Every finding on record at Tuscany Village

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 4 (Cart #3) medication carts reviewed for storage of drugs. The facility failed to ensure that staff personal items were not stored in the medication cart per facility policy. This failure could place residents at risk of medications being cross contaminated with unknown substances in the personal items and possible medication diversion. Findings included: Observation on 8/20/2025 at 9:35 a.m. revealed MA A's personal belongings (handbag, make up bag, lunch bag) in the bottom drawer of medication cart #3. During interview on 8/20/2025 at 9:37 a.m., MA A, said she was sorry, that she always went to the locker room to put her personal items, but she completely forgot. When asked, the risk of leaving personal items in the resident's medication cart, she stated, things can spill, causing contamination and drug diversion could happen. During interview on 8/22/2025 at 3:25 p. m, the DON said staff personal items were not supposed to be in the resident's medication cart. All staff personal items were placed in the locker in the breakroom. When asked, the risk of leaving personal items in the resident's medication cart, she stated, that there could be drug diversion. Record review of facility's undated policy titled employee Handbook - Team Member Property revealed All team members personal belongings shall be stored in the employee breakroom.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that:- 1 one-Gal Ziploc bag of hot dogs was not labeled, not dated in the walk-in refrigerator- 1 one-Gal Ziploc bag of peas and carrots was not labeled, not dated in the walk-in freezerThese deficient practices could place residents who received meals from the kitchen at risk for food borne illness.Findings included: Observation on 8/19/25 at 8:41 A.M. in the walk-in refrigerator revealed one-gallon sized bag of hot dogs not labeled and not dated.Observation on 8/19/25 at 8:55 A.M. in the walk-in freezer revealed one-gallon sized bag of peas and carrots not labeled and not dated. In an interview on 8/21/25 at 2:20 P.M. with the Food Service Manager, she said there was a new Dietary Aide that was cleaning when the groceries came in and he probably put the items on the shelves without labeling them. The Food Service Manager said all dietary staff knew to label and date items in the refrigerator and freezer. She said the Cooks should go behind staff to make sure all food items were labeled and dated. The Food Service Manager said the risk to the resident when food was not labeled or dated was it could make the residents sick because she would not know how long the food had been in the kitchen. In an interview with [NAME] A on 8/21/25 at 2:25 PM, she said all kitchen staff were responsible for labeling and dating. She said the cooks were the ones that went behind kitchen staff to make sure all items were dated. [NAME] A said the groceries came in on Monday and Wednesday and she would label the food items as soon as they came in. [NAME] A said the hot dogs and peas and carrots were not labeled because it could have been a last-minute order placed by a resident and staff were rushing and forgot to label the items. [NAME] A said the risk to the resident when food items were not labeled was, they could get sick because she would not know how long the food had been in the refrigerator and freezer. In an interview with Dietary Aide A on 8/21/25 at 2:30 PM, she said the kitchen staff should label food items after each meal. She said the risk to the resident when food items were not labeled was, they could get sick because residents already had a compromised system and any food that was even a few days old could make them sick. Record review of the policy titled Food Labels in Dietary dated March 2004 read in part . all foods taken out of the original packaging must be labeled from date opened or use by date. Perishable items stored in refrigerator or freezer must also be labeled with a use by date and date opened if expiration date not stamped on food container .

Based on interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 5 residents (Resident #31) reviewed for clinical records.The facility failed to ensure Resident #31's Hydrocodone-Acetaminophen tablet 10-325 mg was documented on the MAR for Hydrocodone doses that were pulled 8/17/25 at 10:34 p.m. and 8/18/25 at 6:41 a.m. This failure could place the residents at risk of not receiving therapeutic doses of their medication and/or emotional distress. Findings included:Record review of Resident #31's face sheet dated 8/21/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Intrahepatic Bile Duct Carcinoma (cancer that is in the bile ducts in the liver). Record review revealed that Resident #31's admission MDS was currently in progress. Record review of Resident #31's Order Summary Report dated 8/21/25 revealed Hydrocodone-Acetaminophen Tablet 10-325 mg with instructions to give 1 tablet by mouth every 4 hours as needed for pain with order and start date of 8/12/25. Record review of Resident #31's Administered Transaction Log for time period of 8/1-8/21/25 revealed that Hydrocodone/APAP 10-325 mg tablet was pulled on 8/17/25 at 10:34 p.m. and 8/18/25 at 6:40 a.m. by RN A. Record review of Resident #31's August 2025 MAR revealed documented administration of Hydrocodone-Acetaminophen Tablet 10-325 mg on 8/17/25 at 6:15 p.m. with the next dose documented on 8/18/25 at 1:33 p.m. During interview on 8/19/25 at 10:39 a.m., Resident #31's family member expressed concern that they could not get a clear answer regarding when Resident #31's last Hydrocodone was administered when they returned on 8/18/25. Resident #31's family member said when they returned on 8/18/25 the board in Resident #31's room had 6:45 a.m. for the last Hydrocodone administration but was told by staff that it was 6 p.m. the night before on their records. Resident #31's family member said they were aware that Resident #31 had received pain medication around 11 p.m. to midnight prior on 8/17/25. Resident #31's family member said they were not present but that other family members who were present believed Resident #31 had received pain medication that morning of 8/18/25. Resident #31's family member said she never received a for sure answer if Resident #31 had gotten pain medication from staff. During interview on 8/21/25 at 1:46 p.m., the state surveyor explained to the DON according to the Administration Transaction Log for Resident #31 there was Hydrocodone pulled on 8/17/25 at 10:34 p.m. and 8/18/25 at 6:41 a.m. which was not documented on the MAR but Resident #31's family member had reported that pain medication was administered to Resident #31 around those times. During interview on 8/21/25 at 3:15 p.m., the DON said it looked like RN G had pulled the Hydrocodone for Resident #31 during the night of 8/17-8/18/25 per the Administration Transaction Log. During interview on 8/21/25 at 3:17 p.m., RN G said she remembered LVN R had pulled medications for Resident #31 during the night shift of 8/17-8/18/25 and she was the witness. During interview on 8/21/25 at 3:17 p.m. the DON said the automated medication dispensing system required two witnesses to pull any narcotic medications. The DON said she had not had any issues with LVN R not documenting medications. The DON said pain medication should be documented on the MAR right after being administered. The DON said the automated medication dispensing system had its own limit so it would not let staff pull the next dose before it was due for narcotics. The DON said audits were done on MARs and TARs for holes or missing documentation by the managers who were assigned different halls that they monitored. The DON said the managers audited daily and this task was worked into their daily work week. The DON said she did not have any knowledge regarding the medications being administered to Resident #31 as she was not present. During interview on 8/21/25 at 3:40 p.m., LVN R said she remembered pulling and administering medications for Resident #31 during the night of 8/17/25 around 10:30 p.m. and then before 7 a.m. the following day. LVN R said they must have two staff to pull narcotics from the automated medication dispensing system. LVN R said she pulled the medications from the automated medication dispensing system and took them straight to the room. LVN R said she had an admission that night and it was hectic. LVN R said she was not sure if she documented the Hydrocodone administration on the MAR. LVN R said she normally documented immediately on the laptop and documented the time the medication was given after going to the automated medication dispensing system. LVN R said training she received from the facility included that when they got medication they had to document, get the pain level and go back and check and see if the medication worked. LVN R said this was what she always did. LVN R said she received in-services weekly from the facility but they were not limited to medications. LVN R said an effect the resident could receive if pain medication was not documented on the MAR was that it could affect follow up with the progress of the medication. During interview on 8/21/25 at 3:50 p.m. the DON said an effect the resident could have if a pain medication was not documented on the MAR was that someone could assume that the pain medication was not administered but the automated medication dispensing system would not let them pull medication if it was not time for the next dose. The DON said that there were three managers, Unit Manager A, Unit Manager B who was off right now and Unit Manager C who worked evenings. During interview on 8/21/25 at 3:53 p.m., Unit Manager A said she tried to do MAR and TAR audits daily or every two days. Unit Manager A said the audit included making sure medications were administered and if not administered then what the reason was. Unit Manager A said she checked to see if as needed medications were given. Unit Manager A said she oversaw the #300 and #600 hallways. Unit Manager A said if she found an issue she reached out to the nurse or medication aide and let them know what happened or to fix it. Record review of the facility's policy Documentation of Medication Administration with revision date of November 2022 revealed A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR) and Administration of medication is documented immediately after it is given.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 4 residents. The facility failed to provide adequate supervision when CR#1, who was identified as a high fall risk, sustained a fall, and was discovered on the floor, nude, with a head injury, and in rigor mortis. This failure could place residents at risk of residents at risk for serious injury, serious harm, serious impairment or death (unwitnessed falls going unnoticed for extended time which could result in serious injuries, serious harm, and/or death). An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:00pm. While the IJ was removed on [DATE] at 4:36 pm, the facility remained out of compliance scoped at isolated with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness. Findings include: Record review of CR#1 face sheet dated [DATE] reflected that he was a [AGE] year-old male that was originally admitted on [DATE]. He had the diagnoses of Sepsis, muscle weakness, hyperlipidemia, pleural effusion, and acute respiratory failure with Hypoxia. Record review of CR #1's care plan dated [DATE] reflected that CR#1 is a high fall risk and that his call light should be kept in reach and that his needs should be responded to in a prompt manner. In an interview with CNA-A on [DATE] at 12:29pm she stated that on [DATE] at around 7pm following a report from the outgoing CNA, she checked on CR#1 and he was in the bed safely and his gown was on and his call light was in reach. She started to provide care for other residents and at 8:00pm she told RN-A that she was starting showers and she needed her to monitor the call lights and to help any of the residents that might need help. CNA-A said that after she was preparing to shower CR#1 when she noticed that his door was closed. She said that she went in his room and CR#1 was laying on the floor in a prone position She said that he was unresponsive and that she immediately called for help. She said that it was approximately 10:45pm when she discovered CR#1 on the floor. She said that help arrived and that when they turned CR#1 over his body was cold and stiff. In an interview with the Administrator on [DATE] at 1:15pm she said that it's her facility policy that residents are rounded on at least once every 8 hours. She said that the DON of nursing could give more information about rounding because that is her area that she supervises. In an interview with the DON on [DATE] at 1:18pm, DON stated it is the goal and expectation that every resident is rounded every two hours. She said that rounding every two hours helps ensure that residents needs are being met, risk of falls are reduced, and that incontinent care is being provided. In an interview with RN-A on [DATE] at 1:30pm RN-A stated she was called to the resident's room by the CNA-A around 10:45 on [DATE]. On getting there, the resident was found lying face down on the floor non-responsive, with his head slightly turned to the left with his raised hand obstructing part of face. The resident was found nude with a brief around his ankles. There was a small amount of blood on his head, and on his fingers, and several small drops of blood on the floor. We called for help, crash cart was brought in and the patient was put on the back board to initiate CPR, noting no rise and fall of chest. Manager on duty called 911. Laying supine on the back board, the patient's head was unable to touch the floor, and a bit stiff, and appears a postmortem rigidity have set in. On arrival, EMS did not initiate CPR, noticing the DNR wrist band from the hospital and the patient already in the rigor mortis stage. The PPD officer provided the Manager on duty with the case number 25000441 and the time of death as 11:02. In an interview with LVN-A on [DATE] at 1:50pm LVN-A said that she received a call to come to room [ROOM NUMBER] right away to assist staff. She said that when she arrived at room [ROOM NUMBER], she saw patient laying on the floor. She said that she yelled to RN-A and asked if the patient was a full code. She said that she then ran down the hall to call EMS. She said that when she returned to room [ROOM NUMBER], she saw that RN-A and CNA-A had turned the patient on his back. She said she noticed that there wasn't any rise or fall of the patient's chest and that it appeared that postmortem rigidity had set in. She said that the patient's neck was stiff and unable to touch the floor while he was laying supine. She said that EMS arrived and did not initiate CPR because rigor mortis and there was a DNR wristband on the patient's wrist. In an interview with the facilities Medical Director on [DATE] at 12:02pm he said that he did receive a message that CR#1 had passed away on [DATE]. He said that he had not had a chance to assess CR#1 before he passed away. He said in his 12yrs as being a Doctor in America that it takes several hours for rigor mortis to set in a human body. Record review of EMS report dated [DATE] reflected that EMS arrived at the facility and CR#1 was found on the floor and not breathing. His skin was cyanotic, mottled, cold lividity and swelling and bleeding was seen on the head and face of CR#1. EMS staff also noted that CR#1 had rigor mortis to hands, and back. EMS confirmed that CR#1 was DOS at 11:02pm and the scene was turned over to Pearland PD. Record review of the facility's routine resident checks policy dated ,d+[DATE] reflected that: 1. To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least once per each 8-hour shift. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting the routine check shall report to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs. 4. The Nursing Supervisor/Charge Nurse keep documentation related to these routine checks, including the time, identity of the person making checks, and any concerns of each check. (Note :CNAs may also record this information and provide it to the Nurse Supervisor/Charge Nurse.) An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:00pm. While the IJ was removed on [DATE] at 4:36 pm, the facility remained out of compliance scoped at isolated with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness. The Plan of Removal was accepted on [DATE]. Plan of Removal Immediate Action: Identified Failures by State: F689: Free of Accident Hazards/Supervision/Devices Immediate Action Taken: 1. All nursing personnel Including RN, LVN, CNA, CMA have been retrained on how to: o Access and view individual patient records. o Perform assigned safety tasks based on each resident's individualized care plan. o Properly document the completion of these tasks. Record review and interview conducted on [DATE] of in-service document dated [DATE] did reveal that facility staff had been in serviced on o Access and view individual patient records. o Perform assigned safety tasks based on each resident's individualized care plan. o Properly document the completion of these tasks. 2. This training was provided by the Director of Nursing and her designee through in-service sessions, completed on [DATE]. This was confirmed by conducting interviews with facility staff on [DATE]. 3. The resident rounding policy was reviewed and updated by the Medical Director, Director of Nursing, and Administrator on [DATE]. It now includes the creation of an individualized safety plan for each resident based on their specific needs. Interventions may include, but are not limited to: o Frequent safety checks. o Use of low beds and fall mats. o Scheduled toileting. o Participation in activities. o Contacting families to provide resources for sitter services. o Use of non-slip socks. o Discharge to home with a one-on-one care arrangement. This information was confirmed by conducting interviews of RN, LVN, CMA, and CNA on [DATE]. The staff told me that their administration had in serviced them on improved safety plan for residents. Also record review was conducted of in-service training sheets dated [DATE]. 4. These interventions will be determined by the nurse conducting the assessment. All staff have been trained on these updates before providing care, with training completed as of [DATE]. Medical Director Notification: The Medical Director was notified of the Immediate Jeopardy (IJ) by the Administrator on [DATE]. ________________________________________ Facility's Plan to Ensure Compliance: 1. A Performance Improvement Plan (PIP) has been implemented, requiring each charge nurse to conduct a daily chart review. This review ensures that nurse aides are completing individualized safety checks for residents in a timely manner. The chart review will cover 25% of the assigned caseload. Record review on [DATE] of the PIP reflected that it was implemented and signed by facility staff on [DATE] at 12:30pm. 2. The findings from these chart reviews will be documented on a PIP assignment sheet and submitted to the Director of Nursing. 3. All staff received training on this new protocol on [DATE], led by the Director of Nursing and the Administrator. This training was completed on [DATE]. Record review on [DATE] reflected that this training did occur on [DATE]. 4. The Director of Nursing, or her equivalent, will review the logs weekly to ensure compliance with safety audits and the fulfillment of each resident's safety measures. Record review on [DATE] reflected that this training/in-service did occur on [DATE]. 5. The findings of these weekly reviews will be reported during the monthly QAPI (Quality Assurance and Performance Improvement) meetings. If necessary, the QAPI team will initiate changes and retrain staff accordingly. Record review was conducted on [DATE] and it reflected that a QAPI team was in serviced on [DATE]. ________________________________________ 1:45pm-Interview with LVN-B on [DATE] LVN-B was able to tell me that she had been in serviced on fall risks, documentation of falls, fall prevention, frequent rounding, and assessments of residents. 1:53pm-Interview with CNA-B on [DATE] CNA_B said that she had been recently in serviced that staff need to frequent rounds more, meaning every two hours or as needed depending on the resident. She was able to tell me that if a resident is a fall risk, then the resident's bed should be in lowest position and falls mats may be placed next to the resident's bed. 2:00pm-Interview with CNA-C on [DATE] CNA-C told me that he had been in serviced on rounding more frequently at least every two hours or [NAME] depending on the resident. He also was able to tell me that if a resident is a fall risk their bed should be in lowest position and fall mats may also be placed next to their bed. 2:05pm-Interview with CNA-D she told me that her in-service was about rounding frequently and more depending on the residents. And that if a resident has a fall, they should not move the resident until they have been assessed. 2:22pm-Interview with LVN- C on [DATE] LVN-C said that she had been in serviced on frequent rounding, charting fall prevention, and assessment. 2:35pm-Interview with CNA-E on [DATE] CNA-E told me that her in service was about frequent rounding and at least every two hours or [NAME] depending on the condition of the resident. She was also able to tell me that a resident should not be moved until and assessment has been performed. 2:40pm-Interview with CMA-A on [DATE] CMA-A said that when she is passing out meds, she makes sure to watch to see if any residents or in distress. She said that her in-service was about frequent rounding. She also said that if a resident is on the floor, then that resident should not be moved before being assessed. 2:45pm Observations were conducted on [DATE] throughout the facility. Staff were attending to resident's needs; call lights were being answered and services were being provide to residents. 2:56pm-Interview with LVN-D on [DATE] LVN-D said she was in serviced on frequent rounding, fall risk prevent, assessments, and charting of residents falls. 3:35pm-Interview with CNA-F on [DATE] CNA-F said she was able to tell me that her in service was on rounding at least every two hours or [NAME] depending on the resident's condition and a resident should not be moved until they have been assessed. 3:50pm-Phone interview with LVN- A on [DATE] LVN-A told me that she had been in serviced via telephone. She was able to tell me about rounding and her responsibility as a nurse regarding charting. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:00pm. While the IJ was removed on [DATE] at 4:36 pm, the facility remained out of compliance scoped at isolated with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that: -Three dented cans were stored with other cans used for resident meals in the dry storage room. -Two storage bins of dry bulk items had scoops stored inside the bins. These deficient practices could place 99 residents who received meals from the kitchen at risk for food borne illness. Findings included: Observation on 7/23/24 at 8:47 am of the dry storage room revealed the following: -One 50 oz can of vegetable soup with a large dent at the top of the seam -One 50 oz can of chicken noodle soup with a small dent at the top of the seam -One 50 oz can of chicken noodle soup with a large dent at the top of the seam -One storage bin labeled flour with a plastic scoop and Styrofoam cup inside the bin. -One storage bin labeled biscuit mix with a plastic scoop inside the bin. Interview on 7/24/24 at 2:38 pm the Food Service Manager said [NAME] A had dropped a package of cans on Monday 7/22/24 when they received the groceries. [NAME] A was responsible for checking the cans for dents and staff were supposed to go behind her to double check for dented cans. She said the risk to the residents was food poisoning. The Food Service Manager said the kitchen staff knew not to store scoops and measuring cups inside the bins for dry bulk foods. She said one of the cooks forgot to take the scoop out of the flour and biscuit mix. The Food Service Manager said the measuring cups and scoops should be stored separately in a Ziploc bag to avoid cross-contamination. She said the night kitchen staff should have been checking the containers. She said the risk to residents from cross-contamination could also lead to food born illness and residents could get sick from cross-contamination. Interview on 7/24/24 at 2:53 pm, [NAME] A said she had worked at the facility for 8 years. [NAME] A said she checked for dented cans on Monday's and Wednesday's when the deliveries arrived. She said a dented can should be placed in the dry panty in its own designated area for dented cans. [NAME] A said she had dropped a package of cans on Monday, 7/22/24. She said a few cans came out of the package and she did not realize some of the cans got dented. She said the other cooks normally went behind her to double check for dented cans. She said the risk to the resident could be food poisoning. [NAME] A said scoops were not supposed to be left in the dry bulk food bins. She said if a scoop was left in the bin, the dry bulk food would need to be thrown away. She said the residents could get sick from leaving the scoop in the dry bulk food bins due to cross-contamination. Interview on 7/24/24 at 2:57 pm, [NAME] B said she had worked at the facility for 3 years. She said dented cans were supposed to be placed in pantry in the designated area for dented cans and she would inform the Food Service Manager. She said the Food Service Manager would tell them to either throw away the dented cans or return them to the vendor to receive credit. She said residents could get sick from botulism if dented cans were used. She said measuring cups and spoons were not supposed to be stored in the dry bulk food bins. She said scoops used in food bins should be stored separately in a Ziploc bag. She said the dry bulk foods could get contaminated if scoops were left inside the bins and make residents sick. Interview on 7/24/24 at 3:03 pm, Dietary Aide A said she had worked at the facility for 2 years. She said if she found a dented can, she was supposed to inform the Food Service Manager and the Food Service Manager would tell them to either throw away or return it to the vendor to receive credit. She said the risk to residents was food poisoning. Dietary Aide A said scoops were not supposed to be stored in the dry bulk food bins. She said this could cross-contaminate the food and the resident could get sick. Record review of the facility's policy titled: Dented Cans-Food Storage, not dated read in part . if any dented cans are identified whether at the time of delivery or on a shelf, must be moved to the Dented Can area when identified. These cans are then returned to vendor or thrown away . Record review of the facility's Food Storage policy not dated read in part . food storage areas shall be maintained in a clean, safe, and sanitary manner .

