/2022 reflected he has a stage 2 pressure ulcer to right gluteal (buttock) fold related to history of ulcers, immobility. The CP indicated the resident's pressure ulcer would remain free from infection by/through the review date. Observation on 06/01/2022 at 2:55 p.m. revealed ADON/Treatment Nurse provided wound care for Resident #32. ADON/Treatment Nurse placed wound care supplies on a piece of wax paper and placed the wax paper with the wound care supplies on Resident # 32's tray table that was not cleaned. She did not clean the tray table prior to placing the waxed paper and wound care supplies on the tray table. Gauze soaked with wound cleanser in a plastic cup fell over and the gauze touched the unclean tray table. The ADON/Treatment Nurse placed it back upright on the wax paper and placed a handful of gloves on the uncleaned tray table. She removed the old dressings from Resident # 32's sacrum and right buttock then removed her gloves and did not wash her hands. She re-gloved and took gauze with wound cleanser and cleaned the wound to the right buttock . Using the same gloved hand, she picked up collagen with her gloved fingers and attempted to put it on the wound to right buttock. It did not stick. She stated the wound was resolved and she would call the Dr. to inform him. She removed the soiled gloves, did not wash her hands, re-gloved then used gauze with wound cleanser to clean the Stage 3 ulcer to his sacrum . She did not change gloves and put her gloved fingers into the collagen and placed it into the wound. Using the same gloved hand, she removed honey gauze and placed it on the sacral wound and covered it with a dry dressing. In an interview on 06/01/2022 at 3:15 p.m. the ADON/Treatment Nurse stated before wound care she should have cleaned the tray table first. She stated the gauze falling onto the table could have been contaminated and could cause infection. The contamination of the gloves could cause infection. When asked if she washed her hands between glove changes, she stated No ma'am. I should for sure have wiped the table down and washed my hands between gloving. I didn't catch that the cup with the gauze fell over onto the tray table. In an interview on 06/03/2022 at 9:50 a.m. with the DON regarding wound care stated the tray table should be cleaned prior to setting down wound care supplies to prevent cross-contamination. Hands must be washed between glove changes to prevent cross-contamination because the wound could possibly get infected. When informed the gauze and gloves used to clean the wound had touched the contaminated tray table, she stated that could cause cross contamination and a chance of infection. She stated, an applicator should be used to apply topical medication otherwise the potential is there to cause infection. She further stated, the Wound Treatment - Proficiency document used by the facility to evaluate wound care was current. In an interview on 06/03/22 at 10:01 a.m. the Administrator stated the tray table should be cleaned before placing wound care supplies per protocol. Nurses need to follow the wound care protocol otherwise it could result in infection to the resident or staff, either one. Record review of the facility undated Wound Treatment - Proficiency document reflected Clean off overbed table and create a clean workspace (wax paper) etc. Wash hands and apply clean gloves, soiled dressing removed and disposed in waste or biohazard bag. Remove gloves and dispose. Wash hands. Open dressing items onto clean field. Apply clean gloves. Clean wound with MD-ordered solution and using proper technique. Remove gloves and dispose. Wash hands. Apply clean gloves. Apply topical medication per MD order. * Use new applicator with each time to dispense.

Based on observations, interviews, record review, and facility policy and document review, the facility failed to ensure one (Resident #1) of three residents received medications as prescribed. Specifically, the facility failed to ensure Resident #1 was free from significant medication errors when the facility failed to administer [MEDICATION(S)] (a compound containing sodium valproate and [MEDICATION(S)] acid; an antiseizure medication and mood stabilizer used primarily to treat [CONDITION(S)] and [CONDITION(S)]) to the resident for five days. This failure resulted in Resident #1 having a subtherapeutic [MEDICATION(S)] level and a post-traumatic [CONDITION(S)]. Findings included: A review of the facility policy titled, Medication Administration Procedures, dated 2003, revealed, Open the unit dose package only when you are administering medication directly to the resident. Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered. After the resident has been identified, administer the medication and immediately chart dose administered on the MAR [medication administration record]. When using electronic documentation all nurses administering medication must document appropriately based on if the medication was given, held, or refused. If a dose of regularly scheduled medication is withheld or refused, when using electronic documentation, the nurse must create a progress note. 1. According to a face sheet, Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the discharge Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. A review of Resident #1's care plan, initiated on 02/24/2020, revealed the resident was at risk for [CONDITION(S)] disorder related to a history of traumatic [CONDITION(S)]. Interventions to address and/or mitigate the risk included providing [CONDITION(S)] medication as ordered. Review of physician orders, dated 11/15/2019, revealed an order directing staff to administer one 500 milligram (mg) [MEDICATION(S)] delayed release tablet two times daily. A review of the January 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a nursing progress note, dated 01/13/2020, revealed Resident #1 experienced uncontrollable jerking, requiring Resident #1 be sent to an emergency department (ED). The hospital laboratory results showed Resident #1's [MEDICATION(S)] acid level was less than 10 milligrams/liter (mg/L), with a normal range identified between 50-100 mg/L. Further review of hospital discharge records revealed Resident #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a facility investigation, dated 01/14/2020, revealed the facility completed a medication review and discovered the pharmacy made an error and did not send Resident #1's [MEDICATION(S)] ER 500 mg tablets on 01/09/2020. Further review revealed the medication error was not discovered until 01/13/2021 when Resident #1 was sent out to the ED and a medication reconciliation was completed on 01/14/2020, post-ED visit. The facility did not have Resident #1's medication from 01/09/2020 through 01/13/2020, which indicated ten ordered doses were not available. During an interview on 01/27/2022 at 9:15 AM, LVN A revealed she could not remember what the process for medication reconciliation was back in 2020. LVN A stated she did not know why she documented in January 2020 that she administered [MEDICATION(S)] ER to Resident #1 when the medication was not available in the facility to administer. LVN A stated that she was in-serviced after that incident about the five rights of medication administration (the right patient, the right drug, the right dose, the right route, and the right time). However, LVN A stated she did not remember if she received education related to proper documentation. LVN A stated that she was audited after the incident during medication pass on a few occasions, but she was not sure if there had been any medication pass audits that had been done in the facility recently.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drug and biologicals) to meet the needs of each resident when 2 of 2 Licensed Vocational Nurses (LVN) (LVN's E and G) failed to follow manufacturer's instructions and use individual lancing Devices (a device that holds a lancet firmly, and when triggered, moves the lancet linearly ahead to prick the skin in a controlled manner) for each resident while performing blood glucose for 2 of 8 residents who receive blood glucose testing (finger sticks).(Resident #'s 7 and 8) This resulted in an Immediate Jeopardy (IJ). On 6/11/12 at 1:50 PM, an IJ had been identified in the area of infection control (failure to use a lancing device for single resident use). This deficient practice placed Resident #'s 7 and 8 and 6 additional residents who receive blood glucose testing (finger sticks) at risk of contracting a blood borne infection, including Hepatitis C (a chronic viral disease that leads to swelling/inflammation of the liver). Findings include: Review of Resident #8's physician orders [REDACTED]. Blood glucose finger sticks were ordered every six hours. Observation on 6/11/12 at 11:12 AM on the West Hall revealed Licensed Vocational Nurse (LVN) E performing blood glucose monitoring. LVN E used a lancing device that is for single use only while performing the blood glucose monitoring for Resident #8. After obtaining blood and completing the monitoring, LVN E wiped the lancing device (pen) with a sani-cloth (an antibacterial wipe) and placed it in the drawer of the medication cart. Review of Resident #7's physician orders [REDACTED]. Observation on 6/11/12 at 11:37 AM on the East Hall revealed LVN G performing blood glucose monitoring. LVN G used a lancing device that is for single patient use only while performing the blood glucose monitoring for Resident #7. After obtaining blood and completing the monitoring, LVN G wiped the lancing device (pen) with a sani-cloth and placed it in the drawer of the medication cart. In an interview on 6/11/12 at 12:50 PM, LVN G stated " We do not have a lancing device for each resident. We use the same lancing device for multiple residents." In an interview on 6/11/12 at 12:51 PM, the Assistant Director of Nurses (ADON) stated that they used the lancing device for multiple residents. She asked, " Should we have one for each resident? " In an interview on 6/11/12 at 1:00 PM, the Director of Nurses (DON) stated that they had been using the lancing pens since she