Does MUSTANG PARK THERAPY AND LIVING CENTER have any serious inspection findings?

Yes, MUSTANG PARK THERAPY AND LIVING CENTER has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 39 total deficiencies from recent inspections.

What are the staffing levels at MUSTANG PARK THERAPY AND LIVING CENTER?

MUSTANG PARK THERAPY AND LIVING CENTER has a one-star staffing rating from CMS with 0.38 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is MUSTANG PARK THERAPY AND LIVING CENTER located?

MUSTANG PARK THERAPY AND LIVING CENTER is located in CARROLLTON, TX. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does MUSTANG PARK THERAPY AND LIVING CENTER have?

MUSTANG PARK THERAPY AND LIVING CENTER has 120 certified beds.

Who owns MUSTANG PARK THERAPY AND LIVING CENTER?

MUSTANG PARK THERAPY AND LIVING CENTER is a for profit - corporation facility and operates independently (not part of a chain).

MUSTANG PARK THERAPY AND LIVING CENTER

Q: What is MUSTANG PARK THERAPY AND LIVING CENTER's CMS rating?

MUSTANG PARK THERAPY AND LIVING CENTER has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Was MUSTANG PARK THERAPY AND LIVING CENTER ever fined?

Yes, MUSTANG PARK THERAPY AND LIVING CENTER has been fined $38,593 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is MUSTANG PARK THERAPY AND LIVING CENTER on any federal watch list?

No, MUSTANG PARK THERAPY AND LIVING CENTER is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

Q: What have inspectors found at MUSTANG PARK THERAPY AND LIVING CENTER?

Medicare inspectors have found 39 deficiencies at MUSTANG PARK THERAPY AND LIVING CENTER: 1 critical, 2 serious, 36 moderate. Each deficiency represents a violation of federal nursing home requirements.

4501 PLANO PARKWAY, CARROLLTON, TX 75010 · (469) 701-5300

For profit - Corporation 120 Beds Independent Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

13/100

#1047 of 1168 in TX

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MUSTANG PARK THERAPY AND LIVING CENTER nursing home in CARROLLTON, TX - Photo 1 of 2

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Last Inspection: January 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Mustang Park Therapy and Living Center has received an F grade for its trust score, indicating significant concerns about the care provided. Ranked #1047 out of 1168 facilities in Texas, they are in the bottom half, and #15 out of 18 in Denton County, meaning only a few local options are worse. Unfortunately, the facility's situation is worsening; it went from 5 issues in 2024 to 7 in 2025. Staffing is a relative strength, with a 0% turnover rate, which is well below the Texas average, suggesting staff are stable and familiar with the residents. However, the facility has incurred $38,593 in fines, which is concerning and may indicate ongoing compliance problems. Some serious incidents have been reported, including a resident who left the facility unsupervised and wandered nearly three miles, raising significant safety concerns. Additionally, a resident developed a severe pressure ulcer due to a failure to properly monitor and treat their condition, highlighting issues with care quality. While there are some strengths, such as low staff turnover, the overall picture raises significant red flags for families considering this nursing home.

Trust Score: F
In Texas: #1047/1168
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: Turnover data not reported for this facility.
Penalties: $38,593 in fines. Higher than 88% of Texas facilities, suggesting repeated compliance issues.
Skilled Nurses: Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 39 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★★★☆

4.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 5 issues

2025: 7 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

1-Star Overall Rating

Below Texas average (2.8)

Significant quality concerns identified by CMS

Federal Fines: $38,593

Above median ($33,413)

Moderate penalties - review what triggered them

The Ugly 39 deficiencies on record

1 life-threatening 2 actual harm

Apr 2025 2 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #6) reviewed for accidents and hazards. The facility failed to ensure Resident #6 did not exit the facility through an unknown door and walk 2.7 miles to a free-standing emergency department where he was found outside. The noncompliance was identified as PNC. The noncompliance began on 03/13/2025 and ended 03/14/2025. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of harm and serious injuries. The findings include: Record review of Resident #6's wandering risk assessment, dated 01/31/2025, reflected a score of 4, which indicated a low risk for elopement. Record review of Resident #6's Quarterly MDS (tool used to assess health status) Assessment, dated 02/13/2025, reflected a BIMS (screening tool to assess cognitive status) was not completed because the resident was rarely/never understood. The staff assessment indicated the resident had moderately impaired cognition for daily decision making. Record review of Resident #6's Comprehensive Care Plan, dated 03/09/2025, reflected Resident #6 had impaired cognitive function/dementia or impaired thought processes related to neurological symptoms: Aphasia. Interventions included Administer meds as ordered. Date Initiated: 02/21/2025. I need supervision/assistance with all decision making. Date initiated 02/21/2025. Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Date initiated 02/21/2025. Record review of Resident #6's Comprehensive Care Plan, dated 03/09/2025 and updated 03/14/2025, reflected Resident #6 was an elopement risk as evidenced by 03/13/2025 2200 (10 PM) last seen in facility - 3/14/25 2:00 (2 AM) Return to facility. Elopement with Hospital Visit, returned to facility. One intervention was 3/13/2025 ELOPEMENT . 1:1 (one on one staff-resident) care for continuous monitoring due to elopement incident to begin on resident return to facility and end on transfer to secure unit/facility. Date Initiated: 03/14/2025. Record review of Resident #6's Face Sheet, dated 04/15/2025, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infarction (blood flow to a part of the brain is blocked, dementia (decline in mental ability that interferes with daily life), aphasia (disorder that affects communication), anxiety disorder with behaviors (persistent worry and fear about everyday situations) and major depressive disorder (persistent feelings of sadness and loss of interest in activities once enjoyed). Observation of all exit doors on 04/15/2025 at 1:20 PM revealed the doors closed and locked properly and alarms could be heard at the nurses' stations. During a telephone interview on 03/25/2025 at 9:45 AM (before midday), a nurse at the hospital ER (department equipped to provide emergency care) stated she was told a bystander saw Resident #6 at a free-standing (not attached to a hospital) ER and called EMS (responds to medical emergencies and transports to appropriate hospital).The ER nurse stated she did not know what time the resident was picked up. She stated when Resident #6 arrived at the hospital ER, he did not have any complaints and could not tell them what he was doing or why he went to the free-standing emergency room. She stated Resident #6 was given medication for anxiety and blood pressure. She stated Resident #6 said he was hungry and thirsty, so they fed him and let him hang out. The ER Nurse stated during her break a co-worker was talking to Resident #6 when he received a call from nursing facility staff. The ER Nurse stated her co-worker talked to the facility staff and was told Resident #6 somehow got out of the facility. She stated her co-worker told the facility staff where Resident #6 was. The ER Nurse stated the ADON came to the hospital to pick up Resident #6. The ER Nurse stated they were concerned because the nursing facility did not know the resident was out of the building for that long. During an interview on 03/25/2025 at 2:30 PM (after midday), the ADON stated LVN E called him on 03/14/2025 about 1:30 AM to notify him Resident #6 was missing. The ADON stated LVN E told him he had not seen Resident #6 during his shift, which began on 03/13/2025 at 10:00 PM. The ADON stated LVN E told him CNA C did not see Resident #6 when he made rounds at 11:00 PM. The ADON stated he told LVN E he should have been notified at 11:00 PM when they could not find the resident. The ADON stated he called LVN A, who was Resident #6's nurse the previous shift on 03/13/2025 from 2:00 PM to 10:00 PM. The ADON stated LVN A said just before 10:00 PM Resident #6 told him he was going to his room to lay down and LVN A saw the resident before he left the facility. The ADON stated LVN A called him on 03/14/2025 at 2:12 AM and told him Resident #6 was at the hospital emergency room. The ADON stated he understood Resident #6 called LVN A who spoke with a nurse in the emergency room. The ADON stated he drove to the hospital to pick up Resident #6 and hospital staff told him there was no need to admit Resident #6. The ADON stated hospital staff told him EMS brought the resident to the hospital ER after he was seen outside a free-standing ER and said he needed help. The ADON stated he returned Resident #6 to the facility where he was placed on one-on-one monitoring until he discharged later that day to another facility. The ADON stated upon his return from the hospital, he immediately did a head count to ensure all residents were accounted for. He stated he contacted the administrator, the director of nurses, the residents family, and the resident's doctor. He stated a wander assessment was completed for all residents, door lock codes were changed, and staff members received in-service training on resident elopement. He stated LVN E was no longer employed at the facility. The ADON stated he believed the resident left the faciity on [DATE] during shift change between 10:30 PM- 11:00 PM. The ADON stated Resident #6 may have exited during shift change, while staff members were entering and leaving the facility, since the door did not alarm. During an interview on 03/25/2025 at 2:55 PM, LVN A stated he was Resident #6's nurse from 2:00 PM-10:00 PM on 03/13/2025. He stated Resident #6 went to his room about 10:00 PM and he was in his room when LVN A left about 10:15 PM. LVN A stated it was after 1:00 AM on 03/14/2025 when Resident #6 called from his cell phone. LVN A stated Resident #6 was aphasic and when trying to communicate his words would get jumbled. He stated if you catch the first couple of words, you can usually figure out what the resident was trying to say. LVN A stated the resident gave the phone to a nurse who said the resident was in the hospital ER. LVN A stated he contacted the ADON and told him where the resident was. An interview was attempted with CNA C on 03/25/2025 at 3:10 PM and was unsuccessful. During an interview on 03/25/2025 at 3:54 PM, the Administrator stated on 03/14/2025 at 11:00 PM staff noticed Resident #6 was not in his room. She stated the resident was rarely in his room. She stated he was usually in the court-yard or the day room. She stated staff did not think much about it, because Resident #6 was only in his room to sleep. She stated she was not sure what time facility staff notified the ADON Resident #6 was not at the facility. She stated facility staff searched all the rooms, closets, offices, common areas, storage areas, and outside the building. She stated a facility nurse spoke with Resident #6 on his cell phone and he gave his phone to a nurse who reported the resident was at the hospital emergency room. She stated the ADON was called, and he went to the hospital and brought Resident #6 back to the facility. The Administrator stated a full skin assessment was completed when the resident returned to the facility, and he had no pain or injury. The Administrator stated the resident was placed on one-on-one monitoring until he was discharged to a facility with a locked unit on 03/14/2025. An interview was attempted with LVN E on 03/25/2025 at 4:23 PM and was unsuccessful. During an interview on 03/25/2025 at 4:35 PM, the DON stated a wandering assessment was completed for all residents on admission and then quarterly. She stated Resident #6 had not displayed exit seeking behavior prior to the elopement. The DON stated after Resident #6 eloped, his care plan was updated and an elopement risk was completed for all residents. She stated no other resident triggered for elopement risk. The DON stated if a resident were exit seeking, the social worker would be notified to look for a secure unit. During an interview on 03/26/2025 at 1:35 PM, the Social Worker stated she was responsible for sending out referrals to find placement. She stated after Resident #6 was able to get out of the building, he could no longer stay at the facility. She stated Resident #6 was placed on one-on-one monitoring until he was transferred to another facility on 03/14/2025. She stated the facility provided in-service training and went over elopement protocols. During an interview on 03/26/2025 at 2:20 PM, CNA B stated she worked 2:00 PM-10:00 PM on 03/13/2025. CNA B stated during her shift Resident #6 kept asking for the time. She stated Resident #6 came out of his room with his coat when he saw she was getting ready to leave and LVN A distracted him. CNA B stated she later realized Resident #6 had asked for the time so he would know when to be at the door. She stated he was not around the door when she left the facility after her shift. CNA B stated LVN A called her on 03/14/2025 at about 1:30 AM and said the ADON texted him that Resident #6 had left the facility. She stated a few minutes later, Resident #6 called her from the hospital ER and she called LVN A on her tablet so the three could communicate. She stated Resident #6 was aphasic and difficult to understand. She stated other people were heard in the background and it took about 10 minutes of them asking Resident #6 to give the phone to someone before he did. CNA B stated the person who took the phone could not provide information about Resident #6 but told them where he was. She stated LVN A notified the ADON. During an interview on 04/15/2025 at 1:15 PM, the Administrator stated Resident #6 was not a known elopement risk. She stated criteria which indicated a resident was high risk for elopement included going to a door, pushing on a door, not re-directable, or exiting the facility. She stated prior to accepting a resident, they always asked the family if there were attempts to leave the home. She stated if they had left home or attempted to but were unsuccessful, they were not accepted. She stated they did not accept a resident from another facility who had this concern. The Administrator stated staff attended elopement in-service training and participated in elopement drills after Resident #6 left the building. She stated training included what to do if staff noticed someone was missing or trying to leave. She stated if a resident was not seen, staff should check to see if they signed out. She stated if not, staff should check every room in the facility and around the outside of the building. She stated if the resident was not found, the police were to be notified. She stated some residents were more independent and if a resident was not seen when staff was rounding, they must look until they lay eyes on the resident. The Administrator stated some resident rooms had a camera but the facility had not placed any cameras inside or outside of the building. An interview attempt with Resident #6's family member on 04/15/2025 at 1:53 PM was unsuccessful. Interviews on 03/25/2025-03/26/2025 and 04/15/2025-04/16/2025 were conducted with multiple staff members which included the Administrator, DON, ADON, LVN A, CMA F, CNA G, Receptionist, Social Worker, CNA B, CNA H, CNA I, LVN J, Maintenance Supervisor, Environmental Services, RN K, Speech Therapist, Physical Therapist, and CNA L. Interviews across multiple shifts revealed staff members received elopement in-service training and participated in elopement drills. The elopement in-service training/drills reflected each staff member was designated an assigned search area and provided a census to cross reference and ensure each resident was present. Staff was educated that when rounding they must lay eyes on each resident. If a resident was not in their room when rounding, staff must search every room in the facility to ensure they were in the building and safe. If a resident was not located, staff must initiate the elopement procedure. If a resident was not located inside or outside the building, police, family, and the physician must be notified. No lack of knowledge or procedure was identified. The facility initiated the following interventions prior to the state surveyor entry on 03/25/2025: Record review of Resident #6's clinical file on 03/25/2025 at 11:15 AM reflected the following: -A full skin assessment of Resident #6, dated 03/14/2025, was completed with no injuries or pain. -Resident #6's Comprehensive Care Plan was updated on 03/14/2025 after the resident exited the building. - Record review of Resident #6's risk assessment, dated 03/14/2025, reflected a score of 11, which indicated a high risk for wandering. -The facility provided a log, dated 03/14/2025, of 1:1 (constant observation) staff monitoring from 2:45 AM until Resident #6 discharged on 03/14/2025 at 4:30 PM. -The medical doctor, psychiatrist, director of nurse, administrator, and Resident #6's family member were notified of the elopement on 03/14/2025. -Documentation of elopement drills and education with all employees beginning with 1st shift staff on 03/14/2025. The elopement drills and education included all residents must be visualized upon making rounds, and if they were not seen initially, the staff must conduct a search of the immediate area. If the resident is not located, they initiate the elopement procedures and notify all relevant parties. No lack of knowledge or procedure was identified. -Elopement drills and in-service training , signed by staff members on 03/14/2025, were cross referenced with the facility staff list to ensure all staff were educated. Record review of the facility's policy Elopements, dated 3/15/2022, reflected .4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate and extensive search of the surrounding area. Record review of the facility's policy Wandering, Unsafe Resident, revised 3/01/2022, reflected 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) . 7. Staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide appropriate or obtain from an outside resource routine dental services, to the extend covered under the State plan, and emergency dental services to meet the needs of each resident for 1 of 6 residents (Resident #1) reviewed for dental. The facility failed to provide proper dental care and assure the denture concerns were addressed with Resident #1. This failure could place residents at risk of not receiving the care needed to maintain their highest, practicable, physical, social, and psychosocial level of well-being. Findings include: Record review of Resident #1's face sheet, dated 03/28/25, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Chronic Obstructive Pulmonary Disease (lung disease that leads to breathing issues), Dysphagia (difficulty swallowing food or liquids), and Bipolar Disorder (shifts in mood, energy, and activity levels). Record review of Resident #1's Care Plan, dated 08/09/24, reflected Resident #1 was on a regular diet, with regular consistency. Record review of Resident #1's quarterly comprehensive MDS assessment, dated 02/24/25, reflected Resident #1 has a BIMS score of 15, which indicated Resident#1's cognition was intact. Section L on the MDS assessment reflected Resident #1 had no problems with dental care. Record review of a dental treatment note, dated 01/17/25, reflected Resident #1 was seen by the dentist and the document noted new dentures were delivered to Resident #1, the dentures were tried on, and Resident #1 was satisfied with the fit. Record review of a dental treatment note, dated 01/27/25, reflected Resident #1 was seen by the dentist and the document noted, F/F not fitting, got them last week. In an observation and interview on 03/28/25 at 10:30 AM, Resident #1 did not have his bottom dentures in his mouth. Resident #1 stated his bottom dentures did not fit, which made it hard for him to eat certain foods. He stated he was unable to eats items like chicken or pork chops, and he had to cut up food items like hamburgers. Resident #1 stated if he left the bottom denture in his mouth, it would have caused pain, but he never wore the bottom denture. Resident #1 stated he told someone in January of this year that his dentures did not fit properly. Resident #1 stated he recently told the ADON about two weeks ago about his dentures not fitting. Resident #1 stated the ADON told him he would contact the dentist to get the issue resolved. Resident #1 stated he told the ADON he did not want to see the mobile dentist the facility used and wanted to go into an actual dentist office. Resident #1 stated the ADON stated he would check on a few things and let him know what could be done for the denture concern. Resident #1 stated the ADON had not followed up about the concern. In an interview on 03/28/25 at 11:58 AM, the Social Worker stated she was not aware or had been informed Resident #1 had issues with his dentures. She stated if she was aware she would have put Resident #1 on the list to be seen by the dentist. The Social Worker stated if Resident #1 was in pain, she would have sent an email to have him seen by the dentist immediately. The Social Worker stated a virtual appointment could have been made, so the dentist could see the issue with Resident #1's dentures as well. She stated the doctors and dentists will upload their own notes, and then it was the responsibility of the nursing staff to review those notes and follow-up with any orders or concerns. In an interview on 03/28/25 at 12:53 PM, the ADON stated Resident #1 complained to him about his denture problem. The ADON stated in January, Resident #1 first said his dentures fit, but a few days later told him they did not fit well. He stated Resident #1 stated the bottom denture was too big. The ADON stated Resident #1 felt the dentist the facility used was not suitable, and the resident asked to be sent out to another dentist. He stated he told him he would look into it and see what his insurance approved. The ADON stated he first told him about two weeks ago, and he still needed to check Resident #1's insurance. The ADON stated he did not follow up on the denture concern, because Resident #1 had not complained about it in two weeks. The ADON stated he did not let the Social Worker know or document the concern on Resident #1's electronic record. The ADON stated he felt there was no risk, because Resident #1 saw the dentist within two months of admitting to the facility, and he stated he felt there was no risk since Resident #1 had not complained within the last two weeks. The ADON stated if he knew it was still a concern he would have followed-up immediately. The ADON stated the resident actually gained weight, so he did not think there was a risk. The ADON stated he should have let the DON or the Social Worker know about Resident #1's denture concern. In an interview on 03/28/25 at 1:38 PM, the DON stated she was not aware Resident #1 had an issue with his dentures. She stated she was not aware he was unable to eat certain items. The DON stated the ADON never told her Resident #1 voiced concerns to him, and he did not document the concern for her to review. The DON stated if she knew she would have notified the Social Worker and had her follow up immediately. The DON stated the risk of Resident #1 not having proper fitting dentures was his inability to eat a proper diet. In an interview on 03/28/25 at 2:20 PM, the Administrator stated she was unaware Resident #1 had issue with his dentures. She stated the Social Worker handled it today once she became aware. She stated Resident #1 was on the list to be seen the next time the dentist visited. The Administrator stated there was no risk, because the resident was seen twice in January and the dentist noted they would follow up regarding the bottom denture. The Administrator stated Resident #1 would be seeing the dentist during the next visit on 04/17/25. Record review of the facility's policy, titled, Dental Services, dated 11/01/17, reflected the following: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.