Based on interview and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for the facility. -The facility failed to have measures to prevent the possible growth of Legionella bacteria (a bacteria which can cause a serious type of pneumonia (lung infection) called Legionnaires' disease) and other opportunistic waterborne pathogens in the building water system. This deficient practice could place residents at risk of infection from waterborne pathogens. Findings include: Interview on 6/1/2023 at 12:41 PM with the DON, she said she was the facility's IP. The DON said the facility reviewed the IPCP monthly during the QAPI meeting, and quarterly during the QA meeting. She said the Medical Director comes to the quarterly meetings and reviews the IPCP during those meeting. The DON said she was unsure if the facility had a water management program. Interview on 6/2/2023 at 11:47 AM with the Admin, he said he had been provided documentation related to water observation plan implementation approximately nine months earlier. The Admin said he was unsure if the City monitored their water for Legionella bacterium or other waterborne illnesses. He said he planned to implement a water observation plan for the facility, but it was not done. Record review of the facility's Legionella Water Management Program policy dated July 2017 read in part .facility is committed to the prevention, detection and control of water-borne contaminants . The policy further read in part .our facility has a water management program . The policy revealed the water management program would include an IDT, a description and diagram of the water system, identification of areas which could encourage growth and spread of waterborne bacteria, identification of situations which could lead to waterborne pathogen growth, specific measures to control the introduction and/or spread of waterborne pathogens, a system to monitor control limits and the effectiveness of the control measures, and a plan relating to if the control limits were not met. The policy documented the water management program would be reviewed at least annually and when the control limits were not consistently met, a major maintenance or water system change occurred, any disease associated with the water system was discovered, and/or if any changes to laws, regulations, standards, or guidelines occurred.

