Every finding on record at Willis Nursing and Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 5 residents viewed for infection control. - LVN B did not wear appropriate PPE when performing wound care on Resident #1, when he was on Enhanced Barrier Precautions. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings include: Record review of Resident #1's undated face sheet, revealed he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses of sepsis (infection throughout the body), urinary tract infection, neuromuscular dysfunction of bladder (bladder does not empty), atrial fibrillation (heart beat is not regular), and acute embolism and thrombosis of deep veins of lower extremity (blood clot in the vein of lower leg). Resident #1's admission MDS Assessment had not been completed yet. Record review of Resident #1's Baseline Care Plan only had a Focus of Sepsis with a goal to not exhibiting signs of infection. The interventions included administering antibiotics (Ceftriaxone). There was also a Focus regarding tasks to be documented in the POC about his bowel movements, bath/showers, food intake, etc. Those were the only two areas on the Baseline Care Plan. Record review of Resident #1's Physician Orders revealed the following orders from MD G:- Zosyn in dextrose (piperacillin-tazobactam-dextrs) [antibiotic] 3.375 g/50ml IV Q8hr, 10pm, 6am, 2pm. Ordered on 12/3/25.- Colostomy [hole through abdomen so stool can drain into a pouch on outside] Care Every Shift. Ordered on 11/21/25.- Enhanced Barrier Precautions-I have a PICC line [IV line that is inserted deeper into vein], foley [tube into bladder to drain urine], colostomy, and wounds. Ordered on 11/25/25.- Foley catheter: Diagnosis: Neurogenic bladder dysfunction. Ordered on 11/21/25.- Wound Treatment Order: Bottom of R great toe/foot: Clean with NS/WC, apply betadine, LOTA, QD. Ordered on 11/26/25.- Wound Treatment Order: R Dorsal [top]: Clean with NS/WC, apply calcium alginate [wound treatment], cover with silicone bordered dressing, QD. Ordered 11/21/25.- Wound Treatment Order: Sacrum [tailbone]/bilateral buttocks: Clean with NS/WC, pack center wound with calcium alginate w/ silver rope, place large calcium alginate sheets on top of wound, cover with silicone bordered dressing, QD. Ordered on 11/26/25.- Midline IV for intravenous therapy to LUA. Ordered on 11/20/25. Record review of Resident #1's Progress Notes revealed a note from 11/20/25 at 10:11pm from RN A that said, .Initial Nursing Services Provided: Intravenous Therapy, Ostomy Care [colostomy], Urinary Catheter Care [tube into bladder to drain urine].Wound Care.Resident is paraplegic [paralyzed in legs] with foley, midline [IV that is deeper in vein] LUA, Colostomy, intact. Extensive wound to coccyx [tailbone], buttocks, left hip, left calf and Right great toe. Skin dry scaly and peeling. Resident to start ceftriaxone 2G Q day x2 days on 11/21. In an observation on 12/3/25 at 10:01am, Resident #1 had an EBP sign on his door with a cart outside his room with PPE in it. Resident #1 was observed lying on his right side in bed while LVN B was performing wound care. LVN B did not have a gown on and only had gloves on. Resident #1 was observed to have a colostomy to his abdomen, a foley catheter hanging on the side of the bed, and a PICC line to his LUA. In an interview on 12/3/25 at 10:10am, LVN B said EBP was to protect everyone from infections, the staff and the residents. He said when a resident was on EBP, staff were supposed to wear a gown and gloves during treatment. LVN B said he was supposed to have worn a gown when he was performing wound care, but he forgot to put it on. LVN B said if he did not wear the appropriate PPE the resident and himself were at risk for getting infections. In an interview on 12/3/25 at 3:49pm, the DON said EBP was for any residents with invasive lines. She said the staff had to wear a gown and gloves, and they were worn during any treatment that was given to the resident. She said EBP was to prevent any contamination from the resident or the staff. The DON said she provided training on EBP at the monthly staff meetings and the last one was in November 2025. Record review of the facility's policy and procedures on Enhanced Barrier Precautions (June 2025) read in part: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., centrallines, urinary catheters, feeding tubes, tracheostomy [tube inserted into hole in throat]/ventilator tubes [machine that breathes for you], hemodialysis catheters [line into vein for dialysis], PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.).The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education.High-contact resident care activities include: Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters, Wound care.Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan or the residents' goals and preference for 1of 2 residents (Resident #34) reviewed for respiratory care.Resident #34 did not receive oxygen at the rate ordered by the physician.This failure could place residents who receive oxygen therapy at risk of receiving the incorrect rate of oxygen and a decline in health.Findings included:Record review of Resident #34's face sheet dated 08/21/25 revealed a [AGE] year-old admitted to the facility on [DATE] and originally admitted on [DATE]. Diagnoses included Metabolic encephalopathy (a change in how your brain works due to an underlying condition), altered mental status, COPD (chronic obstructive pulmonary disease, a lung condition caused by damage to the airway), CHF (Congestive heart failure is a condition where the heart is unable to pump enough blood to meet the body's needs), seasonal allergies and dementia.Record review of Resident #34's quarterly MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating moderate cognitive impairment. Resident #34 had shortness of breath when sitting at rest and when lying flat. Resident #34 received oxygen therapy while a resident.Record review of Resident #34's active MD orders revealed an order for nasal cannula, continuous O2 at 2L/min due to shortness of breath while lying flat due to COPD; every shift, start date 07/15/25. No further instructions were included in the order.Record review of Resident #34's MAR/TAR for 08/01/25 to 08/21/25 revealed oxygen at 2L/m was administered on 08/19/25, 08/20/25: on shift 6:00AM to 6:00PM and shift 6:00PM to 6:00AM and on 08/21/25 on shift 6:00AM to 6:00PM. Record review of Resident #34's O2 saturation log from 07/21/25 to 08/21/25 revealed O2 saturation rates: 97% on 08/19/25 at 7:24 AM and 98% at 8:08PM; 97% on 08/20/25 at 6:24 AM and 97% at 9:11 PM; 94% at 08/21/25 at 8:33AM.Observation and interview on 08/19/25 at 9:05AM, Resident #34 was lying on her back with the head of bed elevated and receiving humidified oxygen at 4L/min via nasal cannula. Resident #34 was able to open her eyes and stated she liked to sleep and did not know why she was getting oxygen.Observation on 08/20/25 at 12:00 PM, Resident #34 was sitting up in bed eating lunch. Oxygen was set at 4L/min and nasal cannula prongs were positioned in the nostrils.Observation on 08/21/25 at 10:25AM, Resident was asleep on her back, chest rising and falling, and the head of bed elevated slightly. Oxygen rate was set at 3.5L/min and nasal cannula prongs were positioned in the nostrils.Interview on 08/21/25 at 10:25AM LVN-B stated she was responsible to make sure Resident #34's oxygen rate was set as ordered and that all nurses were responsible for checking oxygen. She stated Resident #34 had always been on oxygen since she began working at the facility March 2025. LVN-B stated she did not know why she was receiving the oxygen and would have to look in her chart. LVN-B stated she checked the oxygen rate at 8:33AM (8/21/25). She stated the oxygen orders were for 2-3L/min. LVN-B stated she did not know why the settings were at 4L/min and that night shift was responsible for changing the tubing and cleaning the concentrator, so maybe the rate got moved then.Interview on 8/21/25 at 10:35AM, the DON stated Resident #34 was receiving oxygen d/t her O2 saturation rates would drop when she was non-compliant. When asked what the risks were to the resident if she did not receive oxygen as ordered, the DON stated the orders would have to be followed and that she would have to ask the MD. The DON stated she expected the nurses to check oxygen settings every shift at least once a day and follow physician orders.Interview on 8/21/25 at 10:40AM, LVN-A stated she was familiar with Resident #34. LVN-A stated Resident #34 had COPD and would get confused if not enough oxygen or too much oxygen was received. LVN-A stated all the nurses were responsible for checking accuracy of oxygen therapy. LVN-A stated during her first round of the day she would check oxygen settings and the level of water in the bottles.Record review of Resident #34's MAR/TAR revealed the oxygen concentrator filter was cleaned weekly on 08/17/25 between 6:00 PM and 6:00 AM. The oxygen humidification bottle was replaced or refilled as required every shift. (6:00AM-6:00PM, and 6:00PM - 6:00AM).Record review of the facility's policy for oxygen concentrator, date implemented was 07/2025 read in part: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators.2. Oxygen is administered under orders of the attending physician, except in the case of an emergency.4. a. the nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula, etc.).