had been DON at this facility. Observations on 6/11/12 between 11:12 AM and 11:37 AM revealed the medication carts on East and West Halls contained a Lancet pen used on multiple residents. In an interview on 6/11/12 at approximately 3:00 PM, the DON stated her expectations are that the facility nurses follow the manufacturer's recommendations for using the lancing devices. Review of the Manufacturer's Recommendations for lancing devices reflected the following: Warning! The lancing device is for single patient use ONLY. Do not share your lancing device with others, including family members. DO NOT use on multiple patients. ALL parts of the lancing device are considered bio-hazardous and can potentially transmit infectious diseases, even after you have performed cleaning and disinfection. Review of a current facility (undated) Blood Sugar Monitoring policy reflected the following elements: Note: Insert and follow the manufacturer's instructions for the type of equipment used in the facility. Procedure 3. Follow manufacturer's directions for the equipment used in your facility. 4. Discard used lancet in container of used needles This resulted in an Immediate Jeopardy (IJ). On 6/11/12 at 1:50 PM, an IJ had been identified in the area of infection control (failure to use a lancing device for single resident use). A plan of removal of the Immediate Jeopardy (IJ) was accepted by the surveyors on 6/11/12 at approximately 4:35 PM. The plan reflected the following: All lancet pen devices have been destroyed by the ADON. Assure H Plus Safety Lancets (single use lancet) have been implemented and in-service to 7-3 and 3-11 shift by the DON. The DON in-serviced the 7-3 shifts on "Blood Sugar Monitoring" and the CMS Memorandum dated 8/27/10 addressing Point of Care Devices and Infection Control in Nursing Homes. The 11-7 shift will be in-serviced tonight at 11:00 PM by the DON. No blood sugar monitoring will be done by any licensed personnel until they have been in-serviced on the equipment change and the policy and procedure for finger sticks. Consent for HIV testing on all twelve Diabetic residents in the facility has been obtained by the Quality Assurance Nurse for the facility and the ADON. Lab tests for Comprehensive Metabolic Panel, HIV 1 and 2, and Hepatitis Panel has been ordered and will be drawn today. Twelve residents with the [DIAGNOSES REDACTED]. During observations on 6/11/12 at 4:02 PM, LVN H was observed using single use lancets for finger sticks. During observations on 6/11/12 at 4:17 PM, LVN I was observed using single use lancets for finger sticks. During observations on 6/11/12 at 4:40 PM, LVN I was observed using single use lancets for finger sticks. An in-service titled Blood Sugar Monitoring dated 6/11/12 had been initiated. Review of a facility inservice dated 6/11/12 revealed all LVN's were in-serviced about the facility's Blood Sugar Monitoring procedures including LVN E and LVN G. Interviews with random nursing staff on 6/12/12 between 8:30 AM and 10:00 AM including LVN E and LVN G revealed they were aware of the facility's Blood Sugar Monitoring procedures. The Administrator was notified on 6/12/12 at 11:06 AM that although the IJ was lowered to a severity level of potential for more than minimal harm at a scope of a pattern, that is not an IJ, because the facility Administrator and staff needed time to monitor their plan of removal for effectiveness. The ADON identified 8 residents who receive finger sticks.

Based on observation, interview and record review, the facility failed to establish an infection control program to prevent the transmission of infections and disease by blood borne pathogens for 2 of 8 residents who receive blood glucose testing (finger sticks). Licensed Vocational Nurses (LVN) (LVN's E and G) failed to follow manufacturer's instructions and use individual lancing Devices (A device that holds a lancet firmly, and when triggered, moves the lancet linearly ahead to prick the skin in a controlled manner) for each resident while performing blood glucose for 2 of 8 residents who receive blood glucose testing (finger sticks).(Resident #'s 7 and 8) This resulted in an Immediate Jeopardy (IJ). On 6/11/12 at 1:50 PM, an IJ had been identified in the area of infection control (failure to use a lancing device for single resident use). This deficient practice placed Resident #'s 7 and 8 and 6 additional residents who receive blood glucose testing (finger sticks) at risk of contracting a blood borne infection, including Hepatitis C (a chronic viral disease that leads to swelling/inflammation of the liver). Findings include: Review of Resident #8's physician orders [REDACTED]. Blood glucose finger sticks were ordered every six hours. Observation on 6/11/12 at 11:12 AM revealed Licensed Vocational Nurse (LVN) E performing blood glucose monitoring. LVN E used a lancing device that is for single use only while performing the blood glucose monitoring for Resident #8. After obtaining blood and completing the monitoring, LVN E wiped the lancing device (pen) with a sani-cloth (an