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 5%, based on 2 errors out of 37 opportunities, which involved two of three residents (Resident #203 and Resident #205) and two of three staff (RN A and MA A) observed during medication administration, in that: -RN A failed to administer Amantadine (antiviral that can also be used to treat Parkinson's) to Resident #203 during the medication administration pass. -MA A failed to administer Folic Acid (Vitamin used to treat anemia) to Resident #205 during the medication administration pass because it was unavailable. These failures placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings Include: Resident #203 Record review of Resident #203's Admission Record on 6/1/23 at 12:22 p.m., revealed he was a [AGE] year-old male, residing on hall 100 and admitted to the facility on [DATE] with the following diagnoses: epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbances, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), encephalopathy (disease in which the functioning of the brain is affected by some agent or condition), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially impairment of memory and abstract thinking and often with personality changes), and Gastrostomy status (an opening into the stomach from the abdominal wall, made surgically). Record review on 6/1/23 at 9:06 a.m., Resident #203's Physician Order Summary Report dated 6/1/23 revealed an active order for: Amantadine HCI oral Solution 50 MG/ML Give 10 ml via G-Tube two times a day related .Communication Method .Prescriber Written . Order Status . Active .Order Date .05/29/2023 .Start Date .05/30/2023. Record review of Resident #203's Medication Administration Record (MAR) for 6/1/2023-6/30/2023 revealed the Amantadine HCI oral solution 50mg/5ML Give 10 ML via G-Tube two times a day was scheduled for 08:00 a.m. and 4:00 p.m. Observation of medication pass on 6/1/23 at 8:23 a.m., RN A administered the following medications to Resident #203 via G-Tube: ASA 81 mg 1 chewable Ezetimibe 10 MG 1 tab Folic Acid 1 MG 1 tab Furosemide 40 MG 1 tab Lacosamide 200 MG 1 tab Levetiracetam 100MG/ML oral solution 15 cc/ml BID Valproic Acid solution 250 mg/5ml 10cc/ml BID Vitamin B-1 100 mg 1 tab- manufacturer's dosage 1 tab Lactulose 10GM/15ml -30 cc/ml Vitamin B-6 50 MG- 1 tab Metoprolol 25 mg give 0.5 tab =12.5mg HOLD for SBP<110 OR HR <60. HELD per parameters. In an interview with RN A on 6/1/23 at 9:52 a.m., she approached surveyor on a different hall (200), in the hallway, during a different medication administration pass, and said that she had forgotten to give Resident #203 his Amantadine oral solution 50 MG/ML during the medication administration pass observation earlier. She asked surveyor to come and observe her give the medication at this time. Surveyor advised RN A that they were in the middle of conducting a different medication administration and would not be able to observe the missed medication at that time. RN A left the hallway and said she going to give Resident #203 his missed medication. Record review of Resident #203's Medication Administration Record (MAR) for 6/1/2023-6/3/2023 revealed the Amantadine HCI oral solution 50mg/5ML Give 10 ML via G-Tube two times a day was scheduled for 08:00 am and 4:00 pm and that the 08:00 am dose was initialed and signed as being administered by RN A. Resident #205 Record review of Resident #205's Admission Record revealed she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following diagnoses: sepsis (a serious condition resulting in the presence of microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock and death), depression (an illness characterized by persistent sadness and loss of interest in activities that a person may normally enjoy, accompanied by an inability to carry out daily activities), chronic obstructive pulmonary disease (condition involving constriction of the airways and difficulty or discomfort in breathing), hypertension(elevated blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review on 6/1/23 at 10:23 a.m., Resident #205's Physician Order Summary Report dated 6/1/23 revealed an active order for: Folic Acid Oral Tablet (Folic Acid) Give 0.4 mg by mouth one time a day .Communication Method .Prescriber Written .Order Status .Active .Order Date .05/11/2023 .Start Date .05/12/2023. Record review of Resident #205's Medication Administration Record (MAR) for 6/1/2023-6/30/2023 revealed the Folic Acid Oral Tablet Give 0.4 mg by mouth one time a day which was scheduled for 09:00 am. Observation during medication pass on 6/1/23 at 10:23 a.m., MA A completed medication Administration on Resident #205 that included the following medications: Tylenol 500 MG 2 tab -Resident refused- Charge Nurse notified Prednisone 10MG 1 tab PO ASA 81 MG Chewable PO 1 tab Brilinta/ticagrelor 90MG 1 tab Leflunomide 20 MG 1 tab Xeljanz XR 11 MG 1 tab Furosemide 40 mg 1 tab Gabapentin 300 mg 1 tab Isosorbide Mono 30 MG ER 1 tab, HOLD if SBP<110 Montelukast 10 MG 1 tab Potassium Chloride micro-ER 20 MG 1 tab Allopurinol 100 MG 1 Tab Carvedilol 3.125 MG 1 tab, HOLD if SBP less than 110 or HR <60 *37. Folic Acid 0.4mg 1 tab Omitted. In an interview and observation with MA A on 06/01/2023 at 10:23 a.m., Surveyor observed MA A pull an OTC bottle of Folic Acid out of the top drawer of the medication cart. She looked at the back of the bottle and then at her computer screen and returned the bottle of OTC Folic Acid to the top drawer and proceeded to Resident #205's bedside for the completion of the medication administration pass. After she had completed the pass, surveyor asked about the Folic Acid and MA A said she needed to check on it. MA A never returned to explain to surveyor what happened with Resident #205's Folic Acid 0.4 mg. Record review of Resident #205's MAR dated 6/1/2023-6/30/2023, during medication reconciliation, it was revealed that MA A documented the number (9) and initialed in the 09:00 am space allocated for the administration of Folic Acid Oral Tablet (Folic Acid) Give 0.4 mg by mouth one time a day. Further record review at that time, of chart codes revealed the following: 9=Other/See Progress Notes. Record review of Resident #205's progress notes by MA A read as follows: Folic Acid Oral Tablet Give 0.4 mg by mouth one time a day .not available, nurse notified. Record review of the facility's policy titled; Administering Medications dated revised December 2012 revealed the following: .3. Medications must be administered in accordance with the orders, including any required time frame. .4. Medications must be administered within one (1) hour of their prescribed time .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: The facility failed to maintain proper holding temperature for the following food A pan of Breakfast Beef sausage had a temperature of 122 degrees Fahrenheit A pan of Pureed Meat Enchiladas had a temperature of 68 degrees Fahrenheit A pan of Pureed Mixed Vegetables had a temperature of 70 degrees Fahrenheit. 8 Gallons of Milk in a plastic basket/container stored on the floor walk in refrigerator. This failure could place residents at risk of foodborne illness and disease. Findings included: Observation of the facility's kitchen on 4/13/22 between 9:00 am and 9:45 am with the FSD and observed Cook A took food temperature revealed the following: On the steamtable: A pan of Breakfast Beef sausage had a temperature of 122 degrees Fahrenheit A pan of Pureed Meat Enchiladas had a temperature of 68 degrees Fahrenheit A pan of Pureed Mixed Vegetables had a temperature of 70 degrees Fahrenheit. In the walk-in refrigerator: 8 gallons of Milk in a plastic basket/container stored on the floor. Interview with the Food Service Director on 4/13/22 at 9:00 AM revealed potentially/hazardous /time control for safety, cold food should be held at 41 degrees Fahrenheit or lower and hot food should be held at 135 degrees Fahrenheit or higher. She stated she was responsible for training staff on proper storage /temperature for potentially hazardous /time control for safety to prevent residents at risk of foodborne illness and disease. Interview with Cook A on 4/13/22 at 9:05 a.m. revealed she pureed the Meat Enchiladas and Mixed vegetables at 8:15 a.m. and put it in the steamtable for lunch service at 11:30 a.m. FSD instructed Cook A to discard the food. Interview with the food Service Director on 4/13/22 at 9:30 AM revealed that food should not be stored on the floor. Food should be stored 6 inches above the floor to protect food from contamination. Record review of facility's Food and Nutrition Services Policy and Procedure Manual dated revision date 07/2014, read in part, .The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained below 41 degrees Fahrenheit or above 135 degrees Fahrenheit Record review of 228 Texas Food Establishment Rules updated 2017 Food Establishment is deemed to comply with 2-102-12 read in part .All Time/temperature control for safety food that is cooked to the temperature and time required for the specific food under sub part 3-401 and cooled as specified under 3-501.14. Time/temperature control for safety food means a food that requires time/temperature for safety (TCS) to limit pathogenic microorganism growth or toxin formation. (G) Employees are properly cooking Time/Temperature control for safety food being particularly careful in cooking these foods known to cause severe foodborne illness and death, such as eggs and comminuted meats. I) Employees are properly maintaining the temperatures of Time/Temperature Control for safety foods during hot and cold holding through daily oversight of the employees routine monitoring of food temperature. Record review of 228 Texas Food Establishment updated 2017 Food Establishment is deemed to comply with 228.66 (f) Preventing food and ingredient from contamination. Food Storage: Food shall be protected from contamination by storing the food at least (6 inches) above the floor on case lot handling equipment as specified under 4-204.122.

Based on interview and record review, the facility failed to transmit a resident assessment within the required time frame for 3 of 5 (CR #'s 3, 4 and 7) discharged residents) reviewed for data encoding and transmission in that: - The Facility failed to complete and transmit a discharge MDS for CR #3 - The Facility failed to complete and transmit a discharge MDS for CR #4 - The Facility failed to complete and transmit a discharge MDS for CR #7 This failure could place discharged residents at risk of not having their assessments transmitted timely. Findings included: CR #3 Record review of CR#3's face sheet dated [DATE] revealed: a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident discharged on [DATE]. Record review of CR #3's Admission MDS dated [DATE] revealed: she had intact cognition as indicated by a BIMS score of 15 out of 15, needed extensive assistance with most ADLs (Activities of Daily Living), she was always incontinent of bowel and bladder incontinent of bowel, she received occupational therapy and physical therapy. Record review of CR #3's EMR (Electronic Medical Record) on [DATE] revealed: she had no discharge MDS on record. CR #4 Record review of CR#4's face sheet dated [DATE] revealed: a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident discharged on [DATE]. Record review of CR #4's Admission MDS dated [DATE] revealed: she had intact cognition as indicated by a BIMS score of 15 out of 15, limited assistance with most ADLs (Activities of Daily Living), she was always continent of bowel and occasionally incontinent of bladder, she received speech, occupational therapy and physical therapy. Record review of CR #4's EMR (Electronic Medical Record) on [DATE] revealed: she had no discharge MDS on record. CR#7 Record review of CR#7's face sheet dated [DATE] revealed: a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident discharged on [DATE]. Record review of CR #7's Admission MDS dated [DATE] revealed: she had intact cognition as indicated by a BIMS score of 13 out of 15, limited to extensive assistance with most ADLs (Activities of Daily Living), she was always continent of bowel and frequently incontinent of bladder, she received occupational therapy and physical therapy. Record review of CR #7's EMR (Electronic Medical Record) on [DATE] revealed: she had no discharge MDS on record. An interview on [DATE] at 11:22 am with the MDS Coordinator (Minimum Data Set Assessment) he said that CR #3, 4 and 7's Discharge MDS was not completed. He said that the MDS is a quality of measures and monitoring tool guide and is very important to use for measuring quality of care. He said the Discharge MDS should have been completed on the date of the resident's discharge. Record review of facility provided CMS's RAI Version 3.0 Manual, Chapter 5: Submission and Correction of The MDS Assessment revised ,d+[DATE] revealed:5.1 Transmitting MDS data- All Medicare and/or Medicaid-certified nursing facilities or agents of those facilities must transmit required MDS data records to CMS. 5.2 Timeliness Criteria- completion timing . For all other comprehensive MDS assessments, Annual assessment updates . The completion may be no later than 14 days from the ARD. Upon a resident's entry, discharge to community, discharge to another facility or discharge deceased , a subset of items but be completed within 7 days of the Event Date.

Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 4-13-22 at 9:00 am, with the Food Service Director revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster ½ full of garbage and the lids and doors were open. Interview on 4-13-22 at 9:45 am, with the Food Service Director she stated that the dumpster lids always must be closed to keep vermin, pests and insects out of the dumpster and from entering the facility. Record review of facility policy and procedure on Trash Dumpster not dated, revealed: Facility staff who access the dumpster will assure the enclosure doors and dumpster doors are always closed.

Based on record review and interview, the facility failed to ensure they employed a qualified social worker on a full-time basis in that: -The facility did not have a qualified social worker for 2 months. This failure could affect any residents in need of social services at risk of psycho-social decline and poor-quality of life. Findings include: Record review of the facility's Employee Files revealed there was no Social Services Employee file. Record review of the Facility Summary Report revealed the facility had a maximum capacity of 132. During an interview on 9/20/20 at 12:30 p.m., the Case Manager said she was working as the facility's case manager and she assisted the facility in discharge planning. She said she possessed a certificate as a case manager and did not have a social services degree or its equivalent. During an interview 9/20/20 at 3:35 p.m., the Administrator stated the facility had been without a social worker for 2 months. He said the facility had been diligently searching for a social worker. They had been interviewing, but had not been able to find a social worker who was a perfect fit for the facility. He said referrals for auxiliary services such as vision, dental, psychiatric, psychological, and podiatry services were completed by nursing staff. He said the MDS and care plans were completed by the MDS nurse. Record review of the undated Job Description for Social Service Worker revealed: Education - Must be registered as a certified social worker in good standing or in training to satisfactorily complete the requirements to become a certified social worker or completion of secondary education at an approved school of social work.

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, are reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 4 of 6 halls (100, 200, 300, and 400) in that: -The facility failed to report the failure of the call light system on 8/5/18 - 8/7/18. This failure affected 49 residents on the 100, 200, 300, and 400 halls at risk of neglect, decline in their health, and unnecessary pain. Intake: # 5 Findings include: Record review of the Census dated 8/7/18 revealed there were 105 residents in the facility. There were 78 residents on halls 100, 200, 300 and 400 combined. During an interview on 8/8/18 at 2:00 pm the Administrator said he was notified about the call lights on halls 100, 200, 300 and 400 going out due to a severe storm ground strike. He said they called the fire and safety company, but the fire and safety company said they did not have anyone to send out until the morning of 8/6/18. He and the DON instructed the staff to go room-to-room and do a peek in every 15 minutes, where they physically checked on the residents. He said the nursing staff was instructed to write the nurse's station phone number on the communication boards in each resident room as well. He also said a few of the residents were moved to different halls. The fire & safety company came into the facility on [DATE] and got ½ of the lights on the 100 hall and the 300-hall working. They determined they had to order parts from the manufacturer to fix the call lights on ½ of 100, 200 and 400 halls. They returned on 8/7/18 with the parts and the call light system on all of the halls was working by 10:00 am. When asked if this was an incident the Administrator should have called into the state agency he referred to THHSC Provider Letter 17-18 and read the section on reporting incidents including a non-functioning call system. Observations on 8/8/18 from 2:00 pm - 3:42 pm and on 8/13/18 from 9:30 am - 1:00 pm on all 6 halls revealed the call lights were working in resident rooms, resident room/bathrooms, in the halls, and at the nurse's station. During an interview on 8/8/18 at 2:18 pm Resident #2 said she thought the call lights were out for one day. She said the staff checked on her and wrote the nurse's station phone number on her communication board in her room. During an interview on 8/8/18 at 2:40 pm Resident #1 said she was a little worried when the call lights went out. At first, she called out nurse, nurse, but then the staff started coming around and they checked in on her. She was not sure of the amount of days the call lights were not working, because she went out to the hospital and was moved to a different room on a hall where the call lights worked when she returned. During an interview on 8/13/18 at 3:10 pm the Maintenance Director said he was called by the facility staff on Sunday night, 8/5/18. He said he arrived at 7:00 pm. He called the fire & safety company and they attempted to walk him through resetting the call light system twice. Neither time worked. They attempted to contact a service representative and were unable to send someone out until the next morning, 8/6/18. On Monday, 8/6/18 they were able to get ½ of 100 hall and all of 300 hall working. They ordered a part for the call light system and returned on Tuesday morning, 8/7/18. They were able to have the entire call light system working on all of the halls by 10:00 am on 8/7/18. Record review of the invoice from the Fire & Safety company dated 8/7/18 revealed: - Work order 89 - Inspection type - Service call. - 6253*-DIB - Jeron 4 port data isolation board, pre-cat 5 - Quantity 2 - $1512.00 each. - Labor - 8 hours at $98.00 per hour. The invoice total with tax and freight was $4219.86. Record review of the THHSC Provider Letter #17-18 dated 5/3/17 for All Nursing Facilities revealed: Abuse, neglect, exploitation, misappropriation of resident property, and other incidents that must be reported to the Texas Department of Aging and Disability Services . This letter provides guidance for reporting incidents to DADS and . adds two examples to conditions that pose a threat to resident health and safety, an outbreak of disease or illness and a non-functioning call system. Record review of the Provider Investigation Report revealed: - Date reported to HHSC - 8/8/18 at 4:00 pm. - Incident date - 8/5/18 at 5:00 pm - Incident category - Other: Call light failure. - Investigation summary - on 8/5/18, a thunderstorm with lightening strikes caused a temporary power failure which affected part of the facility's call light system. Call lights on 100, 200, 300, and 400 were reported as complete failures . On 5/6/18 (sic 8/6/18)The company did restore 200, 400 and half of 100 call lights. Call lights on 200 and half of 100 were not working on the end of 5/6/18 (sic 8/6/18). On 8/7/18 all call lights restored. Record review of the Policies and Procedures revealed: - Answering the call light, dated as revised on 5/8/08 - The purpose of this. procedure is to respond to the resident's requests and needs . General guidelines - 4. Be sure the call light is plugged in . 7. Report all defective call lights to the nurse supervisor promptly . The Census listed 49 residents on the 100, 200, 300 and 400 halls that were able to use a call light