Jan 2025 5 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or quality of life, recognizing each resident's individuality for 1 (Resident # 24) of 6 residents observed for resident rights. CNA A and CNA B failed to provide Resident #24 with full privacy while he was receiving incontinent care. This failure could place residents at risk of not being treated with dignity and respect. Findings included: Record review of Resident #24's admission Record dated 1/6/25 reflected he was a [AGE] year old male admitted to the facility 4/22/19. Record review of Resident #24's Quarterly MDS assessment dated [DATE] reflected he had severely impaired cognition, he was dependent on staff for toileting, bathing and dressing and required maximum assistance for transfers. He had an indwelling catheter and was frequently incontinent of bowel. His diagnoses included hypertension (high blood pressure); urinary tract infection, stroke, hemiplegia (muscle weakness or partial paralysis on one side of the body), anxiety disorder, depression, and personal history of urinary tract infections Record review of Resident #24's Care Plan reflected the following entry initiated 8/19/22 Focus: [Resident #24] has bowel incontinence . Goal: [Resident #24] will have no complications r/t bowel incontinence .Interventions: Check resident every two hours and assist with toileting as needed, provide pericare after each incontinent episode. During an observation and interview on 1/6/25 at 2:15 PM, Resident #24 was observed in his wheelchair in his room. He was awake and answered questions mainly using yes and no responses. His catheter was observed with a privacy bag attached to his wheelchair. He was transferred to his bed via mechanical lift by CNA A and CNA B. Both CNAs washed their hands, donned gloves and masks and proceeded to provide incontinent care. Resident #24 was lying in bed, his pants and brief were removed leaving him exposed from the waist down. His bed was positioned close to the door to his room. There was no privacy curtain on his side of the room to prevent his exposure to the door. During his care, a knock was heard on the door on two occasions. Both times, the door was opened by unknown persons who leaned their heads into the room, paused, then retreated and closed the door. Neither CNA A or CNA B called out to stop whoever was knocking at the door from opening the door or verbally indicate they were providing care. Both CNA A and CNA B stated they did not know why there was no privacy curtain in the room. CNA B stated resident #24 had recently moved back to the room after being in isolation on another room on the hall. He noted the hooks present on the curtain track above Resident #24's bed and stated it had possibly been removed for cleaning. CNA A stated she typically worked another section of the hall and had not noticed the curtain was missing. Both stated the residents could be embarrassed if exposed during care. CNA A stated they should have asked housekeeping staff if a curtain was missing. During an interview on 1/6/25 at 4:13 PM, the DON stated she did not know why the privacy curtain was missing from Resident #24's room. She stated the curtains were typically replaced at the same time they are removed for cleaning. She stated the staff could have call out they were providing care when knocks were heard at the door and staff should wait for a response when knocking on a door before entering. She stated the risk was a violation of the resident's privacy. During an interview on 1/7/24 at 11:32 AM, the ADON stated privacy curtains were checked as part of weekly room inspections conducted by housekeeping. He stated he was unsure when the curtain had been removed and they were usually replaced at the same time they are removed for any reason. He stated Resident #24 had recently had a deep cleaning done on his room but was unsure of the exact date. The ADON stated, staff should always knock and wait for an answer before entering any room. He stated staff providing care should call out 'patient care' if someone knocked or attempted to enter a room during care. He stated the risk was a loss of the resident's privacy and dignity. During an interview on 1/7/25 at 12:05 PM, LVN C stated she worked the 6 AM to 2 PM shift. She stated she did not notice Resident #24's privacy curtain was missing and did not know when it had been removed. She stated she could not recall whether it had been there when she provided his care the day prior. She stated it caused a risk of privacy loss for the resident. During an interview on 1/8/24 at 9:10 AM, the Administrator stated she learned the housekeeping department had conducted a deep cleaning on Resident #24's room the week prior. She stated whomever removed a privacy curtain for any reason should have replaced it at the same time and she was unsure why that did not happen. The Administrator stated the risk to the resident was low as there was a door and a curtain was available between the roommates' beds. She stated the lack of a privacy curtain removed a layer of privacy for the resident between Resident #24's bed and the door. The Administrator stated she had been unable to locate a policy specific to privacy curtains and would continue to look. During an interview on 1/8/24 at 9:51 AM, the Housekeeping Supervisor stated he made general facility rounds daily. He stated privacy curtains were removed weekly and as needed for cleaning and were supposed to be replaced at the same time. He stated they keep a stock of clean curtains available at all times. The Housekeeping Supervisor stated he believed Resident #24's room was done the week prior because his hall was due that week. He stated he did not know why his curtain was not replaced at the same time and he had not noticed it missing during his rounds. He stated the risk to residents was embarrassment if the door was open and he was exposed to the hallway during care. During an interview on 1/8/25 at 3:56 PM, RN D stated she worked the 2 PM to 10 PM shift and cared for Resident #24. She stated she had worked with Resident #24 the week prior and felt sure he had a privacy curtain at the time. She stated she would have used the curtain while providing his catheter care. She stated the risk would have been a loss of his privacy. Record review of the facility's policy titled, Dressing and Undressing the Resident, Revision Date 6/1/12, reflected: Purpose: The purposes of this procedure are to assist the resident as necessary with dressing and undressing and to promote cleanliness .General Guidelines: 1. Allow the resident as much privacy as possible while he or she is dressing or undressing . Record review of the facility's policy, Residents' Rights Nursing Facilities, dated April 2019, reflected: .You have the right to: Be treated with dignity, courtesy, consideration and respect .Privacy, including privacy during visits, phone calls and while attending personal needs .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #24) of 3 residents reviewed for catheter care. The facility failed to ensure Resident #24 had a catheter stabilization device. These failures could place residents at risk of urinary tract infections and injury from trauma. Findings included: Record review of Resident #24's admission Record dated 1/6/25 reflected he was a [AGE] year old male admitted to the facility 4/22/19. Record review of Resident #24's Quarterly MDS assessment dated [DATE] reflected he had severely impaired cognition, he was dependent on staff for toileting, bathing and dressing and required maximum assistance for transfers. He had an indwelling catheter and was frequently incontinent of bowel. His diagnoses included hypertension (high blood pressure); urinary tract infection, stroke, hemiplegia (muscle weakness or partial paralysis on one side of the body), anxiety disorder, depression, and personal history of urinary tract infections. Record review of Resident #24's Order Summary Report dated 1/8/25 reflected: 10/14/24 Catheter: Ensure catheter securement device and privacy bag in place every shift. Record review of Resident #24's Care Plan reflected the following entry initiated 4/22/24 Focus: [Resident #24] has a chronic indwelling suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen) . Goal: [Resident #24] will remain free from catheter related trauma .Interventions: .Urinary catheter care Q shift. Record review of Resident #24's Treatment Administration Record dated January 2025 reflected: Catheter: Ensure catheter securement device and privacy bag in place every shift . The entry was initialed as completed by LVN C on 1/6/25 during the 6 AM to 2 PM shift. During an observation and interview on 1/6/25 at 2:15 PM, Resident #24 was observed in his wheelchair in his room. Enhanced Barrier Precautions signage was observed hanging outside his door and PPE supplies were observed outside his door. He was awake and answered questions mainly using yes and no responses. His catheter was observed with a privacy bag attached to his wheelchair. He was transferred to his bed via mechanical lift by CNA A and CNA B. Both CNAs washed their hands, donned gloves and masks and proceeded to provide incontinent care. Resident #24 had a suprapubic catheter in place. The tubing was not secured in any way to his body. CNA B stated the tubing was sometimes secured to his leg with a strap to keep it from moving around and he did not know why it was not at that time. During an observation and interview on 1/6/25 at 4:13 PM, the DON stated she had spoken with LVN C, who was Resident #24's charge nurse during the day shift, about his catheter and the LVN had told her the resident had a shower that day and she had forgotten to replace the device. The DON showed the device used by the facility which was a clip attached to an adhesive patch that was to be placed on the resident's leg. The DON stated the risk of not securing catheter tubing was that the tube could become dislodged and cause bleeding. She stated she provided additional in service to LVN C after speaking with her. During an interview on 1/7/25 at 12:05 PM, LVN C stated she worked the 6 AM to 2 PM shift and she checked Resident #24's catheter every day. She stated she had changed his catheter bag on 1/6/25. She stated they checked his urine every shift because he was taking coumadin (a blood thinner) and they monitored him for bleeding. She stated she forgot to go back and change his strap after she changed his bag. She stated the risk for not securing his catheter was the tubing could slide out and cause bleeding. She stated Resident #24 used a wheelchair and a mechanical lift placing him at risk of getting his tubing caught. During an interview on 1/8/25 at 3:56 PM, RN D stated she worked the 2 PM to 10 PM shift and cared for Resident #24. She stated she provided catheter care for Resident #24 every shift which included cleaning the insertion site, monitoring for any bleeding or infection and ensuring the tubing was secured to his leg. She stated securing the tubing was important to reduce his risk of bleeding or the catheter becoming dislodged. Record review of the facility's policy titled, Catheter Care, Urinary, Revision Date 5/31/12, reflected: Purpose: The purpose of this procedure is to prevent infection of the resident's urinary tract .General Guidelines: .15. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.). 16. Report unsecured catheters to the supervisor. Be observant of skin irritation .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #24) of four residents observed for infection control. CNA A and CNA B failed to follow Enhanced Barrier Precautions while providing incontinent care to Resident #24. These failures place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #24's admission Record dated 1/6/25 reflected he was a [AGE] year-old male admitted to the facility 4/22/19. Record review of Resident #24's Quarterly MDS assessment dated [DATE] reflected he had severely impaired cognition, he was dependent on staff for toileting, bathing and dressing and required maximum assistance for transfers. He had an indwelling catheter and was frequently incontinent of bowel. His diagnoses included hypertension (high blood pressure); urinary tract infection, stroke, hemiplegia (muscle weakness or partial paralysis on one side of the body), anxiety disorder, depression, and personal history of urinary tract infections. Record review of Resident #24's Order Summary Report dated 1/8/25 reflected: 10/14/24 Enhance Barrier Precautions for Foley Catheter. Record review of Resident #24's Care Plan reflected the following entry initiated 6/11/24: Focus: [Resident #24] is on enhanced barrier precautions D/T suprapubic catheter [a tube that drains urine from the bladder through a small incision in the lower abdomen] . Goal: [Resident #24] will remain in enhanced barrier precautions without complications through next review. Interventions: .Proper use of PPE to be observed, use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO; Staff to don and doff according to recommendations, which is before entering residents toom and before leaving room .These precautions to be observed by staff during high contact resident care like dressings, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting . During an observation and interview on 1/6/25 at 2:15 PM, Resident #24 was observed in his wheelchair in his room. Enhanced Barrier Precautions signage was observed hanging outside his door and PPE supplies were observed outside his door. He was awake and answered questions mainly using yes and no responses. His catheter was observed with a privacy bag attached to his wheelchair. He was transferred to his bed via mechanical lift by CNA A and CNA B. Both CNAs washed their hands, donned gloves and masks and proceeded to provide incontinent care. Neither CNA donned a gown. Resident #24 had a suprapubic catheter in place. The catheter insertion site and tubing were cleaned during care. Both CNAs performed hand hygiene and changed gloves during care. After care, when CNA A was shown the Enhanced Barrier Precaution sign outside the room, she stated she had received in-service training about the precautions. She stated she worked on another hall but had assisted with Resident #24 on occasion. She stated she was aware he had recently been on isolation for a urinary tract infection but he had since been cleared. She stated she thought the signs were left up by mistake from his previous isolation. CNA A stated she was unaware of the continued need to wear a gown due to his catheter. CNA B joined the conversation and stated he also thought Resident #24's precautions had been lifted. He stated he was unaware of the continued need for wearing a gown. Both CNAs stated the risk for not following proper infection control procedures was the spread of infections between residents and staff. During an interview on 1/6/25 at 4:13 PM, the DON stated CNA A and CNA B had informed her about the issues regarding following enhanced barrier precautions. The DON and the Corporate Nurse stated both had been in-serviced before and were just re-trainied on the procedures. The DON stated they may have gotten confused as Resident #24 had recently come off isolation precautions. They stated they were already in the process of re-training all staff related to enhanced barrier precautions and the need for proper PPE. The DON stated the risk of failing to wear proper PPE was cross contamination and spread of infection between residents and staff. During an interview on 1/7/25 at 11:32 AM, the ADON stated he discussed enhanced barrier precautions with the staff on an ongoing basis. He stated he reminds them to always pay attention to the types of isolation precautions in place for any given resident. He stated the risk to residents was infection transmission. During an interview on 1/7/24 at 12:05 PM, LVN C stated she was Resident #24's charge nurse during the day shift. She stated he was on enhanced barrier precautions due to his catheter because it was an indwelling device and artificial body opening. She stated a gown and gloves should be used for all direct care. She stated the risk to residents was infection transmission. During an interview on 1/8/24 at 8:45 AM, the Corporate Nurse stated the facility followed their policy and CDC guidelines related to Enhanced Barrier Precautions. Review of the CDC website on 1/8/24 reflected: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html reflected: Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) . Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Standard Precautions still apply while using Enhanced Barrier Precautions. .Enhanced Barrier Precautions require the use of gown and gloves only for high-contact resident care activities (unless otherwise indicated as part of Standard Precautions). .Assuming Contact Precautions do not otherwise apply, Enhanced Barrier Precautions are recommended for residents with any of the following: 1) infection or colonization with a MDRO or 2) a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO . Record review of the facility's policy titled, Enhanced Barrier Precautions, dated 6/17/24, reflected: Enhanced Barrier Precautions shall be used at this facility per CDC requirements . The facility understands that EBP is used for the safety and protection of both staff and residents. EBP are indicated for residents with any of the following: .wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide food that was palatable and attractive for two meals from the facility's only kitchen (lunch meals on 01/7/25 and 01/8/25) reviewed for food and nutrition services. The facility failed to deliver food with an appetizing taste for the lunch meal on 01/07/25 and 01/8/25. The deficient practice could place residents at risk of poor intake of nutrition, weight loss, and a decreased quality of life. Findings included: Observation on 01/7/25 at 12:00 PM revealed the 3 lunch test trays for a regular diet, a pureed diet, and a dysphagia altered diet was tasted by four state surveyors. The meal consisted of Swedish Meatballs, Sliced Glazed Carrots, Egg Noodles, [NAME] Dinner Roll, and spiced peaches. The state surveyors stated the glazed carrots, dinner roll, and noodles were tasteless. Surveyor observed kitchen staff plating the food using warmer plates and a cover. Observation on 01/8/25 at 12:00 PM revealed the 3 lunch test trays for a regular diet, a pureed diet, and a dysphagia altered diet was tasted by four state surveyors. The meal consisted of Open Faced Roast Pork Sandwich with brown gravy, Mashed Potatoes, Herbed [NAME] Beans, Lemon Cake. The mashed potatoes were bland tasting, the green beans had a strong vinegar taste. Surveyor observed kitchen staff plating the food using warmer plates and a cover. Dietary Manager stated she was suprised to hear about the taste of the food. During a confidential interview a resident stated the food was not all that great'. The resident stated they ate in their room and lunch and dinner were served cool. They stated it was so salty I can't eat it most of the time. The resident denied complaining to anyone about the food. During a confidential observation and interview a resident stated they ate some meals in the dining room and others in their room. The resident stated meals were often late on the weekends. The resident presented a small bag with what they stated was a piece of cake in it, the cake looked as though it had been squeezed and the resident stated that was the way it had been provided the evening before. They stated the cakes were often burned or undercooked and tasted like batter. The resident stated the cake should be served in a bowl and not a plastic bag. The resident stated the kitchen tended to put gravy on everything, even meatloaf and it made them angry. They stated they didn't complain because they felt there was no point. During a confidential interview it was stated the breakfast is good most of the time but lunch and dinner not so much. Resident stated the food is sometimes cold. During a confidential interview, a resident stated they felt like the food generally tasted ok but was often served cold. They stated they mainly ate the dining room and foods like French fries were often cold. They stated, It tastes like they cook them first and leave them sitting there while they cook the other food so they're cold when they make it to the tables. During a Confidential interview, a resident stated the food is crappy. Resident said the food is sometimes cold when received, resident stated he eats in his room. During a confidential interview, a resident stated the food at the facility had improved since they moved there but it was cold more often that it's not. The resident stated they ate in their room more than the dining room and food was served cold in both areas. Interview on 1/6/2025 at 1:00 PM, Resident #22 stated the food is not good. It could be made better if they make sure the food is not cold. Interview on 01/08/25 at 4:45 PM, Dietitian stated the kitchen staff follows recipes in regard to seasoning the food. Surveyors tasted the mashed potatoes in the dinner meal lacking an appetizing flavor. Dietitian stated the green beans served at the dinner meal was seasoned with black pepper although the four surveyors tasted the green beans, and all four surveyors stated the green beans tasted strongly like vinegar. Interview on 01/08/25 at 4:40 PM, the Dietary Manager revealed from time of plating the meals to the meals arriving on the halls equals 10 15 minutes , within appropriate time frame. Dietary Manager was unaware of any resident complaints about the food. Dietary Manager showed surveyor recipe cards that are followed when preparing the food. Record review on 1/8/25 at 4:45 PM, of the Corporate Recipe Number: 4164 recipe card. Starch Potatoes revealed the ingredients of dry mashed potato, boiling water, and margarine. Record review on 1/8/25 at 4:45 PM, of the Corporate Recipe Number: 5349 recipe card. Vegetable revealed the ingredients of Cut frozen green beans, boiling water, dried Thyme leaf, margarine. On 1/6/25 at 2:52 PM review of the mealtimes revealed Breakfast in Dining room [ROOM NUMBER] AM, [NAME] Hall 7:15 AM, Recovery Hall 7:30 AM. Lunch in Dining room [ROOM NUMBER]:30 AM, [NAME] Hall 11:45 PM, Recovery Hall 12 PM. Dinner in Dining room [ROOM NUMBER]PM, [NAME] Hall 5:15 PM, Recovery Hall 5:30 PM. Review of the facility policy titled. Food Preparation Healthcare Services Group, Inc., and its subsidiaries Dining Services Policy and Procedure Manual, Original 5/2014, Revised 9/2017, 10/2022, 2/2023 Policy Statement All foods are prepared in accordance with the FDA Food Code. 4. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater 41 degrees F and/or less than 135 degrees F, or per state regulation. Review of the facility policy titled. Food: Quality and Palatability Healthcare Services Group, Inc., and its subsidiaries Dining Services Policy and Procedure Manual, Original 5/2014, Revised 9/2017, 2/2023 Revealed: Policy Statement Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive and served in a manner, form, and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. Definitions Food attractiveness refers to the appearance of the food when served to the residents. Food palatability refers to the taste and/or flavor of the food. Proper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns. Procedures Procedures guidelines, and standardized recipes. 1. The dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production. 4. The Cook(s) prepare food in accordance with the recipes, and season for region and/or ethnic preferences, as appropriate. Cook(s) use proper cooking techniques to ensure color and flavor retention.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Data (Tag F0851)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS fiscal year 2024 for the second quarter (January 1, 2024, to March 31, 2024) reviewed for Administration. The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for January 1, 2024, to March 31, 2024. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included: Record review of an email sent to the Administrator on 01/07/25 at 10:28 AM, indicated the [NAME] 3 Report records from CMS revealed that the PBJ Data for Quarter 2 2024 (January 1,2024 - March 31, 2024) was not submitted. Record review of an email received from the Administrator on 01/07/25 at 12:14 PM, indicated the information on the [NAME] 3 Report for the PBJ Data for Quarter 2 2024 (January 1 - March 31) was most likely correct. That was with our old ownership, and I don't think they submitted it. Record review of the CMS PBJ Staffing Data Report (Payroll Based Staffing), CASPER Report (Certification and Survey Provider Enhanced Report) 1705 D FY Quarter 2 2024 (January 1 - March 31), dated 12/31/2024, indicated the following entry: Failed to Submit Data for the Quarter Triggered .Triggered=No Data Submitted for the Quarter. In an interview with the Administrator on 01/08/25 at 1:24 PM, she stated that the PBJ Staffing Data for Quarter 2 for the Fiscal Year 2024 would have been submitted to CMS by the previous owner of the company. She stated that the facility had been under new management since May 2024. She stated that the company's current Chief Operations Officer is responsible for submitting the PBJ Staffing Data. She reported that the current owners of the company do not have any access to any of the PBJ Staffing Data that was submitted during their ownership of the company. She stated that the current Chief Operations Officer had been submitting the PBJ Staffing Data since the Change of Ownership occurred at the facility in May 2024. In a telephone interview with the Chief Operations Officer on 01/08/25 at 3:05 PM, he confirmed that his job duties include submitting the PBJ Staffing Data to CMS. He reported that the facility's previous owners were bankrupt and did not pay their vendors. He stated that the current owners of the facility gained ownership of the facility at the end of May 2024. He reported that the current owner made several attempts to the previous owners' vendors to request records but were unsuccessful due to the previous owners having an unpaid balance with the vendors. He reported that the vendors requested to be paid and the account cleared, prior to releasing any requested information regarding the previous company. He reported that due to the circumstances, the current owners do not have any access to any information or data submissions to CMS. He stated he submits the data for the PBJ Staffing Report on the CMS website. He stated that the facility follows CMS guidelines for Direct-Care Staffing Information of the PBJ Data, a policy was not provided. Record review of an email sent to the Administrator on 01/08/25 at 5:12 PM, requesting the facility's policy regarding PBJ Staffing Data Submission. Record review of an email received from the Administrator on 01/08/25 at 5:17 PM, stated the facility did not have a policy regarding PBJ Staffing Data Submission. She stated that the facility used the PBJ Policy Manual provided by CMS as their policy manual. Record Review revealed the facility was unable to provide any policy regarding their failure to report the PBJ Data to CMS for the Quarter 2 2024 (January 1 - March 31). Record Review of the CMS, Electronic Staffing Data Submission Payroll-Based Journal, Long-Term Care Facility Policy Manual, Version 2.6, June 2022, section 1.2 Submission Timeliness and Accuracy, revealed Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. Policy manual revealed, Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely.

Mar 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for one (Resident #1) of eight resident rooms reviewed for homelike environment. The facility failed to clean Resident #1's bathroom for three days. The deficient practice placed residents at risk of negative psychosocial impacts, infection, illness, and room not feeling homelike. Findings included: Record review of Resident #1's Optional State Assessment MDS dated [DATE] revealed she was a [AGE] year-old female an initial admission date of 08/15/2023 and readmitted to the facility on [DATE] with diagnoses of severe obesity, cellulitis (bacterial infection) of abdominal wall, type 2 diabetes (difficulty managing blood sugar levels), major depressive disorder (mood disorder causing persistent feelings of sadness and loss of interest in activities) and a BIMS score of 14 (cognitively intact). Record review of Resident #1's care plan revealed Resident #1 was to be encouraged to sit on the toilet to evacuate bowels if possible. Observation on 03/26/2024 at 3:43 PM of Resident #1 revealed she was sitting up in bed wearing a night gown, watching television, with her call light within reach. Interview on 03/26/2024 at 3:45 PM with Resident #1 revealed housekeeping came and swept and mopped the floor of her main room but did not go into her bathroom. Resident #1 stated that housekeeping had missed cleaning her bathroom in the past and she was not sure why housekeeping did not regularly clean her bathroom. Resident #1 stated she was frequently incontinent of urine and mostly used the bathroom for bowel movements every 2 or 3 days and used baby powder afterwards. Resident #1 stated she usually could move herself from the bed to the wheelchair but sometimes she needed assistance. Resident #1 stated when housekeeping did not clean her bathroom multiple days in a row it increased her depression because she felt forgotten and self-conscious that housekeeping did not want to look in the bathroom because she was obese. Resident #1 stated she tried to tell housekeepers the bathroom needed to be cleaned but there was a communication barrier with housekeepers only speaking Spanish. Observation on 03/26/2024 at 4:29 PM of Resident #1's bathroom revealed a white powder like substance on the floor around the perimeter of the toilet bowl and 4 gloves on the floor by the trash can. Interview on 03/27/2024 at 12:15 PM with Resident #1 revealed housekeeping had swept and mopped the main area of resident's room and did not go into resident's bathroom. Observation on 03/27/2024 at 12:16 PM of Resident #1's bathroom revealed a white powder like substance on the floor around the perimeter of the toilet bowl and 4 gloves on the floor by the trash can. Observation on 03/28/2024 at 8:52 AM of Resident #1's bathroom revealed a white powder like substance on the floor around the perimeter of the toilet bowl and 4 gloves on the floor by the trash can. Interview on 03/28/2024 at 8:57 AM of MA D and CNA E revealed CNA E told a housekeeper on 03/26/2024 that Resident #1's bathroom needed to be cleaned, was not sure of the housekeepers name, and was not aware that it still had not been done. MA D and CNA E stated the impact to resident was infection risk and a negative impact to the resident's psychosocial health. Interview and observation on 03/28/2024 at 9:15 AM revealed the POA and Housekeeper A were cleaning Resident #1's bathroom. The POA stated resident rooms were cleaned once a day and it was important for the resident's mental health and reduced infection risk. The POA stated it was unacceptable that the resident's bathroom was not cleaned for at least 2 days in a row and had not been able to speak with the housekeeper responsible for resident's room. Housekeeper A stated bathrooms not cleaned regularly resulted in resident rooms not feeling homelike and could negatively impact the resident's mental health and increase risk of infection. The POA stated he was responsible for overseeing housekeeping. Interview on 03/28/2024 at 9:48 AM with ADON C revealed resident rooms were supposed to be cleaned once a day and was not aware of any resident bathroom that was not cleaned for 3 days and the risk to the resident included an environment that was not homelike and increased infection risk. Review of the facility's Housekeeping Services Policy titled Housekeeping Services H5MAPL0897 dated January 2016, reflected housekeepers were to use disinfectant to sanitize and clean all surfaces that may be touched by the resident . bathroom fixtures including handrails, sink, and toilet . etc .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one (Resident #2) of five residents observed for infection control. The facility failed to ensure: LVN G donned the gown when she entered Resident#2's isolation room to provide resident care. This failure could place the residents at risk for infection. Findings include: Record review of Resident #2's Quarterly MDS dated [DATE] reflected Resident #2 was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses included pressure ulcer of sacral ( the portion of your spine between the lower back and tailbone) region, and cellulitis ( a bacterial infection involving the inner layers of the skin) of left lower limb. Resident #2 required extensive assistance of at least two people with ADLs. He was totally dependent, 2 persons assist with transfers, toileting hygiene, and dressing. assessment revealed BIMS of 15 indicating the resident was cognitively intact. Record review of Resident #2's physician's order dated 03/26/24 reflected contact isolation precautions for MDRO (multidrug-resistant Organism). The order was dated 03/19/24. Observation on 03/25/24 at 2:43 PM revealed LVN G had on a PPE mask ad gloves, and she did not have a gown on when entering Resident #2's room to administer to Resident #2 his IV medication. She hanged the resident's urine bag to the bed side, and she provided water to the resident. Interview on 03/25/24 at 2:55 PM with LVN G revealed facility staff should be wearing full PPE when entering a resident room who was on contact isolation precautions. She stated full PPE included a gown, gloves, and face mask. LVN G stated she was busy and she forgot to wear the gown. She stated the risk would be spread of infection. In an interview on 03/27/24 at 11:06 AM the DON stated staff should have worn the full PPE including a gown when entering Resident #2's room. She stated Resident #2 was on contact isolation precautions due to his infected wound. She stated it was important to wear proper PPE when going into the resident room on isolation precautions so not to contaminate. Review of facility's staff Inservice for PPE use dated 03/22/24 reflected LVN G was in-serviced by the DON along with other facility staff. Record review of the facility's policy titled, Isolation Categories of Transmission - Based Precautions, revised December 2009, reflected, .Contact Precautions . d. Gown: 1- In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, nonsterile) for all interactions that may involve contact with the resident or potentially contaminated items in the residents' environment .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. On 03/25/2024 [NAME] F failed to log food temperatures for the dinner service. On 03/26/2024 2 loaves of bread, one bag of hot dogs, and 6 hamburger buns were not labeled with a received or opened date. These failures could place residents at risk for food-borne illness and negatively impact the health and nutrition of residents. Findings included: 1. Observation on 03/26/2024 at 11:40 AM of the food temperature log titled Trayline Temperature Log revealed no food temperatures were written for the 03/25/2024 dinner service. Interview on 03/26/2024 at 11:43 AM with the Dietary Manager revealed the cook was responsible for logging food temperatures before residents were served. The Dietary Manager stated [NAME] F did not log the food temperatures for dinner service. The Dietary Manager stated [NAME] F was a new employee and was still learning. The Dietary Manager stated the expectation was for food temperatures be logged for every meal and showed if food temperatures are being monitored by staff. The Dietary Manager stated the risk to residents would be foodborne illness due to being served food that was possibly held at unsafe food temperatures or was not cooked to safe food temperatures. Record review of menu titled Reinhart Foodservice revealed on 03/25/2024 the dinner menu was sausage links, chocolate chip sheet pan pancakes, hashbrown casserole, strawberries and bananas, margarine, syrup, salt and pepper, milk and water. Record review of food policy titled Food Preparation and Service H5MaPL0333 dated 2001 and revised December 2008 revealed The temperature of foods held in steam tables will be monitored by food service staff. 2. Observation on 03/26/2024 at 11:41 AM of the prep table revealed 1 loaf of white sandwich bread, 1 loaf of Italian sandwich bread, a bag of hamburger buns with 6 buns, and a bag hot dog buns with 5 buns had been opened and were unlabeled with a received or opened date. Observation of the alternative menu, undated, revealed for lunch and dinner hamburger on bun, deli sandwich with white or wheat bread, or grilled cheese. Interview on 03/2026/2024 at 11:44 AM with the Dietary Manager revealed he was responsible for labeling and dating food and did not label the bread products because he was not sure if bread needed to be labeled. The Dietary Manager stated he labeled other items he opened, and it was facility policy to label opened food items with an open date. The Dietary Manager stated that undated and labeled bread products could cause food borne illness from expired food or could be stale. Record review of food policy dated 2001 and revised December 2008 revealed Other opened containers must be dated and sealed . during storage. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-305.11 Food Storage. (B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Mar 2024 2 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Notification of Changes (Tag F0580)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify and consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status for 1 (Resident #1) of 5 residents reviewed for Notification of Changes. 1. The facility failed to notify the wound physician on 01/11/24 about an open area discovered on Resident #1's sacrum. The area developed into an unstageable pressure ulcer (PU) (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present) to the sacrum. The WMD assessed and evaluated the sacrum wound on 01/23/24. The WMD categorized the wound as Unstageable (due to necrosis [death of body tissue]) and surgical excisional debridement was performed on the sacrum wound. The WMD categorized the sacrum wound as a Stage 4 pressure wound after the second surgical excisional debridement (cutting away of devitalized [injured, damaged] wound tissue, necrosis, or slough [yellow/white material in the wound bed] down to viable [healthy] tissue, and outside or beyond wound margin using a blade/scalpel) on 01/30/2024. This failure could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection. Findings included: A record review of Resident #1's Annual MDS Assessment, dated 01/02/24, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Resident #1 had diagnoses of Alzheimer's disease (a progressive disease beginning with mild memory loss); Encounter for palliative care; Muscle wasting and atrophy; and Muscle weakness (generalized). Resident #1's BIMS Summary Score was 06, which suggested severe impaired cognition. Resident #1's functional abilities required one-person physical assist with ADLs and transfers. Resident #1 was frequently incontinent of bowel and bladder. Section M - Skin conditions of the Annual MDS Assessment revealed Resident #1 had one or more unhealed pressure ulcers/injuries. Resident #1 had a Stage 4 pressure ulcer and an unstageable pressure injury presented as a deep tissue injury over bony prominences; and was at risk for developing pressure ulcers/injuries based on clinical assessment. Pressure reducing devices for chair and bed, pressure ulcer/injury care, a turning/repositioning program, and applications of ointments/medication other than to feet were active skin and ulcer/injury treatments in place. Resident #1 was under hospice services. Record review of Resident #1's comprehensive care plan [Date initiated: 04/16/2016; Next Review Date: 12/04/23] Focus problem(s) reflected impaired cognitive function; bladder/bowel incontinence; potential for pressure ulcer development; communication problem; unstageable (DTI) pressure injury to right heel; receiving hospice services; Stage 4 pressure injury to left heel; and ADL self-care performance deficit. Resident #1's care plan goals indicated maintain current level of cognitive function; remain free from skin breakdown r/t incontinence; have intact skin, free of redness, blisters, or discoloration; and will be free from infection or complications r/t unstageable DTI pressure injury to right heel and Stage 4 pressure injury to left heel through review date (Target Date: 03/04/24). Resident #1's care plan interventions/tasks revealed bedside care and assistance, medication administration, pain control, fall prevention, position changes, teaching moments, monitoring, and reporting to doctor as needed, to improve the resident's comfort and health. Record review of Resident #1's Wound Evaluation and Management Summary, dated 01/23/24, revealed the WMD performed an initial evaluation of an unstageable (due to necrosis) wound to the sacrum. The WMD documented the etiology (quality) of the wound was Pressure, was Unstageable, a duration of greater than 5 days, measured (LxWxD) 5 cm x 6 cm x Not Measurable [depth is unmeasurable due to presence of nonviable tissue and necrosis (The skin is severely damaged, and the surrounding tissue begins to die)], and light serous exudate. A surgical excisional debridement procedure was performed to the sacrum and a dressing treatment plan was ordered to perform wound care daily for 30 days. Record review of Resident #1's progress notes did not reflected documentation that the WMD was notified of a wound consultation to assess and evaluate the open area to the sacrum. During an interview on 01/29/24 at 11:02 AM, LVN C indicated she was the 6A - 2P nurse Monday through Friday. LVN C indicated the 2P - 10P shift was responsible for providing wound care. LVN C said that skin assessments were completed weekly by the 2P - 10P shift and as needed. LVN C said that although wound care was not scheduled on her shift, she was still responsible for implementing care to prevent skin breakdown and assessing a resident if it was reported to her about a concern about a resident skin noted during a shower or incontinent care. LVN C said that the WMD followed Resident #1 for other wounds and thought ADON A informed the WMD [on 01/11/24] about the open area to Resident #1's sacrum. An outbound call to the WMD on 01/29/24 at 11:09 AM indicated the WMD rounded at the facility every Tuesday. The WMD followed Resident #1 for wounds to the left and right heels. During the wound care visit on 01/23/24, facility nursing staff informed [the WMD] of a wound consultation for Resident #1. The WMD conducted an initial evaluation of Resident #1's sacrum wound on 01/23/24. The WMD indicated the wound exacerbated due to generalized decline of Resident #1, infection, and compromised nutritional status. The WMD ordered Santyl and Xeroform Gauze as a primary dressing and a bordered gauze as a secondary dressing. The WMD recommended to off-load the wound, reposition per facility policy, and low air loss mattress. The WMD anticipated wound healing over two months and would see Resident #1 at the next visit (01/30/24). During a follow-up interview on 02/23/24 at 12:40 PM, ADON A indicated that there were wound and skin management standing delegation orders in place to treat minor skin tears, abrasions, intact and shallow skin impairment with no or minimal drainage. Treatments included cleaning, topical barrier ointments and creams, dressing change frequency, and protecting the site. ADON A said wounds that were open to the level of fatty tissue (or deeper), mostly red, had more than minimal drainage, or non-healing wounds required a consultation with the WMD. ADON A said that he rounded with the WMD during weekly visits to provide support, and complete wound documentation. ADON A said that the WMD needed to assess a wound to determine the appropriate treatment. ADON A said that a nurse would notify him of a change in wound condition or if a wound consult was needed and he would send the face sheet to the WMD as notification. ADON A said that Resident #1 was already followed by the WMD and thought he notified the WMD about the open area discovered to the sacral area. During a follow-up interview on 02/23/2024 at 1:30 PM, LVN C indicated that she vaguely recalled [on 01/11/24] that a CNA (could not recall who it was) called her into Resident #1's room to look at Resident #1's buttocks for possible skin breakdown. LVN C said that she saw a dime-sized open area to the upper midline groove that separates the buttocks. LVN C said that she notified Resident #1's primary physician and received a telephone order to provide treatment [Clean sacrum with wound cleanser, pat dry, apply xeroform and cover with border gauze every evening (2P - 10P) shift] and to consult the WMD. LVN C said that she notified ADON A that Resident #1 needed a wound consult. LVN C said that was the facility protocol to notify the ADON/DON when a resident required a Specialist/Wound Doctor Consultation. The ADON/DON would request the consultation and rounded with the WMD during weekly visits. LVN C said that she did not document the communication with the primary physician or ADON and did not follow-up if the WMD was consulted. LVN C said that documentation was important to ensure continuity of care and consistency. Record review of the facility's Change of Condition and Physician/Family Notification policy, revised 03/25/21, reflected the purpose to ensure resident's family and physician are notified of changes that fall under: - an accident resulting in injury that has the potential for needed physician interventions - a significant change (example given: Abnormal lab results) - a need to significantly alter treatment - transfer of the resident from the facility