antibacterial wipe) and placed it in the drawer of the medication cart. Review of Resident #7's physician orders [REDACTED]. Observation on 6/11/12 at 11:37 AM revealed LVN G performing blood glucose monitoring. LVN G used a lancing device that is for single patient use only while performing the blood glucose monitoring for Resident #7. After obtaining blood and completing the monitoring, LVN G wiped the lancing device (pen) with a sani-cloth and placed it in the drawer of the medication cart. In an interview on 6/11/12 at 12:50 PM, LVN G stated " We do not have a lancing device for each resident. We use the same lancing device for multiple residents." In an interview on 6/11/12 at 12:51 PM, the Assistant Director of Nurses (ADON) stated that they used the lancing device for multiple residents. She asked, " Should we have one for each resident? " In an interview on 6/11/12 at at 1:00 PM, the Director of Nurses (DON) stated that they had been using the lancing pens since she had been DON at this facility. Observations on 6/11/12 between 111:12 AM and 11:37 AM revealed the medication carts on East and West Halls contained a Lancet pen used on multiple residents. In an interview on 6/11/12 at approximately 3:00 PM, the Director of Nurses (DON) stated her expectations are that the facility nurses follow the manufacturer's recommendations for using the lancing devices. Review of the Manufacturer's Recommendations for lancing devices reflected the following: Warning! The lancing device is for single patient use ONLY. Do not share your lancing device with others, including family members. DO NOT use on multiple patients. ALL parts of the lancing device are considered bio-hazardous and can potentially transmit infectious diseases, even after you have performed cleaning and disinfection. Review of a current facility (undated) Blood Sugar Monitoring policy reflected the following elements: Note: Insert and follow the manufacturer's instructions for the type of equipment used in the facility. Procedure 3. Follow manufacturer's directions for the equipment used in your facility. 4. Discard used lancet in container of used needles. This resulted in an Immediate Jeopardy (IJ). On 6/11/12 at 1:50 PM, an IJ had been identified in the area of infection control (failure to use a lancing device for single resident use). A plan of removal of the Immediate Jeopardy (IJ) was accepted by the surveyors on 6/11/12 at approximately 4:35 PM. The plan reflected the following: All lancet pen devices have been destroyed by the ADON. Assure H Plus Safety Lancets (single use lancet) have been implemented and in-service to 7-3 and 3-11 shift by the DON. The DON in-serviced the 7-3 shifts on "Blood Sugar Monitoring" and the CMS Memorandum dated 8/27/10 addressing Point of Care Devices and Infection Control in Nursing Homes. The 11-7 shift will be in-serviced tonight at 11:00 PM by the DON. No blood sugar monitoring will be done by any licensed personnel until they have been in-serviced on the equipment change and the policy and procedure for finger sticks. Consent for HIV testing on all twelve Diabetic residents in the facility plus Resident #17 has been obtained by the Quality Assurance Nurse for the facility and the ADON. Lab tests for Comprehensive Metabolic Panel, HIV 1 and 2, and Hepatitis Panel has been ordered and will be drawn today. The diabetic resident who is in the hospital, his physician has been notified by the DON. The DON requested this resident be tested as well. Twelve residents with the [DIAGNOSES REDACTED]. No signs and symptoms of infection were noted. During observations on 6/11/12 at 4:02 PM, LVN H was observed using single use lancets for finger sticks. During observations on 6/11/12 at 4:17 PM, LVN I was observed using single use lancets for finger sticks. During observations on 6/11/12 at 4:40 PM, LVN I was observed using single use lancets for finger sticks. An inservice titled Blood Sugar Monitoring dated 6/11/12 had been initiated. Review of a facility inservice dated 6/11/12 revealed all LVN's were inserviced about the facility's Blood Sugar Monitoring procedures including LVN E and LVN G. . Interviews with random nursing staff on 6/12/12 between 8:30 AM and 10:00 AM revealed they were aware of the facility's Blood Sugar Monitoring procedures. The Administrator was notified on 6/12/12 at 11:06 AM that although the IJ was lowered to a severity level of potential for more than minimal harm at a scope of a pattern, that is not an IJ, because the facility Administrator and staff needed time to monitor their plan of removal for effectiveness. The ADON identified 8 residents who receive finger sticks. Non-Immediate Jeopardy information: Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection when: A. Two (2) of 14 employees, Certified Nurse Aide (CNA) C and CNA J were not screened for [DIAGNOSES REDACTED] (TB) (a highly infectious lung disease) before providing care/services in the facility according to Center for Disease Control (CDC) guidelines. B. CNA C provided incontinent care for Resident #1 without