Based on observation, interview, and record review the facility failed to maintain an Infection Control Program designed to prevent the development and transmission of disease and infection for 2 of 16 residents (Resident's #25 and #26) reviewed for infection control in that: --WCN did not perform hand hygiene while performing wound treatment on Resident #26. --CNA 1 did not perform glove change or hand hygiene during Foley catheter/ incontinent care on Resident #25. --Single resident use items were not properly labeled and stored on the 400 and 500 halls. These failures affected 2 residents and placed an additional 114 who required assistance with activities of daily living at risk of cross contamination and infection. Findings Included: Resident #26 Record review of Resident # 26's admission sheet revealed she was [AGE] years old and was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #26's Quarterly MDS assessment dated [DATE] revealed she had Short Term and Long Term Memory problems and severely impaired cognitive skills for daily decision making. She required extensive to total assistance with 1 to 2 person's assistance with Activities of Daily Living (ADLs). She had an indwelling urinary catheter and was always incontinent of bowel. Her mobility around the facility was via wheel chair. Record review of Resident #26's Care Plan revealed she was care planned for having an infected sacral pressure ulcer wound and at risk for potential pressure ulcer development initiated on 11/01/2016. Observation of wound care and treatment on Resident #26 on 09/22/2017 at 9:05 a.m. performed by WCN revealed as follows: --WCN did not perform hand hygiene after cleaning the bedside table with germicidal disinfectant wipes. He used the same gloves to get supplies for the wound treatment (Calcium Alginate, foam dressing, 4 x 4 gauze and normal saline) from his cart. --WCN failed to perform hand hygiene after cleaning Resident # 26's sacral wound, used the same dirty gloves to pat dry the wound with 4 x 4 gauze and applied dressing (Calcium Alginate and foam dressing) on the pressure ulcer. He then reapplied brief on the resident and repositioned her in bed without changing gloves and washing or sanitizing his hands. During an interview on 09/22/2017 at 1:00 p.m. WCN said that if gloves were physically soiled he would wash hands with soap and water, and that he should wash his hands when going from dirty to clean. He said that he was supposed to wash his hands after removing old dressing and after cleaning the wound before applying medication and dressing on the wound for infection control. He said that the disinfectant could be toxic and so he should have removed his gloves and washed his hands after cleaning the bedside table. He said that he gets nervous when watched. Resident #25 Record review of Resident # 25's admission sheet revealed she was [AGE] years old and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #25's Admission MDS assessment dated [DATE] revealed she had a Brief Interview of Mental Status (BIMS) score of 0 indicating she had severely impaired cognition. She required extensive to total assistance with 1 to 2 person's assistance with Activities of Daily Living (ADLs). She had an indwelling catheter and was always incontinent of bowel. Record review of Resident #25's Care Plan revealed she was care planned for being incontinent of bowel and bladder initiated on 08/17/2017 with intervention to monitor for incontinence frequently and change promptly. Observation of indwelling urinary catheter and incontinent care for Resident #25 on 09/22/2017 at 1:40 p.m. performed by CNA 1 and assisted by CNA 2 revealed the following: -- CNA 2 did not wash or sanitize her hands while assisting CNA 1 to turn resident to her sides and held her while she was performing Foley/ incontinent care. CNA 2 removed her gloves and put on clean gloves without hand hygiene. During an interview on 09/22/2017 at 2:00 p.m., CNA 2 said she knew she should have washed or sanitized her hands when she removed her gloves and before putting on clean gloves. When asked why she did not perform hand hygiene when she removed her gloves, she said she forgot her sanitizer. Observations of the 400 and 500 Halls during initial tour on 09/19/2017 beginning at 8: 40 a.m. revealed the following: --room [ROOM NUMBER] Bathroom: There were 3 wash basins on the floor of the bathroom and one kidney dish on top of the toilet bowl that were not placed in a plastic bag. Used, dirty towels were on top of the bath chair. The bathroom was shared. --room [ROOM NUMBER] Bathroom: There was a wash basin on the floor of the bathroom that was not placed in a plastic bag, nor was there any label with a name or room number on it. There was also one wash basin on the floor not placed in a plastic bag. The bathroom was shared. --room [ROOM NUMBER] Bathroom: There were 2 wash basins on the floor not placed in plastic bags. There was a used, dirty bed pad on the bathroom floor. The bathroom was shared. --room [ROOM NUMBER] Bathroom: There was a wash basin on the floor of the bathroom that was not placed in a plastic bag, nor was there any label with a name or room number on it There was also a specimen hat on the floor of the bathroom that was not placed in a plastic bag, nor was there any label with a name or room number on it. The bathroom was shared. --room [ROOM NUMBER] Bathroom: There was a urinal on the grab bar and a kidney dish on the sink that were not placed in plastic bags. --room [ROOM NUMBER] Bathroom: There was a urinal on top of the toilet bowl covered with brownish black substance all over the body. It was not placed in a plastic bag. --room [ROOM NUMBER] Bathroom: There was a urinal on the grab bar that was not placed in a plastic bag, nor was there any label with a name or room number on it. During an interview on 09/19/2017 at 2:55 p.m., the DON said that the facility policy was that wash basins, urinals and such resident use small equipment should be labeled with resident names and room numbers and bagged to prevent cross contamination and for infection control. During another interview on 09/22/2017 at 2:30 p.m., the DON provided a copy of the policy and procedure titled Resident Safety - Personal Hygiene Items and said she was not sure it addressed storage of wash basins, urinals and such resident use small equipment. On hand washing/glove changes, she said that staff know to do hand hygiene. Record review of the facility's policy and procedure titled Resident Safety - Personal Hygiene Items dated 11/13/2012 read in part as follows: the facility shall establish a safe, sanitary, and functional practice to store resident's personal hygiene items . all residents and /or responsible parties and staff shall be informed of the importance of labeling all personal items to ensure the safety of all residents. This policy did not address storage of wash basins, urinals and such resident use small equipment. Record review of the facility's undated policy and procedure titled Infection Control Guidelines for all Nursing Procedures read in part, employees must wash their hands for 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: --Before and after direct contact with residents --After removing gloves If hands are not visibly soiled, use an alcohol-based hand rub .for all the following situations: --Before and after direct contact with residents --Before donning sterile gloves --Before performing any non-surgical invasive procedure. Record review of the facility's policy and procedure on Hand washing/Hand Hygiene revised December 2007 and read in part as follows: employees must wash their hands for 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: --Before preparing or handling medications --Before moving from a contaminated body site to a clean body site during resident care --After contact with a resident's intact skin --After handling dressings, contaminated equipment, etc. --After removing gloves. The use of gloves does not replace hand washing/hand hygiene. The Facility's roster listed 26 residents residing at 400 and 500 Halls. The CMS 672 listed 116 residents who required assistance with to being dependent on staff for activities of daily living.

Based on observation, interview, and record review the facility failed to ensure that 1 of 14 residents (Resident #25) reviewed for Indwelling Urinary Catheter care and incontinent care received appropriate treatment and services to reduce the risk of urinary tract infection in that: -- CNA 1 failed to perform proper indwelling urinary catheter and incontinent care for Resident #25. This failure affected 1 resident and placed and additional 3 residents with an indwelling urinary catheter and additonal 21 other residents who were occasionally or frequently incontinent of bladder residing on 100 hall at risk for cross contamination, urinary tract infection, pain, and hospitalization . Findings included: Resident #25 Record review of Resident # 25's admission sheet revealed she was [AGE] years old and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #25's Admission MDS assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 0 indicating she had severely impaired cognition. She required extensive to total assistance with 1 to 2 person's assistance with Activities of Daily Living (ADLs). She had an indwelling catheter and was always incontinent of bowel. Her mobility around the facility was via wheelchair. Record review of Resident #25's Care Plan revealed she was care planned for having a communication problem related to [MEDICAL CONDITION] initiated on 08/22/2017, ADL self-care performance deficit related to stroke initiated on 08/17/2017, having the potential for pressure ulcer development initiated on 08/17/2017 and being incontinent of bowel and bladder initiated on 08/17/2017 with intervention to monitor for incontinence frequently and change promptly. Observation of indwelling urinary catheter and incontinent care for Resident #25 on 09/22/2017 at 1:40 p.m. performed by CNA 1 and assisted by CNA 2 revealed the following: -- CNA 1 and CNA 2 did not separate resident's legs in order to thoroughly clean the sides of the thigh and perineal area. -- CNA 1 and CNA 2 did not hold Resident # 25's catheter at the meatus while cleaning the catheter. CNA 1 wiped the catheter from insertion point outward away from the body without holding it to stabilize it in order not to pull it out. --CNA 1 and CNA 2 did not spread Resident #25's labia to clean inside the labial skin folds around the opening to the urinary meatus. During an interview on 09/22/2017 at 2:10 p.m., CNA1 was asked how she should clean the perineal area during incontinent/catheter care. She said she should clean resident side by side, clean the middle and then open the legs to clean her well. When asked why she did not separate resident's legs or open her labia when cleaning Resident #25 in order to thoroughly clean the sides of the thigh and perineal area, she said that she did not spread her legs because she would express pain. On cleaning the catheter, she said that she held the catheter while cleaning. During an interview on 09/22/2017 at 2:30 p.m., the DON when asked how staff should perform incontinent /Foley catheter care, said that they should hold the catheter to stabilize it while cleaning from inside to outside. She also said that the staff should separate the labia and the legs to clean inside and that not cleaning resident properly could lead to skin breakdown and infection. Record review of the facility policy and procedure entitled Catheter Care, Urinary revised December 2007 revealed: .Provide perineal care to the incontinent resident to prevent skin rashes and breakdown .with non-dominant hand separate the labia of the female resident .maintain the position of this hand .For the female: use a washcloth with warm water and soap to cleanse the labia .change the position of the washcloth and cleanse around the urethral meatus .use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. Record review of the facility policy and procedure entitled Perineal Care revised September 2005 read in part: .Separate labia and wash area downward from front to back .(Note: if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches.(NAME)rinse and dry the area) . Rinse perineum thoroughly .(Note: If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter) . Record review of a list provided by the DON revealed 4 residents with an indwelling urinary catheter and 21 residents who were incontinent of bladder on the 100 hall.