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote the prevention of pressure ulcer/injury development, the healing of existing pressure ulcers/injuries, and prevent development of additional pressure ulcer/injury for 1 (Resident #1) of 5 residents reviewed for quality of care, in that: 1. The facility failed to consistently perform weekly skin assessments for Resident #1. 2. On 01/11/24, LVN C notified the primary physician of a dime-sized open area to Resident #1's sacrum. The facility implemented the interventions/treatment to the open area but failed to consult the WMD (for 12 days, 01/11/24 - 01/23/24) as ordered. 3. The facility failed to monitor and reassess the wound to Resident #1's sacrum for evidence of progress toward healing. The wound developed into an unstageable pressure ulcer (PU) (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present). 4. The WMD assessed and evaluated the sacrum wound on 01/23/24. The WMD categorized the wound as Unstageable (due to necrosis [death of body tissue]) and surgical excisional debridement was performed on the sacrum wound. The WMD categorized the sacrum wound as a Stage 4 pressure wound after the second surgical excisional debridement (cutting away of devitalized [injured, damaged] wound tissue, necrosis, or slough [yellow/white material in the wound bed] down to viable [healthy] tissue, and outside or beyond wound margin using a blade/scalpel) on 01/30/2024. These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection. Findings included: A record review of Resident #1's Annual MDS Assessment, dated 01/02/24, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Resident #1 had diagnoses of Alzheimer's disease (a progressive disease beginning with mild memory loss); Encounter for palliative care; Muscle wasting and atrophy; and Muscle weakness (generalized). Resident #1's BIMS Summary Score was 06, which suggested severe impaired cognition. Resident #1's functional abilities required one-person physical assist with ADLs and transfers. Resident #1 was frequently incontinent of bowel and bladder. Section M - Skin conditions of the Annual MDS Assessment revealed Resident #1 had one or more unhealed pressure ulcers/injuries. Resident #1 had a Stage 4 pressure ulcer and an unstageable pressure injury presented as a deep tissue injury over bony prominences; and was at risk for developing pressure ulcers/injuries based on clinical assessment. Pressure reducing devices for chair and bed, pressure ulcer/injury care, a turning/repositioning program, and applications of ointments/medication other than to feet were active skin and ulcer/injury treatments in place. Resident #1 was admitted to hospice services on 07/14/23. Record review of Resident #1's comprehensive care plan [Date initiated: 04/16/2016; Next Review Date: 12/04/23] Focus problem(s) reflected impaired cognitive function; bladder/bowel incontinence; potential for pressure ulcer development; communication problem; unstageable (DTI) pressure injury to right heel; receiving hospice services; Stage 4 pressure injury to left heel; and ADL self-care performance deficit. Resident #1's care plan goals indicated maintain current level of cognitive function; remain free from skin breakdown r/t incontinence; have intact skin, free of redness, blisters, or discoloration; and will be free from infection or complications r/t unstageable DTI pressure injury to right heel and Stage 4 pressure injury to left heel through review date (Target Date: 03/04/24). Resident #1's care plan interventions/tasks revealed bedside care and assistance, medication administration, pain control, fall prevention, position changes, teaching moments, monitoring, and reporting to doctor as needed, to improve the resident's comfort and health. A record review of Resident #1's current Physician's orders reflected: - Start Date 07/14/23: Complete Weekly Skin Assessment. Every evening shift, every Saturday. - Start Date 11/10/23: No shoe on the left foot in pressure boot. Every shift for wound left heel to decrease pressure to foot. - Start Date 01/11/24 [Discontinued 01/24/24]: Treatment: Clean sacrum with wound cleanser, pat dry, apply xeroform and cover with border gauze. Every evening shift for Wound Healing. - Start Date 01/24/24: [Discontinued 01/30/24] Treatment: Clean sacrum with wound cleanser, pat dry, apply Santyl, xeroform and cover with border gauze. May use Wound Gel if Santyl is unavailable. Every evening shift for wound healing. - Start Date 01/24/24: Clean DTI to the right heel, pat dry and apply skin prep to area. Every evening shift for wound healing. - Start Date 01/24/24 [Discontinued: 01/29/24]: Clean wound to left heel with NS, pat dry, apply Antimicrobial wound gel and xeroform, and secure with border dressing daily. Every evening shift for wound healing. - Start Date 01/29/24: Clean wound to the left heel with NS, pat dry, apply Santyl, xeroform and secure with border dressing daily. Every evening shift for wound healing. - Start Date 01/31/24: Treatment: Clean sacrum with wound cleanser, pat dry, apply Alginate Calcium with Silver. Apply Metronidazole sprinkles and cover with border gauze. Cleanse peri wound with Dakin's [solution]. Every evening shift for wound healing. A record review of Resident #1's TAR for January 2024 and February 2024 revealed wound care orders were completed as ordered. Record review of Resident #1's Wound Evaluation and Management Summary's, dated 01/09/24 and 01/16/24, reflected the WMD evaluated and treated wounds on Resident #1's left and right heels. The left heel was a Stage 4 pressure wound greater than 119 days and the right heel was an unstageable DTI with intact skin greater than 71 days. The WMD did not evaluate or provide further intervention for other wounds in these or previous visits. Record review of Resident #1's Wound Evaluation and Management Summary, dated 01/23/24, revealed the WMD performed an initial evaluation of an unstageable (due to necrosis) wound to the sacrum. The WMD documented the etiology (quality) of the wound was Pressure, was Unstageable, a duration of greater than 5 days, measured (LxWxD) 5 cm x 6 cm x Not Measurable [depth is unmeasurable due to presence of nonviable tissue and necrosis (The skin is severely damaged, and the surrounding tissue begins to die)], and light serous exudate. A surgical excisional debridement procedure was performed to the sacrum and a dressing treatment plan was ordered to perform wound care daily with Santyl, Xeroform gauze, and cover with bordered gauze dressing for 30 days. As a result of the procedure, 20 percent of nonviable tissue was removed. Record review of Resident #1's Wound Evaluation and Management Summary, dated 01/30/24, revealed the WMD performed a surgical excisional debridement procedure of the sacrum wound. As a result of the procedure, the nonviable tissue decreased to 40 percent. A dressing treatment plan reflected: . discontinue Santyl and Xeroform Gauze. Add Alginate Calcium with Silver and Metronidazole Sprinkled, continue secondary bordered gauze dressing. Cleanse peri wound with Dakin's [solution] once daily for 30 days. The WMD indicated Resident #1's wound exacerbated due to generalized decline (increased weakness, fatigue, and drowsiness. Changes in cognitive and functional abilities), bacterial skin infection (inflammation of the skin and subcutaneous tissues), and compromised nutritional status. A record review of Resident #1's clinical assessments revealed Skin Assessments: Type: Weekly Date and time: 01/02/24 at midnight Signed and locked: 01/04/24 at 11:05 PM by LVN E Skin Condition: Intact. Site(s): BLANK Comments: LVN E entered, healing pressure wound on the left heel, boots on the left leg without shoes per order, continue to monitor. Type: Weekly Date and time: 01/11/24 at midnight Signed and locked: 01/21/24 at 10:02 PM by ADON A Skin Condition: Intact. Site(s): BLANK Comments: ADON A entered, healing pressure wound on the left heel, boots on the left leg without shoes per order, continue to monitor. Type: Admission Date and time: 01/28/24 at 8:00 AM Signed and locked: 01/28/24 at 8:44 AM by LVN F Skin Condition: Bruises . Redness . New Area. Site(s): Right lateral heel - Stage 1 quarter size no drainage, purple discoloration. Left heel - Stage 3, measured (L x W x D) 4.0 cm x 4.5 cm x 0.2 cm, 25% yellow slough, redness to peri wound, moderate amount of serous sanguineous drainage. Left lateral foot - Stage 1, measured 1.5 cm x 1.5 cm x 0 cm. Sacrum - Stage 3, measured 8.0 cm x 7.5 cm x 2.0 cm, eschar, large amount of purulent drainage. Comments: LVN F entered, Need turning Q2H and PRN, will continue to monitor. Neighbor [Resident #1] has poor appetite. Type: Wound Nurse Weekly Skin Assessment Date and time: BLANK Signed and locked: 01/29/24 at 1:16 PM by LVN C Skin Condition: Bruises . Redness . New Area. Site(s): Left heel: Type - Pressure, Stage - IV, measured (L x W x D) 2.0 cm x 2.0 cm x 0.4 cm. Sacrum: Type - Necrosis, Stage - II, measured 5.0 cm x 6.0 cm x N/A. Right heel: Type - Pressure, Stage - Suspected Deep Tissue Injury, measured 3 cm x 2.5 cm x N/. Description of wounds: Stage 4 Pressure Wound of the Left heel full thickness. Exudate light serous drainage. Has no odor. Thick adherent devitalized necrotic tissue, granulation tissue at 40%, other viable tissue at 40%. Unstageable Sacrum Full thickness has some odor, Exudate light serous drainage, and thick adherent devitalized necrotic tissue at 100%. Unstageable DTI Right Heel undermined thickness has no odor or drainage. Skin is intact with purple/ maroon discoloration. Comments: LVN C entered, Recommendation for neighbor are off load wound, Low air loss Mattress, reposition per facility protocol, Float Heels in bed, and wear pressure off loading boats. A record review of the Weekly Skin Log for January 2024 [01/02/24, 01/09/24, 01/16/24, and 01/23/24] reflected Resident #1 had a wound to the left heel and right foot. The Weekly Skin Logs did not reflect a wound to the sacrum on Resident #1. Record review of Resident #1's progress notes reflected: On 01/04/24 at 10:56 PM, LVN E wrote that a Weekly Skin Assessment was completed. On 01/16/24 at 12:47 PM, a Plan of Care Note entered by Social Services, indicated a Quarterly care conference was held (01/16/24) with the RP and other family members in attendance via telephone. ADON discussed wound care; wounds on heels are improving . Next care conference 04/10/24. On 01/17/24 at 9:41 AM, LVN G wrote, Sacral wound dressing removed and redressed. Redness is minimal with no drainage noted. Monitoring is ongoing. On 01/21/24 at 10:01 PM, ADON A wrote that a Weekly Skin Assessment was completed. Healing pressure wound on the left heel . On 01/24/24 at 12:00 PM, LVN G wrote, [Resident #1] has a new order for treatment. Clean sacrum wound with wound cleanser, pat dry, apply Santyl, xeroform and cover with border gauze. On 01/28/24 at 8:32 AM, LVN C wrote that a Weekly Skin Assessment was completed. Need turning Q2H and PRN, will continue to monitor, [Resident #1] has poor appetite. Observation on 01/29/24 at 10:45 AM, revealed Resident #1 on a low air loss mattress lying on her back with head of bed raised approximately 45 degrees and heel boots applied to both feet. Resident #1 was non-interviewable. Resident #1 did not present with visible injuries or behavior suggestive of abuse, neglect, or SQC. During observation of wound care on 01/29/24 at 10:47 AM, LVN C perform wound care to Resident #1. ADON A assisted LVN C with positioning of Resident #1 during wound care. LVN C observed and assessed wounds to left heel, right heel, and sacrum prior to performing treatment. The old dressings that were removed were dated 01/28/2024. During treatment to the sacrum wound, the old dressing presented a brown discoloration and there was a slight odor to the wound. The wound bed to the left lateral border appeared pink in color. The remaining area of the wound bed was covered with dry, black tissue. LVN C performed wound care in accordance with accepted standards of treatment and per physician's orders. During an interview on 01/29/24 at 11:02 AM, LVN C indicated she was the 6A - 2P nurse Monday through Friday. LVN C indicated the 2P - 10P shift was responsible for providing wound care. LVN C said that skin assessments were completed weekly by the 2P - 10P shift and as needed. LVN C said that although wound care was not scheduled on her shift, she was still responsible for implementing care to prevent skin breakdown and assessing a resident if it was reported to her about a concern about a resident skin noted during a shower or incontinent care. LVN C said that the WMD followed Resident #1 for other wounds and thought ADON A informed the WMD about the open area to Resident #1's sacrum. LVN C indicated that the old dressing removed from Resident #1's sacrum had a brown discoloration, the wound bed presented a partial light red wound bed on the left side, and there was necrotic tissue over the other areas of the wound. LVN C said that she would document her findings on the 24-hour report sheet to communicate with other team members. An outbound call to the WMD on 01/29/24 at 11:09 AM indicated the WMD rounded at the facility every Tuesday. The WMD followed Resident #1 for wounds to the left and right heels. During the wound care visit on 01/23/24, facility nursing staff informed [the WMD] of a wound consultation for Resident #1. The WMD conducted an initial evaluation of Resident #1's sacrum wound. The WMD indicated the wound was unstageable due to necrosis. The WMD spoke to the RP and explained treatment options, risks, benefits, and the need for a surgical excisional debridement procedure to remove necrotic tissue from the sacral wound. The WMD explained to the RP that the necrotic tissue interfered with healing. The RP agreed to the procedure. The WMD performed debridement of the sacrum area and removed over a 5.0 square cm area and 0.3 cm depth of necrotic tissue until healthy tissue (bleeding tissue) was observed. The WMD categorized the wound a Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or able to directly feel fascia [thin casing of connective tissue] or muscle) to the sacrum after debridement. The WMD ordered Santyl and Xeroform Gauze as a primary dressing and a bordered gauze as a secondary dressing. The WMD recommended to off-load the wound, reposition per facility policy, and low air loss mattress. The WMD anticipated wound healing over two months and would see Resident #1 at the next visit (01/30/24). During an interview on 01/29/24 at 12:38 PM, ADON A said that he was responsible for overseeing that skin assessments and wound care was completed as ordered. ADON A said that the nurses were responsible for completing the skin assessments and wound care. ADON A said that he was familiar with Resident #1. ADON A said that he recalled a CNA [later identified as CNA D] telling him about a wound to Resident #1's sacrum. ADON A said he couldn't remember when the incident occurred, but he remembered telling the CNA to apply barrier cream to the buttocks when incontinent care was performed. ADON A said that Resident #1 was already getting wound care to the area that CNA reported. Record review of Resident #1 orders and TAR with ADON A revealed an order to clean, apply xeroform (occlusive dressing for use on low exudating wounds), and apply a dressing to the sacrum 01/11/24 - 01/24/24. ADON A said that the WMD was not following the wound to the sacrum and the order was obtained from the primary physician. ADON A said that the order was temporary treatment until seen by the WMD for an appropriate treatment plan and to reduce the amount of pressure on the site. ADON A agreed that he completed the weekly skin assessment on 01/21/24 and documented Resident #1's skin was intact because the sacral area was not open. ADON A could not explain why the skin assessment date and time reflected 01/11/24 if he performed, signed, and locked the skin assessment on 01/21/24 at 10:02 PM. During an interview on 01/29/24 at 12:51 PM, CNA J said that she worked at the SNF for less than 3 months. CNA J said that she provided care to Resident #1 whenever assigned to the LTC unit. CNA J said that Resident #1 required total assistance by one person with ADLs. CNA J said that Resident #1 had a wound on her bottom and on her heels. CNA J said that she tried to check on residents every two hours or more frequently if a high fall risk or require incontinent care often. CNA J said that she would report to the nurse immediately after provided care to the resident and ensured was safe if discovered a skin tear, redness, a rash, or if a dressing was soiled or came off. CNA J said that she applied barrier cream to Resident #1's buttocks after changing the brief to protect skin when soiled and prevent breakdown of skin. During a phone interview on 01/29/24 at 2:09 PM, CNA D stated she worked at the facility for six months. CNA D indicated on Sunday, 01/21/24, while she provided incontinent care to Resident #1, she saw a green-black discoloration on the tailbone area. CNA D stated she notified ADON A about the findings. CNA D said that ADON A told her to put barrier cream on it. CNA D said she applied barrier cream to Resident #1's buttocks as instructed but not directly on the green-black discolored area. During a follow-up interview on 02/23/24 at 12:40 PM, ADON A indicated that there were wound and skin management standing delegation orders in place to treat minor skin tears, abrasions, intact and shallow skin impairment with no or minimal drainage. Treatments included cleaning, topical barrier ointments and creams, dressing change frequency, and protecting the site. ADON A said wounds that were open to the level of fatty tissue (or deeper), mostly red, had more than minimal drainage, or non-healing wounds required a consultation with the WMD. ADON A said that he rounded with the WMD during weekly visits to provide support, and complete wound documentation. ADON A said that the WMD needed to assess a wound to determine the appropriate treatment. ADON A said that a nurse would notify him of a change in wound condition or if a wound consult was needed and he would send the face sheet to the WMD as notification. ADON A said that Resident #1 was already followed by the WMD and thought he notified the WMD about the open area discovered to the sacral area. During a follow-up interview on 02/23/2024 at 1:30 PM, LVN C indicated that she vaguely recalled [on 01/11/24] that a CNA (could not recall who it was) called her into Resident #1's room to look at Resident #1's buttocks for possible skin breakdown. LVN C said that she saw a dime-sized open area to the upper midline groove that separates the buttocks. LVN C said that she notified Resident #1's primary physician and received a telephone order to provide treatment [Clean sacrum with wound cleanser, pat dry, apply xeroform and cover with border gauze every evening (2P - 10P) shift] and to consult the WMD. LVN C said that she notified ADON A that Resident #1 needed a wound consult. LVN C said that was the facility protocol to notify the ADON/DON when a resident required a Specialist/Wound Doctor Consultation. The ADON/DON would request the consultation and rounded with the WMD during weekly visits. LVN C said that she did not document the communication with the primary physician or ADON and did not follow-up if the WMD was consulted. LVN C said that documentation was important to ensure continuity of care and consistency. Review of the Wound Care policy and procedure provided by the facility, revised September 2016 indicated: - Verify that there is a physician's order. - Review the resident's care plan to assess for any special needs of the resident. - Documentation should include the type of wound care given, date and time, all assessment data, how the resident tolerated the procedure and any problems or complaints made by the resident related to the procedure. If a resident refused and why. Review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy and procedure, revised December 2010 indicated: Assessment and Recognition - The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores . - The physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage 1 pressure area that has not yet ulcerated at the surface. - The physician will help the staff define the type and characteristics of an ulceration. Cause Identification - The physician will help identify factors contributing or predisposing residents to skin breakdown . Treatment/Management - The physician will authorize pertinent orders related to wound treatments . - The physician will help identify medical interventions related to wound management. - The physician will help staff characterize the likelihood of wound healing . Monitoring - During resident visits, the physician will evaluate and document the progress of wound healing . - The physician will help the staff review and modify the care plan as appropriate .