Number of residents sampled: Number of residents cited: Based on observations, interviews, and record reviews the facility failed to maintain an effective pest control program so that it remains free of pests for one Resident's bathroom (Resident #19) out of 22 bathrooms and one hallway out of four hallways reviewed for pests.-The facility failed to ensure the building was free of cockroaches. A cockroach was found on the Surveyor's clothing while standing in a hallway during medication pass. A cockroach was observed in Resident #19's bathroom on two separate occasions.These failures could put residents at risk of, infection, allergies, skin irritation, unsanitary living conditions and decline in health and well-being.Findings include:Record review of Resident #19's face sheet dated 08/21/25 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included a stroke, depression, fungal infection of the skin and nails, Hemiplegia (one sided paralysis or severe loss of strength on one side), contractures of the muscle and anxiety.Record review of Resident #19's quarterly MDS dated [DATE] revealed a BIMS score of 11 out of 15 indicating moderate cognitive impairment. Resident #19 was dependent on staff for almost all ADLs.Record review of Resident #6's face sheet dated 08/20/25 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included heart failure, COPD (chronic obstructive pulmonary disease) (a lung condition caused by damage to the airway), schizophrenia, muscle wasting, high blood pressure and depression. Resident #6 used a walker for mobility and independent with all ADLs.Record review of Resident #6s annual MDS dated [DATE] revealed a BIMS score of 12 out of 15 indicating moderate cognitive impairment.Observation and interview on 8/20/25 at 6:30AM, during med pass in the hallway, a small brown, long, thin, oval shaped cockroach was found on Surveyor's shirt. Initially itching began on the back of the neck, then pin prick sensation was felt on back of right shoulder. The cockroach crawled over the front of the chest and then onto the outside of shirt. Immediate itching and two small, raised bumps were on the skin on back of the shoulder. MA-C stated if she saw pests, including cockroaches she would write it in the workorder book at the nurse station and would also inform maintenance.Observation and interview on 08/20/25 at 11:58 AM a long, thin, brown crawling insect was found running out from behind the toilet in Resident #19's bathroom. The Regional Maintenance Consultant at the time of observation, when asked if he were aware of insects in the facility, he stated no, and that the pest control was here last week. When asked who checked for insects, he stated all the staff would report if they saw one. When asked how often the pest control company perform an inspection, he stated monthly and they were on-call. When asked how this affected the residents, he stated it would spread disease, be unsanitary, and there could be a possible infestation.In an interview on 08/20/25 at 3:00 PM, LVN-A was asked how would it affect residents if cockroaches were around, LVN-A stated it would not be clean or healthy and an infection control issue. LVN-A stated if she observed a cockroach, she would write a workorder for the maintenance to address. LVN-A stated we do live in Texas and there are roaches here.In an interview on 08/20/25 at 3:05 PM, The Regional Maintenance Consultant stated he did not see any cockroaches today, and only saw ants outdoors. The Regional Maintenance Consultant stated he heard about the Surveyor's report of the cockroach sighting, and he did some spraying. He stated that staff would document any sightings in the workorder book and let him know. The Regional Maintenance Consultant stated he called pest control today d/t the ants outside and that they would be at the facility 08/21/25.In an interview on 08/20/25 at 3:15 PM, the DON, when asked how cockroaches inside the building affect residents, she stated they were gross and scary. When asked if cockroaches carried disease, the DON stated yes. The DON stated maintenance scheduled monthly Pest Services and they spray for pests.Observation and interview on 08/21/2025 at 12:33 PM in Resident #19's bathroom a small brown cockroach with wings visible crawled in the gap between the toilet and the floor, when the door was opened and the light turned on. Resident #19 stated he had seen the large yard cockroaches come into the building during heavy rain but had not seen any cockroaches recently. Resident #19 stated he did not like them being around and if they don't crawl all over him, he was ok with them. Resident #19 stated he did not use the bathroom as he cannot get out of bed. In an interview on 08/20/25 at 3:25 PM, Resident #6 resided in Hall 5, stated she had not seen any cockroaches recently but when she was in a different hall about a year and a half ago there was an awful cockroach problem. Resident #6 stated her roommate at the time would soil her brief often and thought maybe that was attracting the cockroaches. Resident #6 stated they were icky, and one got onto her face back then, she wanted to scream.Record review of the facility pest control logbook revealed roaches were sighted on, and addressed by pest control technicians: 12/26/24, addressed on 01/09/25 03/13/25, 03/17/25 addressed on 3/17/25 04/10/25, 04/11/125 addressed on 04/11/25 05/12/25, addressed on 05/19/25 07/11/25, addressed on 07/15/25 08/11/25, addressed on 08/13/25.Record review of the facility's pest control invoices dated from 02/17/25, 03/16/25, 4/22/25, 5/19/25, 06/16/25, 07/17/25, and 08/13/25, revealed monthly service was rendered. No further details were included in the invoices.Record review of the facility policy and procedure for Pest Control, revised May 2008 read in part: Policy Statement - Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services are provided by pest control company. 3. Windows are screened at all times 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

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 unit refrigerators. 1. The facility failed to ensure foods were labeled in order to identify the contents and dated when opened. 2. The facility failed to ensure food was properly stored in designated areas at all times. These failures could place residents who ate food from the unit refrigerator at risk of food borne illness and disease. Findings Included: Observation of the unit refrigerator located in the medication room [ROOM NUMBER]/25/24 at 8:50 AM revealed the following: 1. A clear plastic container with a green top which contained a yellow substance that appeared to be pudding had no label and was did not have the date it was prepared. 2. A plastic bag of chips and dips had no label to identify the contents and did not have the date they were prepared. 3. A Whataburger cup with dark liquid that was stuck to bottom of refrigerator door and had no label to identify the contents and did not have the date it was placed in the refrigerator. 4. A plastic container with a frosted chocolate cupcake had that did not have the date it was stored. During an interview on 06/25/24 at 08:59 AM, LVN 1 said the substance in the clear plastic container was pudding that the medication aide uses to give Resident's medications. LVN1 said he was embarrassed because the refrigerator should not look like this, and he did not know who was responsible for cleaning it. When asked why refrigerated foods should be labeled with dates and names, LVN 1 replied that was to prevent cross-contamination or spoilage, and someone could get sick if they eat it. During an interview on 6/26/24 at 1:20pm the ADON stated the charge nurses are responsible for checking the unit refrigerator for labels and dates on the resident's food. The ADON further stated staff was not supposed to put personal items in that refrigerator and the staff had a refrigerator in the break room for their personal use. The ADON stated after the food was discovered without labels and dates, an in-service was done with the staff. During an interview on 6/27/24 at 1:25pm the Administrator stated whoever takes the food from the Resident was responsible for placing the name of resident and the date on the item. It was a shared responsibility between medication aides and nurses. They are the only ones with access to the room. They are also responsible for discarding out of date items. Record review of the facility's policy titled Resident Personal Food Policy dated 9/11/23 Procedure Section C (d) indicated that Foods requiring refrigeration will be received by the facility designee (activity department, food and nutrition department, charge nurse, etc.) to ensure proper and immediate storage including labeling and dating.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 2 residents (Resident #1) reviewed for accidents. -The facility failed to safely transfer Resident #1 and prevent injury during a mechanical lift transfer that resulted in Resident #1 sustaining a laceration to her left leg requiring her to be sent to the hospital This failure could place resident at risk for accidents, injuries, and hospitalization . The noncompliance was identified as PNC. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. Findings Include: Intake ID #433231 Record review of Resident #1's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her admitting diagnoses included a fracture to the lower end of the thigh bone, anemia, malnutrition, and muscle loss. Record review of Resident # 1's quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. Section G: Functional Status revealed the resident required extensive assistance during transfers (resident involved activity, staff provide weight-bearing support) and two plus person physical assist. Record review of Resident #1's care plan dated [DATE] revised [DATE] revealed Resident #1 ADLs Functional Status/Rehabilitation Potential. Interventions are- Consult Physical Therapy, Occupational Therapy, Speech Therapy as needed and Resident care as per facility protocol. Record review of facility's investigation completed by the Administrator dated [DATE] revealed Resident #1 was transferred to hospital on [DATE] due to acquiring a laceration during a Hoyer lift transfer. After further investigation it was determined the resident sustained a mildly displaced and angulated, oblique fracture involving the distal left femoral(a fracture to the lower end of the left thigh bone). The Administrator provided a sign in sheet titled Hoyer Lift and Transfer dated [DATE] and received a document titled Transfer from Bed to chair with a Mechanical Lift- Training. Record review of the hospital records dated [DATE] of Report of Operative Procedure from Hospital #2 revealed, Resident #1 presented to the hospital after sustaining a laceration of the back of the calf and a fracture to the thigh bone at the skilled nursing facility. Further review of hospital records revealed during knee replacement surgery, the resident experience respiratory complications requiring chest compression. The resident was transferred to ICU and passed away. In an interview on [DATE] at 9:30AM with the Administrator, she stated during a use of a mechanical lift, two nurses (LVN A and LVN B) were transferring Resident #1 on back into bed and the resident bumped her leg which caused a laceration. She stated Resident #1 was sent out to the hospital because she had a laceration. The Administrator stated Hospital #1 transferred Resident #1 to Hospital #2 and stated the reason of the 2nd transfer was unknown. She stated the first hospital did not inform the facility that the resident had a fracture, she stated she was informed of the fracture by the 2nd hospital. The Administrator denied that the resident had a fall during the transfer. The Administrator also denied that the fracture was caused by the resident hitting her leg during the transfer. The Administrator reported she believed the fracture could have occurred during the residents transfer to the hospital. In an interview on [DATE] at 10:50AM with LVN B, he stated he had worked at the facility since [DATE] and he worked from 6am-6pm. He stated he and LVN A was assisting Resident #1 with getting back into bed via mechanical lift because the resident was a 2 person assist. He stated the resident scrapped the back of her leg while getting into the bed. LVN B stated he saw the scrape and it looked as if the resident could have required stitches, so she was sent out to the hospital. He stated the resident never fell during the transfer. She stated she was in-serviced on mechanical lift after the incident occurred. In an interview on [DATE] at 11:22AM with LVN A, she stated she had been employed at the facility for [AGE] years. She stated she worked the 6am-6pm shift. LVN A stated Resident #1 had been up and wanted to lay back down. She stated the CNAs were at lunch so she and LVN B helped Resident #1 get back in bed. She stated Resident #1 was in a sling for the mechanical lift, and when she and LVN B went to lay her down the resident's lower leg bumped into the bed, and the resident sustained a cut. She stated Resident #1 was sent out to the hospital because of the cut on her leg. She stated the DON and Administrator was immediately notified. LVN A denied that the resident ever had a fall during the transfer. LVN A stated she was in-serviced on lifts. Observation on [DATE] at 1:53PM of CNA A and CNA B during Resident #2's Hoyer lift transfer into bed. CNA A was observed connecting the slings to the Hoyer lift and CNA B ensured the wheelchair was locked in place. CNA B was observed standing near the residents' feet and CNA A was observed standing near the residents head. CNA A controlled the lift controller. Resident #2 was transferred into bed and there were no concerns. In an interview on [DATE] at 2:23PM with the DON, she stated she had been employed at the facility for a few weeks. She stated she was not familiar with the incident that occurred with Resident #1 because she was not employed at the facility. She stated the expectations for mechanical lift were that it takes at least 2 people to assist the resident. She stated one person should be controlling the machine and the other person should be positioning the patient. She stated the sling should be positioned under the back and bottom. She stated the staff were in-service on lifts annually and if there was an incident, the in service were repeated. Telephone call on [DATE] at 