Based on observation, interview and record review, the facility failed to ensure 1 of 9 residents (CR #1) was free from neglect in that: -PTA A failed to ensure CR #1's legs/feet were safely positioned prior to mobilizing the wheelchair, resulting in a fracture and the need for surgery. -PTA A did not immediately report an incident that resulted in injury to CR #1 resulting in a delay in investigation and treatment. These failures affected one resident (CR #1) and placed an additional 25 residents admitted with skilled services under Medicare at risk of potential abuse or neglect, and a delay in protection, investigation, reporting, and treatment, and a diminished quality of life. Intake #: 5 Intake #: 6 Intake #: 9 Findings included: Record review of the facility Policy and Procedure with title Investigation of Abuse, Abuse Reporting to DADS no date provided revealed in part: .When an allegation of resident abuse is made, follow the outline below: 1: Assess the patient for injury and provide appropriate medical treatment, 2. If the perpetrator is a staff member, suspend the individual until the facility and/or DADS determines if the allegation is substantiated 3. Verbally report the incident to DADS the day the incident occurred ., 4. (g) Complete the Provider Investigation Report and submit to DADS with (5) days of incident. Record review of Provider Letter No. 17-18 Abuse, Neglect, Exploitation, Misappropriation of Resident Property, and Other Incidents that Must Be Reported to the Texas Department of Aging and Disability Services (DADS) (Replaces PL (Provider Letter) 14-13) 2. A NF (Nursing Facility) must report incidents of alleged neglect and all situations in it has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by neglect caused by another person to DADS A certified NF (Nursing Facility) must ensure that all alleged violations of neglect are reported to the Nursing Facility Administrator and to other officials in accordance with Texas law no later than two hours after the allegation is made, if the events that cause the allegation result in serious bodily injury. III. Procedures For The Initial Report of Incidents: NF's (Nursing Facility's) must report the following immediately, but not later than 2 hours after the allegation is made. if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the NF (Nursing Facility) Administrator and to the DADS CRS Record review of CR#1's admission sheet revealed she was an [AGE] year old female who readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's Admission MDS (Minimum Data Set) dated 5/25/17 revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating she was cognitively intact. Mobility devices were listed as walker and wheelchair with the extensive assist of one person for transfers. Locomotion on and off the unit was coded as limited assistance with one person physical assist. Record review of CR #1's care plan initiated 5/22/17 revealed: -Focus: Risk for decreased participation in ADL's and joint pain-Generalized [MEDICAL CONDITION]. Goal: Current ADL status will be maintained and increased joint pain will be relieved within one hour of intervention over next 92 days, target date: 8/2/17. Focus: the resident has an ADL self-care performance deficit-Disease Process: Muscle weakness, Limited Mobility -Interventions PT/OT evaluation and treatment per MD orders. Record review of CR #1's May and June 2017 MAR (Medication Administration Record) revealed she had a order for [MEDICATION NAME] 5-325 mg, give 1 tablet by mouth every 4 hours as needed for pain. Record review of CR #1's Progress note dated 6/2/17 revealed that at 12:44 p.m. CR #1 was administered 1 [MEDICATION NAME] tablet 5-325 mg which was documented as effective at 1:10 p.m. At 5:02 p.m. she received 1 [MEDICATION NAME] 5-325 mg. On 6/2/17 at 6:25 p.m. Record review of CR #1's Progress note dated 6/2/17 at 6:25 p.m. revealed a health status note revealed that resident (CR #1) complained of pain and soreness to the left leg and said when physical therapy took her earlier in the day her leg was caught under the wheelchair. The note went on to read that LVN D went and got PT (Physical Therapy) and the doctor was there. The doctor ordered left femur, knee, and ankle two view X-rays to rule out injury. Record review of CR #1's Progress note dated 6/2/17 at 11:43p.m. revealed CR #1's family was notified about CR #1's leg and wheelchair with physical therapy and that the doctor ordered an X-ray of the knee, femur and ankle The note was signed by LVN D. Record review of CR #1's Progress note dated 6/3/17 revealed CR #1 was administered a [MEDICATION NAME] 5-325 mg tablet at 12:00 a.m. on 6/3/17. Record review of CR #1's health status note dated 6/3/17 at 12:12 a.m. revealed off going nurse reported X-ray results of left knee, and left femur was just received. Left ankle intact. Left distal femur impression is acute distal fracture femur fracture. Call was placed to the doctor on call number, new order was given to send to hospital. Notified resident (CR #1) of happening, also called (family member). At 12:25 p.m., call for EMS transport. On 6/3/17 at 12:57 a.m. EMS here to transport. Record review of Physical Therapy Treatment Encounter Note, date of service 6/2/17, electronically signed by PTA A revealed a note: Patient (CR #1) complains of 9/10 pain in LLE hamstring area and requesting to defer gait training and standing activities for today. Manual therapy STM with Biofreeze to left hamstring and knee area in order to decrease pain level and increase activity tolerance for strengthening. A note with date of service 6/2/17, completed date 6/7/17 revealed a note: I examined the patient (CR #1) due to complained of injury with therapist. Patient (CR #1) was seen lying on the bed with speech therapist in the room. Upon questioning, patient (CR#1) related she heard a pop at the back of the thigh. Left leg was palpated for which left knee was found to be warm to touch. Patient (CR #1) verbalized pain symptoms when palpating ankle region which was normal to touch. Called LVN D through extension phone as he was not seen in the nurse station. Findings of examination was related and suggested whole leg x-ray due to the extent of patient's (CR #1) complaint for safety. Charge Nurse (LVN D) agreed and stated he will go ahead and order the x-rays. electronically signed on 6/7/17 at 1:49 p.m. by PT B. Record review of the radiology report with date of service 6/2/17, electronically signed at 10:57 p.m. revealed Ankle AP and LAT 2V (views), Left: Findings [MEDICAL CONDITION] femur seen just above the prosthesis with moderate angulation. Impression: Acute distal femur fracture. Record review on 6/15/17 of the local hospital electronic medical record revealed that on 6/3/17 CR #1 was diagnosed with [REDACTED]. On 6/4/17 arthoplasty was performed on CR #1. Observation on 6/15/17 at 1:25 p.m. of CR #1 in a local hospital revealed she was working with physical therapy. Observation at 1:45 p.m. on 6/15/17 of CR #1 in the local hospital revealed she was dressed in gown and was sitting in a recliner with legs elevated. She was receiving oxygen. During an interview on 6/13/17 at 10:24 a.m. with the Administrator he said, CR #1's family was meeting with him today (6/15/17) and that he would tell them the Surveyor was in the facility. He said he would get the DOR to speak to the surveyor about the incident, (Name of Physical Therapy Company) was the new company that the facility had a contract with for PT services. During an interview on 6/13/17 at 10:30 a.m. with the DOR she gave the identity of PTA A and said they had in-serviced staff on safe handling, safe transfers, and clinicals. She said PTA's were supervised and you had to have a license to be a PTA. She said she did not think it (the injury to the CR #1) was done on purpose. She said all of their staff were trained on reporting. She said it was unfortunate that PTA A did not report the incident timely, but she did not think it was on purpose. During an interview on 6/13/17 at 12:32 p.m. with the DOR, she said on 6/2/17 the ST documented that CR #1 reported knee pain to the nurse. She said the incident was reported to the Physical Therapist and X-rays were ordered at that time. She said she told the Physical Therapist to look at CR #1 because she was leaving the facility. During an interview on 6/13/17 at approximately 12:40 p.m. with the Administrator he said as the Abuse Coordinator he completed the investigation and because PTA A failed to report the incident found that PTA A was neglectful and then he reported immediately to DADS. When asked if he documented his account of the events that lead up to his findings, he said he would type a note up and give it to the surveyor. Record review of the note from the Administrator dated 6/13/17 and signed by the Administrator revealed it read, .At approximately 12:01 on 6/3/17 (Saturday) I received a voicemail from (Staff Member B) indicating (CR #1) had been sent to the hospital due to a fracture possibly occurring during a therapy session on 6/2/17. I advised Staff Member B I would interview therapy contractor upon my return to office on Monday so as to determine cause of hospitalization . Upon my return on 6/13 (Monday) I requested a meeting with therapy contractor to determine whether (CR #1) had received therapy and whether any incident had been reported. Although no incident had been reported, Director of Therapy (DOR) was able to confirm PT session at 12:00 on 6/2 and confirmed name of person providing therapy. At this point I requested to speak with the care giver and preceded to interview her as results did implicate a material incident did occur but she failed to report. At this point in the investigation I felt an injury had been caused by contractor (PTA-A) which contractor (PTA-A) had failed to report. Reviewing the timeline of when the incident occurred and when the facility had knowledge patient was suffering I determined the patient's injury had been neglected due to contractor's (PTA-A) failure to report. At this point it was my opinion neglect had occurred at which time I called and reported the incident. During an interview on 6/13/17 at 1:01 p.m. with the Physical Therapist, she said that on 6/2/17 the PT Director (DOR) asked her to check CR #1. She said she checked with LVN D and asked CR #1 about her pain. She said CR #1 said she heard a pop at the back of her thigh. She said she thought CR #1 said when she was being transported was when she heard it pop. She said she assessed the knee, tried to palpate and the temperature was ok but a little warm. She said she told CR #1 she would talk to LVN D. She said she called LVN D and suggested an X-ray. She said LVN D said he would order the X-ray. She added the reason she ordered the X-ray was because she felt warmth. She said CR #1 did not say what time or who was transporting her. During an interview on 6/13/17 at 1:15 p.m. with SLP, she said CR #1 told her she heard a pop while being pushed in a wheelchair. During an interview on 6/15/17 at 1:35 p.m. with the local hospital Social Worker she. said CR #1 would be discharged today. She CR #1 told her that her leg got caught in a wheelchair. During an interview on 6/15/17 at 1:46 p.m. with CR #1 at a local hospital, she said on the way back to rehab PTA A was pushing her in her wheelchair when they stopped and her foot was on the floor. She said PTA A did not check to see if her foot was on the foot rest when she started pushing the wheelchair again and it started pulling her foot back. She said her foot cracked. She said she did not have a brace or anything on her leg that day. She said what had her upset was the facility said she fell but she did not fall. She said PTA A took her on to rehab and she told PTA A she could not handle anymore. She said PTA A took her back to her room. She said when she got in bed, she started swelling. She said the evening shift came and the nurse said they had to get her out of there because her leg was swelling so bad. She said her leg was hurting immediately. She said her leg hurt all the time but this was different. She said she had a knee replacement [AGE] years ago and that made it worse. She said her knee replacement lasted [AGE] years, her hip replacement lasted [AGE] years. she said she was doing ok so far. She said after she told the staff what happened a nurse came and assessed her. She said she was upset because they did not report it. She said it took 6 hours for the X-ray. She said prior to the incident they could not do the surgery because of her heart but then they had to do a knee replacement. During a telephone interview with PTA A on 7/5/17 at approximately 3:30 p.m. she said, she had no ill intent. She said she told the nurse that CR #1 complained of pain and needed medicine but she did not correlate the pain with the leg getting caught under the wheelchair. She said she did tell them later that day about the incident but she did not think the pain was due to the incident. She said she was very remorseful. She said that was her first time working with CR #1. She acknowledged being trained on reporting abuse, neglect, and on safe transfers. Record review of the (Rehab Company Name) Rehabilitation Incident Response Form with date of incident 6/2 with a line marked through and then dated 6/3/17, initialed by PTA A revealed time of incident 12:30 p.m. Type of Incident: Level 3-Significant Injury-requires hospitalization and/or invasive medical treatment. Description of Incident: CR #1 was being wheeled in wheelchair to therapy gym by therapist with legs elevated above ground and no leg rest on the wheelchair. CR #1 suddenly dropped feet to ground without warning causing wheelchair to jerk back and both knees to bend. CR#1 was wearing left knee brace during incident. CR#1 immediately complained of pain to left hamstring area stating that her hamstring is normally 7/10 pain and is now a 9/10, and requested pain meds which were administered by nursing. CR #1 continued to be seen by therapy for sitting therapeutic exercise only as well as superficial soft tissue mobilization .Patient then stated that hamstring pain had slightly decreased. Patient left in room, at end of treatment session, sitting upright in wheelchair with call bell in reach. Signed by PTA A. Record review of the facility's Action Summary/Discharge report revealed that CR # 1 was discharged to the hospital on [DATE] at 1:02 a.m. for an acute distal femur fracture, 11 1/2 hours after the incident occured. Record review of the facility's Provider Investigation Report dated 6/5/17 and reported to DADS on 6/5/17 at 4:50 p.m. revealed: -Incident category: Patient Injury -Date of incident 6/2/17 at 12:00 p.m. -Who made the allegation: the patient (CR #1) at 5:30 p.m. Resident is not independently ambulatory, she is interviewable and has the capacity to make informed decisions. -Alleged Perpetrator: PTA A -How was the Alleged Perpetrator identified: by facility investigation. -Did investigation reveal the presence of a witness: No -Statement attached: Yes -Description of the Allegation: While being transported from patient's (CR #1) room to the therapy gym via wheelchair, contractor and patient (CR #1) stopped for water. Per resident family member, foot came off leg rest while stopped, then while accelerating away, foot was rolled over by leg rest. Injury/Adverse effect: Yes Description of injury: [MEDICAL CONDITION] femur Assessment date: 6/2/17, time 5:25 p.m. Description of Assessment: Pain and soreness to left leg. Notified Doctor who ordered X-Ray. Treatment provided: No, transfer to hospital 6/3/17 at 12:01 a.m. Investigation Summary: This incident was not reported to the charge nurse even though both the contractor and contract company who were treating the patient (CR #1) were trained to report incidents that may cause injury to a patient. Per my investigation, facility staff were not aware of incident for approximately five hours due to the contractor' s failure to report. Facility staff learned of some of the facts of incident at 5:25 when charge nurse was rounding as patient (CR #1) mentioned the incident. Although I received a voicemail from staff at 12:01 a.m. on 6/3, I was not able to discuss incident with family Responsible Party until 6/7. The testimony pertaining to this incident was noticeably different when comparing the contractor's account to that of the patient (CR #1) representatives. Per the PR, the injury occurred while the patient was on her way to the therapy gym. Per her report, the PTA was pushing the patient (CR #1) to the therapy gym, stopped for water, then when accelerating away from this brief stop, turned the chair rolling over the patient's (CR #1) ankle with the lower portion of the leg rest. In contrast to the RP's (Responsible Party) report, contractor indicated she was pushing patient (CR #1) to the gym as patient (CR #1) suddenly dropped her feet creating a jerking motion causing both knees to bend. The contractor acknowledged in her report the patient (CR #1) experienced immediate pain as she reported to a nurse patient's (CR #1s) pain but made no mention an incident had just occurred. Nurse assessed patient (CR #1) then administered pain medication. Note patient (CR # 1) did not mention incident to medication nurse. Also note this patient (CR #1) had chronic leg pain receiving [MEDICATION NAME] twice a day for previous 16 days. Based on the contractor's (PTA-A)documented training to report injuries, her failure to timely report such incident, the fact that she notified nurse that patient (CR #1) was in pain but failed to discuss incident with such nurse, and the glaring differences of her testimony, its my opinion the contractor (PTA-A) intentionally neglected to report this injury. Based on this summary, its my opinion this individual should be referred to her state board. -Investigation Findings: confirmed. -Provider Action Taken Post-Investigation-The contract company was advised to terminate the contractor (PTA-A) and disallow such contractor (PTA-A) from working in other company owned facilities. Therapy company staff were re-trained on policies associated with reporting of incidents. Facility staff will be trained on wheelchair safety. signed by the Administrator, dated 6/8/17. Record review of the Therapy Services Agreement revealed: This Agreement, made on this 15th day of November, 2016 is by and between (Rehabilitation Company Name) .and (Facility) A. Supplier provides professional therapy services through licensed individuals, to patients of health care facilities Record review of the (Rehabilitation Company Name) Statement of Policy: Patient Incident Reporting dated 8/1/16 revealed, Purpose: In addition to ensuring that rehabilitation staff follows the incident reporting procedures of both the Facility and (Rehabilitation Company Name), the Patient Incident Reporting Policy provides a mechanism to assess and improve the safety and quality services delivered to patients .Procedure: The rehabilitation staff shall first comply with the patient incident reporting policy of the facility, using the facility's form. According to the CMS 672, facility census sheet, there were 25 residents admitted to the facility for Skilled services under Medicare.