changing surfaces on the wipe or changing wipes, washing her hands, or changing gloves, wiped left buttocks with a back and forth motion, and did not clean the inner thighs or the right hip that was positioned on a wet diaper. CNA A and CNA B provided incontinent care for Resident #2 without changing surfaces on the washcloth or changing washcloths, wiped in circular motions on the lower abdomen, groin/peri area and from back to front in the rectal area. C. One (1) of 1 Licensed Vocational Nurse (LVN) A failed to wash or sanitize her hands between dirty and clean procedures during observations of wound treatment for [REDACTED]. She did not dispose of soiled equipment and gauze in a red biohazard bag or a plastic bag. D. 2 of 2 common use shower rooms located on 2 of 2 halls ( East and West Halls) had brown build-up and debris around the base tiles of the showers. Two shower chairs had brown matter under the seats. E. The beauty shop had hair and a white film on the hair washing sink and a dirty wash cloth and debris in the area behind the sink. There were brown stains on the wood under the sink and on each cabinet door. There was a build-up of hair on the wall vent cover, brown debris on top of towel container and dust on the two dryer chairs. F. Laundry personnel did not have adequate available personal protective equipment (PPE) to wear when sorting linen. G. One (1) of 1 LVN (E) failed to maintain clean procedures during wound treatment for [REDACTED]. This deficient practice placed 34 residents at risk for contracting [DIAGNOSES REDACTED]. This deficient practice placed 2 residents at risk for cross contamination and infection and an additional 12 residents that are incontinent of bowel and bladder at risk for infections. This placed 2 residents observed for wound care at risk for infection and 2 additional residents identified as receiving wound care at risk for cross contamination and infections. Findings include: A. 1. Review of CNA C's personnel record reflected a hire date of 5/20/12, Her first day to furnish services to the residents was 5/31/12. Her TB test was administered 6/1/12. 2. Review of CNA J's personnel record reflected a hire date of 5/26/12. Her first day to furnish services to the residents was 5/26/12. Her TB test was administered 5/29/12. During interview on 6/14/12 at 3:15 PM, the Director of Nurses (DON) stated that she was unaware that the TB test had to be given before the employees could provide services to the resident. She stated, "I thought it was 14 days from the hire date like our policy states." Review of a facility TB Testing for all Employees policy dated 06/02 revealed the following element: "The facility will screen all employees for [DIAGNOSES REDACTED] within two weeks of employment and annually thereafter, according to center for disease control (CDC) guidelines." B. Observation on 6/13/12 at 4:05 PM revealed Certified Nurse Aide ( CNA) C and CNA D providing incontinent care to Resident #1. They washed their hands and gloved upon entering the room. CNA C used one disposable wipe, and started cleaned down the left side of the perineal area 2 times without changing the surface of the wipe. She spread the labia and gave it a fast swipe and turned the resident to the right side. She changed gloves but did not wash or sanitize her hands. CNA C used a wipe to cleanse the left buttock in a back and forth motion, instead of wiping away from the clean area. CNA C stated, " Oh, I wiped the wrong way " . CNA C proceeded to do the same thing again. CNA C removed the wet diaper from under Resident #1 ' s right hip but did not clean the right hip or buttock. Observation of incontinent care provided for Resident #2 (not interviewable) on 6/12/12 at 1:50 PM revealed CNA A and CNA B washed their hands, donned gloves. CNA A performed incontinent care for Resident #2 while CNA B assisted with positioning . They filled two basins of water and placed them on the overhead table beside Resident # 2's bed. CNA wet a wash cloth and began to wash Resident # 2's lower abdomen and groin area in circular motions and wiped several areas without folding the washcloth. She folded the same wash cloth and washed the penis multiple times without folding the wash cloth or using a clean wash cloth. CNA B assisted with turning Resident # 2 onto his left side and CNA A washed the rectal area from back to front multiple time without folding the washcloth or obtaining a clean washcloth. CNA A placed a clean diaper next to the folded soiled diaper, turned the resident to his back and CNA B removed the soiled diaper and placed it in a plastic bag. CNA A obtained Derma cream (protective barrier) from the night stand drawer, rubbed it on Resident # 2's buttocks and fastened the clean diaper. During interview on 6/14/12 at 10:20 AM, CNA A stated she was nervous and just forgot she was supposed to wash from front to back in the perineal area and from bottom to top of the rectal area. During an interview on 6/14/12 at approximately 9:00 AM, the Director of Nurses (DON) stated they had provided in-services in March and June 2012 for the CNA's regarding the proper procedure for incontinent care and transfers. Reviews of a current (undated) facility policy titled, 'Incontinence Care' reflected the following elements: Purpose 1. To keep skin clean, dry, free of irritation and odor. 3. To prevent skin breakdown. 