Dec 2023 15 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 of 5 residents (Resident #48) reviewed for accommodation of needs. The facility failed to ensure Resident #48's call light was placed within her reach on 12/05/23. This failure could place dependent residents at risk of injuries and unmet needs. Findings included: Review of Resident #48's face sheet, dated 12/07/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included unspecified psychosis (a condition of the mind that results in difficulties determining what is real and what is not real), and schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal). Review of Resident #48's Quarterly MDS Assessment, dated 09/26/23, reflected she had a BIMS score of 07 indicating moderate cognitive impairment. Further review revealed Resident #48 required extensive assistance for bed mobility, transfers, locomotion on and off unit, toilet use, and personal hygiene. Observation and interview on 12/05/23 beginning at 9:50 AM revealed Resident #48 was lying in her bed and her call light was in her bedside table drawer a few feet from her. Resident #48 said she was doing good but could not reach her call light since it was in the bedside table drawer out of her reach. Observation and interview on 12/05/23 at 10:05 AM revealed Resident #48 was still lying in bed and her call light was in her bedside table drawer a few feet from her. Observation on 12/05/23 at 10:11 AM revealed ADON W walked into and then out of Resident #48's room. Interview on 12/05/23 at 10:12 AM, ADON W stated he went into Resident #48's room to check on her and saw her call light was in her bedside table drawer out of her reach. ADON W said he moved her call light to her bed where she could reach it. ADON W said he was a nurse manager and went around to check on call light placement for residents regularly. ADON W said he assumed staff was in Resident #48's room earlier providing care and must have forgotten to put her call light back within her reach before leaving the room. ADON W said the purpose of the call light was to make sure it was within the resident's reach so the resident could ask for help if they needed anything. Interview on 12/06/23 at 2:43 PM, the CNO stated a resident's call light should be clipped to their pillow or bedsheet, somewhere they could easily reach it. The CNO stated the purpose of the call light was so that the resident could notify or call if they needed something right away. The CNO said the last person in the room was responsible for ensuring it was within reach of the resident. The CNO said nurses should be making rounds to monitor and make sure call lights were within reach of the residents and so do management staff. The CNO said the concern with a resident's call light not being within their reach was that they could need something and not be able to reach staff to let them know. Review of the facility's Answering the Call Light policy, revised September 2003, reflected: .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort including referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for level II resident review upon significant change in status assessment for 1 of 2 residents (Resident #11) reviewed for PASRR. The facility failed to refer Resident #11 to the appropriate state-designated mental health authority for review when he received a new diagnosiss of paranoid schizophrenia on 08/23/23. These failures could affect residents with psychiatric diagnoses who may not be evaluated by the facility and receive needed PASRR services. Findings included: Record review of Resident #11's face sheet, dated 12/07/23, revealed the resident was [AGE] year-old male initially admitted to the facility on [DATE]. His diagnoses included paranoid schizophrenia and major depressive disorder. Record review of Resident #11's MDS quarterly assessment, dated 09/27/23, revealed the resident had active diagnoses of depression, schizophrenia, and anxiety disorders. Resident#11 had moderate cognitive impairment, with a BIMS score of 12. Record review of Resident #11's Care Plan, dated 06/20/23, did not reflect paranoid schizophrenia. Record review of Resident#11 physician orders dated 8/23/23 revealed a new diagnosis of paranoid schizophrenia and risperidone 1 mg by mouth once daily for psychosis. Review of the Resident #11's PASRR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment dated [DATE], reflected he did not have a mental illness. Review of Resident #11's continuity of care document, dated 08/24/23, reflected he was diagnosed with paranoid schizophrenia, which was being medically managed. Telephone interview on 12/07/23 at 12:11 PM with the Regional MDS Coordinator revealed she missed the new diagnosis and that was why she had not initiated significant changes after Resident #11 was diagnosed with paranoid schizophrenia and she was owning the mistakes. The MDS Coordinator stated when Resident #11 received a new diagnosis of mental illness, she would have submitted Form 1012 for the resident to be reviewed for PASRR services. The Regional MDS Coordinator stated she was responsible for ensuring the PASRR Level 1 Screening form was submitted accurately to the long term care portal. The MDS Coordinator said the purpose of the PASRR Level 1 Screening form being accurate was to ensure the resident was receiving the appropriate services. Review of the facility's Resident Assessment Instrument (MDS Completion) & PASRR policy, revised January 2017, reflected: .10.If a new diagnosis is added which would make a resident change from PL1 a positive ,while resident is in the facility, a 1013 form must be completed immediately and submitted to PASRR services within 20 days of noted change .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 resident (Resident #59) reviewed for peripheral intravenous care. The facility failed to ensure Resident #59 PICC line dressing was dated on 12/03/23. This failure placed residents at risk of developing an infection. Findings included: Review of Resident #59's face sheet, dated 12/07/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included charcot's joint left ankle and foot (a chronic destructive disease of the bone structure), type 2 diabetes mellitus (high level of sugar in the blood), muscular wasting and atrophy (wasting of muscle tissue) and cutaneous abscess of right upper limb (localized collection of pus in the skin and may occur on any skin surface). Review of Resident #59's quarterly MDS assessment, dated 12/04/23, reflected a BIMS score of 15 indicating no cognitive impairment. Review of Resident #59's undated care plan did not address her antibiotic therapy. Review of Resident #59's physician's orders as of 12/07/23 reflected an order for Cefepime HCl Intravenous Solution 2 gm/100 mL (Cefepime HCl) Use 20 ml intravenously every 12 hours for wound infection please flush PICC line before and after administer. The order start date was 11/24/23. Review of Resident #59's physician's orders as of 12/07/23 reflected an order for Central, PICC, and Midline flush orders: Number of Lumens: (1) Flush each Lumen with 10cc normal saline every shift for Antibiotic Therapy. The order had a start date of 11/25/23. Review of Resident #59's physician's orders as of 12/07/23 reflected an order for transparent dressings per sterile technique upon admission, every 7 days, and PRN if wet, loose, or soiled. If site is not visible for assessment, change dressing every 48hrs. Change injection caps to each lumen upon admission, every 7 days, and after blood draws. as needed as needed soilage as needed for IV Therapy Change as needed if wet, loose, or soiled. If site is not visible for assessment, change dressing every 48hrs. The order had a start date of 11/25/23. Review of Resident #59's November and December 2023 MAR/TAR revealed the dressing was changed on 11/26/23 and 12/03/23. Observation and interview on 12/06/23 beginning at 9:59 AM with Resident #59 revealed she was laying in her bed and stated she was doing good. Observed Resident #59 had a PICC line in her left upper arm covered with a transparent dressing. The transparent dressing was not dated. There was no redness, drainage, or swelling to the resident's left arm. Resident #59 stated she was on antibiotics due to an infection on her right arm, she stated she had an abscess and had it surgically removed. Resident #59 stated her dressing was last changed on Sunday (12/03/23) or Monday (12/04/23). Observation and interview on 12/07/23 beginning at 10:16 AM with Resident #59 revealed she was laying in her bed. Observed Resident #59 PICC line in her left upper arm covered with a transparent dressing. The transparent dressing was not dated. There was no redness, drainage, or swelling to the resident's left arm. Interview and observation on 12/07/23 beginning at 10:30 AM Am with ADON Z revealed she was the nurse assigned to Resident #59. ADON Z stated Resident #59 had a PICC-line and was on antibiotics. She stated she was unsure when the dressing needed to be changed. ADON Z reviewed Resident #59's physician orders and stated resident dressing needed to be changed every 7 days or PRN if soiled. The ADON stated when a dressing was changed it should be dated. Observed ADON Z entered Resident #59's room and observed Resident #59' PICC line and stated the dressing was not dated. Resident #59 told the ADON that the dressing was changed either Sunday or Monday. ADON Z stated it was the nurse on duty's responsibility to date the dressing after every dressing change. ADON Z further stated the potential risk of not dating the PICC line dressing could cause them to leave the dressing longer or could cause an infection to the site. Interview on 12/07/23 at 10:56 AM with the DON revealed her expectation was for nurses to be checking the PICC lines every shift, flush before and after medication, every shift, and to change the dressing once a week. The DON stated the PICC line dressing should be dated. She stated the nurse who changed the dressing was responsible for dating the dressing. The DON stated the ADONs were responsible for ensuring PICC line dressings were being dated. The DON further stated PICC line dressings should be changed accordingly to prevent chances of infection and dressing should be dated so staff are aware if the dressing had been changed. Review of the facility's Central Venous Catheter Dressing Changes policy, dated April 2009, reflected: The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings .10. Apply sterile transparent dressing (no gauze) to area, making sure to center the dressing over the insertion site. Starting at the catheter, smooth dressing outward toward the edges to remove air. While removing the paper around edges of dressing, press down on the edges of the dressing. Label with initials, date and time.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored securely for one of three medication carts reviewed for storage of medications. The facility failed to ensure the nurse medication cart for the Recovery Unit was locked when unattended on 12/07/23. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: Observation on 12/07/23 at 1:04 PM revealed medication cart for the Recovery Station parked next to the nurse's station facing the 100 Hall was unlocked. Observed 5 residents around the nurse's station. Medication cart was unattended and unlocked. Interview on 12/07/23 at 1:10 PM with RN D revealed the medication cart located at the nurse's station was last used by her. RN D stated when medication cart were not being used they should be locked. RN D was informed the medication cart was unlocked; RN D stated the medication cart was not far from her. Observed RN D locked the medication cart. RN D stated the risk of leaving unlocked medication cart could lead to someone getting into the medications she had in the medication cart. Interview on 12/07/23 at 2:58 PM the DON revealed her expectations when medication carts were not being used was for her nurses to close their computers and to lock the medication cart when they step away or when not being used. She stated the risk of leaving medication cart unlocked would be confused residents taking something. Review of the facility Administering Medications policy, dated April 2012, reflected: .Medications shall be administered in a safe and timely manner, and as prescribed 10. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents for 1 of 1 resident (Resident #30) reviewed for labs and cultures. The facility failed to provide evidence they obtained routine labs for Resident #30's PT/INR levels on 12/02/23 and 12/03/23, as ordered by the physician. This failure could place residents at risk of a delay in receiving the necessary interventions to treat their medical condition(s). Findings included: Review of Resident #30's face sheet, dated 12/07/23, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris (occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body [arteries] become thick and stiff) and atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat). Review of Resident #30's MDS Assessment, dated 10/20/23, reflected he had a BIMS score of 99 indicating he was unable to complete the interview. Further review revealed Resident #30 had an active diagnosis of a cardiorespiratory condition (any disease involving the heart or blood vessels) and that he was taking an anticoagulant. Review of Resident #30's undated care plan reflected the following: Focus: [Resident #30] has coronary artery disease r/t Atrial Fibrillation, Hypertension, and CVA w/ Residual weakness. Goal: [Resident #30] will exhibit reduction of cardiac symptoms through the review date. [Resident #30] will be free from s/sx of complications of cardiac problems through the review date. There was no mentioned of the need for regular lab work to be completed. Review of Resident #30's physician's orders, dated 12/07/23, reflected the following: warfarin sodium oral table (warfarin sodium), give 6.5 mg by mouth one time a day for blood clots with an order start dated of 11/28/23 and PT/INR Daily one time a day for lab with a start date of 12/02/23. Review of Resident #30's December 2023 MAR/TAR reflected he received his warfarin every day since 12/02/23. Review of Resident #30's laboratory work/results reflected no results for his PT/INR lab draws for 12/02/23 or 12/03/23. Review of Resident #30's progress notes for December 2023 reflected no notes for 12/02/23 or 12/03/23 regarding his laboratory work/results or any communication with the NP or Physician. Interview on 12/06/23 at 1:15 PM with Resident #30 revealed he was laying in his bed. Resident #30 said lab came every day to draw his blood and he was not experiencing any issues related to his anticoagulant medication. Resident #30 said the lab company did not come for him today so far and could not remember if they had come earlier in the week or over the weekend. Interview on 12/06/23 at 1:31 PM with LVN R said she was caring for Resident #30 today and was on the anticoagulant warfarin. LVN R said she knew Resident #30 was supposed to have a lab draw daily to monitor his PT/INR levels. LVN R said the lab already came earlier in the day for Resident #30 and the results were still pending. LVN R said typically the lab was drawn during her shift in the morning but the results did not come until the next shift in the afternoon. LVN R said the shift that received the lab results would reach out to the NP or Doctor for any changes in his medications. LVN R said she was not aware of a time that lab had not come in December 2023. LVN R said Resident #30 had not shown any signs or symptoms of an issue related to his anticoagulant. LVN R said if the lab did not come during her shift or Resident #30 started exhibiting signs or symptoms of an issue with his medication, she would contact the lab and the NP both. Interview on 12/06/23 at 2:24 PM with LVN S revealed this was her first day back in a long time and she just started her shift and was not familiar or aware of any orders for Resident #30 yet. Interview on 12/07/23 at 1:08 PM with ADON Z revealed she looked at the lab results received and did not find any for Resident #30 on 12/02/23 or 12/03/23. ADON Z said she was not sure why there were no lab results for those days, but she thought it was because they were not drawn. ADON Z said it was the responsibility of that nurse on duty to ensure the labs were drawn and followed up on or communicated about to the next shift. ADON Z said she expected staff to follow orders and also follow-up with the NP or doctors regarding Resident #30's lab results. Interview via phone on 12/07/23 at 1:22 PM with the NP revealed the doctor ordered daily labs for Resident #30 because they wanted to monitor his levels closely. The NP said staff were supposed to make sure that the lab came every day for Resident #30 and then after they received the results to call and notify her. The NP said the purpose of having the lab drawn daily was to check Resident #30's INR and make sure it was within range. The NP said she was trying to get Resident #30's blood levels to be therapeutic so he did not form blood clots. The NP said anything was possible and it was hard to predict what could happen but based on his clinical chart he was at risk of having a stroke if his blood levels were out of range. Interview on 12/07/23 at 3:03 PM with the CNO revealed she asked ADON Z about Resident #30's lab draws, and it was the responsibility of the nurse on shift of that day to ensure the lab came for him. The CNO said she did not have a lot of information because she just found out about the situation herself. The CNO said ADON Z should have followed-up with the nurses to ensure labs were drawn for Resident #30. The CNO said the purpose of making sure labs were drawn was so that staff knew how to adjust the dose according to those results because it could be dangerous if the dose was too high or low. The CNO said the risk of this was not knowing if staff were giving Resident #30 the correct dose or not without knowing his levels. Review of the facility's Lab and Diagnostic Test Results- Clinical Record policy, revised April 2007, reflected: .1. The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent residents from abuse, neglect, exploitation, and misappropriation of resident property for 2 out of 7 employees (CNA Y and CNA X) reviewed for annual EMR/NAR checks. The facility failed to ensure EMR/NAR checks were completed annually for CNA Y hired 08/04/15 and CNA X hired 07/21/21. This failure could place residents at risk of abuse, neglect, and/or misappropriation of personal property. Findings included: Review of the facility's undated employee list revealed the following staff names and hire dates: CNA Y was hired 08/04/15 and CNA X was hired 07/21/21. Review of CNA Y's latest EMR/NAR search revealed it was run 02/08/18. Review of CNA X's latest EMR/NAR search revealed it was run on 07/01/21. In an interview on 12/06/23 at 3:00 PM with HR stated she had been at the facility for a few months now and was responsible for completing the EMR/NAR searches. HR said she did not know the EMR/NAR searches were supposed to be completed after an employee was already hired. HR said she did not know that EMR/NAR searches were also supposed to be completed annually based on an employee's hire date. HR said the purpose of the EMR/NAR search was to ensure all current employees were still eligible for hire. In an interview on 12/07/23 at 3:34 PM with the Administrator revealed HR was responsible for completing EMR/NAR searches annually for each employee but HR was not aware of that as of yesterday (12/06/23). The Administrator said the VP of Operations was responsible for overseeing employee files and ensuring HR was up to date with all EMR/NAR searches for employees. The Administrator said the concern with the two employee's EMR/NAR searches not being up to date was that if someone had a new criminal history that could potentially affect them from being allowed to work at the facility, they would need to know about it. Review of CNA Y and CNA X's EMR/NAR searches were completed on 12/06/23 with no findings. Review of the facility's Preventing Resident Abuse-001 policy, updated 01/24/17, reflected: .2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: l. Conducting background investigations to avoid hiring persons or admitting new residents who have been found guilty (by a court of law) of abusing, neglecting, or mistreating individuals or those who have had a finding of such action entered into the state nurse aide registry or state sex offender registry. The following registry checks will be completed: .2. Texas Nurse Aide Registry Certification Verification: prior to hire, and annually. 3. Texas Employee Misconduct Registry: prior to hire and annually.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 7 of 10 residents (Residents #2, #9, #22, #27, #39, #44, and #45) reviewed for quarterly assessments, in that: 1. The facility did not ensure Resident #2's Quarterly MDS Assessment, dated 11/02/23, was completed within 92 days of the previous assessment. 2. The facility did not ensure Resident #9's Quarterly MDS Assessment, dated 11/01/23, was completed within 92 days of the previous assessment. 3. The facility did not ensure Resident #22's Quarterly MDS Assessment, dated 11/05/23, was completed within 92 days of the previous assessment. 4. The facility did not ensure Resident #27's Quarterly MDS Assessment, dated 10/13/23, was completed within 92 days of the previous assessment. 5. The facility did not ensure Resident #39's Quarterly MDS Assessment, dated 10/13/23, was completed within 92 days of the previous assessment. 6. The facility did not ensure Resident #44's Quarterly MDS Assessment, dated 11/01/23, was completed within 92 days of the previous assessment. 7. The facility did not ensure Resident #45's Quarterly MDS Assessment, dated 10/11/23, was completed within 92 days of the previous assessment. These failures could place residents at-risk of not having their assessments completed timely. Findings included: 1. Review of Resident #2's face sheet, dated 12/07/23, revealed the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included multiple sclerosis (a disease that affects central nervous system) and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). Review of Resident #2's EHR revealed her quarterly MDS assessment, dated 11/03/23, was still in progress and had not been completed or transmitted to the CMS system. Her previous quarterly MDS assessment was dated 08/03/23. 2. Review of Resident #9's face sheet, dated 12/07/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes and major depressive disorder (a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Review of Resident #9's EHR revealed her quarterly MDS assessment, dated 11/01/23, was still in progress and had not been completed or transmitted to the CMS system. Her previous quarterly MDS assessment was dated 08/01/23. 3. Review of Resident #22's face sheet, dated 12/07/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder (disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and major depressive disorder (a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Review of Resident #22's EHR revealed her quarterly MDS assessment, dated 11/05/23, was still in progress and had not been completed or transmitted to the CMS system. Her previous quarterly MDS assessment was dated 08/05/23. 4. Review of Resident #27's face sheet, dated 12/07/23, revealed the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal) and anemia (a deficiency of healthy red blood cells in blood). Review of Resident #27's EHR revealed her quarterly MDS assessment, dated 10/13/23, was still in progress and had not been completed or transmitted to the CMS system. Her previous annual MDS assessment was dated 07/13/23. 5. Review of Resident #39's face sheet, dated 12/07/23, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included Parkinson's disease (a condition that affects the brain and causes problems with movement, balance, and coordination) and type 1 diabetes. Review of Resident #39's EHR revealed his quarterly MDS assessment, dated 10/13/23, was still in progress and had not been completed or transmitted to the CMS system. His previous admission MDS assessment was dated 07/13/23. 6. Review of Resident #44's face sheet, dated 12/07/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included major depressive disorder (a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities) and schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Review of Resident #44's EHR revealed her quarterly MDS assessment, dated 11/01/23, was still in progress and had not been completed or transmitted to the CMS system. Her previous quarterly MDS assessment was dated 08/01/23. 7. Review of Resident #45's face sheet, dated 12/07/23, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included acute kidney failure (a medical condition in which the kidneys can no longer adequately filter waste products from the blood) and spinal stenosis (the space inside the backbone is too small). Review of Resident #45's EHR revealed his quarterly MDS assessment, dated 10/11/23, was still in progress and had not been completed or transmitted to the CMS system. His previous admission MDS assessment was dated 08/04/23. Telephone interview on 12/06/23 at 1:20 PM with the Regional MDS Coordinator revealed she was assisting the building in completing the residents' MDS assessments since the facility was currently without a MDS Coordinator. The Regional MDS Coordinator said she knew some of the residents' MDS assessments were still in progress and had not been completed or transmitted timely. The Regional MDS Coordinator said she was responsible for making sure the MDS assessments were completed and transmitted timely. The Regional MDS Coordinator said consultants were recently hired to help her complete this task, but she was still overall responsible for ensuring the MDS assessments were completed and transmitted timely (to the CMS system). The Regional MDS Coordinator said the purpose of the MDS was to gather information and have a whole approach to look at during the IDT meetings to meet residents needs socially and psychologically. The Regional MDS Coordinator said the MDS assessment was supposed to be completed every 92 days with 14 days to review and close them. The Regional MDS Coordinator said the concern with not completing and timely submitting residents' MDS assessments was that a need or want might not have been identified yet and it was very important to do that as soon as possible. Interview on 12/06/23 at 2:43 PM with the CNO revealed the Regional MDS Coordinator was responsible for making sure all resident's MDS assessment were up to date and submitted timely. Review of the facility's MDS Submission Timeframes policy, revised December 2010, reflected: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes .2. The following submission timeframe for MDS records will be observed by this facility: .Type of Record: Quarterly Assessment, Final Completion or Event Date: R2b [Date of the RN assessment coordinator's signature, indicating that the MDS is complete (MDS Completion Date)], Submit By: R2b+31 [Date of the RN assessment coordinator's signature, indicating that the MDS is complete (MDS Completion Date) plus 31 days] .3. Submission of MDS records to the State MDS database will be by electronic means.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete comprehensive assessment for 3 of 7 residents (Residents #48, #59, and #11) reviewed for comprehensive assessments. 1. The MDS Coordinator failed to ensure Resident #11's care plan accurately reflected, paranoid schizophrenia, and use of psychotropic medication Risperidone on 08/23/23. 2. The MDS Coordinator failed to ensure Resident #48's care plan was up-to-date to include her use of psychotropic medication for her active diagnosis of depression. 3. The MDS Coordinator failed to ensure Resident #59's care plan was up-to-date to include her use of the sedative/hypnotic medication Ambien on 11/30/23 and address her IV antibiotic therapy on 11/24/23. These failures could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs. Findings included: 1. Record review of Resident #11's face sheet, dated 12/07/23, revealed the resident was [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia (is a severe, lifelong brain disorder that causes people to interpret reality abnormally) and major depressive disorders (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities). Record review of Resident #11's MDS quarterly assessment, dated 09/27/23, revealed the resident had moderate cognitive impairment, with a BIMS score of 12, and active diagnoses of anxiety disorder, schizophrenia, and depression. Record review of Resident #11's Care Plan, dated 06/20/23, did not address his use of psychotropic medications and a diagnosis of paranoid schizophrenia. Record review of Resident #11's physician orders, dated 08/23/23, reflected paranoid schizophrenia and was put on risperidone 1 mg by mouth once daily for psychosis. Review of the Resident #11's PASRR (is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment dated [DATE] revealed Resident #11 was negative for mental illness and intellectual disability. Telephone interview on 12/07/23 at 12:11 PM with the Regional MDS Coordinator revealed she and the interdisciplinary team were responsible for developing and updating residents care plans. She stated any care/treatment a resident was receiving at the facility should be care planned. She stated Resident #11's care plan was supposed to be updated after he was diagnosed with a new diagnosis of mental illness and to show that he was on psychotropic medication, and he needed monitoring for behaviors and side effects. The Regional MDS Coordinator stated failure to update the care plan will interfere with Resident #11 care. She stated she took full responsibility for not having the care planupdated. She stated she had a team of auditors that were helping her to ensure they were updated. Interview on 12/07/23 at 2:59 PM with the DON revealed Resident #11 was supposed to be care planned since he had new diagnosis of mental illness. The DON stated failure to have Resident #11's care plan updated for the use of psychotropic medications could interfere with his plan of care. 2. Review of Resident #48's face sheet, dated 12/07/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and generalized anxiety disorder (a group of mental illnesses that cause constant fear and worry). Review of Resident #48's quarterly MDS assessment, dated 09/26/23, reflected a BIMS score of 07 indicating moderate cognitive impairment. Further review revealed active diagnoses of anxiety disorder and depression. Review of Resident #48's physician's orders as of 12/07/23 reflected an order for Zoloft oral tablet 25 mg (sertraline HCl), give 1 table by mouth one time a day related to depression, unspecified. The orders did not address monitoring the anti-depressant medication. Review of Resident #48's undated care plan revealed it did not address her use of anti-depressant medication. Review of Resident #48's December 2023 MAR/TAR revealed she had been receiving Zoloft one time a day as ordered. The MAR/TAR did not include documented evidence the facility was monitoring for side-effects related to the use of the Zoloft. Observation and interview on 12/05/23 at 9:50 AM with Resident #48 revealed she was lying in her bed, and she stated she was doing good. Interview on 12/07/23 at 10:47 AM with ADON Z revealed Resident #48 had a diagnosis of depression for which she was receiving Zoloft. Telephone interview on 12/07/23 at 2:44 PM with the Regional MDS Coordinator revealed a resident's care plan should address the resident's diagnosis of depression and if that resident was taking an anti-depressant medication. The Regional MDS Coordinator said she was still going through all of the care plans and updating them. The Regional MDS Coordinator said she was responsible for completing and updating resident's care plans. Interview on 12/07/23 at 11:17 AM with the CNO revealed Resident #48's care plan should include her use of an anti-depressant medication and the diagnosis of depression. The CNO said the purpose of this was so that anyone providing her care was aware she did have the diagnosis and took the medication. The CNO said the nurse managers were responsible for ensuring the care plans were completed and up-to-date. The CNO said the concern with a resident's care plan not being updated or completed was that it could interfere with the plan of care set up for the resident. 3. Review of Resident #59's face sheet, dated 12/07/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included charcot's joint left ankle and foot (a chronic destructive disease of the bone structure), Type 2 diabetes mellitus (high level of sugar in the blood), and muscular wasting and atrophy (wasting of muscle tissue). Review of Resident #59's quarterly MDS assessment, dated 12/04/23, reflected a BIMS score of 15 indicating no cognitive impairment. Review of Resident #59's undated care plan did not address her use of sedative/hypnotic medication or IV antibiotic therapy. Review of Resident #59's physician's orders as of 12/07/23 reflected an order for Ambien Oral Tablet 5 mg (Zolpidem Tartrate) Give 1 tablet by mouth in the evening for insomnia. The orders did not address monitoring the sedative/hypnotic medication. Review of Resident #59's December 2023 MAR/TAR revealed she had been receiving the Ambien one time a day as ordered. The MAR/TAR did not include documented evidence the facility was monitoring for side-effects related to the use of the Ambien. Review of Resident #59's physician's orders as of 12/07/23 reflected an order for Cefepime HCl Intravenous Solution 2 gm/100 mL (Cefepime HCl) Use 20 mL intravenously every 12 hours for wound infection please flush PICC line before and after administer. The order start date was 11/24/23. Review of Resident #59's physician's orders as of 12/07/23 reflected an order for Central, PICC, and Midline flush orders: Number of Lumens: (1) Flush each Lumen with 10cc normal saline every shift for Antibiotic Therapy. The order start date was 11/25/23. Review of Resident #59's physician's orders as of 12/07/23 reflected an order for transparent dressings per sterile technique upon admission, every 7 days, and PRN if wet, loose, or soiled. If site is not visible for assessment, change dressing every 48hrs. Change injection caps to each lumen upon admission, every 7 days, and after blood draws. as needed soilage as needed for IV Therapy Change as needed if wet, loose, or soiled. If site is not visible for assessment, change dressing every 48hrs. The order start date was 11/25/23. Review of Resident #59's November and December 2023 MAR/TAR revealed the dressing was changed on 11/26/23 and 12/03/23. Observation and interview on 12/06/23 beginning at 9:59 AM with Resident #59 revealed she was laying in her bed and stated she was doing good. Resident #59 stated she was on Ambien medication for insomnia due to having trouble sleeping at night. She stated she gets her medication at night. Observed Resident #59 had a PICC line in her left upper arm covered with a transparent dressing. The transparent dressing was not dated. There was no redness, drainage, or swelling to the resident's left arm. Resident #59 stated she was on antibiotics due to an infection on her right arm, she stated she had an abscess and had it surgically removed. Resident #59 stated her dressing was last changed on Sunday (12/03/23) or Monday (12/04/23). Interview on 12/07/23 at 1:48 PM with ADON Z revealed she was familiar with Resident #59 and stated she was ordered Ambien for insomnia. When asked if a resident receiving sedative/hypnotic medication and was on an antibiotic therapy should it be care planned, ADON Z stated she was not sure. ADON Z stated she was not sure who was responsible for updating residents care plans. Interview by phone on 12/07/23 at 2:12 PM with the Regional MDS coordinator revealed that a resident's care plan should address the use of sedative/hypnotic medication, antibiotic therapy, and wound care. She stated the facility interdisciplinary team was responsible for updating care plans; however, she was helping the facility update residents care plans and an audit list of resident's care plans that needed to be updated. The Regional MDS Coordinator stated she would take full responsibility for care plans not being up to date. She stated the risk for care plans not being accurate could lead to residents needs not being addressed. Review of the facility's Care Planning policy, revised December 2008, reflected: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to use the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week in the facility for 4 of 60 days (09/02/23, 09/09/23, 09/16/23, and 10/22/23) reviewed for RN coverage. The facility failed to have RN coverage in the facility for eight consecutive hours on 09/02/23, 09/09/23, 09/16/23, and 10/22/23. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Findings included: Review of RN V's time sheets from 09/01/23 to 12/04/23 reflected she worked the following dates and hours: 09/09/23 for 7.63 hours and then 7.38 hours, 10/22/23 for 7.45 hours and then 5.52 hours. Review of RN T's time sheets from 09/01/23 to 12/04/23 reflected she worked the following dates and hours: 10/16/23 for 4 hours and then 3.5 hours. Review of the CNO's time sheets from 09/01/23 to 12/04/23 reflected no hours on 09/02/23. In an interview on 12/07/23 at 11:09 AM with the CNO revealed she was not aware the facility did not have full RN coverage for the dates listed above. The CNO said there was supposed to be an RN working eight consecutive hours on the weekends. The CNO said the purpose of this was because the RN can do more things than an LVN so an RN would be available in that case. The CNO said the responsibility was on HR who was assisting with scheduling and the ADON. The CNO said the DON would be monitoring staffing overall and would be responsible for also ensuring there was an RN working for at least eight consecutive hours each day. The CNO said the concern was that there should be an RN because it was a state regulation and could pose a danger to the residents. The CNO said she was unaware of any significant incident occurring on the above dates. In an interview on 12/07/23 at 3:34 PM with the Administrator revealed the purpose of having an RN for eight consecutive hours each day was because it was a regulation. The Administrator said HR does all the scheduling for the facility and the VP of Operations oversees that process. The Administrator said the concern was that there was not anyone to oversee nursing care if an RN was not in the building for eight consecutive hours. The Administrator said she was unaware of any significant incident occurring on the above dates. Review of the facility's Staffing policy, revised April 2007, reflected: .6. The facility will follow federal guidelines to ensure that an RN is on staff for a minimum of eight (8) hours per twenty-four (24) hour period