Based on observation, interview and record review, the facility failed to ensure an allegation of neglect was reported immediately to the State Agency (DADS) within 2 hours for 1 of 9 residents (CR#1) reviewed for neglect. -PTA A did not immediately report an incident that resulted in injury to CR #1 resulting in a delay in investigation, treatment, and reporting to DADS. -The facility failed to report within required timeframes to the State Survey Agency (DADS) when CR #1 sustained an injury on 6/2/17 which resulted in hospitalization and surgical procedures. The facility did not report the injury until 6/5/2017 but had knowledge that the CR #1 had an incident with injury on 6/2/17. This failure affected one resident (CR #1) and placed an additional 25 residents admitted with skilled services under Medicare at risk of potential abuse or neglect, a delay in protection, investigation, and reporting. Intake #: 5 Intake #: 6 Intake #: 9 Findings included: Record review of CR#1's admission sheet revealed she was an [AGE] year old female who readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's Admission MDS (Minimum Data Set) dated 5/25/17 revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating she was cognitively intact. Mobility devices were listed as walker and wheelchair with the extensive assist of one person for transfers. Locomotion on and off the unit was coded as limited assistance with one person physical assist. Record review of CR #1's care plan initiated 5/22/17 revealed: -Focus: Risk for decreased participation in ADL's and joint pain-Generalized [MEDICAL CONDITION]. Goal: Current ADL status will be maintained and increased joint pain will be relieved within one hour of intervention over next 92 days, target date: 8/2/17. Focus: the resident has an ADL self-care performance deficit-Disease Process: Muscle weakness, Limited Mobility -Interventions PT/OT evaluation and treatment per MD orders. Record review of CR #1's May and June 2017 MAR (Medication Administration Record) revealed she had a order for [MEDICATION NAME] 5-325 mg, give 1 tablet by mouth every 4 hours as needed for pain. Record review of CR #1's Progress note dated 6/2/17 revealed that at 12:44 p.m. CR #1 was administered 1 [MEDICATION NAME] tablet 5-325 mg which was documented as effective at 1:10 p.m. At 5:02 p.m. she received 1 [MEDICATION NAME] 5-325 mg. On 6/2/17 at 6:25 p.m. Record review of CR #1's Progress note dated 6/2/17 at 6:25 p.m. revealed a health status note revealed that resident (CR #1) complained of pain and soreness to the left leg and said when physical therapy took her earlier in the day her leg was caught under the wheelchair. The note went on to read that LVN D went and got PT (Physical Therapy) and the doctor was there. The doctor ordered left femur, knee, and ankle two view X-rays to rule out injury. Record review of CR #1's Progress note dated 6/2/17 at 11:43p.m. revealed CR #1's family was notified about CR #1's leg and wheelchair with physical therapy and that the doctor ordered an X-ray of the knee, femur and ankle The note was signed by LVN D. Record review of CR #1's Progress note dated 6/3/17 revealed CR #1 was administered a [MEDICATION NAME] 5-325 mg tablet at 12:00 a.m. on 6/3/17. Record review of CR #1's health status note dated 6/3/17 at 12:12 a.m. revealed off going nurse reported X-ray results of left knee, and left femur was just received. Left ankle intact. Left distal femur impression is acute distal fracture femur fracture. Call was placed to the doctor on call number, new order was given to send to hospital. Notified resident (CR #1) of happening, also called (family member). At 12:25 p.m., call for EMS transport. On 6/3/17 at 12:57 a.m. EMS here to transport. Record review of Physical Therapy Treatment Encounter Note, date of service 6/2/17, electronically signed by PTA A revealed a note: Patient (CR #1) complains of 9/10 pain in LLE hamstring area and requesting to defer gait training and standing activities for today. Manual therapy STM with Biofreeze to left hamstring and knee area in order to decrease pain level and increase activity tolerance for strengthening. A note with date of service 6/2/17, completed date 6/7/17 revealed a note: I examined the patient (CR #1) due to complained of injury with therapist. Patient (CR #1) was seen lying on the bed with speech therapist in the room. Upon questioning, patient (CR#1) related she heard a pop at the back of the thigh. Left leg was palpated for which left knee was found to be warm to touch. Patient (CR #1) verbalized pain symptoms when palpating ankle region which was normal to touch. Called LVN D through extension phone as he was not seen in the nurse station. Findings of examination was related and suggested whole leg x-ray due to the extent of patient's (CR #1) complaint for safety. Charge Nurse (LVN D) agreed and stated he will go ahead and order the x-rays. electronically signed on 6/7/17 at 1:49 p.m. by PT B. Record review of the radiology report with date of service 6/2/17, electronically signed at 10:57 p.m. revealed Ankle AP and LAT 2V (views), Left: Findings [MEDICAL CONDITION] femur seen just above the prosthesis with moderate angulation. Impression: Acute distal femur fracture. Record review on 6/15/17 of the local hospital electronic medical record revealed that on 6/3/17 CR #1 was diagnosed with [REDACTED]. On 6/4/17 arthoplasty was performed on CR #1. Observation on 6/15/17 at 1:25 p.m. of CR #1 in a local hospital revealed she was working with physical therapy. Observation at 1:45 p.m. on 6/15/17 of CR #1 in the local hospital revealed she was dressed in gown and was sitting in a recliner with legs elevated. She was receiving oxygen. During an interview on 6/13/17 at 10:24 a.m. with the Administrator he said, CR #1's family was meeting with him today (6/15/17) and that he would tell them the Surveyor was in the facility. He said he would get the DOR to speak to the surveyor about the incident, (Name of Physical Therapy Company) was the new company that the facility had a contract with for PT services. During an interview on 6/13/17 at 10:30 a.m. with the DOR she gave the identity of PTA A and said they had in-serviced staff on safe handling, safe transfers, and clinicals. She said PTA's were supervised and you had to have a license to be a PTA. She said she did not think it (the injury to the CR #1) was done on purpose. She said all of their staff were trained on reporting. She said it was unfortunate that PTA A did not report the incident timely, but she did not think it was on purpose. During an interview on 6/13/17 at 12:32 p.m. with the DOR, she said on 6/2/17 the ST documented that CR #1 reported knee pain to the nurse. She said the incident was reported to the Physical Therapist and X-rays were ordered at that time. She said she told the Physical Therapist to look at CR #1 because she was leaving the facility. During an interview on 6/13/17 at approximately 12:40 p.m. with the Administrator he said as the Abuse Coordinator he completed the investigation and because PTA A failed to report the incident found that PTA A was neglectful and then he reported immediately to DADS. When asked if he documented his account of the events that lead up to his findings, he said he would type a note up and give it to the surveyor. Record review of the note from the Administrator dated 6/13/17 and signed by the Administrator revealed it read, .At approximately 12:01 on 6/3/17 (Saturday) I received a voicemail from (Staff Member B) indicating (CR #1) had been sent to the hospital due to a fracture possibly occurring during a therapy session on 6/2/17. I advised Staff Member B I would interview therapy contractor upon my return to office on Monday so as to determine cause of hospitalization . Upon my return on 6/13 (Monday) I requested a meeting with therapy contractor to determine whether (CR #1) had received therapy and whether any incident had been reported. Although no incident had been reported, Director of Therapy (DOR) was able to confirm PT session at 12:00 on 6/2 and confirmed name of person providing therapy. At this point I requested to speak with the care giver and preceded to interview her as results did implicate a material incident did occur but she failed to report. At this point in the investigation I felt an injury had been caused by contractor (PTA-A) which contractor (PTA-A) had failed to report. Reviewing the timeline of when the incident occurred and when the facility had knowledge patient was suffering I determined the patient's injury had been neglected due to contractor's (PTA-A) failure to report. At this point it was my opinion neglect had occurred at which time I called and reported the incident. During an interview on 6/13/17 at 1:01 p.m. with the Physical Therapist, she said that on 6/2/17 the PT Director (DOR) asked her to check CR #1. She said she checked with LVN D and asked CR #1 about her pain. She said CR #1 said she heard a pop at the back of her thigh. She said she thought CR #1 said when she was being transported was when she heard it pop. She said she assessed the knee, tried to palpate and the temperature was ok but a little warm. She said she told CR #1 she would talk to LVN D. She said she called LVN D and suggested an X-ray. She said LVN D said he would order the X-ray. She added the reason she ordered the X-ray was because she felt warmth. She said CR #1 did not say what time or who was transporting her. During an interview on 6/13/17 at 1:15 p.m. with SLP, she said CR #1 told her she heard a pop while being pushed in a wheelchair. During an interview on 6/15/17 at 1:35 p.m. with the local hospital Social Worker she. said CR #1 would be discharged today. She CR #1 told her that her leg got caught in a wheelchair. During an interview on 6/15/17 at 1:46 p.m. with CR #1 at a local hospital, she said on the way back to rehab PTA A was pushing her in her wheelchair when they stopped and her foot was on the floor. She said PTA A did not check to see if her foot was on the foot rest when she started pushing the wheelchair again and it started pulling her foot back. She said her foot cracked. She said she did not have a brace or anything on her leg that day. She said what had her upset was the facility said she fell but she did not fall. She said PTA A took her on to rehab and she told PTA A she could not handle anymore. She said PTA A took her back to her room. She said when she got in bed, she started swelling. She said the evening shift came and the nurse said they had to get her out of there because her leg was swelling so bad. She said her leg was hurting immediately. She said her leg hurt all the time but this was different. She said she had a knee replacement [AGE] years ago and that made it worse. She said her knee replacement lasted [AGE] years, her hip replacement lasted [AGE] years. she said she was doing ok so far. She said after she told the staff what happened a nurse came and assessed her. She said she was upset because they did not report it. She said it took 6 hours for the X-ray. She said prior to the incident they could not do the surgery because of her heart but then they had to do a knee replacement. During a telephone interview with PTA A on 7/5/17 at approximately 3:30 p.m. she said, she had no ill intent. She said she told the nurse that CR #1 complained of pain and needed medicine but she did not correlate the pain with the leg getting caught under the wheelchair. She said she did tell them later that day about the incident but she did not think the pain was due to the incident. She said she was very remorseful. She said that was her first time working with CR #1. She acknowledged being trained on reporting abuse, neglect, and on safe transfers. Record review of the (Rehab Company Name) Rehabilitation Incident Response Form with date of incident 6/2 with a line marked through and then dated 6/3/17, initialed by PTA A revealed time of incident 12:30 p.m. Type of Incident: Level 3-Significant Injury-requires hospitalization and/or invasive medical treatment. Description of Incident: CR #1 was being wheeled in wheelchair to therapy gym by therapist with legs elevated above ground and no leg rest on the wheelchair. CR #1 suddenly dropped feet to ground without warning causing wheelchair to jerk back and both knees to bend. CR#1 was wearing left knee brace during incident. CR#1 immediately complained of pain to left hamstring area stating that her hamstring is normally 7/10 pain and is now a 9/10, and requested pain meds which were administered by nursing. CR #1 continued to be seen by therapy for sitting therapeutic exercise only as well as superficial soft tissue mobilization .Patient then stated that hamstring pain had slightly decreased. Patient left in room, at end of treatment session, sitting upright in wheelchair with call bell in reach. Signed by PTA A. Record review of the facility's Action Summary/Discharge report revealed that CR # 1 was discharged to the hospital on [DATE] at 1:02 a.m. for an acute distal femur fracture, 11 1/2 hours after the incident occured. Record review of the facility's Provider Investigation Report dated 6/5/17 and reported to DADS on 6/5/17 at 4:50 p.m. revealed: -Incident category: Patient Injury -Date of incident 6/2/17 at 12:00 p.m. -Who made the allegation: the patient (CR #1) at 5:30 p.m. Resident is not independently ambulatory, she is interviewable and has the capacity to make informed decisions. -Alleged Perpetrator: PTA A -How was the Alleged Perpetrator identified: by facility investigation. -Did investigation reveal the presence of a witness: No -Statement attached: Yes -Description of the Allegation: While being transported from patient's (CR #1) room to the therapy gym via wheelchair, contractor and patient (CR #1) stopped for water. Per resident family member, foot came off leg rest while stopped, then while accelerating away, foot was rolled over by leg rest. Injury/Adverse effect: Yes Description of injury: [MEDICAL CONDITION] femur Assessment date: 6/2/17, time 5:25 p.m. Description of Assessment: Pain and soreness to left leg. Notified Doctor who ordered X-Ray. Treatment provided: No, transfer to hospital 6/3/17 at 12:01 a.m. Investigation Summary: This incident was not reported to the charge nurse even though both the contractor and contract company who were treating the patient (CR #1) were trained to report incidents that may cause injury to a patient. Per my investigation, facility staff were not aware of incident for approximately five hours due to the contractor' s failure to report. Facility staff learned of some of the facts of incident at 5:25 when charge nurse was rounding as patient (CR #1) mentioned the incident. Although I received a voicemail from staff at 12:01 a.m. on 6/3, I was not able to discuss incident with family Responsible Party until 6/7. The testimony pertaining to this incident was noticeably different when comparing the contractor's account to that of the patient (CR #1) representatives. Per the PR, the injury occurred while the patient was on her way to the therapy gym. Per her report, the PTA was pushing the patient (CR #1) to the therapy gym, stopped for water, then when accelerating away from this brief stop, turned the chair rolling over the patient's (CR #1) ankle with the lower portion of the leg rest. In contrast to the RP's (Responsible Party) report, contractor indicated she was pushing patient (CR #1) to the gym as patient (CR #1) suddenly dropped her feet creating a jerking motion causing both knees to bend. The contractor acknowledged in her report the patient (CR #1) experienced immediate pain as she reported to a nurse patient's (CR #1s) pain but made no mention an incident had just occurred. Nurse assessed patient (CR #1) then administered pain medication. Note patient (CR # 1) did not mention incident to medication nurse. Also note this patient (CR #1) had chronic leg pain receiving [MEDICATION NAME] twice a day for previous 16 days. Based on the contractor's (PTA-A)documented training to report injuries, her failure to timely report such incident, the fact that she notified nurse that patient (CR #1) was in pain but failed to discuss incident with such nurse, and the glaring differences of her testimony, its my opinion the contractor (PTA-A) intentionally neglected to report this injury. Based on this summary, its my opinion this individual should be referred to her state board. -Investigation Findings: confirmed. -Provider Action Taken Post-Investigation-The contract company was advised to terminate the contractor (PTA-A) and disallow such contractor (PTA-A) from working in other company owned facilities. Therapy company staff were re-trained on policies associated with reporting of incidents. Facility staff will be trained on wheelchair safety. signed by the Administrator, dated 6/8/17. Record review of the Therapy Services Agreement revealed: This Agreement, made on this 15th day of November, 2016 is by and between (Rehabilitation Company Name) .and (Facility) A. Supplier provides professional therapy services through licensed individuals, to patients of health care facilities Record review of the (Rehabilitation Company Name) Statement of Policy: Patient Incident Reporting dated 8/1/16 revealed, Purpose: In addition to ensuring that rehabilitation staff follows the incident reporting procedures of both the Facility and (Rehabilitation Company Name), the Patient Incident Reporting Policy provides a mechanism to assess and improve the safety and quality services delivered to patients .Procedure: The rehabilitation staff shall first comply with the patient incident reporting policy of the facility, using the facility's form. Record review of the facility Policy and Procedure with title Investigation of Abuse, Abuse Reporting to DADS no date provided revealed in part: .When an allegation of resident abuse is made, follow the outline below: 1: Assess the patient for injury and provide appropriate medical treatment, 2. If the perpetrator is a staff member, suspend the individual until the facility and/or DADS determines if the allegation is substantiated 3. Verbally report the incident to DADS the day the incident occurred ., 4. (g) Complete the Provider Investigation Report and submit to DADS with (5) days of incident. Record review of Provider Letter No. 17-18 Abuse, Neglect, Exploitation, Misappropriation of Resident Property, and Other Incidents that Must Be Reported to the Texas Department of Aging and Disability Services (DADS) (Replaces PL (Provider Letter) 14-13) 2. A NF (Nursing Facility) must report incidents of alleged neglect and all situations in it has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by neglect caused by another person to DADS A certified NF (Nursing Facility) must ensure that all alleged violations of neglect are reported to the Nursing Facility Administrator and to other officials in accordance with Texas law no later than two hours after the allegation is made, if the events that cause the allegation result in serious bodily injury. III. Procedures For The Initial Report of Incidents: NF's (Nursing Facility's) must report the following immediately, but not later than 2 hours after the allegation is made. if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the NF (Nursing Facility) Administrator and to the DADS CRS According to the CMS 672, facility census sheet, there were 25 residents admitted to the facility for Skilled services under Medicare.