4. To prevent infection. General infection Control Guidelines 1. Observe (standard) universal precautions or other infection control standards as approved by appropriate facility committee. 2 Wash your hands before and after all procedures. Wear gloves when appropriate. Review of a facility in-service on June 8, 2012, attended by CNA C and D revealed the following element: " Cannot stress the importance of washing hands and doing it right-wash before you start something, in-between, and when finished. " Review of the Texas Curriculum for Nurse Aides in Long Term Care facilities (Third Edition 2000) reflected the following elements: Procedural Guideline #7 - Hand-Washing 1. Hand-washing is the single most important method in the prevention and control of infection. 2. Hand-washing should be done at the following times: a. Before applying gloves and after removing gloves. e. After contact with blood, body fluids and contaminated items. Procedural Guideline #24 - Perineal care/Incontinent Care - Female a. Wash hands. Wear gloves and follow Standard Precautions if contact with blood or body fluids is likely. 7. Gently wash, rinse and dry perineal area, wiping from " clean " urethral area toward " dirty " rectal area to avoid contaminating urethral area with germs from rectal area. b. Separate inner labia and wash down the center over the urethral area, wiping downward from front toward back and stopping at the base of labia. c. Continue to wash the rest of the perineal area, wiping form front to back, alternating from side to side and moving outward to the thighs. 10. Gently wash, rinse and dry the rectal area and buttocks, wiping form base of labia downward over rectal area until entire area is clean. Do not wipe back over urethral area. Review of a facility mandatory in-service for all staff dated June 8, 2012 reflected the following elements: Compliance Monitoring II. Observation Each new employee providing direct resident care will be observed during orientation. Specific items related to compliance with infection control policies will be included on the evaluation form. Review of CNA C's personnel filed revealed a hire date of 5/26/12. Her orientation/training was completed at that time. C. Observation on 6/12/12 at 1:30 PM revealed LVN E performing wound care for Resident #1. LVN E had placed the wound care supplies on top of the treatment cart. She then placed a sheet of wax paper on the top of the cart and moved her supplies to the wax paper. She picked up the wax paper and held the supplies against her chest and carried them into the Resident ' s room. She placed supplies on the bedside table and washed her hands, pulled the curtain and closed the screen around the end of the bed. She donned gloves and opened Resident #1 ' s diaper. She left the room to get a wound measuring guide. She removed one glove and placed it on the wax paper. She measured the wound using the guide against the wound. She then laid the measuring guide on the wax paper next to the packages of wound coverings. She donned a glove on the ungloved hand. She sprayed the wound with wound cleanser and reached into a package of 4x4 gauze and then used the gauze to clean the wound. LVN E did not change surfaces on the gauze as she wiped the wound twice. Further observation revealed LVN E wadded up the used gauze and placed it in the palm of her hand and covered the used gauze with clean gauze from the package. She sprayed the wound with wound cleaner and wiped the wound 2 times without changing the surface of the gauze. LVN retrieved a pair of scissors from her pocket with her gloved hand and cut open a package of Calcium Alginate (topical wound dressing) and a package of bordered foam dressing. LVN E did not clean the scissors before opening the packages or before placing them on the clean field of wax paper. LVN E then squeezed Hydrogel ([MEDICATION NAME] gel) on the wound and placed the bottle on the bedside table. She placed the Calcium Alginate on the wound and covered it with the bordered foam dressing. She retrieved a pen from her pocket and dated the dressing. LVN E closed the diaper on Resident #1 and covered her without removing her gloves or washing her hands. She touched the bed railing, the curtains and the screen without washing her hands. LVN E removed her gloves wadded the wax paper up with all the trash in it and picked up the wound cleanser and the package of gauze and carried the items to her cart. She threw the trash into the trash bin attached to the cart. LVN E then washed her hands in the resident's room and pushed the treatment cart containing the used container of hydrogel, wound cleanser, and the gauze to the nursing station. During an interview on 6/13/12 at 3:00 PM, the Assistant Director of Nurses (ADON) stated that LVN E should not have carried supplies against her chest. The ADON stated that she should have carried a red bag (biohazard waste bag) into the room to dispose of trash and washed her hands and changed her gloves between dirty and clean tasks. Review of a current (undated) facility policy titled "Dressing Change (Clean) reflected the following elements: General Infection control Guidelines 1. Observe (standard universal precautions or other infection control standards as approved by appropriate facility committee. 