3:02 PM to NP-No answer, voicemail was full so unable to leave a message. Telephone call on [DATE] at 3:04PM to Physician- phone went to voicemail, voicemail was left. In an interview on [DATE] at 4:00PM with OT- She stated she did therapy with Resident #1 when she was at the facility for about 3 weeks until she went into the She stated the resident did need a lot of assistance due to being blind and she also required self-care skills with feeding. She stated Resident #1 had a spacer in her left knee which always kept her leg extended. She stated the resident had an elevated footrest to keep her foot to an extent. The resident had to be transferred towards her right leg and use the gait belt to keep it extended. The resident was non weight barring on that left leg. She stated the therapist used a gait belt to transfer the resident during therapy sessions and the staff members used a Mechanical Lift for transfers when the resident needed to be transferred. She stated the staff did not have to get any type of special training to transfer the resident since Mechanical lifts did not require the resident to have any weight on her legs during transfers. Telephone call on [DATE] at 10:02 AM to NP-No answer, voicemail was full so unable to leave a message. Record review of Resident #1's PT Evaluation and Plan of Treatment dated [DATE] revealed the residents weight bearing status was non weightbearing on her left lower extremity. Record review of Resident #2 face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Type 2 diabetes mellitus without complications, brain damage caused by lack of oxygen, muscle loss, contracture of muscle to the right lower leg, and contracture of muscle to the left lower leg. Record review of the Gait Belt Transfer Skills Checklist for LVN A dated on [DATE] read in part: .Comments: Education and training on 2-man Hoyer lift transfers as well . Record review of the Gait Belt Transfer Skills Checklist for LVN B dated on [DATE] read in part: .Comments: Education and training on 2-man Hoyer lift transfers as well . Record review of Hoyer Lift and Transfer training for all staff dated [DATE]. Record review of incident intake #433231 read in part: .Narrative of The Incident - Resident #1 was discharged to Hospital #1 on [DATE] after acquiring a laceration during a Hoyer transfer. On [DATE] the facility was contacted by the family of Resident #1 and informed that the resident expired on ,d+[DATE] due to a blood clot during a knee and femur surgery at Hospital #2 . Record review of the facilities Safe, Lifting and Movement of Residents policy dated [DATE] read in part: .In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation: 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents . 3.Staff will document resident transferring and lifting needs in the care plan .4. Staff responsible for direct care will be trained in the use of manual .and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents .Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies; .d. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies. It was determined these failures resulted in a deficient practice from [DATE] to [DATE]. facility took the following action to correct the non-compliance on [DATE]:

Based on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for one (Nurse Cart #6) of four medication carts reviewed for storage of medications. Nurse Cart #6 had a punctured protective seal on the back of a narcotic medication blister pill card. This failure could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion. Findings included: Observation on 09/24/2023 at 12:20 PM revealed the narcotic storage of Lorazepam 0.5 mg tablets # one tablet had a torn protective seal. The blister contained one and a half small white tablets. This was the last dose in the pill card that had 30 blisters. In an interview on 09/24/2023 at 12:20 PM with LVN A stated she was not sure why the tear on the back of the Lorazepam pill card was there. LVN A stated she counted with the night nurse in the AM and did not notice the tear. LVN A stated if the Lorazepam was due again, she would see the tear and would waste (destroy and render unusable) it. LVN A stated she would waste the medication with another nurse. LVN A stated it would not be OK to ever tape over the tear. LVN A stated sometimes during popping out of a tablet, our fingers may puncture the back of the blister package. In an interview on 09/28/2023 at 1:50 PM, the Clinical Resource Nurse stated torn blister cards should not be in the medication cart. She stated the nursing staff should be looking at the back of the cards to make sure there are no holes. She stated the risk to the resident would be an infection control risk. She stated if the tablet should fall out, it could be a case of drug diversion. She stated if the tablet falls to the floor, hopefully it would not be picked up and taken by a resident as it could cause adverse reactions. Record review of facility's policy titled Storage of Medications, revised November 2020 revealed in part .Policy heading: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments and under proper temperature .2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner .6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes containing drugs and biologicals re locked when not in use .

Based on observation, interview, and record review, the facility failed to provide dignity and respect for 1 of 5 (Resident #5) residents observed for privacy and dignity in that: -The facility failed to pull the privacy curtain in Resident #5's room during incontinent care. This failure could affect resident (s) that required assistance with care at risk for embarrassment and lower self-esteem. Findings included: Resident #5 Record review of Resident#5's face sheet revealed an [AGE] year-old female who was admitted to the NF on 11/03/2021 and readmitted on [DATE]. Her diagnoses included Parkinson's disease (a disorder of the brain that causes unintended or uncontrollable movements), pneumonia (in infection that inflames the air sacs of the lungs), unspecified Essential (primary) hypertension (high blood pressure), Anxiety disorder( feeling of fear, dread and uneasiness), Fever (high body temperature of over 100 degrees), anorexia (an eating disorder), acute embolism and thrombosis of unspecified deep veins of lower extremity (when arteries are blocked by a blood clot), constipation (difficulty passing stool), unspecified dementia (memory loss), insomnia (sleep disorder, having problems falling asleep), moderate protein-calorie malnutrition(inadequate intake of protein, and calories), pain, hypokalemia (low potassium in the blood), Vitamin D deficiency ( body does not adequate vitamin D), anemia (the body does not have enough healthy red blood cells), and Cardiac arrhythmia (irregular heart beat). Record review of Resident #5's quarterly MDS dated [DATE] revealed her cognitive skills for decision the resident was coded as severely impaired (never/rarely made decision). For activities of daily living Resident #5 was coded for bed mobility and toileting use as total dependence with one person assist and transfer as total dependence and two plus persons physical assist and for eating, she was coded as extensive assistance with one-person physical assist. For bowel and bladder Resident #5 was coded as incontinent of bowel and bladder. Observation on 10/18/2023 at 11:45 a.m. revealed CNA A providing incontinent care to Resident #5. The surveyor knocks, on the door and was told to come in. CNA A had Resident #5's adult diaper down and Resident #5 roommate was in her bed, and she did not pull the privacy curtain to provide privacy to Resident #5. The privacy curtain to the door was not drawn and the resident was visible from the hallway. The Surveyor exit the room and on exiting CNA A drew the curtain between the two beds. Further observation at 11:55 a.m. the Surveyor then knocks on the door and CNA A was trying to put Resident #1's pant up, the privacy curtain between Resident #5 and her roommate's bed was drawn but the one to the entrance door to the hallway was not drawn. At that point the Surveyor told her to pull the privacy curtain to the entrance door to the hallway. In an interview with CNA A on 10/18/2023 at 12:30 p.m. she said she usually does not pull the privacy curtain when she provides care to Resident #5 because her roommate was not usually in the room. She said she was taught to pull the privacy curtain when providing care to residents. She said Resident #5 roommate was in the room and she should have drawn the privacy curtain. She said she did not know what happened, because she usually pulls the privacy curtain when Resident #5 was in the room. She said she was in-service on providing privacy that means she should always pull the privacy curtain and closed the doors when providing care. She said she did not know why she did not do what she was trained to do. During an interview on 10/18/2023 at 12:55 pm., with the DON said that when staff were providing care to residents, they should always provide privacy, drawing the privacy curtains, closing the door, and talking to them to make them comfortable. She said they were in-serviced on privacy. She said she will just have to in-service them again. Record review of the facility's policy and procedure dated February 2021 title Dignity read in part . Policy Statement: Each resident shall be cared for in a matter that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. Employees should treat all residents with kindness, respect and dignity. Policy Interpretation and Implementation 11. Staff promotes, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Perineal Care Policy Statement: Perineal care is providing cleanliness and comfort to the resident, to prevent infection, skin irritation and to observe the resident skin condition. Steps in procedure: 1. Introduce self to resident and explain care that will be provided. Provide privacy i.e. pull curtain and close door.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 5 residents (Resident #1) reviewed for activities of daily living. -The NF failed to provide proper perineal/incontinent care for Resident #1. This failure placed resident at risk for UTI's (urinary tract infections), sepsis (presence of harmful bacteria in the blood), and unwanted hospitalization . Findings included: Resident #1 Record review of Resident #1's face sheet revealed a 62year old male admitted to the NF on 08/26/2023 with diagnoses that included the following: monoplegia (paralysis to one extremity or region of the body) upper limb following nontraumatic subarachnoid hemorrhage (bleeding on the brain) affecting left non-dominant side, dementia (impairment of memory and judgement) moderate, with other behavior disturbance, gastro-esophageal reflux disease (stomach acid or bile flows into the food pipe and irritates the lining) without esophagitis (inflammation that damages the tube running through the throat to the stomach), benign (growth that is not cancerous) prostatic hyperplasia (prostate enlargement that can cause urination difficulty) without lower urinary tract symptoms, dysphagia (difficulty swallowing), aphasia (loss of the ability to understand or express speech), and gastrostomy (surgical opening into the stomach from the abdominal wall). Record review of Resident #1's MDS dated [DATE] revealed that resident had a BIMS score of 3 indicating that resident cognition was severely impaired. Further review revealed that resident required assistance with activities of daily living due to total dependence with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Further review revealed that resident was always incontinent of bowel and bladder. Record review of Resident #1's Care Plan dated 08/21/2023 revealed that resident was being care planned for incontinence of bowel and bladder with intervention that included to provide incontinent care after each in incontinent episode and to monitor skin and report any changes. Observation on 10/18/2023 at 12:55pm CNA B performing perineal care for Resident #1 with the assistance of LVN D. CNA B entered resident room and washed her hands with soap and water, placed on a set of gloves and began to remove resident brief that was stained with feces. CNA B positioned resident to his left side with the assistance of the LVN D and began to clean resident rectal area with disposable wipes one wipe at a time. CNA B placed soiled material inside of a plastic bag. When CNA B was done cleaning resident anus and buttocks, she then positioned resident on his back with the assistance of the LVN D and began to clean resident perineal area (skin between the scrotum and anus and bottom region of the pelvic). The CNA B did not change her gloves and wash her hands. The CNA B proceeded to clean resident groin that had feces on the disposable wipes. When CNA B was done cleaning the groin area, she then began to clean resident penis starting at the urethral meatus (opening from the inside to the outside) not cleaning downward and away from the urethral meatus instead, cleaned in a circular motion upward. When CNA B was done providing care, she then removed her gloves and washed her hands with soap and water. Interview on 10/18/2023 at 1:10pm CNA B said she should have cleaned resident first starting in the front and moving to the back. CNA B said she should have started at the tip of resident penis retracting the foreskin of the penis and cleaning the penis by moving downward in a circular motion away from the urethral meatus. CNA B said these steps should have been taken to avoid infections like UTI's. CNA B said she became nervous and started making mistakes. Interview on 10/18/2023 at 1:35pm the DON said when administering perineal/incontinent care for a male resident, the staff should be starting at the meatus cleaning down and away from the meatus to prevent introducing bacteria in the urinary tract that could cause UTI's. Record review of the NF Policy on Perineal Care revised 01/20/2023 revealed in part: .Perineal Care is providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the residents skin condition .For male resident .clean perineal area starting with urethra and working outward .Retract foreskin of the uncircumcised male .Clean urethral area with a cleansing wipe using a circular motion .Continue to clean the perineal area including the penis, scrotum, inner thighs .Turn on his side .clean the anus, and buttocks .