Based on observations, interviews and record reviews, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 of 10 (Resident #23) residents reviewed for pharmacy services in that: ---Resident #23's bottle of Keppra solution was labeled to administer the medication by mouth but the physician's orders [REDACTED]. This failure affected 1 resident and could place 100 other residents at risk for adverse medication consequences including decline in health and worsening medical condition in the event of medications being labeled incorrectly. Findings Include: Record review of Resident #23's admission record revealed she was [AGE] years old and was admitted to the facility on 10/ 21/2013. Her [DIAGNOSES REDACTED]. Observation of medication pass for Resident #23 via gastrostomy tube on 10/06/15 at 10:20 a.m. revealed she received her medications including the Keppra solution via her gastrostomy tube due difficulty in swallowing. Observation at that time of the medication bottle showed the pharmacy label on the bottle read to administer the medication by mouth. During an interview on 10/06/15 at 1:30 p.m. with RN 1 she said that she administered the medication via GT to Resident #23 as ordered by her physician. She said Resident #23 had difficulty swallowing. She checked the medication label, acknowledged that it said to give the medication by mouth and said, . basically the label should be changed. During an interview on 10/07/15 at 3:15 p.m. the DON said that pharmacy already placed a change in order sticker on the bottle. Record review of the facility's policy and procedure titled Labeling of Medication Containers revised April 2007 read in part, .medication labels must be legible at all times . labels for individual drug containers shall include all necessary information such as - direction for use. The facility roster listed a census of 101 residents.

Based on observation, interviews and record review, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for 4 of 10 residents reviewed for infection control (Residents #4, #10, #23 and #24) in that: --RN 1 did not wash or sanitize her hands before applying gloves and after glove change at various times during medication administration via Gastrostomy tube (GT) for Resident #23. She also allowed the tip of the GT to touch Resident #23's hand and gown after disconnecting the tubing and placed the uncovered GT on the Resident's gown and bed linen. --LVN B did not clean the Glucometer before using it to check Resident #24's blood sugar. --LVN A prepared and crushed Resident # 10's medication, placed the medication cups on the sink counter close to the faucet while washing and drying her hands. The water splashed the medications. --MA 2 prepared Resident # 4's medications, placed the medication cups on the sink counter close to the faucet while washing and drying her hands. The water splashed the medications. --Single resident use items were not properly labeled and stored on the 300 hall. These failures affected 4 residents and placed 64 other residents residing on Halls 100, 200, and 300 at risk for infections due to cross contamination. Findings include: Resident #23 Record review of Resident #23's admission record revealed she was [AGE] years old and was admitted to the facility on 10/ 21/2013. Her [DIAGNOSES REDACTED]. Observation of medication pass for Resident #23 via GT on 10/06/15 at 10:20 a.m. revealed the following: RN 1 did not wash her hands after removing her gloves. She then proceeded to take medications and other supplies from the cart; RN 1 did not wash or sanitize her hands before applying gloves to open a [MEDICATION NAME] capsule. After disconnecting the GT feeding solution from Resident #23's gastrostomy tube, she held the tubing in her left hand while using the right hand to move the resident's gown and linen away from the gastrostomy site and in the process let the tip of the tubing touch the resident's hand and gown. She then placed the uncovered GT on the Resident's gown and bed linen; and After checking GT placement and residual, RN 1 with her gloved hands moved Resident #23's gown and linen away from the GT site to create a work area and using the same gloves picked up the syringe and started administering medication to Resident # 23. During an interview on 10/06/15 at 1:30 p.m. RN 1 said she should have washed her hands after removing gloves before touching or administering medications to Resident #23. She acknowledged that she should have covered the tip of the tubing and placed it on the infusion pole and that she ought to have cleared the GT site and placed a clean towel or chux pad to create a working environment in order to avoid placing the tubing on the resident's gown and linen. When asked the risk of not washing her hands appropriately she said that it could lead to infection. Resident #24 Record review of Resident #24's admission record revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Observations of medication pass for Resident #24 on 10/06/15 at 11:17 a.m. and 11:30 a.m. respectively revealed LVN B did not clean the Glucometer before use to check blood sugar on Resident #24. During an interview on 10/06/15 at 11:40 a.m. LVN B said she was supposed to clean the glucometer but that she cleaned it when she last used it. During an interview on 10/7/16 at 3:15 p.m. with the DON, she was asked for the policy and procedure for cleaning glucometers. She did not provide the policy prior to exit on 10/7/16. Resident #4 Record review of Resident #4's clinical record revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Observations of medication pass on 10/06/15 at 4:35 p.m. revealed MA 2 prepared Resident # 4's medications, placed the medication cups on the sink counter close to the faucet then washed and dried her hands. The water splashed on the medications. During an interview on 10/06/15 at 4:50 a.m. MA 2 said she should have kept the medication and water cups on the resident's bedside table and acknowledged the possibility that dirty water from her hands could have splashed into the cups. She further said that could lead to infection. Resident #10 Record review of Resident #10's clinical record revealed she was [AGE] years old and was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Observations of medication pass on 10/06/15 at 8:45 a.m. revealed LVN A prepared and crushed Resident # 10's medications, put them in a cup, poured water in one cup and took the cups to Resident # 10's room. LVN A placed the medication cups and the water on the sink counter close to the faucet then washed and dried her hands. The water splashed the medications. Observations during initial tour rounds on 10/5/16 at 10:15 a.m. with LVN D revealed some single resident use items were not properly labeled and stored on the 300 hall as follows: The toilet room in room [ROOM NUMBER] had 2 urinals placed on the grab rails and 1 bed pan on the floor. None of the items were in plastic bags or labeled with a name or room number. The toilet was shared by two residents in the room. The toilet in room [ROOM NUMBER] had 1 bed pan on the floor. The item was not in a plastic bag or labeled with name or room number. In the toilet in room [ROOM NUMBER] there was one graduated measuring cup on top of the toilet tank. The item was not in a plastic bag or labeled with name or room number. The toilet was shared by two residents in the room. The toilet in room [ROOM NUMBER] had one graduated measuring cup in the toilet without it being labeled with name or room number. Interview on 10/05/16 during initial tour rounds from 9:05 a.m. to 10:50 a.m. with LVN D when asked what the facility policy and procedure was on the use and storage of urinals and wash hand basins in single and multi-use bathrooms, she said the items must be labeled and bagged at all times. When asked the risk of not labeling the items and not placing them in bags, she said, . cross contamination. During an interview on 10/07/16 at 3:15 p.m. the DON said the items should be labeled and bagged at all times. When asked the risk of not labeling the items and not placing them in bags, she said that it could lead to cross contamination and infection. She said that staff should wash or sanitize their hands after removing gloves and before putting on clean gloves saying that it could lead to cross contamination if they did not. Record review of the facility's policy and procedure on Hand Washing/Hand Hygiene revised December 2007 read in part .employees must wash their hands under the following conditions . after removing gloves .before donning sterile gloves . before preparing or handling medications. Record review of the facility's policy and procedure on Personal care revised April 2007 read in part, . Store the bedpan or urinal per facility policy . do not leave it in the bathroom or on the floor .; remove gloves . discard into designated container . wash and dry your hands thoroughly . clean wash basin and return to designated storage area. The facility roster listed a census of 68 residents residing on Halls 100, 200 and 300.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit neglect for 1 of 3 residents (CR #1) who received heat therapy during physical therapy that was not adequately supervised. --Heat therapy was administered to CR#1 and she was not supervised which resulted in a second degree burn. This failure affected 1 former resident and placed 2 current residents who received heat therapy at risk of injury. Intake # 7 Findings Include: Record review of CR#1's admission sheet revealed she was a [AGE] year old who was admitted on [DATE]. Her [DIAGNOSES REDACTED]. She was discharged to home on 12/16/2015. Record review of CR#1's admission Minimum Data Set assessment dated [DATE] revealed she was assessed as a 13 out of 15 on her brief interview for mental status indicating she was cognitively intact. She required the extensive assistance of 1 staff for most activities of daily living. She required supervision and setup help for eating. She had no range of motion limitations. Record review of the facility grievances revealed a statement dated 12/1/15 which read, .I was answering the call light for (CR#1). She asked to be put on the bedpan. While rolling her over, the corner of her right shoulder blouse had fallen down and I noticed a scab like area on her shoulder. I asked her 'what happened.''' She stated 'therapy did that with a hot pack. I told them that it was hot and the therapist stated 'it's fine.'(CR#1) asked me, 'is it bad?' I told her 'it looks bad, like a burn.' I reported the skin issue to the charge nurse and documented it in my POC.' Record review of CR#1's Wound Care Nurse assessment dated [DATE] revealed documentation of a burn related to hot pack in occupational therapy acquired during the stay. The wound measured 8.8 centimeters by 3.7 centimeters on the right shoulder. During an interview on 12/29/15 at 11:28 p.m. with the DON, she said on 12/1/15 a nurse's aide was rolling CR#1 and saw a reddened area on her shoulder. She said the Administrator who is unavailable as he is traveling out of the country conducted the incident investigation She said COTA A administered the treatment. Record review of the therapy agency, Agency C's, incident reporting form dated 12/1/15 at approximately 10:00 a.m. revealed, .Employee's Account of the Incident: .Pt (patient) c/o (complains of) pain/soreness in R (right) shoulder /p (after) PT (Physical Therapy) tx (treatment). Therapist applied 7 layers of towels /c (with) moist hot pack cover x (times) 15 min (minutes). Pt cognitively in tact & able to verbalize pain/being uncofortable (sic) & has full BUE (bilateral upper extremity) ROM (range of motion) to remove hot pack, however, pt never expressed pain to therapist. Pt's skin on R shoulder was pink & had dead skin peeling /c Biofreeze application. Therapy session completed w/out (without) pt verbalizing any pain/incident. Therapist notified of incident following day. The document was signed by COTA A. During an interview on 12/29/15 at 12:44 p.m. with the Director of Rehabilitation, she said the therapy agency's incident reporting form does not have CR#1's name on it but it is the report for CR#1. Record review of the facility's incident report dated 12/2/15 revealed documentation of CR#1 being burned on her right shoulder, .hot pack from therapy left on shoulder too long and burn her. Record review of physician's orders [REDACTED]. Record review of CR#1's Occupational Therapy Daily Notes by COTA A dated 12/1/15 revealed, .Pt (patient) requested moist heat to R (right) shoulder to decrease soreness (after PT tx) (treatment). BioFreeze rub followed & therapist noticed skin peeling on shoulder joint. Notified pt that heat can no longer be applied due to sensitive/fragile skin. Pt with skin tears (& bleeding) on L (left) forearm. Notified charge nurse to apply band aides. Her note by COTA A dated 12/2/15 revealed, .Therapist went into pt's (patient's) room with DOR (Director of Rehabilitation) present, to apologize for having not checked pt's skin prior to moist heat aplication (sic) layered with big & hand towel & for any soreness/pain pt is in. Pt stated being aware of having sensitive & fragile skin that tears easing stating, 'My skin isn't how it used to be when I was younger. My skin is very fragile now.' .Therapist apologized to pt again. Pt stated, 'Don't worry about it, this kind of stuff happens to all of us.' During a telephone interview on 12/30/15 at 10:07 a.m. with CR#1, she said the day she received the heat treatment staff used a moist hot pad on her shoulder and left. She said she moved it off of her shoulder since it was hot. She said she did not feel it was her place to leave it off. She said the staff did not set up a timer to monitor the heat treatment duration. She said when the staff came back and removed the heat pack she told her her skin looked .really red, and then the staff member put Biofreeze on her shoulder. She said the same day (12-1-15) it turned into a large blister. She said at least one towel was used on CR #1's skin. She said the heat was left on for 20 minutes or longer. She said after the Biofreeze was applied CR #1 was taken back to her room. CR #1 said she called the nurse and showed the nurse the burn to her shoulder. She said the nurse called the doctor. During a telephone interview on 12/30/15 at 11:23 a.m. with Physician B, he said CR#1 sustained a 2nd degree burn. He said he saw CR#1 the day it occurred. He said CR#1 told him the burn happened during occupational therapy. He said she was receiving a heat treatment due to pain. He said older people are sensitive and if they do not pay attention it can, even at normal heat, do this. He said the shape of the burn was that of a heat pad. He said he did not believe the burn was greater than a 2nd degree. He said leaving heat on CR #1's shoulder for a short period of time could have resulted in a burn. He said for elderly residents with fragile skin the heating time should be shorter and the pack wrapped. He said heat treatments should be monitored every 5 to 10 minutes. During an interview on 12/30/15 at 11:47 a.m. with COTA A, she said she had been a certified occupational therapy assistant for 7 years. She was shown Agency C's incident reporting form and she said it was the report on CR#1. She said she was not sure why the patient identifying information was left blank. She said she did give a heat treatment to CR#1's right shoulder on 12/1/15. She said the process is to check the skin before. She said the resident was wearing a loose fitting gown. She said you put the hot pack into a protective covering and towels between the skin and the hot pack. She said she had 10 layers of towels between CR#1's skin and the covered heat pack. She said she documents treatments in the daily notes. She said CR#1 had dry skin all over her body and fragile skin but her shoulder .looked fine. She said the treatment was started at 10:15 a.m. She said she timed the treatment using the clock over CR #1's room door. She said she checked on CR#1 throughout the treatment and was in the room. She said, You know, we rely on the patients to let us know if it's getting too hot. She said, I was within her area during the treatment, not further than 6 feet from her. She said the heat pack was left on for 15 minutes before doing skin checks on CR #1. She said CR #1 did not remove the heat pack during treatment. She said when she removed the pack CR#1's skin was pink and said that was not uncommon. She said that was not the first time she had applied a heat pack treatment to CR#1's shoulder. She said after occupational therapy was done CR#1 was taken to the nurse's station and skin tears on her arm were reported to her nurse. She said she was shocked when she found out about CR#1's shoulder. She said she was trained to check a resident's skin during a heat treatment. She said CR #1 could communicate so she thought it was fine. She said since the incident they were in-serviced and provided with timers. She said they had a timer but it was broken. When asked if this had not been a routine treatment how often would she have checked the resident's skin, she said at least once during the 15 minute treatment and more often depending on the person's cognition. Record review of CR#1's Wound Care Specialist Initial Evaluation dated 12/3/15 revealed, .Patient has a wound on their shoulder.She presents with a burn wound of the right shoulder of at least 2 days duration.WOUND SIZE .8.8 x 3.7 x Not Measurable cm (centimeters).ETIOLOGY .: Burn . During an interview on 12/30/15 at 3:24 p.m. with PTA E, he said he checks moist heat pack treatments every 5 minutes. He said they check the temperature of the moist heat packs every morning to ensure they are safe to use. During an interview on 12/30/15 at 3:28 p.m. with COTA D, she said if she is applying a heat pack they layer towels, 8 layers, then place the hot pack with it's cover on top of the towels. She said the skin is checked every 3 minutes by pulling back the pad and checking the skin. She said that was how she had been doing moist heat packs for the past [AGE] years. Record review of Agency C's undated In-Service on Hot Packs revealed, .IMPORTANT TO REMEMBER: .3) Skin assessment will be done PRIOR to and AFTER application of hot packs and immediately report any skin breakdown or injury. 4) Apply hot packs no more than 20 minutes at a time unless recommended by MD (Medical Doctor) or therapist 5) Set a timer or time monitor. 6) Instruct patient to inform therapist at any time for any discomfort or pain. The in-service did not address visually inspecting the patient's skin during the treatment. Record review of Lippincott's Nursing Procedures Fifth Edition dated 2009 revealed, .Applying a warm compress or pack .Check the patient's skin every 5 minutes for tissue tolerance. Remove the device if the skin shows excessive redness, maceration, or blistering or if the patient experiences pain or discomfort. Record review of facility undated policy titled Abuse/Neglect Identification and Reporting Procedure revealed .Neglect-A deprivation of life's necessities of food, water or shelter, or failure of an individual to provide services, treatment or care to a resident which causes mental or physical injury or harm or death to the resident. Record review of a list provided by the DON revealed 3 residents were receiving heat treatments as part of their physical therapy services.