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 2 halls (Recovery Halls Medication Cart) medication carts and 1 of 5 residents (Resident #37) reviewed for pharmacy services. 1. MA B failed to ensure she did not pre-pop medications in advance and put them in cups on her before she was ready to administer the morning medications to residents. 2. MA B failed to follow the physician orders while administering eye ointment to Resident #37. This failure could place residents at risk of not receiving the therapeutic dose of medication and consuming unsafe medications. Findings included: Review of Resident #37's Quarterly MDS assessment, dated 09/30/23, reflected the resident was [AGE] year-old female who admitted to the facility on [DATE].The resident had diagnoses including acute follicular conjunctivitis in the right eye. Resident #37 had moderate cognitive impairment with a BIMS score of 09. Review of Resident #37's December 2023 physician orders revealed orders for Erythromycin Ophthalmic Ointment 5 mg/gm instill 1 ribbon in right eye two times a day for dryness. Observation on 12/06/23 at 7:48 AM with MA B revealed she put on gloves and administered 1 ribbon of erythromycin Ophthalmic Ointment to both of Resident #37's eyes, instead of just the right eye as ordered. Observation of the medication cart for Recovery Hall on 12/06/23 at 8:18 AM revealed the cart had 4 medication cups with 24 unknown pills in 3 cups and another cup with crushed medications mixed together that were not labeled. MA B was noted to have checked off the pills on MAR as administered. Interview on 12/06/23 at 8:33 AM with MA B revealed she was the one that put the medications in the cups, and she was preparing for other residents in another hall. She stated she knew she was not supposed to prepare the medications in advance before she got to the resident's room. She stated she was supposed to put the names, so that she will not mix them. MA B stated she had made a mistake by checking off the medications as administered while they were not administered. She stated the risk of pre-popping medications was that residents could be administered the wrong medications. She stated she had done training on medication administration. Interview on 12/06/23 at 8:38AM with MA B revealed she did not follow the physician order while administering eye ointment to Resident #37. MA B stated she was aware the order reflected to administer one ribbon on the right eye, but she made decision to administer the eye ointment to both eyes. She could not give reason for this decision. Interview on 12/07/23 at 10:57 AM with the Regional DON revealed, it was her expectation that staff would not prepare the medications a head of getting to residents' rooms and stored in cups. She stated her expectation was that staff prepare medications when they were ready to administer the medications to residents. She stated the failure with preparing medications in advance and putting them on the cart the MA B could give residents the wrong medications by picking the wrong cup leading to a medication error. She stated she was not sure if she had done training on medication administration, and she could not produce any training record for MA B. Interview on 12/07/23 at 11:32 AM with the Regional DON revealed it was her expectation that staff would follow the physician orders. She stated MA B was supposed to administer eye ointment only to the right eye and not make decision on administering on both eyes without notifying the nurse if she had noted a problem with the left eye . She stated the facility had done training on medication administration on 03/06/23. She stated could not provide and training records regarding following physician orders. Record review of facility's Administering Medication policy, revised April 2012, reflected: .3.Medications must be administered in accordance with the orders, including any required time frame. 9. Medications may not be prepared in advance .12. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have adequate monitoring in place for side effects associated with the use of psychotropic medications and documented in the clinical record for 3 of 5 residents reviewed (Residents #48, #59, and #11) for unnecessary psychotropic drugs. 1. The facility did not monitor Resident #48 for side-effects related to the use of the anti-depression medication Zoloft. 2. The facility did not monitor Resident #59 for side-effects related to the use of the sedative/hypnotic medication Ambien. 3. The facility did not monitor Resident #11 and #51 for side-effects related to the use of the psychotropics and antidepresants medication Risperidone,Geodon from the time they were prescribed . These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: 1. Review of Resident #48's face sheet, dated 12/07/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and generalized anxiety disorder (a group of mental illnesses that cause constant fear and worry). Review of Resident #48's quarterly MDS assessment, dated 09/26/23, reflected a BIMS score of 07 indicating moderate cognitive impairment. Further review revealed active diagnoses of anxiety disorder and depression. Review of Resident #48's physician's orders as of 12/07/23 reflected an order for Zoloft oral tablet 25 MG (sertraline HCI), give 1 table by mouth one time a day related to depression, unspecified. The orders did not address monitoring the anti-depressant medication. Review of Resident #48's undated care plan did not address her use of anti-depression medication. Review of Resident #48's December 2023 MAR/TAR revealed she had been receiving the Zoloft one time a day as ordered. The MAR/TAR did not include documented evidence the facility was monitoring for side-effects related to the use of the Zoloft. Observation and interview on 12/05/23 beginning at 9:50 AM with Resident #48 revealed she was laying in her bed and said she was doing good. Interview on 12/07/23 at 10:47 AM with ADON Z revealed she was familiar with Resident #48 and said she was ordered Zoloft for depression. ADON Z said Resident #48 did not have a monitoring order in the system for the anti-depressant. ADON Z said the nurse who put the medicine order in would have been responsible for ensuring the monitoring order was also put in. ADON Z said the purpose of having a monitoring order was to make sure the medication was working and that the resident was not experiencing any side effects from the medication. ADON Z said the concern with not having the monitoring order was that the resident could be having severe reactions that staff do not know about. ADON Z said both ADON's would have been responsible overall for monitoring and ensuring all orders were in place. Interview on 12/07/23 at 11:17 AM with the CNO revealed Resident #48 was ordered Zoloft for depression and should have monitoring orders for the anti-depressant medication. The CNO said the purpose of having the monitoring order was to make sure the medication was working, and the resident was not having side effects or experiencing behaviors from the medication. The CNO said the responsibility for ensuring the monitoring order was put in was on the nurse on the floor and the ADON's come behind and check them to make sure everything is correct for every admission. The CNO said the concern for not having a monitoring order was that the staff were not monitoring for side effects or behaviors or the medicine's effectiveness. 2. Review of Resident #59's face sheet, dated 12/07/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included charcot's joint left ankle and foot (a chronic destructive disease of the bone structure), type 2 diabetes mellitus (high level of sugar in the blood), and muscular wasting and atrophy (wasting of muscle tissue). Review of Resident #59's quarterly MDS assessment, dated 12/04/23, reflected a BIMS score of 15 indicating no cognitive impairment. Review of Resident #59's undated care plan did not address her use of sedative/hypnotic medication. Review of Resident #59's physician's orders as of 12/07/23 reflected an order for Ambien Oral Tablet 5 mg (Zolpidem Tartrate) Give 1 tablet by mouth in the evening for insomnia. The orders did not address monitoring the sedative/hypnotic medication. Review of Resident #59's December 2023 MAR/TAR revealed she had been receiving the Ambien one time a day as ordered. The MAR/TAR did not include documented evidence the facility was monitoring for side-effects related to the use of the Ambien. Observation and interview on 12/06/23 at 9:59 AM with Resident #59 revealed she was lying in her bed and stated she was doing good. Resident #59 stated she was on Ambien medication for insomnia due to having trouble sleeping at night. She stated she got her medication at night. Interview on 12/07/23 at 1:08 PM with ADON Z revealed she was familiar with Resident #59 and stated she was ordered Ambien for insomnia. ADON Z reviewed Resident #59 physician orders and stated resident did not have a monitoring order in the system for the sedative/hypnotic medication. ADON Z said the nurse who put the medicine order in would have been responsible for ensuring the monitoring order was also put in. She stated the ADON's would have been responsible overall for monitoring and ensuring all orders were in place. ADON Z said the purpose of having a monitoring order was to make sure the medication was working and that the resident was not experiencing any side effects from the medication. ADON Z said the concern with not having the monitoring order was that the resident could be having severe reactions or altered mental statues that staff do not know about. Interview on 12/07/23 at 2:58 PM with the DON revealed residents who are on anti-depressant medications, sedative/hypnotic or antibiotic medications should have monitoring orders. The DON stated the nurses who put the medicine order in would have been responsible for ensuring the monitoring order was also put in. She stated the ADONs were responsible for ensuring all orders were in place and monitor behaviors were being completed. The DON stated the risk of not having monitoring orders could lead to side effects or behaviors. 3. Record review of Resident #11's face sheet, dated 12/07/23, revealed the resident was [AGE] year-old male initially admitted to the facility on [DATE]. His diagnoses included paranoid schizophrenia (altered perception of reality), and major depressive disorder (clinical depression). Record review of Resident #11's MDS quarterly assessment, dated 09/27/23, revealed the resident had active diagnoses of depression, schizophrenia and anxiety.Resident#11 had moderate cognitive impairment, with a BIMS score of 12. Record review of Resident #11's undated Care Plan, use of psychotropic/anti-depressant medication was not addressed. Record review of Resident #11 physician orders, dated 08/23/23, reflected an order for risperidone 1 mg by mouth once daily for psychosis and Cymbalta oral capsule DR 20 mg by mouth to once daily. Review of Resident #11's December 2023 MAR/TAR revealed he was receiving for Risperidone 1 mg by mouth once daily. There was no documentation reflecting the facility was monitoring for side-effects of the Risperidone nor monitoring behaviors. Observation and interview on 12/05/23 at 10:34 AM with Resident #11 revealed he was lying in his bed and said he was doing good. 4. Record review of Resident #51's face sheet, dated 12/07/23, revealed the resident was [AGE] year-old female initially admitted to the facility on [DATE]. Her diagnoses included bipolar disorder(mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and major depressive disorder (clinical depression). Record review of Resident #51's MDS quarterly assessment, dated 09/28/23, revealed the resident had active diagnoses of depression, post-traumatic stress disorder and anxiety. Resident#51 was cognitive intact, with a BIMS score of 15. Record review of Resident#51's Care Plan, dated 09/28/23,revealed Resident#51 had diagnosis of bipolar, depression and post-traumatic stress disorder, and she was using psychotropic. Record review of Resident#51 physician orders dated 11/08/2023 reflected Geodon Oral Capsule 20 mg morning and Geodon Oral Capsule 40 mg at night for bipolar disorder. Review of Resident#51's December 2023 MAR/TAR revealed she was receiving Geodon Oral Capsule 20 mg morning and Geodon Oral Capsule 40 mg at night. There was no documentation reflecting the facility was monitoring for side-effects of the Geodon nor monitoring behaviors. Observation and interview on 12/05/23 at 12:49 PM with Resident #51 revealed she was seated on her wheelchair in her room listening to music through her earphones. She stated said she was doing good. Interview on 12/07/23 at 1:13 PM with LVN E revealed she was aware Resident #11 and #51 were on psychotropic medications, and she was supposed to be monitoring and documenting the behaviors and side effects. LVN E stated the failure to monitor the behavior and side effects of the medications was that staff would not be able to measure the effectiveness of the medication and side effects so that they could be addressed. Interview on 12/07/23 at 2:59 PM with the Regional DON revealed when a resident was admitted the nurses were supposed to enter the behavioral monitoring orders together with other the orders. The Regional DON stated the ADON was responsible for monitoring the nurses. She stated the failure to monitor for behaviors was that it could affect the care administered because staff were not able to determine what was causing behaviors and the incoming shifts would not be able to tell whether the resident was having behaviors on the previous shift for continuity of care. Review of the facility's Antipsychotic Medication Use policy, revised December 2021, reflected: .14. Nursing staff shall monitor and report any of the following side effects to the Attending Physician: a. Sedation; b. Orthostatic hypotension; c. Lightheadedness; d. Dry mouth; e. Blurred vision; f. Constipation; g. Urinary retention; h. Increased psychotic symptoms (atropine psychosis); i. Extrapyramidal effects; j. Akathisia; k. Dystonia; l. Tremor; m. Rigidity; n. Akinesia; or tardive dyskinesia .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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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 for one of one kitchen reviewed for food and nutrition services. 1. The facility failed to provide dietary staff with proper handwashing facilities with hot water when the temperature only reached 75 degrees Fahrenheit. 2. Dietary Aide E and Dietary Aide F failed to wear a hair restraint and Dietary Aide G failed to wear a beard restraint while in the facility's kitchen on 12/05/23. 3. The facility failed to ensure food items were properly labeled, dated, and thawed in accordance with professional standards. These failures could place residents at risk for food contamination and foodborne illness. Findings included: Observation of the kitchen on 12/05/23 at 9:18 AM revealed the kitchen had two handwashing sinks in which the water failed to rise above a moderately warm temperature to touch after running on hot, full, for greater than 1 minute. Further observation revealed Dietary Aide E, and Dietary Aide F not wearing hair restraints while in the kitchen. Dietary Aide G was observed without a beard restraint while in the kitchen. Observation of the kitchen refrigerator on 12/05/23 at 9:24 with the [NAME] H revealed the following: - one plastic bag with a seal contanining biscuits did not have an item description or a use by date; - 8 single wrapped bowls of sliced peaches did not have an item description or a use by date; - one container of left-over tomato sauce did not have an item description or a use by date; - individual containers of apple sauce did not have an item description or a use by date; and - individual containers of ranch sauce did not have an item description or a use by date. Observation of the walk-in cooler on 12/05/23 at 09:28 AM with the Dietary Aide G revealed the following: - one packaged of ground meat on top of a pan sheet with its original package thawing- unlabeled with no pull date or use by date; and - one packaged of ham on top of a pan sheet with its original package thawing- unlabeled with no pull date or use by date. Observation on 12/05/23 at 12:50 PM of water temperature at the handwashing sink in the kitchen checked by Dietary Manager revealed the hot water reached 75 degrees Fehrenheit. Interview on 12/05/23 at 9:32 AM with Dietary Aide E revealed she had been employed for 8 months. She stated the first thing the staff were required to wear upon entry of the kitchen was to put on a hairnet restraint. Dietary Aide E stated the reason she was not wearing hairnet restraint was due to them not having any. Dietary Aide E stated they had been without hairnets since Thursday 11/30/23. She stated an order was put in and the delivery truck comes in tomorrow 12/06/23. She stated for the mean time they are making sure their hair was up in a ponytail. She stated the potential risk of not wearing hairnet restraints could cause hair to fall inside the food. Dietary Aide E stated all foods items that were open should be labeled and dated and it was the responsibility of all kitchen staff to ensure it was being done. She stated some of the food items in the refrigerator were used yesterday (12/04/23) and today (12/05/23). She stated not having foods properly sealed, labeled, or dated could led staff to cook foods that are expired or out of date causing residents to get sick. Dietary Aide E stated they had been having issues with the hot water for more than 4 months. She stated the hot water comes and goes. She stated the Administrator, and the Maintenance Director were aware of the concern. She stated they have tried to fix it; however, it only lasts for a few days. She stated when they notify the Maintenance Director of the hot water concern, he would manually turn the boiler on and once the water is hot it would turn off by itself. She stated the kitchen had two sinks and both do not have hot water; however, the dishwasher area does have hot water. Dietary Aide E stated if the water not being hot enough, bacteria may be still on your hands, and you cannot wash your hands properly. Interview on 12/05/23 at 9:39 AM with Dietary Aide F revealed she had been employed for about a year. She stated the first thing the staff were required to wear upon entry of the kitchen was to put on a hairnet restraint. Dietary Aide F stated the reason they are not wearing hairnet restraints was due to them not having any. Dietary Aide F stated they had been without hairnets since Thursday 11/30/23. She stated for the mean time they are making sure their hair was up properly in a ponytail. She stated the potential risk of not wearing hairnet restraints could cause hair to fall inside the food. Dietary Aide F stated food items that were open should be labeled and dated and it was the responsibility of all kitchen staff to ensure it was being done. She stated when she opens a food items, she makes sure to label and date them, she stated sometimes the 2nd shift forgets to label and date food items. She stated not having foods properly sealed, labeled, or dated could led staff to cook foods that were expired or out of date causing residents to get sick. Dietary Aide F stated they had been having issues with the hot water for months now. She stated the hot water comes and goes. She stated the Dietary Manager was aware of the concern and she had been trying to fix the hot water issue. She stated when they notify the Maintenance Director of the hot water concern, he would manually turn the boiler on and once the water was hot it would turn off by itself. She stated the kitchen dishwasher room was the only place in the kitchen that had hot water. Interview on 12/05/23 at 9:43 AM with Dietary Aide G revealed he had been employed for 9 months. He stated staff were required to wear hairnet restraint while in the kitchen. Dietary Aide G stated the reason they are not wearing hairnet restraints or himself not wearing a beard restraint was due to them not having any. Dietary Aide G stated they had been without hairnets since last Thursday 11/30/23. He stated they would a delivery truck sometime this week. He stated the potential risk of not wearing hairnet or beard restraint could cause hair to fall inside the food. Dietary Aide G stated they had been having issues with the hot water for about 3 months. He stated the hot water comes and goes, he stated when they do not have hot water, they would notify the Maintenance Director and he would manually turn on the boiler. He stated when the Maintenance Director turns on the boiler manually the hot water would last for a few hours or a few days. He stated the Dietary Manager was aware of the concern and she had been trying to fix the hot water issue by notifying the Administrator and Maintenance Director. Interview on 12/05/23 at 9:43 AM with [NAME] H revealed she had been employed for 3 years. She stated all open foods items should be labeled and dated and it was the responsibility of all kitchen staff to ensure it was being done. She stated some of the food items in the refrigerator were used yesterday (12/04/23) and today (12/05/23). She stated she was the one who removed the ground beef and ham from the freezer to the cooler to thaw this morning. She stated she got busy and forgot to label and date them. She stated not having foods properly sealed, labeled, or dated could led staff to cook foods that are expired or out of date causing residents to get sick. Interview on 12/05/23 at 11:31 AM with Dietary Manager revealed she had been employed for 3 months. Dietary Manager revealed all staff should wear hairnets and beard restraint while in the kitchen. She stated they ran out of hairnets and beard restraints yesterday (12/04/23). She stated she purchased hairnets and beard restraint today (12/05/23) and provided them to her staff. Dietary Manager stated the potential risk of not wearing hairnet or beard restraint could cause hair to get into the food. She stated all food items that are open should be labeled and dated and it was the responsibility of all kitchen staff to ensure it was being done. She stated it was her responsibility to ensure her staff are labeling and dating open food times. She stated not having foods properly labeled, or dated could led staff to cook foods that are expired and could cause residents to get sick. Dietary Manager stated they have had an issue with hot water prior to her being employed. She stated the facility has hot water everywhere expect the two handwashing sinks in the kitchen. She stated the Administrator and Maintenance Director were aware of the concern and they have had someone come out and fixed it. However, the hot water would only last for a few days and it would stop working. She stated in the meantime they would notify the Maintenance Director and he would turn on the water heater/boiler manually. She stated the hot water would last a few hours or days. When asked about the potential risk, the Dietary Manager stated her kitchen staff are utilizing gloves and handwashing in between. Interview on 12/06/23 at 10:54 AM with the Maintenance Director revealed he had been employed for 2 years. He stated he was aware of the facility kitchen handwashing sinks having issues with the hot water. The Maintenance Director stated the water heater blower motor was broken and he would have to turn it on manually. He stated the water heater was located in the kitchen back area. He stated the water heater had been broken for about a month and half. He stated he had a technician come out and look at the water heater a month ago and stated it was about $1,600 to fix it. He stated he provided the information to corporate; however, he was still waiting for it to be approved. Review of the facility's Maintenance Purchase Order Form, dated 08/18/23, revealed the following: Department: Maintenance, Description: Blower Motor for hot water heater, Amount $1,615.09. Form had not approval signatures of the request. Interview on 12/07/23 at 3:31 PM the Administrator revealed she was aware of the hot water issue in the kitchen. She stated they had an issue with the water heater blower motor, she stated they had submitted a PO (purchase order) to corporate back in August 2023; however, it had not been approved. The Administrator stated they had someone one come out to fix it, but it stopped working again. The Administrator stated kitchen staff have access to the room where the water heater boiler was located and the kitchen staff know how to turn on the water heater. She stated the hot water comes and goes. She stated they are waiting on the regional team to approve the PO and they would fix it. Review of the facility's Food Receiving and Storage policy, revised December 2008, reflected: Food shall be received and stored in a manner that complies with safe food handling practices. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of the facility's Preventing Foodborne Illness - Employee Hygiene and Sanitary Practice policy, revised date December 2008, reflected: Food services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. 6. Employees must wash their hands. 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 5 residents (Residents #30 and #44) reviewed for clinical records. 1. The facility failed to ensure staff accurately documented on Resident #30's MAR and in the progress notes regarding his PT/INR lab results on 12/03/23. 2. The facility failed to ensure staff accurately documented on Resident #44's MAR for side effect and behavioral monitoring for her antidepressant medication. These failures could affect residents that received medications and place them at risk of inaccurate or incomplete clinical records. Findings included: 1. Review of Resident #30's face sheet, dated 12/07/23, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris (occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body [arteries] become thick and stiff) and atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat). Review of Resident #30's MDS Assessment, dated 10/20/23, reflected he had a BIMS score of 99 indicating he was unable to complete the interview. Further review revealed Resident #30 had an active diagnosis of a cardiorespiratory condition (any disease involving the heart or blood vessels) and that he was taking an anticoagulant. Review of Resident #30's undated care plan reflected the following: Focus: [Resident #30] has coronary artery disease r/t Atrial Fibrillation, Hypertension, and CVA w/ Residual weakness. Goal: [Resident #30] will exhibit reduction of cardiac symptoms through the review date. [Resident #30] will be free from s/sx of complications of cardiac problems through the review date. Review of Resident #30's physician's orders, dated 12/07/23, reflected the following: PT/INR Daily one time a day for lab with a start date of 12/02/23. Review of Resident #30's December 2023 MAR/TAR reflected on 12/03/23 for his PT/INR order a number 9 was entered and ADON W initialed it. According to the chart codes table on Resident #30's MAR reflected 9= Other/See Nurse Notes. Review of Resident #30's progress notes for December 2023 reflected no notes for 12/03/23 regarding his laboratory work/results or any communication with the NP or Physician. Interview on 12/06/23 at 1:15 PM with Resident #30 revealed he was laying in his bed. Resident #30 said lab came every day to draw his blood and he was not experiencing any issues related to his anticoagulant medication. Resident #30 said the lab company did not come for him today so far and could not remember if they had come earlier in the week or over the weekend. Interview on 12/07/23 at 4:02 PM with the CNO revealed ADON W should have documented a progress note for Resident #30's lab draw from 12/03/23 because of the code entered. The CNO said the number 9 meant that a progress note should have been added to explain why the lab was not drawn on that day. The CNO said ADON W would have been responsible for making sure the necessary information was included in the progress note and she was not sure why he did not add a progress note. The CNO said ADON W was out of the country on vacation today (12/07/23) and could not be reached by phone. 2. Review of Resident #44's face sheet, dated 12/07/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE]. His diagnoses included disorder of brain, major depressive disorder (depressed mood or loss of interest), and schizoaffective disorder bipolar type (hallucinations or delusions, and symptoms of a mood disorder). Review of Resident #44's quarterly MDS Assessment, dated 11/01/23, reflected he had a BIMS score of 13 indicating no cognitive impairment. Review of Resident #44's undated care plan reflected the following: Focus: [Resident #44] take antidepressant medication r/t dx of depression. Goal: [Resident #44] will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions/Tasks: Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. Monitor/document/report to MD PRN ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Review of Resident #44's physician's orders for December 2023 reflected: Depakote Tablet delayed release 125 MG (Divalproex Sodium) Give 125 mg by mouth three times a day related to schizoaffective disorder, bipolar type. Review of Resident #44's physician's orders for December 2023 reflected: Paxil Tablet 30 mg (PARoxetine HCl) Give 1 tablet by mouth one time a day for Depression. Review of Resident #44's physician's orders for December 2023 reflected: Antidepressant Medication - Monitor for side effects: Sedation, Drowsiness, Dry mouth, Blurred vision, Urinary retention, Tachycardia, Muscle Tremor, Agitation, Headache, Skin rash, Photosensitivity of skin, Excess weight gain. every shift for Behavior Monitoring related to Major Depressive Disorder, recurrent, unspecified. Review of Resident #44's November 2023 MAR reflected blanks (not entered) on the following dates and times for her antidepressant medication side effects and behavior monitor: 11/02, 11/03, 11/04 - day/evening/night shift, 11/05 - day/evening shift, 11/06 - day/evening/night shift, 11/07,11/08, 11/09, /11/10 evening/night shift, 11/11 - day/evening/night shift, 11/12 - day/evening shift, 11/13, 11/14 - evening/night shift, 11/15 - day/evening/night shift, 11/16, 11/17 - evening/night shift, 11/18 - day/evening/night shift, 11/19, 11/20 -day/evening shift, 11/21 evening/night shift, 11/22 - day/evening/night shift, 11/23 evening shift, 11/24 - night shift, 11/25 day/evening/night shift, 11/26 - evening shift, 11/27, 11/28, 11/29 evening/night shift and 11/30 night shift. Review of Resident #44's December 2023 MAR reflected blanks (not entered) on the following dates and times for her antidepressant medication side effects and behavior monitor: 12/01 - day shift, 12/02 - day/evening shift, 12/03 - day shift, 12/04 - evening/night shift, 12/05 - day/evening/night shift, 12/06 - evening/night shift, 12/07 - day shift. Observation and interview on 12/05/23 beginning at 11:18 AM of Resident #44 revealed she was lying in bed in her room and stated she had been receiving her medications as ordered as far as she knew. Interview on 12/07/23 at 1:15 PM with LVN E revealed she was the nurse assigned to Resident #44. She stated Resident #44 was on antidepressant medication and antipsychotic medications. LVN E stated Resident #44 had an order for behavioral monitoring. LVN E stated she checks for behaviors during her shift and documents them in the Resident MAR. LVN E reviewed Resident #44 MAR/TAR and stated resident had missing checks for her behavioral monitoring. LVN E stated if there were no checks on the MAR for her behavioral monitoring indicated the nurses were not accurately documenting. LVN E stated the risk of not documenting behaviors would be for incoming staff not knowing if the resident had behaviors. While interviewing LVN E the Administrator approached LVN E and told her to not provide or show any residents information or MAR/TAR to the surveyors. Telephone interview on 12/07/23 at 2:44 PM with the Regional MDS Coordinator revealed any resident who are receiving antipsychotic, or antidepressant mediations nursing staff should monitor for behaviors and document on the residents MAR/TAR. She stated the potential risk of not documenting behaviors/side effects for the use of antipsychotic, or antidepressant mediations could cause delirium on a resident. Interview on 12/07/23 at 2:58 PM with the DON revealed residents who are on anti-depressant, psychotropic medications, sedative/hypnotic or antibiotic medications should have monitoring orders. The DON stated behaviors should be monitor during every shift and the nurse on duty was responsible for documenting on the resident MAR/TAR. She stated if a resident MAR/TAR had blank boxes would mean that the nursing staff are not documenting and are not performing the monitoring for behaviors. The DON stated it was the ADONs responsibility to ensure behavior monitoring are being completed. She stated the potential risk would be residents having behaviors or side effect and the incoming staff would be unaware. Review of the facility's Charting and Documentation Compliance policy, revised May 2017, reflected: .1. All observations, medications administered, services performed, etc., must be document in the resident's clinical records