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to restore, if possible, oral skills and to prevent complication of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal pharyngeal ulcers for 1 of 5 residents (Resident #1) reviewed for quality of care. -CNA failed to inform the nurse to stop Resident #1's continuous gastrostomy feedings while providing incontinent care with resident head of bed flat. The failure placed resident at risk for aspiration, pneumonia, and unwanted hospitalization . Findings included: Record review of Resident #1's face sheet revealed a 62year old male admitted to the NF on 08/26/2023 with diagnoses that included the following: monoplegia (paralysis to one extremity or region of the body) upper limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, dementia, moderate, with other behavior disturbance, gastro-esophageal reflux disease without esophagitis, benign prostatic hyperplasia without lower urinary tract symptoms, dysphagia, aphasia, and gastrostomy. Record review of Resident #1's MDS dated [DATE] revealed that resident had a BIMS score of 3 indicating that resident cognition was severely impaired. Record review of Resident #1's Care Plan dated 08/21/2023revealed that the NF was care planning resident for feeding tube an intervention that included to provide enteral (nutrition delivered using the stomach) feedings as ordered. Record review of Resident #1's Physician orders revealed the following orders dated 08/12/2023 enteral feeding (aspiration precaution) elevate HOB 30-45-degree, order dated 08/30/2023 for enteral free water give 200ml per tube q hrs., and an order dated 10/17/2023 revealed enteral formula Glucerna 1.5 to run at 55ml/hr. for 22 hours per day. Observation on 10/18/23 at 11:40am Resident #1 was resting on his left side in bed on an air mattress with head of bed flat. Resident was receiving continuous gastrostomy feedings Glucerna 1.5 (hung on 10/18/23 at 4:00am) infusing at 55ml/hr. Further observation was made of resident also receiving water flush 200ml every 4 hours. NA C was providing incontinent care for resident who had a bowel movement. Further observation was made of resident not appearing to be in any distress. Interview on 10/18/23 at 11:50am NA C said LVN D was aware that she was going to provide incontinent care for Resident #1. NA C said she had been working at the NF for 8 weeks and was not supposed to be working on the unit by herself. NA C said she was not a CNA because she was still in training. NA C said she did not know what she was supposed to do prior to providing incontinent care for a resident on continuous gastrostomy feedings. Interview on 10/18/23 at 11:55am LVN E said she was not the nurse taking care of Resident #1 and believed resident nurse may had been on break. When LVN E observed resident head of bed being flat with continuous feedings infusing, LVN E said resident head of bed should be elevated to 45 degrees to prevent resident from aspirating. LVN E elevated resident head of bed. Interview on 10/18/23 at 12:00pm LVN D said she had been working at the NF for a little over a year. LVN D said NA C never asked her to assist with incontinent care for Resident #1. LVN D said whenever incontinent care was being provided for a resident receiving continuous gastrostomy feedings, the feedings must be stopped to prevent resident from aspirating. LVN D said NA should have informed her what she was going to do so she could have placed the feeding on hold and disconnect tubing from resident. LVN D said she would have assisted NA C with incontinent care if she had asked. Further interview on 10/18/23 at 12:10pm NA C said she was in the TNA (Training Nurse Aide) Program and had completed her hours just needed to take her exam. NA C said she became frustrated when she said she was not supposed to be working at the NF by herself. NA C said Resident #1 had a new G-Tube (gastrostomy tube) because she had worked with Resident #1 in the past and he did not have one that she could remember. NA C said she had gone to LVN D for assistance and that LVN D did not respond to her when she had asked her what she was supposed to do because resident was receiving continuous gastrostomy feedings. NA C said LVN D did not answer because she was busy doing something else. NA C said she proceeded to care for Resident #1 because he was incontinent of stool and needed to be cleaned. Interview on 10/18/2023 at 12:22pm DON said she had been working at the NF for 1 month. The DON said the TNA (Training Nurse Aide) Program she believed the policy stated that another staff member must buddy up with the person in training until they became a CNA but would have to confirm with the Administrator. The DON said prior to a staff providing care for a resident (s) with a continuous feeding they should inform the nurse first so that the nurse could stop and disconnect the feedings. The DON said this was done to prevent the resident from aspirating. Further interview with the DON said the NF had 4 residents that were receiving continuous gastrostomy feedings. Interview on 10/18/23 at 1:25pm Administrator said the NF did not have a policy on their TNA Program but went by the state guidelines regarding training for nurse aide. The Administrator said there was nothing in the NATCEP (Nurse Aide Training and Competency Evaluation Program) that specified that NA C could not be alone when administering care for the residents. The Administrator said moving forward, she would ensure that NA C received more training in the areas of gastrostomy tubes. The Administrator said NA C had completed her competency skill check list regarding resident care. The Administrator said it was CNA B that checked NA C off in her competency skills. The Administrator said it was ultimately the DON that was responsible in ensuring that the nurse aides was able to perform each task on the competency check off list. The Administrator said the Corporate Regional Nurse also assisted with the nurse aide skills competency checkoff. The Administrator said the previous DON left the facility in July 2023 and after that, the NF had two interim DON in the month of August 2023. The Administrator said the NF new DON started working at the NF on 09/01/2023. Record review of Nurse Aide Skills Competency Checklist for NA C revealed that NA C had been checked off for nutrition and elimination regarding G-Tube (Gastrostomy Tube) on 08/02/2023. Record review of the NF Policy on Enteral Feedings-Safety Precautions revised May 2014 revealed in part: .Always elevate the head of bed at least 30-45 degree during tube feeding .

35822 Based on observation, interview, and record review the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 1 of 5 (Resident #1) reviewed for infection control. -NA C failed to place soiled linen in bag during incontinent care, instead of placing the soiled linen on floor. This failure placed residents at risk for cross contamination, spread of infections, and decrease in quality of life. Findings included: Record review of Resident #1's face sheet revealed a 62year old male who was admitted to the NF on 08/26/2023 with diagnoses that included the following: monoplegia (paralysis to one extremity or region of the body) upper limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, dementia, moderate, with other behavior disturbance, gastro-esophageal reflux disease without esophagitis, benign prostatic hyperplasia without lower urinary tract symptoms, dysphagia, aphasia, and gastrostomy. Record review of Resident #1's MDS dated [DATE] revealed that resident has a BIMS score of 3 indicating that resident cognition was severely impaired. Further review revealed that resident required assistance with activities of daily living due to total dependence with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Further review revealed that resident was always incontinent of bowel and bladder. Record review of Resident #1's Care Plan dated 08/21/2023 revealed that resident was being care planned for incontinence of bowel and bladder with intervention that included to provide incontinent care after each in incontinent episode and to monitor skin and report any changes. Observation on 10/18/23 at 11:40am Resident #1 was resting on his left side in bed on an air mattress. Resident was receiving gastrostomy feeding via (by way of) pump. Further observation was made of NA C providing incontinent care for resident who had a bowel movement. There was soiled linen directly on floor not inside a bag. Interview on 10/18/23 at 11:50am NA C said the reason she placed the soiled linen on the floor was because the soiled linen barrel was right outside resident's door. NA C said she did not have a bag to place the soiled linen inside of. Further interview with NA C she said she should have bagged the soiled linen and placed it inside of soiled linen barrel to prevent the spread of infections. NA C said she did not know why she did that because she had been trained on infection control. Interview on 10/18/23 at 12:00pm LVN D said she was the nurse for Resident #1 and that soiled linen should be placed inside of plastic bag and transferred to soiled utility room for infection control purposes. Interview on 10/18/2023 at 12:22pm the DON said she had been working at the NF for 1 month. The DON said when the nursing staff provide incontinent care for a resident, the soiled barrel should be outside the resident door so that the nursing staff could place the soiled linen inside of the barrel. The DON said if the barrel for soiled linen was not at the doorway, the staff had to bag the soiled linen and take to the soiled utility room. The DON said this was done to prevent the spread of infections. Record review of the NF Policy on Infection Prevention and Control Program revised October 2020 revealed in part: .An infection prevention and control program was established and maintained to provide a safe, sanitary comfortable environment and to help prevent the development and transmission of communicable disease and infections .