2. Wash your hands before and after all procedures. Wear gloves when appropriate. 5. Dispose of disposable equipment appropriately. 6. Dispose if infectious materials appropriately. 7. Thoroughly clean all equipment used. 1. Place plastic bag near foot of bed to receive soiled dressing. 2. Create clean field with paper towels or towelette drape. 5. Put on first pair of disposable gloves. 6. Remove soiled dressing and discard in plastic bag. 7. Dispose of gloves in plastic bag. 8. Put on second pair of disposable gloves. 9. Pour prescribed solution onto gauze to be used for cleaning 10. cleanse wound with prescribed solution. 11. Apply prescribed medication if ordered. 12 Apply dressings 13. Remove gloves and discard with all unused supplies in plastic bag. D. Observation on 6/12/12 at 9:00 AM revealed the shower rooms on the East and West halls had a brown build-up and brown matter under the seats of both shower chairs. There was brown build up around the base of the tiles in the shower stalls. E. Observation of the beauty shop on 6/12/12 at approximately 9:15 AM revealed hair and a white film on/in the hair washing sink and a dirty wash cloth and debris in the area behind the sink. There were brown stains on the covering under the sink and on each cabinet door, a build-up of hair on the wall vent cover, brown debris on top of towel container and dust and debris on the two dryer chairs. Review of the facility Infection Control Policy (dated 2004, page 2) reflected the following element: 1. Work areas, surfaces and equipment will be maintained in a clean manner and in good repair. 3. Towels will be washed between use. F. Observation on 6/12/12 at 9:30 AM revealed the laundry staff did not have plastic/vinyl aprons/gowns to use to prevent moisture from the isolation bags of laundry from getting onto their clothing. During an interview on 6/12/12 at 9:30 AM, the laundry aide stated they had gloves, masks, and gowns to use when sorting laundry. In an interview on 6/12/12 at 4:00 PM, the Administrator stated that housekeeping was responsible for cleaning the shower rooms, laundry area and beauty shop. The Administrator stated the CNA's should clean/disinfect the shower chairs after each use. The Administrator stated the laundry personnel used the yellow gowns (used when residents are isolated for infections) and she thought that was adequate, but she would get plastic/vinyl aprons/gowns for their use. Review of the facility Infection Control (dated 2004, page 12) policy reflected the following element: Protective Personnel Who Sort Laundry A. In the laundry, handwashing facilities and protective barriers (gowns, gloves, masks/face protection should be made available to personnel who sort laundry. G. During observations of LVN E performing wound care for Resident #3, LVN E did not follow clean procedure when she held clean 4 x 4's in her right hand and attempting to open a "pink bullet " (a pink plastic ampoule containing sterile water) which she was holding in her left hand. As she was twisting the top off, the pink bullet slipped and landed onto the clean 4 x4. LVN E picked the pink bullet up and removed the top and proceeded to wet the 4 x 4 with sterile water. LVN E then placed the surface of the 4 x 4 which the pink bullet had landed on directly against Resident #3's wound. An interview with the ADON on 6/15/12 at 10:42 AM revealed LVN A should have disposed of the non-clean 4 x 4 gauze dressing and started with a clean 4 x 4 when a non-clean surface had come in contact with the clean 4 x 4. The facility completed CMS 672 form reflected a census of 34 with 13 residents identified as occasionally or frequently incontinent of bladder and bowel and 3 residents with pressure sores.

Based on observation, interview and record review, the facility failed to maintain the highest practicable physical, mental, and psychosocial well-being of each resident when Licensed Vocational Nurses (LVN) (LVN's E and G) failed to follow manufacturer's instructions and use individual lancing Devices (a device that holds a lancet firmly, and when triggered, moves the lancet linearly ahead to prick the skin in a controlled manner) for each resident while performing blood glucose for 2 of 8 residents who receive blood glucose testing (finger sticks).