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 5 of 5 residents (Resident #1, Resident# 37 Resident # 39, Resident #46 and Resident #60) reviewed for infection control. 1. MA B and MA C failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #46, #1, #37, #39 and #60 during medication administartion. 2. MA B failed to perform hand hygiene between residents while administering medications to Residents #1, #37 and #46. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident# 1's entry MDS assessment, dated 12/07/23, revealed the resident was [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included elevated blood pressure, and peripheral vascular disease. Resident # 1 had severe cognitive impairment with a BIMS score of 03. Review of Resident #1's December 2023 physician orders revealed an order for amlodipine besylate oral tablet 10 mg, Carvedilol oral tablet 25 mg 1 tablet by mouth two times a day and lisinopril oral tablet 10 mg 1 tablet by mouth one time a day. Review of Resident #60's quarterly MDS assessment, dated 09/30/23, revealed the resident was [AGE] year-old male admitted to the facility on [DATE] with diagnoses including essential hypertension( elevated blood pressure) and hypertensive crisis (sudden, severe increase in blood pressure. Resident #60 had moderate cognitive impairment with a BIMS score of 11. Review of Resident #60's December 2023 Physician Orders revealed an order for Spironolactone oral tablet 50 mg 1 tablet by mouth one time a day. Hold for Systolic blood pressure less than 110, Diastolic blood pressure less than 60,or heart rate less than 60,Clonidine transdermal patch Weekly 0.2 mg/24 hr. Apply 1 patch transdermally every Thursday, hydralazine oral tablet 100 mg 1 tablet by mouth three times a day and nifedipine extended release 24 hour 90 mg 1 tablet by mouth two times a day. Review of Resident #46's Quarterly MDS assessment, dated 10/7/23, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. The resident had diagnoses including elevated blood pressure, anxiety, and muscle weakness. Resident#46 had moderate cognitive impairment with a BIMS score of 09. Review of Resident #46's December 2023 physician orders revealed orders for Metoprolol tablet 25 mg give 1 tablet by mouth two times a day, Nifedipine extended release 24 hour 60 mg 1 tablet by mouth one time a day. Review of Resident # 37's Quarterly MDS assessment, dated 09/30/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses including elevated blood pressure, anxiety, and muscle weakness. Resident# 37 had moderate cognitive impairment with a BIMS score of 09. Review of Resident #37's December 2023 physician orders revealed orders for hydralazine tablet 10mg 1 tablet by mouth two times a day, amlodipine besylate tablet 5mg 1 tablet by mouth one time a day, losartan Potassium oral tablet 50mg 1 tablet by mouth one time a day. Review of Resident #39's Quarterly MDS assessment, dated 10/13/23, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. The resident had diagnoses including elevated blood pressure, anxiety, and muscle wastage. Resident# 37 was cognitively intact with a BIMS score of 15. Review of Resident #39's December 2023 physician orders revealed orders for felodipine extended-release oral tablet 24-hour 5 mg 1 tablet by mouth one time a day, metoprolol succinate oral tablet extended release 24-hour 50 mg 1 tablet by mouth two times a day . Observation on 12/06/23 at 7:30 AM revealed MA B performing morning medication pass, during which time MA B checked Resident #1's blood pressure. MA B did not disinfect the blood pressure cuff after using it on Resident #1. MA B put the blood pressure cuff on top of the medication cart after use.MA B did not perform hand hygiene before administering the medications and after administering . Observation on 12/06/23 at 7:48 AM revealed MA B continued to perform morning medication pass, during which time she checked the blood pressure on Resident #37. MA B used the same blood pressure cuff right after using it on Resident#1. MA B did not disinfect the blood pressure cuff before or after using it on Resident #37. She left the blood pressure cuff on top of the medication cart.MA did not perform hand hygiene after Resident #1 or before administering medications to Resident#37.She was observed administering eye drops on Resident #37 on both eyes without performing hand hygiene before donning the gloves and after doffing the gloves. Observation on 12/06/23 at 8:09 AM revealed MA B continued to perform morning medication pass, during which time she checked Resident#46's blood pressure.MA B used the same blood pressure cuff right after using it on Resident#37.MA B did not disinfect the blood pressure cuff before or after using it on Resident#46.She did not perform hand hygiene before and after contact with resident#46. Interview on 12/06/23 8:33 AM with MA B revealed reusable equipment, like blood pressure cuffs, should be disinfected with wipes between each resident use (before and after use on each resident) to prevent transmitting of infection from one resident to another. MA B revealed she disinfect her blood pressure cuff at the end of her shift though she was aware it was after every use. MA B stated she was not disinfecting the blood pressure cuffs because she did not have the disinfectant wipes but she was observed opening the cart drawer, she pulled a container of disinfectant wipes.MA B stated she was supposed to perform hand hygiene after contact with each resident or between the procedures to prevent contamination and spread of infection.MA B stated she does not have any reason as to why she was not performing hand hygiene .MA B stated she had completed training on infection control, handwashing, and disinfection of reusable equipment. 2. Observation on 12/06/23 8:46 AM revealed MA C performing morning medication pass, during which time MA C checked Resident #39's blood pressure. MA C did not disinfect the blood pressure cuff after using it on Resident #39. MA B put the blood pressure cuff on top of the medication cart after use. Observation on revealed MA C performing morning medication pass, during which time MA C checked Resident #60's blood pressure. MA C did not disinfect the blood pressure cuff after using it on Resident #39. MA B put the blood pressure cuff on top of the medication cart after use. Observation on 12/06/23 8:53 AM revealed MA C continued to perform morning medication pass, during which time she checked the blood pressure on Resident #60. MA C used the same blood pressure cuff right after using it on Resident#39. MA C did not disinfect the blood pressure cuff before or after using it on Resident #60. She left the blood pressure cuff on top of the medication cart. Interview on 12/06/23 8:54 AM with MA C revealed reusable equipment, like blood pressure cuffs, should be disinfected with wipes after each use or after (3) three residents to prevent transmitting of infection from one resident to another. MA C revealed she had not disinfected her blood pressure cuff since she reported on duty that morning because she did not have disinfectant wipes on her cart. MA C stated she was not disinfecting the blood pressure cuffs because the facility did not have the disinfectant wipes. MA C stated failure to disinfect the blood pressure cuff would lead to contamination. MA C stated she had done training on infection control, handwashing, and disinfection of reusable equipment. Interview on 12/07/23 at 10.57 AM with the Regional DON revealed her expectation was that staff would disinfect all reusable equipment between each resident use with disinfectant wipes. The DON stated hand hygiene should be performed between residents, before, and after medication administration. The DON stated the facility had trained staff on hand washing, and she was not sure on disinfecting of reusable items. Record review on 12/07/23 revealed training on cleaning medical equipment dated 03/06/23 and MA C attended. Record review of facility's Cleaning and Disinfecting Resident Care Items and Equipment policy, revised May 2009, reflected: .non-critical items are those that come in contact with intact skin but not mucous membranes bed pans, blood pressure cuffs .Reusable items are cleaned and disinfected or sterilized between residents Record review of facility's Hand Washing/Hand Hygiene policy, revised December 2010, reflected: This facility considers hand hygiene the primary means to prevent the spread of infections 5. Employees must wash their hands for at least fifteen ( 15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); l. Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident) u. After removing gloves or aprons. 6. In most situations, the preferred method of hand hygiene is with a hand sanitizer. If hands are not visibly soiled, use a hand sanitizer for all the following situations: a. Before and after direct contact with residents. b. Before donning sterile gloves. d. Before preparing or handling medications. I. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and j. After removing gloves.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Data (Tag F0851)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. The facility failed to submit accurate staffing information to CMS for FY Quarter 2 2023 (January 1- March 31). The facility failed to submit accurate licensed nurse hours for 04/09/23, 05/13/23, 06/10/23, 06/11/23, 06/18/23, and 06/25/23. The facility's failures could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Review of the CMS PBJ report for CMS for FY Quarter 2 2023 (January 1-March 31) indicated the facility had failed to submit data for the quarter triggered. Review of the CMS PBJ report for CMS for FY Quarter 3 2023 (April 1- June 30) indicated the facility had failed to have Licensed Nursing Coverage 24 hours/day triggered. Review of the CMS PBJ report for FY Quarter 3 2023 (April 1- June 30) indicated the facility did not have licensed nursing coverage 24 hours/day triggered for the following dates: 04/09 (SU ), 05/13 (SA ), 06/10 (SA), 06/11 (SU), 06/25 (SU). Review of staff timesheets for 04/09/23, 05/13/23, 06/10/23, 06/11/23, 06/18/23, 06/25/23 indicated there was licensed nursing coverage for 24 hours on those days. In an interview via phone on 12/08/2023 at 11:30 AM with the VP of Operations revealed she was responsible for submitting the PBJ information to CMS for the facility. The VP of Operations said in regard to failing to submit data for the second quarter there were a few things that had happened at the facility around that time, and she was locked out of the system. The VP of Operations said she waited too long to try and submit the information and once she was locked out, she could not get her password to reset and submit the data even though she had it available and ready to submit. The VP of Operations said in regard to not having licensed nurse coverage was because the days were on the weekends and when staff call in, managers like the ADON's or DON or the CNO would pick up the shifts. The VP of Operations said the managers do not clock in or out, so the data submitted does not show they worked those dates. The VP of Operations said the purpose of submitting the PBJ staffing information on time and accurately was to help see where the facility lies compared to the baseline standards of the industry and region. In an interview on 12/07/23 at 3:34 PM with the Administrator revealed the VP of Operations was responsible for submitting all the PBJ staffing data. Review of the facility's Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual Version 2.6 policy, dated June 2022, reflected: .(u) Mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