Based on interview, observation, and record review, the facility failed to honor the rights of the resident to self-determination and to make decisions about their care for 1 of 6 residents (Resident #25) reviewed for resident rights. The facility failed to accommodate Resident #25's right to refuse her therapeutic diet. This failure could place residents at psychosocial and emotional risk by not having their rights upheld. Findings included: Record review of Resident #25's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her relevant diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), contracture of muscles (permanent tightening of muscles). Record review of MDS revealed Resident #25 with BIMS of 14 reflecting that Resident #25 has sufficient judgement, planning, and organization to make her own decisions. Record review of Speech Language Therapy Evaluation and Plan of Care dated 4/26/23 revealed that Resident #25 was assessed for swallowing ability and was recommended a pureed diet (food blended to smooth, pudding-like consistency) with thin liquids due to with inability to fully clear mouth of leftover food after chewing and swallowing because of lingual weakness (weakness / difficulty moving the tongue). Record review of Resident #25's progress note dated 4/26/23 revealed that staff observed Resident #25 being fed onion rings and a hamburger by a relative. Per note, relative was told that Resident #25 would continue to receive a pureed diet until the diet order is changed by the physician. Record review of Resident #25's care plan nutritional status dated 5/1/23 revealed that Resident #25 was ordered a pureed diet and the goal was for resident to maintain weight. This section of the care also stated that the resident is noncompliant with MD prescribed diet (pureed) and that family and resident were educated of the risks of consuming otherwise (regular textures). No interventions, resolutions, or accommodations were identified in the care plan to address Resident #25's wishes for a non-pureed diet. Record review of DON progress note dated 5/1/23 revealed that the DON educated Resident #25 and RP concerning failed swallow study emphasizing that it is unsafe for Resident #25 to consume regular textures after RP had fast food delivered to Resident #25. Per note, the RP verbalized that she would take risk of resident having whatever she wants to eat. Per note, RP stated that she was willing to sign a form to state that she and Resident #25 assume the risk of the resident eating what she wants. Per note, the DON educated the RP that the facility does not have a form/waiver to address that concern. Record review of the NP Progress dated 5/2/23 revealed that Resident #25 reported to NP that she was being provided a pureed diet and did not want it. NP note stated that Resident #25 is non-compliant with recommended diet and is not willing to be. NP documented that she explained to Resident #25 that the risk of a regular diet overweighs the benefit. Resident #25 confirmed understanding but still wishes to be on a regular diet. Record review of Resident #25's meal ticket dated 5/11/23 revealed that resident has an active order for and continues to receive Pureed diet. Record review of Resident Rights Under Federal Law: Attachment F (revised 2/22/22) revealed the following: 1. The Resident has a right to a dignified existence, self-determination . 5. The Resident has the right to refuse treatment . 9. The Resident has a right to participate in planning of his or her care and treatment or changes in care and treatment unless adjudged incompetent or otherwise . Observation on 5/9/23 at 12:30pm revealed that there was no tray in the resident's room during lunch time, only a bottle of Vanilla Ensure Enlive . In an interview on 5/9/23 at 12:30pm, Resident #25 stated that she supplements her diet with Ensure because she will not eat the pureed foods that she is being provided by the facility. Resident #25 said that she had a swallow test about two weeks ago and was ordered a pureed diet which she refuses to eat unless it is a food that's soft in its normal form (i.e. mashed potatoes, pudding). She said that she has expressed to doctor (NP), the nurse manager (DON), and anyone who will listen that she refuses to eat the pureed diet and would even sign something to say that she assumes the risks. She stated that the facility has made no accommodation for her in the 2 weeks she has been admitted and her family brings food and sometimes has food delivered that she can eat. Resident #25 stated that the situation is upsetting and that she would rather starve than eat the pureed meals provided to her . In an interview on 5/10/23 at 9:50am, the Administrator and DON both agreed that the resident has the right to refuse the pureed diet. The DON stated that the facility is honoring Resident #25's rights by not interfering with food brought from outside the facility. She said the facility only offers resident pureed items. The DON said that corporate does not offer a waiver for Resident #25 to decline pureed diet and accept risks of having a diet upgrade. The DON stated that Resident #25 failed a swallow test and for that reason, they must follow the physician order for the pureed diet. The DON stated that failure to honor the resident's rights could negatively impact the resident emotionally . In an interview on 5/10/23 at 10:15am, LVN C stated that all residents have the right to accept or refuse care. In an interview on 5/10/23 at 11am, Resident #25's NP stated that she is aware of Resident #25's request for a diet upgrade despite failed swallow test. She stated that she would be comfortable upgrading resident's diet if there was a waiver and plan in place that would allow for the resident and her RP to sign off stating they understand and accept the risks of upgrading resident's diet. She said that the problem is that the facility has no such waiver available. In an interview on 5/10/23 at 11:05am, the Social Worker acknowledged that the resident has the right to refuse a therapeutic diet even if prescribed for safety. She stated that she does not have a definite answer as to how the resident's rights will be honored as this issue has never come up at the facility in the [AGE] years she has been there. The SW acknowledged that not upholding resident's rights can have negative emotional impact because the facility is their home where their choices should be respected.

Based on interview, observation, and record review the facility failed to honor the right of the resident to participate in the planning process and revision of the care plan to for 1 of 6 residents (Resident #25) reviewed for care plan. The facility failed to accommodate Resident #25's right to refuse her therapeutic diet and include accommodations in the resident's care plan. This failure could place residents at risk for not having their right to participate in the planning process of their individual person-centered plans of care. Findings included: Record review of Resident #25's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her relevant diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), contracture of muscles (permanent tightening of muscles). Record review of MDS revealed Resident #25 with BIMS of 14 reflecting that Resident #25 had sufficient judgement, planning, organization to make her own decisions. Record review of Speech Language Therapy Evaluation and Plan of Care dated 4/26/23 revealed that Resident #25 was assessed for swallowing ability and was recommended a pureed diet (food blended to smooth, pudding-like consistency) with thin liquids due to with inability to fully clear mouth of leftover food after chewing and swallowing because of lingual weakness (weakness / difficulty moving the tongue). Record review of Resident #25's progress note dated 4/26/23 revealed that staff observed Resident #25 being fed onion rings and a hamburger by a relative. Per note, relative was told that Resident #25 would continue to receive a pureed diet until the diet order was changed by the physician. Record review of Resident #25's care plan nutritional status dated 5/1/23 revealed that Resident #25 was ordered a pureed diet and the goal was for resident to maintain weight. This section of the care also stated that the resident is noncompliant with MD prescribed diet (pureed) and that family and resident were educated of the risks of consuming otherwise (regular textures). Record review of DON progress note dated 5/1/23 revealed that the DON educated Resident #25 and RP concerning failed swallow study emphasizing that it was unsafe for Resident #25 to consume regular textures after RP had fast food delivered to Resident #25. Per note, the RP verbalized that she would take risk of resident having whatever she wanted to eat. Per note, RP stated that she was willing to sign a form to state that she and Resident #25 assumed risk of resident eating what she wanted. Per note, the DON educated RP that the facility did not have a form/waiver to address that concern. Record review of the NP Progress dated 5/2/23 revealed that Resident #25 reported to NP that she was being provided a pureed diet and did not want it. NP note stated that Resident #25 was non-compliant with recommended diet and was not willing to be. NP documented that she explained to Resident #25 that the risk of a regular diet overweighed the benefit. Resident #25 confirmed understanding but still wished to be on a regular diet. Record review of Resident #25's meal ticket dated 5-11-23 revealed that resident had an active order for and continued to receive Puree diet. Record review of Resident Rights Under Federal Law: Attachment F (revised 2/22/22) revealed the following: 1. The Resident has a right to a dignified existence, self-determination . 5. The Resident has the right to refuse treatment . 9. The Resident has a right to participate in planning of his or her care and treatment or changes in care and treatment unless adjudged incompetent or otherwise . Observed on 5-9-23 at 12:30pm that there was no tray in the resident's room during lunch time, only a bottle of Vanilla Ensure Enlive. In an interview on 5-9-23 at 12:30pm, Resident #25 said that she had a swallow test about two weeks ago and was ordered a pureed diet which she refused to eat unless it was a food that's soft in its normal form (i.e. mashed potatoes, pudding). She said that she had expressed to doctor (NP), the nurse manager (DON), and anyone who would listen that she refused to eat the pureed diet and would even sign something to say that she assumed the risks. She stated that the facility has made no accommodation for her in the 2 weeks she had been admitted and her family brought food and Ensure and sometimes had food delivered that she can eat. Resident #25 said that she drinks the Ensure to supplement her diet when she refused the facility food. Resident #25 stated that the situation was upsetting and that she would rather starve than eat the pureed meals provided to her. In an interview on 5-10-23 at 9:50am, the Administrator and DON both agreed that the resident had the right to refuse the pureed diet. The DON stated that the facility was honoring Resident #25's rights by not interfering with food brought from outside the facility. She said the facility only offered the resident pureed items. The DON said that corporate did not offer a waiver for Resident #25 to decline pureed diet and accept risks of having a diet upgrade. The DON stated that resident failed a swallow test and for that reason, they must follow the physician order. The DON stated that failure to honor the resident's rights could negatively impact the resident emotionally. In an interview on 5-10-23 at 11am, Resident #25's NP stated that she was aware of Resident #25's request for a diet upgrade despite failed swallow test. She stated that she would be comfortable upgrading resident's diet if there was a waiver and plan in place that would allow for the resident and her RP to sign off stating they understand and accepted the risks of upgrading resident's diet. She said that the problem was that the facility had no such waiver available. The NP said that she had not yet discussed with the physician but would have that conversation with him. The NP said that that the team (Admin, DON, SW, NP) had been discussing among themselves how to handle the situation, but there was no documentation of a formal meeting having taken place. In an interview on 5-10-23 at 11:05am, the social worker acknowledged that the resident has the right to refuse a therapeutic diet even if prescribed for safety. She stated that she did not have a definite answer as to how the resident's rights will be honored as this issue has never come up at the facility in the [AGE] years she had been there. The social worker said their next step would be to have a care plan meeting and include the resident, her daughter, and the ombudsman but, at that time, it had not been scheduled.