Based on interview and record review the facility failed to provide an environment that is free from accident hazards over which the facility has control and provides supervision for 1 of 3 residents (CR#1) reviewed for accidents and supervision. --Heat therapy was administered to CR#1 and she was not supervised which resulted in a second degree burn. This failure affected 1 former resident and placed 2 current residents who received heat therapy at risk of injury. Intake # 7 Findings Include: Record review of CR#1's admission sheet revealed she was a [AGE] year old who was admitted on [DATE]. Her [DIAGNOSES REDACTED]. She was discharged to home on 12/16/2015. Record review of CR#1's admission Minimum Data Set assessment dated [DATE] revealed she was assessed as a 13 out of 15 on her brief interview for mental status indicating she was cognitively intact. She required the extensive assistance of 1 staff for most activities of daily living. She required supervision and setup help for eating. She had no range of motion limitations. Record review of the facility grievances revealed a statement dated 12/1/15 which read, .I was answering the call light for (CR#1). She asked to be put on the bedpan. While rolling her over, the corner of her right shoulder blouse had fallen down and I noticed a scab like area on her shoulder. I asked her 'what happened.''' She stated 'therapy did that with a hot pack. I told them that it was hot and the therapist stated 'it's fine.'(CR#1) asked me, 'is it bad?' I told her 'it looks bad, like a burn.' I reported the skin issue to the charge nurse and documented it in my POC.' Record review of CR#1's Wound Care Nurse assessment dated [DATE] revealed documentation of a burn related to hot pack in occupational therapy acquired during the stay. The wound measured 8.8 centimeters by 3.7 centimeters on the right shoulder. During an interview on 12/29/15 at 11:28 p.m. with the DON, she said on 12/1/15 a nurse's aide was rolling CR#1 and saw a reddened area on her shoulder. She said the Administrator who is unavailable as he is traveling out of the country conducted the incident investigation She said COTA A administered the treatment. Record review of the therapy agency, Agency C's, incident reporting form dated 12/1/15 at approximately 10:00 a.m. revealed, .Employee's Account of the Incident: .Pt (patient) c/o (complains of) pain/soreness in R (right) shoulder /p (after) PT (Physical Therapy) tx (treatment). Therapist applied 7 layers of towels /c (with) moist hot pack cover x (times) 15 min (minutes). Pt cognitively in tact & able to verbalize pain/being uncofortable (sic) & has full BUE (bilateral upper extremity) ROM (range of motion) to remove hot pack, however, pt never expressed pain to therapist. Pt's skin on R shoulder was pink & had dead skin peeling /c Biofreeze application. Therapy session completed w/out (without) pt verbalizing any pain/incident. Therapist notified of incident following day. The document was signed by COTA A. During an interview on 12/29/15 at 12:44 p.m. with the Director of Rehabilitation, she said the therapy agency's incident reporting form does not have CR#1's name on it but it is the report for CR#1. Record review of the facility's incident report dated 12/2/15 revealed documentation of CR#1 being burned on her right shoulder, .hot pack from therapy left on shoulder too long and burn her. Record review of physician's orders [REDACTED]. Record review of CR#1's Occupational Therapy Daily Notes by COTA A dated 12/1/15 revealed, .Pt (patient) requested moist heat to R (right) shoulder to decrease soreness (after PT tx) (treatment). BioFreeze rub followed & therapist noticed skin peeling on shoulder joint. Notified pt that heat can no longer be applied due to sensitive/fragile skin. Pt with skin tears (& bleeding) on L (left) forearm. Notified charge nurse to apply band aides. Her note by COTA A dated 12/2/15 revealed, .Therapist went into pt's (patient's) room with DOR (Director of Rehabilitation) present, to apologize for having not checked pt's skin prior to moist heat aplication (sic) layered with big & hand towel & for any soreness/pain pt is in. Pt stated being aware of having sensitive & fragile skin that tears easing stating, 'My skin isn't how it used to be when I was younger. My skin is very fragile now.' .Therapist apologized to pt again. Pt stated, 'Don't worry about it, this kind of stuff happens to all of us.' During a telephone interview on 12/30/15 at 10:07 a.m. with CR#1, she said the day she received the heat treatment staff used a moist hot pad on her shoulder and left. She said she moved it off of her shoulder since it was hot. She said she did not feel it was her place to leave it off. She said the staff did not set up a timer to monitor the heat treatment duration. She said when the staff came back and removed the heat pack she told her her skin looked .really red, and then the staff member put Biofreeze on her shoulder. She said the same day (12-1-15) it turned into a large blister. She said at least one towel was used on CR #1's skin. She said the heat was left on for 20 minutes or longer. She said after the Biofreeze was applied CR #1 was taken back to her room. CR #1 said she called the nurse and showed the nurse the burn to her shoulder. She said the nurse called the doctor. During a telephone interview on 12/30/15 at 11:23 a.m. with Physician B, he said CR#1 sustained a 2nd degree burn. He said he saw CR#1 the day it occurred. He said CR#1 told him the burn happened during occupational therapy. He said she was receiving a heat treatment due to pain. He said older people are sensitive and if they do not pay attention it can, even at normal heat, do this. He said the shape of the burn was that of a heat pad. He said he did not believe the burn was greater than a 2nd degree. He said leaving heat on CR #1's shoulder for a short period of time could have resulted in a burn. He said for elderly residents with fragile skin the heating time should be shorter and the pack wrapped. He said heat treatments should be monitored every 5 to 10 minutes. During an interview on 12/30/15 at 11:47 a.m. with COTA A, she said she had been a certified occupational therapy assistant for 7 years. She was shown Agency C's incident reporting form and she said it was the report on CR#1. She said she was not sure why the patient identifying information was left blank. She said she did give a heat treatment to CR#1's right shoulder on 12/1/15. She said the process is to check the skin before. She said the resident was wearing a loose fitting gown. She said you put the hot pack into a protective covering and towels between the skin and the hot pack. She said she had 10 layers of towels between CR#1's skin and the covered heat pack. She said she documents treatments in the daily notes. She said CR#1 had dry skin all over her body and fragile skin but her shoulder .looked fine. She said the treatment was started at 10:15 a.m. She said she timed the treatment using the clock over CR #1's room door. She said she checked on CR#1 throughout the treatment and was in the room. She said, You know, we rely on the patients to let us know if it's getting too hot. She said, I was within her area during the treatment, not further than 6 feet from her. She said the heat pack was left on for 15 minutes before doing skin checks on CR #1. She said CR #1 did not remove the heat pack during treatment. She said when she removed the pack CR#1's skin was pink and said that was not uncommon. She said that was not the first time she had applied a heat pack treatment to CR#1's shoulder. She said after occupational therapy was done CR#1 was taken to the nurse's station and skin tears on her arm were reported to her nurse. She said she was shocked when she found out about CR#1's shoulder. She said she was trained to check a resident's skin during a heat treatment. She said CR #1 could communicate so she thought it was fine. She said since the incident they were in-serviced and provided with timers. She said they had a timer but it was broken. When asked if this had not been a routine treatment how often would she have checked the resident's skin, she said at least once during the 15 minute treatment and more often depending on the person's cognition. Record review of CR#1's Wound Care Specialist Initial Evaluation dated 12/3/15 revealed, .Patient has a wound on their shoulder.She presents with a burn wound of the right shoulder of at least 2 days duration.WOUND SIZE .8.8 x 3.7 x Not Measurable cm (centimeters).ETIOLOGY .: Burn . During an interview on 12/30/15 at 3:24 p.m. with PTA E, he said he checks moist heat pack treatments every 5 minutes. He said they check the temperature of the moist heat packs every morning to ensure they are safe to use. During an interview on 12/30/15 at 3:28 p.m. with COTA D, she said if she is applying a heat pack they layer towels, 8 layers, then place the hot pack with it's cover on top of the towels. She said the skin is checked every 3 minutes by pulling back the pad and checking the skin. She said that was how she had been doing moist heat packs for the past [AGE] years. Record review of Agency C's undated In-Service on Hot Packs revealed, .IMPORTANT TO REMEMBER: .3) Skin assessment will be done PRIOR to and AFTER application of hot packs and immediately report any skin breakdown or injury. 4) Apply hot packs no more than 20 minutes at a time unless recommended by MD (Medical Doctor) or therapist 5) Set a timer or time monitor. 6) Instruct patient to inform therapist at any time for any discomfort or pain. The in-service did not address visually inspecting the patient's skin during the treatment. Record review of Lippincott's Nursing Procedures Fifth Edition dated 2009 revealed, .Applying a warm compress or pack .Check the patient's skin every 5 minutes for tissue tolerance. Remove the device if the skin shows excessive redness, maceration, or blistering or if the patient experiences pain or discomfort. Record review of a list provided by the DON revealed 3 residents were receiving heat treatments as part of their physical therapy services.