Oct 2023 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for two (Resident #2 and Resident #3) of eight residents reviewed for ADLs. The facility failed to provide Resident #2 with a shower/bath for 3 Saturdays. The facility failed to provide Resident #3 with a showers/bath on her scheduled days. The resident missed two showers. This failure could place 62 residents who required assistance of 1 or 2 staff or dependent on staff for bathing at risk of not receiving care and services to meet their needs. Findings included: Observation on 10/31/2023 at 9:19 AM revealed the clean linen closet had no available towels. Interview with LVN J on 10/31/2023 at 9:21 AM, LVN J confirmed there were no towels inside the clean linen closet. LVN J stated the CNAs already used the towels that morning for the showers. Resident #2 Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #2 had an intact cognition with a BIMS score of 15. Resident #2 required one person assist for bed mobility, transfer, dressing, toilet use, and bathing. The Quarterly MDS Assessment also indicated the primary reason for admission was other neurologic conditions. Primary medical conditions included cerebral palsy (a disorder that affects movement and muscle tone due to brain injury), anxiety disorder, depression, post-traumatic stress disorder, and insomnia. Observation and interview with Resident #2 on 10/31/2023 at 10:20 AM, Resident #2 stated her shower schedule was on Tuesdays, Thursdays, and Saturdays. Resident #2 said that she would usually get a shower on Tuesdays and Thursdays but not on the weekends. Resident #2 added that this had been going on for a month and that she was not able to have showers for three weekends. Resident #2 said the CNA would tell her that she could not have a shower because there were no towels. Resident #2 repeated she was not able to have a shower on the weekend because there were no towels at all. Resident #2 added she heard the washing machines, and the dryers were not working. Resident #2 was noted frustrated while saying that she needed her shower because it was uncomfortable not having the scheduled shower. Record review of Resident #2's shower sheet on 10/31/2023 revealed no showers done on 10/21/2023 and 10/14/2023. Resident #3 Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #3 had a moderately impaired cognition with a BIMS score of 10. Resident #3 required one man physical assist for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. The Quarterly MDS Assessment also indicated the primary reason for admission was medically complex conditions such as type 2 diabetes mellitus, heart failure, anxiety disorder, depression, and primary insomnia. Observation and interview with Resident #3 on 10/31/2023 at 10:31 AM, Resident #3 stated her shower schedule was on Tuesdays, Thursdays, and Saturdays. Resident #3 said she had not had a shower since last Tuesday (10/24/2023). Resident #3 checked the calendar on her cellphone and counted how many showers she missed. Resident added that she missed two showers. She said that she hadn't had a shower because the CNA told her there were no towels. She said this had been a problem in the last month. Resident #3 said the washers and dryers were not functioning. Record review of Resident #3's shower sheet on 10/31/2023 revealed no shower done on 10/17/2023. Interview with CNA I on 10/31/2023 at 11:37 AM, CNA I stated that he worked double weekend from 6 AM to 10 PM. CNA I said they did not have towels last Saturday that was why he was not able to give showers. CNA stated there were times he could not give a shower because there were no towels. CNA I added they had no towels because of the broken down washing machines and dryers. CNA I further stated he heard it happened also to other staff on different shifts. Interview with CNA U on 10/31/2023 at 11:52 AM, CNA U stated that she would sometimes pick up shifts on the weekend. CNA U said there would be times were there would be no towels to use. CNA U added she would hear about the shortage of bath towels from other shifts, too. CNA U further stated she heard sometimes there are no bath towels or washcloths when CNAs want to do showers. CNA U said she would hear from laundry lady that the reason for not having enough towels was because she was only using one washing machine. Interview with CNA H on 10/31/2023 at 12:31 PM, CNA H stated sometimes they do have towels but sometimes they do not have any towels. Since the residents needed to be showered, she would use flat sheets or a pillowcases to dry them up. CNA H stated this had happened about a dozen of times in the month or so because the washing machines was broken again. Interview with Administrator on 10/31/2023 at 1:34 PM, the Administrator stated she was not aware the residents were not getting their scheduled shower. She said there were no shortage on towels because even though the two of the three washers and two of the three dryers were not working, they still have a washer and a dryer. The laundry team just needed to wash more frequently. She added they were also using the washer and dryer on the therapy room. Interview with LVN B on 10/31/2023 at 2:28 PM, LVN B stated sometimes there were not enough towels because not all the washers and dryers were operating. LVN B added sometimes she would end up waiting until laundry would bring the towels. When this happens she would go to the laundry room to get more, however sometimes there isn't any. LVN B further stated sometimes when there were no towels available, she would go to the laundry room and wash the towels so that she would have towels to use. Review of facility's policy, Accommodation of Individual Needs and Preferences, 2001 Med-Pass, Inc., rev. October 2009 revealed Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving in dependent functioning, dignity, and well-being . 1. The resident's individual needs and preferences shall be accommodated to the extent possible .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. The facility failed to repair two of three washing machines, which resulted in facility not having adequate supply of bath towels. The facility failed to repair two of three dryers, which resulted in facility not having adequate supply of bath towels. This failure could place 62 residents who required towels for shower/bed bath not having showers because of two of the washers and two of the dryers were not working. Findings included: Observation on 10/31/2023 at 9:19 AM revealed the clean linen closet had no available towels. Interview with Resident #2 on 10/31/2023 at 10:20 AM, Resident #2 stated her shower schedule was on Tuesdays, Thursdays, and Saturdays. Resident #2 said that she would usually get a shower on Tuesdays and Thursdays but not on the weekends. Resident #2 added that this had been going on for a month. Resident #2 said the CNA would tell her that she could not have a shower because there were no towels. Resident #2 added she heard the washing machines, and the dryers were not working. Interview with Resident #3 on 10/31/2023 at 10:31 AM, Resident #3 stated her shower schedule was on Tuesdays, Thursdays, and Saturdays. Resident #3 said she had not had a shower since last Tuesday (10/24/2023). She said that she hadn't had a shower because the CNA told her there were no towels. She said this had been a problem in the last month. Resident #3 said the washers and dryers were not functioning. Observation on 10/31/2023 at 10:46 AM revealed the laundry room had three washing machines and three dryers. It was noted that two of the washing machines had a note stating, out of order. Two of the dryers were also out of order. Interview with Laundry B on 10/31/2023 at 10:50 AM, Laundry B stated there were three washers but two of the washers were down. Laundry B said it was the same thing with the dryers, there were three dryers but only one was operating. Interview with Laundry O on 10/31/2023 at 10:59 AM, Laundry O stated there were three washing machines, but two of the washing machines needed service. Laundry O said she reported it to the Plant Operation Manager a month a half ago. Laundry O said there were three dryers but only one dryer was working. Laundry O added she also reported the broken dryers to the Plant Operation manager. Laundry O further stated the washing machine had been broken intermittently for a while and currently only one washing machine was in operation. Laundry O also said the turnover of towels were so fast that sometimes she could not keep up. Interview with CNA I on 10/31/2023 at 11:37 AM, CNA I stated that he worked double weekend from 6 AM to 10 PM. CNA I said they did not have towels last Saturday that was why he was not able to give showers. CNA stated there were times he could not give a shower because there were no towels. CNA I added they had no towels because of the broken down washing machines and dryers. CNA I further stated he heard it happened also to other staff on different shifts. Interview with CNA U on 10/31/2023 at 11:52 AM, CNA U stated that she would sometimes pick up shifts on the weekend. CNA U said there would be times were there would be no towels to use. CNA U added she would hear about the shortage of bath towels from other shifts, too. CNA U further stated she heard sometimes there are no bath towels or washcloths when CNAs want to do showers. CNA U said she would hear from laundry lady that the reason for not having enough towels was because she was only using one washing machine. Interview with Maintenance Manager on 10/31/2023 at 12:20 AM, Maintenance Manager said he was made aware two of the three washers and two of the three dryers were not working. He said one of the washers were always broken and then two washer broke down a month ago. He said somebody came to service the washer. The service man took a piece from one of the washer and put it on the other washer. The washer worked for a week and broke down again. The Maintenance Manager said it was scheduled to be serviced again. He said one of the machine needed a part to get fixed and said the facility was waiting for the financial approval from the regional to have the dryers and washers fixed or buy new washers and dryers. He stated for the meantime, they were using the washer and the dryer on the therapy unit for the residents' clothes and use the working washer and dryer on the laundry room for the beddings and linens. Interview with CNA H on 10/31/2023 at 12:31 PM, CNA H stated sometimes they do have towels but sometimes they do not have any towels. Since the residents needed to be showered, she would use flat sheets or a pillowcases to dry them up. CNA H stated this had happened about a dozen of times in the month or so because the washing machines was broken again. Interview with Administrator on 10/31/2023 at 1:34 PM, the Administrator stated the facility had three washers and three dryers. The Administrator said she was aware that two of the dryers and two of the washers were not working. She added a service man came two weeks ago to check on the washers and dryers. The Administrator said a service man took some part from the other washer and put it on one of the washer. She added she was waiting for the regional's financial approval to have someone fix the broken washers and dryers. She said The Administrator added it was important to have the washers and dryers fixed so that the residents will have their clothes and the other things needed to be washed. Interview with LVN B on 10/31/2023 at 2:28 PM, LVN B stated sometimes there were not enough towels because not all the washers and dryers were operating. LVN B added sometimes she would end up waiting until laundry would bring the towels. When this happens she would go to the laundry room to get more, however sometimes there isn't any. LVN B further stated sometimes when there were no towels available, she would go to the laundry room and wash the towels so that she would have towels to use. Review of facility's policy, Supplies and Equipment, Environmental Services, 2001 Med-pas, Inc., rev. April 2009 revealed Housekeeping/laundry department supplies, and equipment shall be readily available so that department personnel can perform necessary tasks . 1. Equipment must be ready for use at all times To serve the residents' needs.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide for the maintenance of comfortable sound levels for 3 (Residents #1, #2, and #3) of 6 residents reviewed for comfortable sound levels. The facility failed to maintain a comfortable sound level for Residents #1, #2, and #3 due to Resident #7's yelling. This failure placed residents at risk of being unable to sleep at night. Findings included: Resident #1 Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #1 had an intact cognition with a BIMS score of 15. The Quarterly MDS Assessment also indicated the primary reason for admission was medically complex conditions such as type 2 diabetes mellitus without complications, hypertension, obstructive uropathy (a blockage in the urinary tract), and depression. Review of Resident #1's Physician Order dated 09/22/2023 reflected, Venlafaxine HCL ER tablet extended release 24 hrs 150 mg: Give 1 tablet by mouth one time a day for depression. Observation and interview with Resident #1 on 10/31/2023 at 10:11 AM, Resident #1 was on her bed resting. Resident #1 stated that she did not hear any staff yelling at any resident. Resident #1 added she did hear a male resident always shouting at staff at no specific time. The male resident would shout even at the middle of the night and early morning. Resident #1 said at first it did not bother her, but the shouting was getting worse and woke her up sometimes. Resident #2 said she had filed a grievance about a resident always yelling. Resident #2 Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #2 had an intact cognition with a BIMS score of 15. The Quarterly MDS Assessment also indicated the primary reason for admission was other neurologic conditions. Primary medical conditions included cerebral palsy (a disorder that affects movement and muscle tone due to brain injury), anxiety disorder, depression, post-traumatic stress disorder, and insomnia. Review of Resident #2's Physician Order dated 09/22/2023 reflected, Trazadone HCL Tablet 50 mg: Give 1 tablet by mouth at bedtime related to insomnia, unspecified, 1 tablet q (every) HS (at bedtime). Review of Resident #2's Physician Order dated 03/29/2023 reflected, Escitalopram Oxalate Oral Tablet 20 mg: Give 1 tablet by mouth one time a day for antidepressant. Observation and interview with Resident #2 on 10/31/2023 at 10:20 AM, Resident #2 was on her bed, semi awake. Resident #2 stated she was still sleepy even though it was already 10:30 AM because she was awaken early morning when a resident from hall 700 started shouting as early as 3 AM. Resident #2 added the situation had been getting worse and going on since she cannot remember. Resident #2 said she already filed a grievance report for the male resident that was always yelling. Resident #3 Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #1 had a moderately impaired cognition with a BIMS score of 10. The Quarterly MDS Assessment also indicated the primary reason for admission was medically complex conditions such as type 2 diabetes mellitus, heart failure, anxiety disorder, depression, and primary insomnia. Review of Resident #3's Physician Order dated 10/12/2023 reflected, Trazadone HCL Oral Tablet: Give 50 mg by mouth at bedtime for insomnia. Review of Resident #3's Physician Order dated 10/22/2023 reflected, Xanax Oral Tablet 0.25 mg (Alprazolam): Give 1 tablet by mouth every 12 hours as needed for anxiety until 11/05/2023. Observation and interview with Resident #3 on 10/31/2023 at 10:39 AM, Resident #3 was on her bed listening to music. Resident stated she loved listening to music because music made her feel relaxed. Resident #3 said sometimes she would wake up in the middle of the night or early morning because she would be hearing a loud noise from the hallway. The noise was a man yelling incessantly. Resident #3 added she could hear the noise because it was quiet at night. Resident #3 further added sometimes the shouting would happen during daytime. Resident #7 Record review of Resident #7's MDS Quarterly assessment dated [DATE] reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #7 was cognitively intact with a BIMS score of 15. The MDS Quarterly Assessment also indicated the primary reason for admission was debility (weakness), cardiorespiratory conditions such as unspecified chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure, and hypertension. Resident #7 also had anxiety disorder, depression, and bipolar disorder. Interview with LVN A on 10/31/2023 at 11:21 AM, LVN A stated Resident #7 was situated on hall 700. LVN A said Resident #7 was sometimes ok but most of time not. LVN A clarified when resident is ok, she meant Resident #7 was not yelling at the staff, when resident was not ok, she meant Resident #7 would be shouting at the staff. LVN A added that during shift report, the night nurse gave details about Resident #7 being verbally abusive to staff and started throwing things on the staff. Review of Resident #7' Progress Notes dated 10/31/2023 revealed . Inappropriate verbal behaviors were observed, he was yelling, screaming, cursing the staff, and throwing away things at the staff who went to help . Review of Resident #7's Progress Notes dated 10/26/2023 revealed . he has been seating on the TV area, was heard yelling and cursing out at CNA who was trying to transfer him back to his room . Review of Resident #7' Progress Notes dated 10/23/2023 revealed . nurse went to the room to give him medication and breathing treatment . neighbor yelling, screaming telling get out of my room you are so lazy why don't give me up . Review of Resident #7' Progress Notes dated 10/17/2023 revealed . neighbor was heard screaming down the hall . stated therapist couldn't find his blue shorts . Interview with CNA O on 10/31/2023 at 12:31 PM, CNA O stated Resident #7 would be verbally abusive to the staff. CNA O said there were no specific time of the day or night that Resident #7 would start yelling. Interview with Administrator on 10/31/2023 at 1:34 PM, the Administrator stated she had tried to provide the needs of Resident #7 to appease him. The Administrator said she had tried all the available tools to provide him the care he needed. The Administrator added she was upset because the other residents were affected. The Administrator stated the residents should have peace and quiet especially at night where they could sleep soundly. Review of facility policy, Noise Control, 2001 Med-Pass rev. April 2010, revealed The facility strives to maintain comfortable sound levels that enhance privacy . 1. Resident care and services should be provided in a manner that promotes calm, organized, and comfortable sound level. Review of facility policy, Quality of Life - Homelike Environment, 2001 Med-Pass, Inc., rev. October 2009, revealed residents are provided with a safe, clean, comfortable, and homelike environment . H. comfortable noise level.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to make prompt efforts to resolve grievances the residents may have for 5 (Residents #1, #2, #3, #4, and #5) of 8 residents reviewed for Grievances. The facility failed to provide prompt response to the grievance of Resident #1 about a person screaming and yelling day and night. The facility failed to provide prompt response to the grievance of Resident #2 about a person yelling and screaming. The facility failed to provide prompt response to the grievance of Resident #3 about a person cursing at staff. The facility failed to provide prompt response to the grievance of Resident #4 about hearing a man scream with his door open or close. The facility failed to provide prompt response to the grievance of Resident #5 about a man who screams all the time demanding immediate attention. This failure could place the residents at risk of not having their grievances resolved when concerns were brought to the attention of the facility. Findings included: Resident #1 Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #1 had an intact cognition with a BIMS score of 15. The Quarterly MDS Assessment also indicated the primary reason for admission was medically complex conditions such as type 2 diabetes mellitus without complications, hypertension, obstructive uropathy, and depression. Record review of Resident #1's Physician Order dated 09/22/2023 reflected, Venlafaxine HCL ER tablet extended release 24 hrs 150 mg: Give 1 tablet by mouth one time a day for depression. Record review of facility's grievance report on 10/31/2023 reflected Resident #1 filed a concern on 10/10/2023 about a person screaming and yelling day and night. Observation and interview with Resident #1 on 10/31/2023 at 10:11 AM, Resident #1 was on her bed resting. Resident #1 stated that she did not hear any staff yelling at any resident. Resident #1 added she did hear a male resident always shouting at staff at no specific time. The male resident would shout even at the middle of the night and early morning. Resident #1 said at first it did not bother her, but the shouting was getting worse and woke her up sometimes. Resident #2 said she had filed a grievance about a resident always yelling. Resident #2 Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #2 had an intact cognition with a BIMS score of 15. The Quarterly MDS Assessment also indicated the primary reason for admission was other neurologic conditions. Primary medical conditions included cerebral palsy, anxiety disorder, depression, post-traumatic stress disorder, and insomnia. Review of Resident #2's Physician Order dated 09/22/2023 reflected, Trazadone HCL Tablet 50 mg: Give 1 tablet by mouth at bedtime related to insomnia, unspecified, 1 tablet q(every) HS (at bedtime). Review of Resident #2's Physician Order dated 03/29/2023 reflected, Escitalopram Oxalate Oral Tablet 20 mg: Give 1 tablet by mouth one time a day for antidepressant. Record review of facility's grievance report on 10/31/2023 reflected Resident #2 filed a concern on 10/10/2023 about a person yelling and screaming. Interview with Resident #2 on 10/31/2023 at 10:20 AM, Resident #2 stated the situation had been getting worse and going on since she cannot remember. Resident said she would wake up at the middle of the night because of the noise. Resident #2 added that all the facility was doing was give them a piece of paper to write their concerns, but nothing has been done. Resident #3 Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #3 had a moderately impaired cognition with a BIMS score of 10. The Quarterly MDS Assessment also indicated the primary reason for admission was medically complex conditions such as type 2 diabetes mellitus, heart failure, anxiety disorder, depression, and primary insomnia. Review of Resident #3's Physician Order dated 10/12/2023 reflected, Trazadone HCL Oral Tablet: Give 50 mg by mouth at bedtime for insomnia. Review of Resident #3's Physician Order dated 10/22/2023 reflected, Xanax Oral Tablet 0.25 mg (Alprazolam): Give 1 tablet by mouth every 12 hours as needed for anxiety until 11/05/2023. Record review of facility's grievance report on 10/31/2023 reflected Resident #3 filed a concern on 10/01/2023 about a person cursing at staff. Interview with Resident #3 on 10/31/2023 at 10:39 AM, Resident #3 she could hear the loud noise from the hallway. The noise is a man yelling incessantly. Resident #3 added she could hear the noise because it was quiet at night. Resident #3 said the facility was aware but did not know if the facility was doing anything to resolve the issue. Resident #3 added she cannot sometimes because of the noise. Resident #4 Record review of Resident #4's Quarterly MDS assessment dated [DATE] reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #4 had an intact cognition with a BIMS score of 15. The Quarterly MDS Assessment also indicated the primary reason for admission was other neurologic conditions such as Parkinson's disease and hemiplegia (paralysis on one side of the body) or hemiparesis (weakness on one side of the body). Resident #4 also had diabetes mellitus, hypertension, and anxiety disorder. Review of Resident #4's Physician Order dated 07/05/2023 reflected, Clonazepam Oral Tablet 0.5 mg (Clonazepam): Give 1 tablet by mouth at bedtime for anxiety. Review of Resident #4's Physician Order dated 07/05/2023 reflected, Trazadone HCL Oral Tablet: Give 50 mg by mouth at bedtime for insomnia. Record review of facility's grievance report on 10/31/2023 reflected Resident #4 filed a concern on 10/01/2023 about hearing a man scream with his door open or close. Resident #5 Record review of Resident #5's Quarterly MDS assessment dated [DATE] reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #5 had an intact cognition with a BIMS score of 15. The Quarterly MDS Assessment also indicated the primary reason for admission was medically complex conditions such as multiple sclerosis, anxiety disorder, depression, and post-traumatic stress disorder. Review of Resident #5's Physician Order dated 10/26/2023 reflected, Lorazepam Oral Tablet 0.5 mg (Lorazepam): Give 0.5 mg by mouth three times a day for anxiety. Review of Resident #5's Physician Order dated 08/12/2023 reflected, Rizatriptan benzoate tablet 10 mg: Give 1 tablet by mouth every 2 hours as needed for MIGRAIN May repeat dose Q2H (every two hours) x 2 doses. **MAX DOSE OF 30MG IN 24 HOURS**. Review of Resident #5's Physician Order dated 08/12/2023 reflected, Ramelteon Tablet 8 MG: Give 1 tablet by mouth at bedtime for Insomnia please give at bedtime. Record review of facility's grievance report on 10/31/2023 reflected Resident #5 filed a concern on 10/10/2023 about a man who screams all the time demanding immediate attention. Interview with Administrator on 10/31/2023 at 1:34 PM, the Administrator stated she had tried to provide the care needed Resident #7. The Administrator said she had tried all the available tools to provide him the care he needed. The Administrator added she was upset because the other residents were affected. The Administrator acknowledged the yelling has been going on and havent' been resolved. The Administrator stated the residents should have peace and quiet especially at night where they could sleep soundly. Review of facility's policy, Filling Grievances/Complaints Social Services Policy Manual, 2001 Med-Pass, Inc., rev. September 2005 revealed Our facility will assist residents, their representatives (sponsors), other interested family members, or residents advocates in filling grievances or complaints . 5. Upon receipt of a written grievance . will investigate the allegation . 7. The residents . will be informed of the findings and the actions that will be taken to correct any identified problem .

May 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure drugs and biologicals were secured properly in 1 (500-600 medication cart) of 4 Medication carts reviewed for drug storage. The medications were not secured properly in the 500-600 medication cart. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. The findings were: Record review of Resident #1's quarterly MDS assessment, dated 03/06/23, reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), schizoaffective disorder (A mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder.), neurocognitive disorder with Lewy bodies(a nervous system disorder characterized by a decline in intellectual function (dementia), a group of movement problems and visual hallucinations). He had a BIMS of 0 indicating he was not cognitively intact. During an observation on 05/01/23 beginning at 12:00 PM, the medication cart facing hallway 600 outward was unlocked and unsupervised. Further observation revealed the nursing station behind the cart and with no visible staff. Observed different staff walk by the unsecured medication cart and LVN B returned to the nursing station. LVN B faced hallway 800 while she worked on the computer. Resident #1 was observed sitting in a chair facing the unsecured medication cart. During an interview on 05/01/23 at 12:30 PM, LVN B stated the medication and treatment cart should never be left unlocked. No carts in the facility should be left unlocked. LVN B stated Residents could get into the medication cart and take something that they are not supposed to. LVN B stated the medication cart belonged to CNA/MA A who had left for a break. During an interview on 05/01/23 at 1:00 PM the DON stated the medication cart should never be left unlocked, whenever you walk away the medication cart should be locked. We have residents that will get into the cart and may take something they are not supposed to take. The DON stated she has talked to CNA/MA A several times about keeping the medication cart locked. Each staff are responsible for their assigned cart for the day. DON stated she would be going to talk with CNA/MA A again about securing the cart. During an interview on 05/01/23 at 1:25 PM CNA/MA A stated it was her fault the medication cart was left unlocked. CNA/MA stated she forgot to lock the medication cart before her break. CNA/MA A stated she had been trained about securing the medication cart at the facility and at school. CNA/MA stated by leaving the cart unlocked residents have a high risk of getting into the medication. During an interview on 05/01/23 at 2:20 PM LVN C stated medication cart should be looked locked when not being used. LVN C stated residents can get into the cart and take the wrong medication. Record review of the facility's policy titled Storage of medication (revised April 2007), revealed: policy statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely for one (Resident# 1) of two residents observed for medication administration and storage. The facility failed to ensure fluticasone nasal spray and a Ventolin inhaler were not left in Resident #1's room. This failure could place residents at risk of overmedication, misuse, adverse drug reactions, and not receiving the intended therapeutic effects. Findings included: Record review of Resident #1's face sheet, dated 04/13/23, revealed the resident was an [AGE] year-old female who was admitted on [DATE]. Resident #1 had diagnoses that included diabetes (high blood glucose levels, dependence on supplemental oxygen, and chronic obstructive pulmonary disease with acute exacerbation (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #1's care plan, dated 01/14/23, revealed the resident had chronic obstructive pulmonary disease. Interventions were to give the resident aerosol or bronchodilator as ordered and to monitor/document any side effects and effectiveness. Record review of Resident #1's admission MDS assessment, dated 01/21/23, revealed the resident's cognition was moderately impaired with a BIMS score of 12. Record review of Resident #1's physician order summary for April 2023 revealed she had an order for fluticasone propionate 50 mcg spray with a start date of 03/30/23. The order reflected to instill 2 sprays into both nostrils twice daily for itching and running nose. Resident #1 did not have an order for Ventolin inhaler. Observation and interview on 04/13/23 at 3:56 PM with Resident #1 revealed there was a bottle of fluticasone prop 50 mcg spray and ProAir Ventolin HFA (albuterol sulfate inhalation) on Resident #1's table in her room. She revealed she had been keeping them and she used the fluticasone spray in the mornings and evening, and she used the Ventolin inhaler as needed. She stated she had been keeping the medications since she had been in the facility. She revealed a nurse gave the fluticasone spray to her after refill for her to keep, but she could not provide the nurse's name. She revealed she brought the Ventolin inhaler from home. Interview and observation on 04/13/23 at 4:04 PM with LVN A, who was the charge nurse for Hall 500, revealed the facility did not have residents who self-administered medications. Observation with LVN A of the nurse's medication cart revealed Resident #1's fluticasone nasal spray that was delivered on 03/30/23 from the pharmacy was still intact and not opened. LVN A revealed he was not aware that Resident #1 kept medications in her room. He stated it was best practice not to leave medications in the resident's room. He stated residents were not allowed to keep medications in their rooms and families were educated not to leave over-the-counter medications with the residents. He stated the risk of leaving the medication in the resident room was that it could cause Resident #1 to overdose, miss a dose or misuse, and she might not administer the medication as scheduled. He stated regarding the Ventolin inhaler Resident#1 was supposed to have an order. Interview and observation on 04/14/23 at 4:14 PM with the DON of the nurse's medication cart revealed there were no residents in the facility who self-administered their own medications. She stated her expectation was that when staff admitted a resident, they should collect all the medication brought from home or another facility and give the medication back to the families or lock them in the nurses' carts. The DON stated staff should not leave medications in a resident's room because this would allow residents to overdose and could lead to misuse because they did not know when to use them. The DON stated it was the nursing staff's responsibility to ensure there were no medications left in residents' rooms during medication pass and at all times. The DON stated after checking the medication cart Resident #1's inhaler was intact and not opened. Regarding the Ventolin inhaler, the DON stated there was no order so she suspected the resident's family had supplied Resident #1 with it. She stated she did not know what was going on with the fluticasone administration. The DON stated she had not done any training regarding this since she had been at the facility since November 2022. The facility was asked to provide the policy regarding medication administration; however, the facility did not provide the policy prior to exit as requested.

Jan 2023 2 deficiencies

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 4 (Halls 500, 600, 700, and 800) of 4 Halls reviewed for medication storage. The facility failed to secure a medication room and multiple medication carts, as well as monitor the temperatures of medication storage refrigerators. These failures placed residents at risk of accessing medications they were not prescribed, and being administered medications not stored at proper temperatures. Findings included: Observation on 01/05/23 at 10:00 AM of the medication room located at the [NAME] nurses' station revealed the door was not secured. The door appeared to be accessible only by key, but the surveyor was able to open the door without a key. The medication room contained multiple medications, both over-the-counter and prescription medications, and four medication refrigerators. Observation of the refrigerator temperature log revealed for January 2023, the temperature had only been recorded on 01/04/23. Observation on 01/05/23 at 10:08 AM, the Treatment Cart for [NAME] nurses' station was unsecured. The treatment cart contained multiple syringes and needles as well as medications for wound care. The cart was unattended at the nurses' station. Observation on 01/05/23 at 10:10 AM, the Hall 700/800 Medication Aide cart was unsecured. The cart contained over-the-counter and prescription medications for multiple residents. The cart was unattended at the nurses' station. Observation on 01/05/23 at 10:12 AM, the Hall 700/800 nurses' medication cart was unsecured. The cart contained over-the-counter and prescription medications for multiple residents. The cart was unattended at the nurses' station. Observation on 01/05/23 at 10:15 AM, the Hall 500/600 nurses' medication cart was unsecured. The cart contained over-the-counter and prescription medications for multiple residents. The cart was unattended at the nurses' station. Interview on 01/05/23 at 10:20 AM, LVN A stated the medication room and all medication carts should be secured if they were left unattended. LVN A stated failing to do so put residents at risk of gaining access to medications not prescribed for them. Interview on 01/05/23 at 10:25 AM, the DON stated the medication room should be secured to prevent residents from accessing medication in the room. She stated the treatment and medication carts should always be secured when the staff member was away from them. She was unaware staff had not secured the medication room or their medication carts. Review of the facility's policy Storage of Medications, dated April 2007, reflected: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. .Compartments (including but not limited to, drawers, cabinets,rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts shall not be left unattended if open or otherwise potentially available to others Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 carts (Medication carts for Halls 500/600 and 700/800 Hall) of 8 carts and 1 ([NAME] Station) of 1 nurses' station reviewed for infection control 1. The facility failed to monitor the sharps containers for multiple medication carts, and change them out when they were full. 2. Physician B failed to doff isolation PPE prior to exiting a COVID-19 positive room and entering a non-COVID-19 positive room, and before entering the nurses' station to document. 3. Housekeeper C failed to doff her isolation PPE prior to exiting a COVID-19 positive room to retrieve items from her cart located across the hall from the room, and returning to the same room. Housekeeper C than failed to doff again when exiting the room and returning to her cart. Housekeeper C doffed her PPE at her cart. These failures placed residents at risk of exposure to infectious materials and pathogens. Findings included: Observation on 01/05/23 at 10:00 AM, the sharps container on the Hall 700/800 nurses' medication cart was overfilled to the point new sharps could not be deposited if needed. Observation on 01/05/23 at 10:13 AM, the sharps container on the Hall 500/600 nurses' medication cart was overfilled to the point new sharps could not be deposited if needed. Observation on 01/05/23 at 10:18 AM, Physician B entered the room of a resident, who was COVID-19 positive and under droplet precautions. Upon entering this room, Physician B wore gloves, gown, face shield, and N-95 face mask. Physician B then exited this COVID-19 positive room, and he proceeded to enter the room a resident who did not have COVID-19. Without doffing the PPE, Physician B exited the room and proceeded to the [NAME] nurses' station before doffing his isolation gown. Interview on 01/05/23 at 10:30 AM, Physician B stated staff were allowed to wear an isolation gown from room to room as long as they were not providing direct patient care. He stated staff only needed a gown and N-95 mask when entering a droplet precaution room as long as they were not providing direct patient care. Interview on 01/05/23 10:35 AM, the DON stated isolation gowns could not be worn room to room, regardless of the type of contact you had with the resident. All PPE should be doffed inside the room before exiting the room. The PPE for droplet precautions was a gown, gloves, N-95 mask, and face shield or goggles. The DON stated nurses were responsible for monitoring their sharps containers and changing them out before they become overfilled. Observation on 01/05/23 at 12:00 PM, Housekeeper C exited a droplet precaution room with her gown, mask, gloves, and face shield in place, crossed the hall to her cart to retrieve an item, and returned to the room. Observation on 01/05/23 at 12:10 PM, Housekeeper C exited the droplet precaution room to her cart across the hallway, placed her cleaning items on the cart and then doffed her gown, gloves,and face shield to the trash container on her cart. Interview on 01/05/23 at 12:11 PM, Housekeeper C stated she had been trained on infection control and the use of PPE the previous week. She stated PPE should be doffed inside the room prior to exit. She stated she was unaware that she had not followed the CDC's guidelines for doffing of PPE. She stated she just did not pay attention. Interview on 01/05/23 at 2:00 PM, the DON stated housekeeping was allowed to park their cart directly outside the door of an isolation room so that they could retrieve items without having to doff PPE. The DON stated walking across the hall to their housekeeping cart with PPE on was not allowed. Review of the facility's COVID-19 Surveillance and Emergency Action Plan, dated 03/05/20, reflected: Personal Protective Equipment (PPE) is to be worn at all times when entering a contaminated area. PPE will consist of isolation gown, gloves, N-95 mask, and face shield or goggles. PPE is to be worn if the facility has a positive COVID-19 resident, at all times, in all resident care areas of facility, even non-'hot zone' COVID area. The facility was asked to provide the facility's policy regarding sharps containers; however, the facility did not have a policy. Review of the CDC guidelines, posted in Health and Human Service's Nursing Facilities Response Actions in the Event of a COVID-19 exposure, dated 11/18/22, reflected the following: - PPE must be donned correctly before entering the patient area - PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas - PPE must be removed slowly and deliberately in a sequence that prevents self-contamination, prior to exiting the contaminated area Review of OSHA standards on sharps, as described on their website osha.gov, reflected: 1910.1030(c)(1)(i) Each employer having employees with occupational exposure to bloodborne pathogens shall establish an Exposure Control Plan designed to eliminate or minimize employee exposure 1910.1030(d)(1) General Universal precautions shall be observed to prevent contact with blood or other potentially infectious material. 1910.1030(d)(2)(i) Engineering and work practice controls shall be used to eliminate of minimize employee exposure to bloodborne pathogens 1910.1030(d)(2)(viii) Immediately, or as soon as possible after use, contaminated sharps shall be placed in appropriate containers. These containers shall be: . Puncture resistant . Labeled or color-coded . Leakproof 1910.1030(d)(4)(iii)(A)(2) During use containers for sharps shall be: . Easily accessible to personnel . Maintained upright throughout use . Replaced routinely and not be allowed to overfill . Containers should be closed immediately to prevent spillage or protrusions of contents during handling, storage, transport, or shipping.