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance to professional standards of practice and the resident's person-centered care plan for 1 of 12 residents (Resident #5), in that: - Resident #5's laceration on foot failed to be reported to the Wound Care Nurse and treated. This failure could place residents at risk of not receiving adequate care in a timely manner. Findings included: Record review of Resident #5's face sheet revealed a [AGE] year old male who was admitted into the facility on [DATE] and was diagnosed with contracture of right lower leg muscle and quadriplegia, paralysis affecting all extremities below the neck. Record review of Resident #5's care plan, dated 02/11/2020, stated: Problem: [Resident #5] has current skin concerns as evidenced by: -irritation to face -tinea pedis -tinea unguium 04/10/2020. dry itching bilateral feet. - Apply Nystatin/Kenalog cream and OTC antifungal cream as ordered PRN. - Keep MD and RP informed of residents progress. - Keep MD and RP informed of residents progress. - Skin assessments as scheduled and PRN. Record review of Resident #5's physician's orders, dated 05/11/2023, revealed the resident had an active order to: - Apply OTC antifungal cream to bilateral feet QD PRN dryness or itching since 4/10/2020 - Apply compound nystatin cream/kenalog apply to face BID prn irritation since 02/25/2015 Record review of Resident #5's MDS, dated [DATE], revealed the resident had a BIMS score of 12 indicating resident's cognition was slightly impaired. Observations and interview with CNA G on 05/09/23 at 09:47 AM, revealed Resident #5 was observed with an approximately 2 X 0.5 inch scratch on the top of the resident's right foot that was pink in color. Resident #5 was observed rubbing his feet and legs against each other to scratch himself. CNA G said Resident #5 was known to have very dry skin and scratch himself and she uses a warm towel and cream to help with the itching, but his skin just soaks all the moisture up. CNA G said it was the first time she had seen this scratch on his foot and that it looked fresh. In an interview with Resident #5 on 05/09/23 at 12:23 PM, he stated his main concern was that his skin on his inner thigh and top of his foot felt very itchy. In an interview with the Wound Care Nurse, on 05/11/2023 at 1:55PM, she stated she knew the resident has had complications with itchy skin and flare-ups for a while and had PRN creams to help with the itch but she was not recently notified about any new skin issues that Resident #5 had. She stated the nurse aides have to do skin assessment/shower sheet and report any new concern to her and the nurse aides have not been doing them or else it would have been reported to her. Record review of Resident #5's shower sheets revealed the last shower sheet documented was from 05/08/2023 with no noted skin issues on his feet. Observations and interview with LVN K on 05/11/2023 at 2:00PM, he stated he was not made aware of any new skin concerns for Resident #5 recently. Surveyor requested to observe Resident #5's skin while resident was dressed and lying in a Geri chair. Resident #5 was seen grimacing saying I don't want-- repeatedly as LVN pulled the resident's sock off. The resident's skin appeared bright reddish pink and LVN K saw his skin on left foot and stated, that's definitely open. Resident #5 was then observed being taken back to his room by LVN K and the Wound Care Nurse for a skin assessment. Record review of Resident #5's skin assessment dated [DATE] at 2:57PM revealed resident was assessed to have a skin tear/laceration and was ordered new wound treatment. In an interview with CNA F on 05/11/23 at 02:23 PM, CNA F reported Resident #5 was given a bed bath this morning after being soiled and she forgot to write it on a shower sheet that he had a sore on his right foot, it was not bleeding but it was very open. She stated she put his personal Vaseline over it and put his socks on. She stated that was the first time she had seen the wound and she would usually call a nurse to notify them then and there, but she did not notify the nurse because it slipped her mind. She stated the risk of not reporting and addressing open wounds is possible infection. In an interview with the DON on 05/11/2023 at 2:37PM she stated CNA F should have reported the skin change to the charge nurse who would have followed up by looking at the resident's skin or sending wound care to assess and coordinate appropriate treatment with the doctor to ensure treatment is appropriate. She stated the risks of not having resident's skin concerns reported is that the resident's skin would remain not intact and could potentially get worse.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one resident (Resident #1) of 9 residents reviewed for care plans. The facility failed to care plan for Resident #1's weight loss and three pressure ulcers. This failure could place residents at risk for lack of quality of care and services. Findings included: Review of Resident #1's face sheet dated 12/01/21 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MDS dated [DATE] reflected she had a BIMS score of 8 indicating cognitive impairment. Review of Resident #1's Care Plan dated 11/16/21 reflected Resident #1 was care planned for nutritional status, Resident #1 had the potential for nutritional issues, Resident #1 would achieve oral intake and sustain current weight for the next 90 days. Resident #1 was not care planned for weight loss. Review of Resident #1's Care Plan dated 11/16/21 reflected Resident #1 was care planned for being at risk for pressure ulcers and was not care planned for the three pressure ulcers. Review of Resident #1's Weight Variance Report dated 12/01/21 reflected the following: Date Weight 12/01/21 194.50 11/30/21 199.8 11/23/21 207.4 11/16/21 209 11/05/21 206.4 10/05/21 211.6 Review of Resident #1's hospital records dated 11/17/21 indicated she came back from the hospital with three pressure ulcers. The resident was in the hospital for two days. In an interview with Resident #1's family on 12/01/21 at 3:44 pm she stated Resident #1 did not want to lose this weight, Resident #1 can not help herself. She needs help. They leave her plate and walk off, she need help. The agency aide just Sunday put down the plate, took the top off, and left. She asked the agency aide to help her. They neglect Resident #1. The administrator told her, there are no excuses, we have enough staff here. Review of an email from the Registered Dietician to the DON dated 12/01/21 reflected the following: Subject: Resident #1's Weights, Resident #1's weights have been stable for 6 months, so this is a brand-new weight loss today. This could be related to hospitalization ; the resident also has CHF and is on diuretic, so some weight fluctuations are anticipated. She is on prostat to better meet her needs as well. We could continue weekly weight monitoring and add large protein portions to her meals to mitigate weight loss until her wound heals. Would you like me to input a note and recommendation for that this afternoon? Thank you! In an interview with the Administrator on 12/01/21 at 12:04 PM she stated the DON is responsible for the care plans but she was working the floor. In an interview on 12/01/21 at 1:15 PM the DON stated she was responsible for care plans but was working the floor. In an interview on 12/01/21 at 1:40 PM LVN J stated she was responsible for the MDS assessments and the DON was responsible for the care plans. Review of the facilities Dignity policy dated February 2021 reflected: 3. Individual needs and preferences of the resident are identified through the assessment process.

Based on interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for one resident (Resident #1) of 9 residents reviewed for weight loss. The facility failed to implement weight loss precautions for Resident #1 when she lost 17.1 pounds from October 2021 to December 2021. This failure could place residents at risk for Inadequate nutritional and hydration status. Findings included: Review of Resident #1's face sheet dated 12/01/21 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MDS dated [DATE] reflected she had a BIMS score of 8 indicating cognitive impairment. Review of Resident #1's Care Plan dated 11/16/21 reflected Resident #1 was care planned for nutritional status. Resident #1 had the potential for nutritional issues,. Resident #1 would achieve oral intake and sustain current weight for the next 90 days. Resident #1 was not care planned for weight loss. Review of Resident #1's records dated 11/27/21 reflected she was on [MEDICATION(S)] 20mg oral tablet, 20 mg 1 tablet, PO, daily. Review of Resident #1's Weight Variance Report dated 12/01/21 reflected the following: Date Weight in pounds 12/01/21 194.50 11/30/21 199.8 11/23/21 207.4 11/16/21 209 11/05/21 206.4 10/05/21 211.6 Observation on 12/01/21 between 12:00pm and 1:00 PM revealed Resident #1 ate 90 percent of her meal with assistance. An interview on 12/01/21 at 3:52 PM the DON was asked anbout Resident #1's weight loss and what the facility had done about it. DON stated she was not aware of it prior surveyor bringing it to her attention. DON further said she would notify the dietician regarding the weight loss immediately. In an interview with Resident #1's family on 12/01/21 at 3:44 pm she stated Resident #1 did not want to lose this weight, my mom Resident #1 can not help herself. She needs help. They leave her plate and walk off, she need help. The agency aide just Sunday put down the plate, took the top off, and left. She asked the agency aide to help her. They neglect her. The administrator told her, there are no excuses, we have enough staff here. Review of an email from the Registered Dietician to the DON dated 12/01/21 reflected the following: Subject: Resident #1's Weights, Resident #1's weights have been stable for 6 months, so this is a brand-new weight loss today. This could be related to hospitalization ; the resident also has CHF and is on diuretic, so some weight fluctuations are anticipated. She is on prostat to better meet her needs as well. We could continue weekly weight monitoring and add large protein portions to her meals to mitigate weight loss until her wound heals. Would you like me to input a note and recommendation for that this afternoon? Thank you! In an interview with the Administrator on 12/01/21 at 12:04 PM she stated the DON was out when Resident #1 came back from the hospital. In an interview on 12/01/21 at 3:00 PM the DON stated she was about to care plan and see all of Resident #1's records because she just came back. She was not here on 12/27/21 when the resident came back from the hospital. The resident was in the hospital for two days. When asked about notifying the Dietician and care planning for Resident #1's weight loss she stated she would have just caught it today after she was weighed with the surveyor. She stated her weight can fluctuate due to diuretics. Review of the facilities Dignity policy dated February 2021 reflected: 3. Individual needs and preferences of the resident are identified through the assessment process.