(Resident #'s 7 and 8) This resulted in an Immediate Jeopardy (IJ). On 6/11/12 at 1:50 PM, as notified that an IJ had been identified in the area of infection control (failure to use a lancing device for single resident use). This deficient practice placed Resident #'s 7 and 8 and 6 additional residents who receive blood glucose testing (finger sticks) at risk of contracting a blood borne infection, including [MEDICAL CONDITION] (a chronic [MEDICAL CONDITION] disease that leads to swelling/inflammation of the liver). Findings include: Review of Resident #7's physician orders [REDACTED]. Observation on 6/11/12 at 11:12 AM revealed Licensed Vocational Nurse (LVN) E performing blood glucose monitoring. LVN E used a lancing device that is for single use only while performing the blood glucose monitoring for Resident #7. After obtaining blood and completing the monitoring, LVN E wiped the lancing device (pen) with a sani-cloth (an antibacterial wipe) and placed it in the drawer of the medication cart. Review of Resident #8's physician orders [REDACTED]. Blood glucose finger sticks were ordered every six hours. Observation on 6/11/12 at 11:37 AM revealed LVN G performing blood glucose monitoring. LVN G used a lancing device that is for single patient use only while performing the blood glucose monitoring for Resident #8. After obtaining blood and completing the monitoring, LVN G wiped the lancing device (pen) with a sani-cloth and placed it in the drawer of the medication cart. In an interview on 6/11/12 at 12:50 PM, LVN G stated " We do not have a lancing device for each resident. We use the same lancing device for multiple residents." In an interview on 6/11/12 at 12:51 PM, the Assistant Director of Nurses (ADON) stated that they used the lancing device for multiple residents. She asked, " Should we have one for each resident? " In an interview on 6/11/12 at 1:00 PM, the Director of Nurses (DON) stated that they had been using the lancing pens since she had been DON at this facility. In an interview on 6/11/12 at approximately 3:00 PM, the Director of Nurses (DON) stated her expectations are that the facility nurses follow the manufacturer's recommendations using the lancing devices. Review of the Manufacturer's Recommendations for lancing devices reflected the following: Warning! The lancing device is for single patient use ONLY. Do not share your lancing device with others, including family members. DO NOT use on multiple patients. ALL parts of the lancing device are considered bio-hazardous and can potentially transmit infectious diseases, even after you have performed cleaning and disinfection. Review of a current facility (undated) Blood Sugar Monitoring policy reflected the following elements: Note: Insert and follow the manufacturer's instructions for the type of equipment used in the facility. Procedure 3. Follow manufacturer's directions for the equipment used in your facility. 4. Discard used lancet in container of used needles This resulted in an Immediate jeopardy (IJ). On 6/11/12 at 1:50 PM, an IJ had been identified in the area of infection control (failure to use a lancing device for single resident use). A plan of removal of the Immediate Jeopardy (IJ) was accepted by the surveyors on 6/11/12 at approximately 4:35 PM. The plan reflected the following: All lancet pen devices have been destroyed by the ADON. Assure H Plus Safety Lancets (single use lancet) have been implemented and in-service to 7-3 and 3-11 shift by the DON. The DON in-serviced the 7-3 shifts on "Blood Sugar Monitoring" and the CMS Memorandum dated 8/27/10 addressing Point of Care Devices and Infection Control in Nursing Homes. The 11-7 shift will be in-serviced tonight at 11:00 PM by the DON. No blood sugar monitoring will be done by any licensed personnel until they have been in-serviced on the equipment change and the policy and procedure for finger sticks. Consent [MEDICAL CONDITION] on all twelve Diabetic residents in the facility has been obtained by the Quality Assurance Nurse for the facility and the ADON. Lab tests for Comprehensive Metabolic Panel,[MEDICAL CONDITION] and 2, and [MEDICAL CONDITION] Panel has been ordered and will be drawn today. Twelve residents with the [DIAGNOSES REDACTED]. During observations on 6/11/12 at 4:02 PM, LVN H was observed using single use lancets for finger sticks. During observations on 6/11/12 at 4:17 PM, LVN I was observed using single use lancets for finger sticks. During observations on 6/11/12 at 4:40 PM, LVN I was observed using single use lancets for finger sticks. An inservice titled Blood Sugar Monitoring dated 6/11/12 had been initiated. Review of a facility inservice dated 6/11/12 revealed all LVN's were inserviced about the facility's Blood Sugar Monitoring procedures including LVN E and LVN G. Interviews with random nursing staff on 6/12/12 between 8:30 AM and 10:00 AM revealed they were aware of the facility's Blood Sugar Monitoring procedures. The Administrator was notified on 6/12/12 at 11:06 AM that although the IJ was lowered to a severity level of potential for more than minimal harm at a scope of widespread, that is not an IJ, because the facility Administrator and staff needed time to monitor their plan of removal for effectiveness. The ADON identified 8 residents who receive finger sticks.