Oct 2022 4 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident's #42 and #45) of 3 residents reviewed for comprehensive care plans. The interdisciplinary team failed to develop and implement a comprehensive person-centered care plan for Resident #42 regarding tube feedings and Resident #45 regarding wound care. This failure could affect all residents at the facility by placing them at risk for not having their individual needs identified and met. Findings included: Review of Resident #42's Face Sheet, undated, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cerebral infarction (an event which occurs as a result of disrupted blood flow to the brain), hemiplegia (a condition caused by brain damage or spinal cord injury leading to paralysis on one side of the body) and hemiparesis (a significant loss of strength and mobility on one side of the body) affecting the left side, dysphagia (difficulty swallowing), aphasia (an inability to comprehend or formulate language) and dementia (a disorder involving progressive impairments in memory, thinking, and behavior). Review of Resident #42's Comprehensive Care Plan, dated as initiated 3/11/17; next review date 2/13/22, revealed g-tube feedings were not addressed. Review of Resident #42's Quarterly MDS Assessment, dated 9/26/22, Section C-Cognitive Patterns, revealed a BIMS score of 0, indicating severe cognitive impairment. Section K-Swallowing and Nutritional Status revealed resident had a feeding tube. Observation of Resident #42 on 10/25/22 at 9:10 a.m. revealed a continuous g-tube feeding of Jevity 1.5 (therapeutic nutrition that provides complete, balanced nutrition for tube feeding) set to infuse per infusion pump at 70ml/hour. Review of Resident #42's physician's orders revealed an order dated 8/21/22 for G-tube-Jevity 1.5 @ 70ml/hour x 22 hours. Water flush 55ml/hour x 22 hours off at 12:30 p.m./on at 2:30 p.m. two times/day. Review of Resident #45's Face Sheet, undated, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Type II diabetes (a chronic condition that affects the way the body processes blood sugar), cellulitis (a bacterial infection involving the inner layers of skin), traumatic brain injury, and depression. Review of Resident #45's Comprehensive Care Plan, dated as initiated 8/20/22; next review date 3/21/22, revealed resident had a diabetic ulcer to the left heel. Resident's right foot wound was not addressed on this care plan. Review of Resident #45's Quarterly MDS Assessment, dated 10/6/22, Section C-Cognitive Patterns, revealed a BIMS score of 11, indicating moderate cognitive impairment. Section M-Skin Conditions revealed resident had a diabetic foot ulcer(s). Interview and observation of Resident #45 on 10/24/22 beginning at 2:00 p.m. revealed both feet and lower legs wrapped with Kerlix (a bandage wrap) up to the mid-calf area. Resident #45 reported that every morning the staff put a chemical on both feet and wrap them, and the wrapping is taken off at night when he goes to bed. Review of Resident #45's physician's orders revealed an order dated 9/27/22 to cleanse wound to left heel with wound cleanse or normal saline, pat dry. Apply xeroform to wound bed. Cover with dry protective dressing every shift for diabetic ulcer. An order dated 9/29/22 to cleanse wound to right plantar foot with wound cleanse or normal saline, pat dry. Apply xeroform to wound bed. Cover with dry protective dressing every day shift. An interview with the MDS Nurse on 10/26/22 at 2:23 p.m. revealed she was aware Resident #42 had tube feedings, and tube feedings not being addressed on his care plan was an oversight on her part. MDS Nurse stated she planned to update Resident #42's care plan but did not say when. The MDS Nurse said she did not have the information regarding Resident #45's right foot wound at the time of his last assessment, this resident's care plan was already on her list to correct, and she planned to update Resident #45's care plan. The MDS Nurse said that she was currently being assisted with care plans by the ADON's, as she had been unable to do them due to being hospitalized . She said she was also assisted by a remote MDS Nurse when the staff had their morning meetings. She said she herself planned to participate remotely in the morning meetings and work with the DON and Administrator. She said she was in the process of hiring staff to assist with the MDS and care plan process. The MDS Nurse said it was important for a care plan to be accurate and current as it was reflective of how the patient was; it was a picture of the resident's needs, ever-growing and reflective as a resident's needs changed. She said a resident may not meet the criteria for an actual change in MDS, but the care plan should be updated to reflect any change. Interview on 10/26/22 at 2:55 p.m. DON stated she had been trying to work on updating resident's care plans as she could. DON said anyone can update a care plan, and the importance of an accurate, current care plan was to provide accurate care, and to make sure nothing was being missed for the resident. Review of the facility policy Care Plans-Comprehensive, dated 12/2009, revealed .The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans: a. When there has been a significant change in the resident's condition .d. At least quarterly .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident's #14 and #37) of two residents reviewed for infection control. CNA C failed to perform hand hygiene after assisting LVN B with Resident #14's wound care procedure, and prior to assisting Resident #14's roommate. -CNA E failed to perform hand hygiene between glove changes throughout a peri-care procedure on Resident #37. These failures could place residents at risk for cross-contamination and infection. Findings included: Review of Resident #14's Face Sheet, undated, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Type II diabetes (a chronic condition that affects the way the body processes blood sugar), major depressive disorder, stage 4 pressure ulcer of the sacral region, obesity and hypertension (high blood pressure). Review of Resident #14's Quarterly MDS Assessment, dated 8/12/22, revealed resident required extensive assistance with bed mobility and had one stage 4 pressure ulcer. Review of Resident #14's Comprehensive Care Plan revealed resident had a stage 4 pressure ulcer on her sacrum (a large, triangular bone at the base of the spine). Observation of a sacral wound care procedure provided to Resident #14 on 10/25/22 at 3:05 p.m. by LVN B, with assistance provided by CNA C, revealed CNA C to walk away from Resident #14's bedside after the wound care procedure was completed. CNA C walked directly to the trash can located by the bathroom in the resident's room, took his gloves off, threw them in the trash can. Without performing hand hygiene, CNA C walked over to Resident #14's roommate's bedside to help with her TV remote control. Interview on 10/25/22 at 3:15 p.m., CNA C stated hand hygiene policy was to wash hands when entering a room and when leaving. CNA C stated he forgot to wash his hands after removing his gloves. CNA C stated you are always supposed to wash your hands. CNA C stated he wasn't doing care, Resident #14's roommate had just asked for a remote control. CNA C stated infection control could be a potential problem with not washing his hands. Review of Resident #37's Face Sheet, undated, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a degenerative disorder affecting the central nervous system), hypertension (high blood pressure) and atrial fibrillation (an abnormal heart rhythm). Review of Resident #37's admission MDS Assessment, dated 10/2/22, revealed she was always incontinent of bowel and bladder. Observation of incontinence care provided to Resident #37 by CNA E and CNA D on 10/26/22 at 10:15 a.m. revealed hand hygiene and gloves was donned (put on)by both CNA's. CNA E pulled the residents brief down and Resident #37 was assisted by both CNA E and CNA D to roll to her right side. Resident #37's draw sheet was rolled underneath her right hip, and a clean draw sheet was placed. Resident #37 was assisted to roll onto her back by CNA D. CNA E removed the brief and discarded it into a trash bag. CNA E removed her gloves and donned new gloves without performing hand hygiene. CNA E wiped the resident's peri-area from front to back, using one wipe to make one swipe at a time before discarding the wipe, and repeated this several times. CNA E removed her gloves and donned new gloves without performing hand hygiene. Resident was assisted to roll to her right side by both CNA E and CNA D. CNA E wiped the resident's buttock area from front to back, using one wipe to make one swipe at a time before discarding the wipe, and repeated this several times. CNA E removed her gloves and donned new gloves without performing hand hygiene. CNA E placed a new pad and brief under resident's right side. Resident was assisted to roll to her back by CNA D and the brief was secured. CNA D removed his gloves, performed hand hygiene, and donned new gloves. CNA E moved to the other side of the resident's bed and removed the used draw sheet and brief, discarding them into plastic bags. CNA E removed her gloves and donned new gloves without performing hand hygiene. Resident was positioned in her bed by both CNA E and CNA D. CNA E and CNA D then removed their gloves and washed their hands at the sink in the resident's bathroom. Interview on 10/26/22 at 10:30 a.m. CNA E. stated hand hygiene was washing hands and using hand sanitizer from time to time if water was not available. CNA E stated hand hygiene should be completed when entering the room, and if water was available, you should use water to wash your hands. CNA E stated the surveyor observed peri-care procedure she provided to Resident #37 was what she typically does. CNA E stated she had received no instruction about hand hygiene after removing gloves. CNA E stated she had training on hand hygiene at the facility yesterday (10/25/2022). CNA E stated a potential problem with not following hand hygiene policy was that it could lead to infection. Interview on 10/26/22 at 2:55 p.m. DON stated her expectation of staff was to sanitize their hands and put gloves on when they entered a resident's room. When going from dirty to clean, staff should take their gloves off, sanitize their hands before donning new gloves, and sanitize their hands at the end of the procedure. The DON stated a potential problem with staff not following the facility hand hygiene policy was causing an infection to the resident. Review of the facility Handwashing/Hand Hygiene policy, dated 4/2010, revealed The facility considers hand hygiene the primary means to prevent the spread of infection .5. Employees must wash their hand for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions .c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) .l. Upon and after coming into contact with a resident's intact skin .u. After removing gloves .6.use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations .j. After removing gloves .8. The use of gloves does not replace handwashing/hand hygiene .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the laundry services necessary to maintain a safe, clean, and comfortable environment for 49 of the 49 residents residing in the facility reviewed for resident rights. 1.Resident #34 reported there are no towels available when she wanted to take a shower. 2. Residents stated during a confidential group interview that towels were not available for showers. 3. Clean towels were not available to residents or staff on the morning of 10/26/22. This failure places residents in the facility at risk for an unsanitary and uncomfortable living environment. Findings included: Review of Resident #34's Face Sheet, undated, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including cerebral infarction (the process that results in an area of necrotic tissue in the brain, caused by a disrupted blood and oxygen supply), dementia (involving progressive impairments in memory, thinking and behavior), depression and hypertension (high blood pressure). Review of Resident #34's Quarterly MDS Assessment, dated 9/28/22, revealed a BIMS score of 9, suggesting moderate cognitive impairment. Section G-Functional Status revealed resident required physical help in part of bathing activity. Interview on 10/24/22 at 11:16 a.m. Resident #34 reported that sometimes there are no towels, bath towels or face towels, when she wanted to take a shower. Resident #34 stated she required assistance from staff with her showers. Interview on 10/25/22 at 11:00 a.m. during a confidential group interview, two residents stated towels were not available for showers. Interview and Observation on 10/26/22 at 8:55 a.m. CNA D revealed the staff did not have clean towels. CNA D stated the staff were waiting for the towels to be cleaned. CNA D stated towels were stored in the two shower rooms on the [NAME] Hall. CNA D showed this surveyor the two shower rooms; both had towel warmers that were empty. CNA D showed this surveyor the Linen Closet on the [NAME] Hall, reporting that sheets and blankets were kept in this closet, and had no clean towels. Interview on 10/26/22 at 9:25 a.m. CNA E revealed the staff was waiting for towels. CNA E stated they don't always have to wait, it depends, and stated most often towels were available, but not today. CNA E stated staff tells the guy in the laundry to get towels for them when they need them. CNA E stated there were some days residents have not received a shower because she did not have towels. CNA E stated a potential problem with this is a resident not feeling comfortable. Interview on 10/26/22 at 9:35 a.m. District Director of Plant Operations revealed he had worked at the facility for 10 months as the Plant Operations Manager prior to a recent promotion. He reported that the facility is trying to hire a Plant Operations Director. He said they were short-staffed in the laundry yesterday, and the towels were in the wash and would be brought out when they were done. He said the facility had enough towels, that he constantly ordered them, but thought they were being thrown away or being used for something, like cleaning up, inappropriately. He said this had been an off and on problem that came up when the laundry aide called in sick. He said the problem was brought to his attention about 3 months ago, and he immediately ordered 4 dozen more towels at that time. He said the facility was actively working on this issue. He said the towels had been separated by shift, and there were more than enough for each shift, but were being used inappropriately by staff and residents. He said if the residents asked for a towel for any reason, the staff would offer them one, and said the towels were for showering and hygiene. He said it concerned him that towels were being used to clean up the floor, for example, instead of a mop. The District Director of Plant Operations said a potential problem with a resident not having towels would be they couldn't take showers, which could result in a resident not feeling good about themselves, and not meeting basic human needs. Interview on 10/26/22 at 2:55 p.m. Administrator said the issue with the towels was not a lack of supply, but the turn-around, as so many were used. She said the facility had plenty of towels, but sometimes they were used to clean up messes, and sometimes residents requested multiple towels. She said they were trying, and it was more of a staffing issue to get the linens cleaned and back to the floor than it was an issue of having enough linens. The Administrator said they were actively hiring for another laundry person to work the evening shift to help with this issue. She said staff could get more towels from the laundry after hours if they were needed. The Administrator said she had not seen an issue where they couldn't provide baths or showers due to not having towels and planned to investigate this issue to find out what was going on. She said the laundry department was responsible for ensuring the facility had the towels needed to provide care for the residents, and a potential problem with the facility not having towels available for residents would be a delay of the residents' showers. Review of the facility Linen Availability policy, dated 12/2010, revealed .1. Clean linen (e.g., bed sheets, blankets, towels, etc.) will be available at all times for resident care .3. Linen Par Levels of 3 sets of linens per resident will be kept in the facility at all times. 4. Linen purchase is to be requested each month to bring linen levels to par according to resident census .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 the facility's only kitchen. 1.The facility failed to ensure food items in the refrigerators (2), freezers (2) and dry storage were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to discard items stored in refrigerators (3) or dry storage that were not properly sealed/secure or past the 'best buy', consume by or expiration dates. 3. The facility failed to develop, implement and or provide a policy for Food Labeling and Procurement and or holding leftovers in the refrigerator. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observations of the reach-in refrigerator on 10/21/22 at 09:48 AM, revealed the following: On the left side of the reach-in refrigerator: -15 clear plastic cups of white liquid, covered with plastic wrap, there was no label of item description, no pulled date, no consume by date or discard date. -1 medium square clear plastic container with individual containers of jelly. There was no received by date, no consume by or discard date. -1 gallon pitcher with red top, half filled with yellow liquid. There was no label of item description, no pull date, no consume by or discard date. -1 small square clear plastic container with blue lid. There was no label of item description, no pull date, no consume by or discard date. -1 clear pitcher, covered with plastic wrap, with a dark colored liquid. There was no label of item description, no pull date, no consume by or discard date. On the right side of the reach-in refrigerator: -On a tray, 8 magic cups, no label of item description, no pull date, no consume by or discard date. ' -1 medium square container of individual butter packets. There was no label of item description, no pull date, no received date, no consume by or discard date. -1 small square container with aluminum foil cover dated 10-22-22 8pm. There was no label of item description, no consume by or discard date. -1 tray with 12 small plastic containers of chocolate pudding. Manufacturer's expiration date 10/29/22. There was no pull date, no received by date, no consume by date. -1-16 oz plastic bottle of water. There was no label, no received date, no discard date. -1-32 oz aluminum insulated container in a small canvas bag, no label of item description, no received date, no discard date. -1 medium silver packet with a spout, inside of a plastic pitcher. The silver packet had been cut open and left unsecured closed. There was no label of item description, no consume by or discard date. -1 croissant in a large zip top bag, dated 10/21, no label of item description, no consume by or discard date. -1-8 oz plastic jar with lid of thickener, dated 9/7, no open date, no consume by or discard date. -46 oz plastic container with thickened cranberry juice, no open date, no received by date, no consume by or discard date. Observations of the Reach-in Freezer on 10/24/22 at 10:06 AM, revealed the following: -1 large box of pork skinless sausage links, the box is previously opened. There was a large blue plastic bag that was opened, no received by date, no opened date, no consume by date. -1 large clear plastic bag with small number of rolls with ice crystals attached to the rolls and inside the bag. There was no label of item description, no received by date, no consume by date. -2 loaves of garlic bread, manufacturer's expiration date 4/24/23, no received by date. -1 large box of biscuits, previously opened, manufacturer's use by date 9/17/23, no received by date, no opened date, no consume by date. -1 large box of [NAME] a la francesa (French fries), previously opened, no received by date, no opened date, no consume by date. -1 small plastic bag of fried okra wrapped in plastic wrap, no label of item description, no received by date, no opened date and no consume by date. -1 large plastic bag of fried okra, no label of item description, no received by date. -1 plastic bag of 3 personal size pizzas, no label of item description, no received by date, no consume by date. -1-32 oz bag of broccoli, no label of item description, no received by date. -1 large box of sugar cookie dough, previously opened, no received by date, no opened date, no consume by date. -1 large box of breaded chicken tenderloins strips, previously opened, no received by date, no opened date, no consume by date. Observations of the Walk-in Refrigerator on 10/24/22 at 10:20 AM, revealed the following: -1 medium zip top bag with 4 boiled eggs, dated 10/14, no consume by or discard date. -2-1quart cartons of heavy cream, dated 10/14, manufacturer's expiration date 10/17/22. -1 medium zip top bag with half a green bell pepper, no label of item description, no opened date, no consume by or discard date. -1 medium zip top bag with sliced fresh onions, no label of item description, no opened date, no consume by date. The zip top bag also had a hole in the bottom of the bag and onions pieces are sticking out of the hole in the bag. -On a sheet pan, on a rack with 3 large packages of thawing ground beef. Manufacturer's use by date 10/20/22. There was no label of item description, no pulled date, no use by date. Observations of the Kitchen on 10/24/22 at 09:35 AM, revealed the following: -Dietary Aide F in the kitchen, near stove, removing fish fillets from individual packets and placing them in an extra-large stainless-steel bowl. Dietary Aide F had on a N95 mask but only has one strap over her head and the other strap was hanging from the bottom of the mask, below her chin. -Hospitality Aide H entered the kitchen with an ice chest on top of a cart. She did not wash her hands using the hand sink or put on a hairnet (in container outside of the kitchen door and inside the kitchen as well). -At the staff handwashing sink, there is a foot-pedal operated garbage receptacle that sat outside the staff restroom. The garbage receptacle was for the sink but not next to the sink. It had other items in trash other than paper towels: gloves. -46 dinner roll was sitting in 2 muffin tins, uncovered. There was no label of item description, no pull date, no consume by or discard date. - Next to reach-in refrigerator, on a tray located on the bottom shelf of a large stainless-steel shelf, there were 11 bowls of various cereals, covered with plastic wrap. There was no label of item description, no pull date, no consume by or discard date. -On 3rd shelf, in a small zip top bag, half of a cookie. There was no label of item description, no pull date, no consume by or discard date. -1 large plastic bag with a small number of individually wrapped saltine crackers, no received by date, no consume by date or discard date. -On preparation table, next to handwashing sink, with a meat/cheese electric slicer on the table, there was a personal insulated water bottle and a cell phone on the table. On the shelf beneath the preparation table, was a large purse. (Staff lockers next to restroom in the kitchen) Observations of the Walk-in Freezer on 10/24/22 at 10:28 AM, revealed the following: -1 loaf of raisin bread, no label of description, no received by date, no use by date. -On top shelf to the right of the door was 1 large clear plastic bag with 3 pizzas, the bottom pizza broken in 3 pieces, no label of description, no received by date, no opened date, no consume by date. Observation of Dry Storage Room on 10/24/22 at 10:32 AM, revealed the following: -4 large plastic bins with blue lids, each with a different type of dry cereal, there was no label of item description, no received by date, no opened date, no consume by or discard date. -6 large silver bags of dry cereal, no label of item description, no consume by or discard date. In an interview on 10/26/22 at 03:07 PM with the Dietary Manager. She stated that leftover items in the refrigerator were kept 2-4 days, depending on what it is. Meats were no more than 24 hours. Dietary Manager stated that she did the labeling of inventory when it is delivered but the staff labeled items as they used them and staff is expected to put opened dates on items when they open them. The Dietary Manager stated that she does not label the cereals when taken out of the boxed, just placed dates on them. When asked how she knew which cereal is which when the bags were opaque (not transparent), she stated she did not know without the bag being opened. The Dietary Manager stated that for the four weeks she had been working here, she had started to go through the inventory that had predated her and remove old items and rotated the stock. She stated that they (dietary staff) use a first in -first out system. She stated when it came to rotating stock for the bigger bins, she expected that the staff would first use the product in the big bin, clean and dry the bin before adding new ingredients to the bins and place labels on them. The Dietary Manager stated the dented cans are kept on the bottom shelf near the door of the dry storage room. The Dietary Manger stated that she was unaware that they could not have their personal items in the kitchen just that they had to be kept away from food and equipment for food use. She stated she also noted that it was an issue having the non-dietary staff come in the kitchen and not wash their hands or put on a hairnet, though she had asked the staff to do so and there was a sign also placed on the door that stated to put on a hairnet prior to coming in the kitchen. She stated that she had also previously mentioned this to the ADMIN. Review of the Facility's Nutrition Services Food Receiving and Storage Policy, 2001 MED-PASS, Inc. (Revised December 2008), reflected Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: . 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by date). Such foods will be rotated using a first in- first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 10. The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing. Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s), 2 harm violation(s), $38,593 in fines, Payment denial on record. Review inspection reports carefully.
• 39 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $38,593 in fines. Higher than 94% of Texas facilities, suggesting repeated compliance issues.
• Grade F (13/100). Below average facility with significant concerns.

Bottom line: Trust Score of 13/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Mustang Park Therapy And Living Center's CMS Rating?

CMS assigns MUSTANG PARK THERAPY AND LIVING CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Texas, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Mustang Park Therapy And Living Center Staffed?

CMS rates MUSTANG PARK THERAPY AND LIVING CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.

What Have Inspectors Found at Mustang Park Therapy And Living Center?

State health inspectors documented 39 deficiencies at MUSTANG PARK THERAPY AND LIVING CENTER during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 36 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Mustang Park Therapy And Living Center?

MUSTANG PARK THERAPY AND LIVING CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 120 certified beds and approximately 64 residents (about 53% occupancy), it is a mid-sized facility located in CARROLLTON, Texas.

How Does Mustang Park Therapy And Living Center Compare to Other Texas Nursing Homes?

Compared to the 100 nursing homes in Texas, MUSTANG PARK THERAPY AND LIVING CENTER's overall rating (1 stars) is below the state average of 2.8 and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Mustang Park Therapy And Living Center?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.

Is Mustang Park Therapy And Living Center Safe?

Based on CMS inspection data, MUSTANG PARK THERAPY AND LIVING CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Mustang Park Therapy And Living Center Stick Around?

MUSTANG PARK THERAPY AND LIVING CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.

Was Mustang Park Therapy And Living Center Ever Fined?

MUSTANG PARK THERAPY AND LIVING CENTER has been fined $38,593 across 3 penalty actions. The Texas average is $33,465. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Mustang Park Therapy And Living Center on Any Federal Watch List?

MUSTANG PARK THERAPY AND LIVING CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 120
Avg. Residents: 64
Occupancy: 53.8%
Ownership: For profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
1 Immediate Jeopardy citation: -12
2 Actual Harm citations: -10
39 Deficiencies: -10
Fines ($38,593): -5
Final Score: 13/100

Nearby Alternatives

GOOD SAMARITAN SOCIETY-DENTON ... 4-star LAKE FOREST VILLAGE BY PUREHEA... 4-star PILOT POINT CARE CENTER 4-star

View all in CARROLLTON →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 676363