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to 2 of 4 medication carts. - LVN D failed to ensure the nurses' medication cart was not left unlocked, unsecured and unattended. -The facility failed to ensure all medications were secured properly in the nurse medication cart when one pill was found loose in the bottom of the medication drawer. -The facility failed to ensure all medications were secured properly in the medication aide's medication cart on hall 6 when one pill was found loose in the bottom of the locked narcotic drawer. These failures could affect all the facility residents who received medications from the facility, by placing them at risk for loss of their medications resulting in a delay in medication administration. Findings included: Observation and Interview on 6/12/19 at 12:30 p.m. revealed Medication Cart located at the nursed station was left in the hallway, unlocked with the drawers facing the hallway. There were no Nurses and no other Facility Employees at the Nurses station. Surveyor was able to open all the drawers to the medication cart. Noted inside the second drawer were multiple blister packs of various resident's prescription medications and to the right were multiple bottles of liquid prescription medications. At 12:35pm the DON came from down hall 100 and around nurse's station to ask surveyor if she needed help. The DON was shown the unlocked the medication cart, and DON then noticed the medication cart draws were open and paged, LVN D, the nurse in charge of the cart. DON stated the medication cart should not be opened and was going to check the medications to make sure they were all there. DON also said LVN D went to the dining room and must have forgotten to lock the cart. Interview with LVN D on 6/12/19 at 12:40 p.m. revealed he had been away from the medication cart for about 20 minutes. He stated that he left the cart to put a resident on oxygen and then went to the dining room and did not return to the cart until the DON paged for him. LVN D said the cart should be locked if unattended because residents could get into the medication, and if a resident was to get in the cart it could be dangerous for the resident. He stated he was the only one with a key to the medication cart and that he must have forgotten to lock it. Observation on 06/13/19 at 07:33 am. of nurse's medication cart while accompanied by the DON revealed a loose round orange unidentified pill in the bottom of drawer 2 between the resident's individual bubble packet. The DON researched the pill by the mark on it and identified it as [MEDICATION NAME]. Observation on 06/13/19 at 07:45 AM of the medication aide medication cart for hall 6 while accompanied by the DON revealed a locked narcotic box with one loose round white unidentified pill in the bottom of the drawer between the resident individual bubble packs. The DON researched the pill by the mark on it and identified it as [MEDICATION NAME]. In an interview on 06/13/19 at 07:55 AM with the DON she stated, they check the carts and do an inventory with an audit every time they get new medications in. She said that if the staff finds a loose pill they should report it to her. She said there was no shortage of any medications. Record Review of the facility policy titled Medication Storage Storage of Medication dated 2007 read in part . Policy: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall only be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: . 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications(such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access 15. Medication storage should be kept clean, well lit, organized and free of clutter

Based on observation, interview, and record review the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report for 1 of 12 residents reviewed for PASRR (Resident # 46). The facility stopped Specialized PT, OT, and ST services and did not order a bariartric wheelchair requested and approved for payment by PASRR for Resident # 46. This failure affected 1 resident and placed her at risk of not having her special needs met by the facility. Findings include: Record review of Resident # 46's medical records revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident # 46's quarterly MDS assessment dated [DATE] revealed she was unable to complete the BIMS interview and her cognitive skills for daily decision making were coded a 3 - Severely impaired. She required supervision and set up help only with bed mobility, locomotion, dressing and eating, and limited one person assistance with toileting and personal hygiene. She used a wheelchair for ambulation. She was 67 inches tall and weighed 250 pounds. Record review of Resident # 46's Care Plan inititated on 9/10/18, last updated 6/09/19, revealed she was care planned for having been identified as having PASRR positive status related to a severe mental illness: [MEDICAL CONDITION] disorder. Approaches included: Invite the LIDDA representative and RP to the quarterly care plan meeting to discuss functional status; provide services coordination with representative from the LIDDA .; Report any need to evaluate for habilitative services and/or durable medical equipment to maintain current level of function; report any need to re-evaluate for additional TRR specialized services . Resident # 46 was also care planned on 9/10/18 for cognitive impairment: short and long term memory problems with impaired decision making skills related to [MEDICAL CONDITION] disorder and intellectual disabilities, and communication: problems with making self understood and understanding others related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. (MONTH) miss part of or intent of message. (Resident # 46) will mumble and talks in low tones, unable to distinguish. History of falls, transfers self, uses a wheelchair, resists ADL care, and unplanned weight gain were also care planned. Record review of an undated printout for the facility from SimpleLTC titled Active Residents with PASRR Positive PE revealed Resident # 46 was listed with Status Date of 12/19/2018. PE TMHP Status read Positive PASRR Eligibility and Special Services read Yes for Resident # 46 on this report. Record review of a HHSC form titled Local Authorities (LA) Individual Service Plan/Transition Plan - NF for Resident # 46 dated 5/29/19 revealed the form included Service Planning Team (SPT) Meeting Summaries from dates: 7/26/18, 9/04/18, 12/18/18, 2/12/19, 3/18/19, 5/02/19, and 5/29/19. Team meeting notes indicated Resident # 46 participated in PT, OT, and ST specialized services. Notes dated 2/12/19 indicated she was recommended for a bariatric wheelchair and the Service Coordinator would apply for it. SPT Meeting notes dated 5/02/19 read that the facility advised the PASRR Service Coordinator that Resident # 46's PT, OT, ST habilitative services were stopped and she was placed in restorative therapy due to a loss in Medicaid benefits at the end of (MONTH) 2019 as per instructions from the NF corporate office. The Local Authority was contacted during the meeting over the telephone and the Assistant Administrator of PASRR & Continuity of Care confirmed that the Local Authority was not pulling her off services because she is classified as having Permanent Medical Necessity and that an email confirming that services should not be stopped were forwarded to the facility and she was to continue to be provided PT, OT, ST three times a week for 30 minutes each session. Record review of an email sent on 4/29/19 from HHSC PASRR Support, Program Specialist, regarding Resident # 46 to the Assistant Administrator PASRR, ADON, and PASRR Service Coordinator revealed it read, You only need to discontinue the habilitative therapies if the individual loses their NF Medicaid (Daily Care). Currently, our records show that the individual still has NF Medicaid. If you check MESAV and the individual loses NF Medicaid, discontinue the therapies and you should have an SPT to document why you stopped services and that you will look to start them up again once the individual is back on NF Medicaid. Record review of the PT - Therapist Progress & Discharge Summary, dated 5/31/19 revealed it read Awaiting approval from PASSR to continue. Record review of OT - Therapist Progress dated 5/30/19 revealed it read under Updates to Treatment Approach, Resident currently pending Medicaid, therefore she is on hold with OT habilitative services. Once she is approved, plan to continue with OT habilitative services to achieve her highest level of function. Currently participating with a RNP to maintain her current levels of function. Record review of the ST - Therapist Progress dated 5/17/19 revealed it read, Patient is currently on hold for skilled therapy at this time due to change in payor source, awaiting approval and Continues to require skilled tx for cognitive skills training and speech intelligibility. Observation and Interview with Resident # 46 on 6/12/19 at 10:33 AM revealed she was sitting in the dining room in a regular wheelchair at a table by herself. She was quiet. When asked if she was supposed to get a new wheelchair she nodded and said Yes. When asked if she was getting therapy, she said No and shook her head. When asked if she was supposed to get therapy she nodded yes. Resident # 46 began talking in a low voice and the surveyor could not understand what she said. Observation of Resident # 46 on 6/13/19 at 8:38 AM revealed she was in the hall heading toward her room in a wheelchair. She was wheeling herself very slowly. Her wheelchair was observed to be a wide, large wheelchair. One of the arm rests appeared cracked and worn. Resident # 46 nodded when asked how she was and began to mumble. She was not able to be understood. Interview with the DON on 6/13/19 at 8:52 AM when asked why Resident # 46's therapy and wheelchair were not provided she stated We were told she didn't have a payor source. She stated it had been reinstated now and she would need the BOM and DOR to explain further. In an interview with the BOM and the DOR, on 6/13/19 at 8:56 AM the BOM stated that Resident # 46's SSI was denied on 2/28/19 due to an incorrect address, because there was never a change of address for the resident. She stated they did submit a change of address form to Social Security back when she first admitted to the facility in 2013. She stated she found a copy of it. She stated on 3/01/19 she did not have applied income showing in the computer and Medicaid wouldn't approve her services from there. The BOM stated they received the notice in (MONTH) 2019 and they tried to call the Social Security office with Resident # 46, but Resident # 46 can't be understood, so they told them to mail a form to correct the address. She stated she mailed the form and they did not process the form she sent. Then in (MONTH) 2019 she went to the Social Security office twice and gave them the change of address form. Then in (MONTH) 2019, she went to the Social Security office again and gave them the form and then they finally corrected her address and immediately at that time turned her SSI right back on. The DOR stated they placed Resident # 46's services on hold and placed her in Restorative therapy. She stated when they finally reinstated her SSI they argued with Medicaid for three weeks to get it fixed. She stated they did not submit the paperwork for her wheelchair because they learned she had no payor source. The DOR stated they will be re-evaluating her today for her OT, PT, and ST and will have to wait for the Dr to sign her wheelchair request again. In the meantime they gave her a bariatric wheelchair to use. In an interview with the BOM on 6/13/19 at 9:45 AM she was asked how Resident # 46's nursing home bill was being paid if Social Security did not have her correct address. She stated Resident # 46 was a Full vendor and her copay was $0. So, the nursing home was being paid. She was to receive a SSI check for $30 a month. She stated the Social Security office wouldn't tell them where her $30 check was being mailed to all that time. She stated her family member signed her in to the nursing home in (MONTH) 2013. The BOM was asked if she took Resident # 46 to the Social Security office to try to get it straightened out and she said No I did not take her to the Social Security office. She stated she does not take the residents to the Social Security office. She stated she just goes to the Social Security office herself and waits for them to call her and then she turns their paperwork in. The BOM stated Resident # 46's Medicaid was reinstated in (MONTH) from 3/01/19. In an interview with the Administrator on 6/13/19 at 11:05 AM he was asked why the resident's were not taken to the Social Security office to get changes or corrections made. He stated the Social Security office was busy and had a long wait for the residents. He was asked why Resident # 46's services were denied even though they knew she was eligible and that her SSI and Medicaid would be reinstated. The Administrator stated, I don't know but I'll find out. The Administrator did not provide an answer prior to exit. In an interview with the DOR on 6/13/19 at 11:30 AM she stated they reevaluated Resident # 46 on today for OT and they don't need a new evaluation for the wheelchair. She stated they are requesting the physician sign the request for her wheelchair again, so they can submit it. The Administrator stated on 6/13/19 at 11:35 AM that the facility doesn't have any policy regarding PASRR and they just follow the State and Federal policy guidelines.

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 18 residents (Resident #31) reviewed for supervision. -The facility failed to ensure restricted items were not kept at the bedside for Resident #31. This failure affected one resident and placed her at risk for accidents and injury. Findings included: Resident #31 Record review of Resident # 31's medical records revealed she was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 31's Initial Care Admission MDS assessment dated [DATE] revealed her BIMS as 5 out of 15, indicating severe cognitive impairment. She required limited assistance of one person assistance for bed mobility and dressing. She required extensive assistance of one person for locomotion on unit. She required total assistance of one person for transfer, dressing, eating, toilet use and personal hygiene. Observation of Resident #31's room on 6/13/19 at 9:30 am revealed Dermasil lotion and Perfect Purity lotion at the bedside. The Dermasil bottle had a warning stating Keep Out of Reach of Children. Resident #31's call light was underneath these two hazardous bottles. At this time, the charge nurse came into the room and picked up the bottles to retrieve the call light but did not remove the hazards from the bedside table. Observation of Resident #31' room on 6/14/19 7:50 am revealed Dermasil lotion and Perfect Purity lotion were still at the bedside. Interview with DON on 06/14/19 at 8:00 am in Resident #31's room, Surveyor showed her the bottles at the bedside. DON removed both items immediately. DON said that these should not be at the bedside. Interview with DON on 6/14/19 at 9:00 a.m. she said there were two wanders on this hallway. Record Review of the facility's Admission Handbook, Page 10 of 20 revealed that the following items were not allowed in resident rooms due to a potential for harm/fire/or other dangerous situation: 5. Oils and powders which can cause a slip hazard and 13. Any item with danger warning harmful if swallowed, Keep out of reach of children, Danger if inhaled.

Based on observation 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 7%, based on three errors out of 38 opportunities, which involved three of nine residents (Resident # 5, Resident #11, and Resident # 38) and two of 3 staff (LPN-H and MA-A) reviewed for medication administration, in that: - MA-A failed to administer 2 tablets of Vitamin D 1000iu for Resident #5, as ordered by the physician. - LPN-H failed to administer [MEDICATION NAME] 10mg tablet for Resident #11 as ordered by the physician. - LPN-H administered [MEDICATION NAME] 220mg/5ml to Resident #38 when the order stated to give Multivitamin minerals with iron These failures affected three current residents and had the potential to affect the remaining 32 residents who reside on the 100 and 500 halls of not receiving the care and services ordered by the physician and a decline in health status Findings Include: Resident # 11 Record review of Resident #11's clincial record revealed she was a 50 female, admitted originally on 8/27/2004 and most recently on 10/14/2017 with the following Diagnosis: [REDACTED]. Observation on 06/06/18 at 7:12am of MA-A administering Resident #11 the following morning medication: [MEDICATION NAME] 25mg - gave 1 tablet [MEDICATION NAME] 200mg - gave 1 tablet Vitamin D 1000iu - gave 1 tablet [MEDICATION NAME] 50mg - gave 1 tablet Fish Oil 1000iu - gave 1 capsule Olopatadine 0.2% drops - Instilled 1 drop in both eyes Record Review of Resident #11's (MONTH) (YEAR) MAR/TAR revealed that MA-A was to administer two Vitamin D 1000iu's daily . Resident # 5 Record review of Resident #5's clinical record revealed she was a [AGE] year old female, admitted originally 01/29/2011 and readmitted [DATE] with the following Diagnosis: [REDACTED]. Observation of LPN - H administering the following morning medication on 06/06/2018 at 8:05am via [DEVICE]; Vitamin C 500mg - 1 tablet via [DEVICE] once daily [MEDICATION NAME] sulfate solution 220mg/5ml - Give 5ml via [DEVICE] once daily Folic Acid 400mg - Give 1 tablet via [DEVICE] once daily [MEDICATION NAME] 5mg - Give 1 tablet via [DEVICE] once daily for [MEDICAL CONDITION] Arthritis [MEDICATION NAME] 100mg - Give 1 tablet via [DEVICE] once daily for [MEDICAL CONDITION] Multivitamin liquid - Give 15ml via [DEVICE] once daily [MEDICATION NAME] 2mg - Give 1 tablet via [DEVICE] twice daily for [MEDICAL CONDITION] [MEDICATION NAME] 2mg - Give 1 tablet via [DEVICE] twice daily for anxiety [MEDICATION NAME] solution 100mg/ml - Give 10ml via [DEVICE] twice daily for convulsions [MEDICATION NAME] 250mg/5ml - Give 5 ml via [DEVICE] three times daily for convulsions [MEDICATION NAME] 250mg/5ml - Give 12 ml via [DEVICE] for diabetic [MEDICAL CONDITION] Tylenol 300mg/ [MEDICATION NAME] 60mg - Give 1 tablet via [DEVICE] three times daily for pain. Record Review of Resident # 5's (MONTH) (YEAR) MAR/TAR revealed that LPN-H failed to administer via [DEVICE], physician ordered [MEDICATION NAME] 10mg. The order was for [MEDICATION NAME] 10mg - Give 1 tablet via [DEVICE] three times daily for muscle spasm. Resident # 38 Record review of Resident #38's clincial record revealed she was a [AGE] year old female, originally admitted [DATE] and most recently admitted on [DATE] with the following Diagnosis: [REDACTED]. Observation of LPN - H administering the following morning medication on 06/06/2018 at 8:50am via [DEVICE]; [MEDICATION NAME] 220mg - Give 15ml via [DEVICE] once daily for vitamin deficiency [MEDICATION NAME] 1mg - Give 1 tablet via [DEVICE] once daily for anxiety [MEDICATION NAME] 100mg/ml - Give 5 ml via [DEVICE] twice daily for convulsions Record review of Resident # 38's (MONTH) (YEAR) MAR/TAR at 11:25am on 6/6/18 revealed that LPN-H was to administer a multivitamin with minerals and [MEDICATION NAME] liquid which includes 9mg iron / 15ml once a day. LPN-H administered [MEDICATION NAME] 220mg / 15ml resulting in 220 mg of iron per day verses 9 mg of iron order. Record Review of the facility's Policy /Procedure on Medication Administration effective date of 06/2012 and revised on 04/2018 states as follows: It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations According to facility provided Form 671, Census was 45

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including any services that would otherwise be required but are not provided due to the resident's exercise of the right to refuse treatment for 1 of 12 residents (Resident # 16) reviewed for care plans. -The facility failed to ensure Resident # 16 had care plans for impaired range of motion, contractures, restorative therapy and frequent refusals of therapy. This failure affected one resident and had the potential to affect 24 other residents currently receiving rehabilitative services by placing them at risk of not receiving needed care and services which could lead to a further decline in health status. Findings include: Record review of Resident # 16's medical records revealed she admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident # 16's quarterly MDS assessment dated [DATE] revealed she was totally dependent with two-person assistance with transfers, and one person assistance with bed mobility, locomotion, dressing, and bathing. She required supervision only eating and required extensive one-person assistance with personal hygiene. She had range of motion impairment on one side of upper extremity, and impairment on both sides of lower extremity. Record review of Resident # 16's April-June (YEAR) Physician order [REDACTED]. Record review of Resident # 16's Care Plans last updated 3/24/18 revealed she was care planned for ADL functional rehabilitation potential for transfers, ambulation, and positioning, required assistance with grooming, bathing, and dressing, had episodes of resistance to ADL care as evidenced by refusal to eat, refusal to be changed, refusal to shower and yells at staff when not attended to immediately and hits and grabs staff. There were no care plans found for range of motion, contractures, or restorative therapy in Resident # 16's records. Further record review of Resident # 16's medical records revealed records of Occupational Therapy conducted in (YEAR) only and Speech therapy records conducted in (YEAR)-2017. No Physical Therapy or Restorative therapy records were found in her medical records. No current therapy records were noted in her medical records. Observation of Resident # 16 on 6/05/18 at 11:15 AM revealed she was in her room sitting up in a geri-chair. She was unable to speak, but was alert and appeared to understand what was said to her and began to make noises in her throat and gestures with her left hand and face, trying to respond. She showed the surveyor a small bruise on her left forearm and showed the surveyor her right hand. Resident # 16's right hand was closed and she pulled on her fingers to open the hand up part way. She then pointed to the right hand with her left forefinger making crying noises. Her right hand was contracted and she did not move her right arm. She had full range of motion in her left arm and hand only. Observation of Resident # 16 on 6/05/18 at 11:25 AM revealed she was seated in the geri chair on the back porch with a full long plastic vinyl bib and an ash tray smoking a cigarette with her left hand. She had no difficulty handling the cigarette with her left arm and hand. Several residents were on the porch smoking with staff supervising at this time. In an interview with the OTR on 6/07/18 at 10:12 AM she stated Resident # 16 had therapy when she first admitted to the facility in (YEAR) and she made no progress. She stated she was Medicaid pending at that time. She stated if a resident is denied coverage for therapy on their insurance, they still see them for two weeks to get a baseline and then they discharge them to Restorative therapy. She stated she gave Resident # 16 a carrot (carrot shaped hand roll to help prevent further contracture) and she would take it out of her hand. She stated this happened on two different occasions. She stated everyone who d/c's from therapy goes to Restorative. She stated the MDS Coordinator was responsible for the Restorative program. She stated Resident # 16 can't move her legs. She can move her left toe and she had foot drop to her right foot. She stated she wrote a Restorative plan for her and she gives everything to the MDS Coordinator. In an interview with Restorative Aide on 6/07/18 at 10:43 AM, he stated he was not doing Restorative therapy with Resident # 16. He stated he used to do Restorative with her, but not now. He stated she used to have a hand roll for her hand. He stated he keeps a log of the residents he sees for Restorative and turns everything in to the MDS Coordinator. Observation of Resident # 16 at this time with the Restorative Aide revealed she could not move her right arm or her legs. Her right foot was observed to have foot drop. She was able to move her toes on her left foot. In an interview with the MDS Coordinator on 6/07/18 at 10:51 AM she stated it had been a long time since Resident # 16 was in the Restorative program. She was observed looking for paperwork for her in her office. She stated she didn't know where her paperwork was and she would continue to look for it. The MDS Coordinator stated Resident # 16 refuses therapy most of the time. She stated Resident # 16 pulls on her hand all the time trying to open it up. She stated she refused the hand roll. She stated Resident # 16 won't let you do anything with her lower extremities, she'll just scream. In an interview with the DON on 6/07/18 at 1:35 PM she stated the MDS Coordinator could not find Resident # 16's Restorative Plan or notes. She stated Resident # 16 had frequently refused therapy in the past. She stated Resident # 16's impaired range of motion, contractures, restorative therapy and refusals of therapy should be care planned. No additional documentation was provided prior to exit regarding Resident #16's care plan. Record review of the facility's policy titled Care Plan-Resident revision date 12/2016, read in part; It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident .The specific problem as well as the underlying cause should be listed .Sources are, but are not limited to: 1. Problems relating to [DIAGNOSES REDACTED]. Behavior control problems .10. All problems identified on all assessments . According to the facility's CMS Form 672 there were 8 residents with contractures and 25 residents receiving rehabilitative services.