Does ASHFORD GARDENS have any serious inspection findings?

Yes, ASHFORD GARDENS has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 16 total deficiencies from recent inspections.

What are the staffing levels at ASHFORD GARDENS?

ASHFORD GARDENS has a two-star staffing rating from CMS with 0.30 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 ASHFORD GARDENS located?

ASHFORD GARDENS is located in HOUSTON, TX. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does ASHFORD GARDENS have?

ASHFORD GARDENS has 202 certified beds.

Who owns ASHFORD GARDENS?

ASHFORD GARDENS is a for profit - corporation facility and is part of the CANTEX CONTINUING CARE chain.

What questions should families ask when visiting ASHFORD GARDENS?

Families visiting ASHFORD GARDENS should ask about how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does ASHFORD GARDENS compare to other nursing homes?

ASHFORD GARDENS has a 4-star overall rating, placing it above average compared to other nursing homes in TX. Higher-rated facilities typically have better inspection results and staffing levels.

ASHFORD GARDENS

Name: ASHFORD GARDENS
Address: 7210 NORTHLINE DR, HOUSTON, TX, 77076, US
Telephone: (713) 699-2882
Rating: 4.0

7210 NORTHLINE DR, HOUSTON, TX 77076 · (713) 699-2882

For profit - Corporation 202 Beds CANTEX CONTINUING CARE Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

61/100

#182 of 1168 in TX

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Last Inspection: January 2025

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

Overview

Ashford Gardens has a Trust Grade of C+, which indicates that it is slightly above average but not outstanding. It ranks #182 out of 1,168 nursing homes in Texas, placing it in the top half of facilities in the state, and #18 out of 95 in Harris County, meaning there are only 17 local options better. Unfortunately, the facility is experiencing a worsening trend, with issues increasing from 1 in 2024 to 6 in 2025. Staffing is a notable weakness, rated at 2 out of 5 stars, with a turnover rate of 45%, which is below the Texas average of 50%. Additionally, inspector findings revealed concerning incidents, including a failure to properly treat residents' pressure ulcers and inadequate infection control practices, highlighting areas that need significant improvement. While the facility has strengths, such as a solid quality measures rating of 5 out of 5, families should weigh these along with the highlighted weaknesses when considering Ashford Gardens.

Trust Score: C+
In Texas: #182/1168
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 45% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $11,009 in fines. Lower than most Texas facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 16 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★☆

4.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★★

5.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2024: 1 issues

2025: 6 issues

The Good

5-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

Staff Turnover: 45%

Near Texas avg (46%)

Higher turnover may affect care consistency

Federal Fines: $11,009

Below median ($33,413)

Minor penalties assessed

Chain: CANTEX CONTINUING CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 16 deficiencies on record

1 life-threatening

Jan 2025 6 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

Notification of Changes (Tag F0580)

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 immediately consult with the resident's physician when there was a change in residents health status for 1 of 8 residents (Resident #72) reviewed for notification of changes. LVN A failed to notify Resident #72's physician when he reported to him that a car ran over his foot while out of the facility on an unknown date. This failure could place residents at risk of injury, hospitalization, or death. Findings include: Record review of Resident #72's face sheet revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnosis included multiple sclerosis and seizures. Record review of Resident #72's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #72's care plan dated 3/3/23 - Current revealed the resident was at risk for injury related to falls and was resistant to care. Record review of Resident #72's care plan initiated 12/9/24 revealed no documentation of his allegation that a car ran over his foot. Record review of Resident #72's nursing note dated 12/6/24 written by LVN O revealed resident complained of right foot pain due to a car running over his foot 2 days ago. No swelling noted, no warmth to touch, no bruising on right foot. Resident medicated for pain, NP notified, and new order received for right foot x ray stat. Record review of Resident #72's Radiology report dated 12/6/24 revealed no fractures to right ankle, foot, or tibia and fibula. In an interview on 1/8/25 at 4:30 p.m., LVN A said Resident #72 returned to the facility from the store late at night and told him someone hit him. He said the resident informed him the ambulance brought him back to the facility and nothing was wrong with him. LVN A said he assessed the resident, and he was normal with no pain. He said he did not report the incident to anyone and did not document because nothing was wrong. He said if something was wrong, he would have notified the MD. LVN A said he left to go home and was off work for the next few days. In an interview on 1/9/25 at 8:13 a.m., the DON said LVN A should have notified the MD, DON, and Administrator of what Resident #72 said. She said the resident could have been hurt and at risk for harm. In an observation and interview on 1/9/25 at 11:52 a.m., of Resident #72, he shrugged his shoulder when asked if he had an incident where a car ran over his foot. He said he had normal pains. In an observation on 1/9/25 at 12:49 p.m., the Social Worker conducted a BIMS assessment on Resident #72 with a result of 14 of 15 which indicated no cognitive impairment. In an interview on 1/9/25 at 1:35 p.m., the Administrator said she was not aware Resident #72 said his foot was run over by a car until the Surveyors started investigating it. She said she would have requested a physical assessment, notified the doctor, reported it to State and investigated it. In an interview on 1/9/25 at 2:29 p.m., the DON said she expected staff to notify her of any incident to know what is going on and keep the residents safe. She said LVN A informed her (upon investigation) that Resident #72 said someone hit or ran over him with a car. She said LVN A assessed the resident and there was no redness, swelling or signs of injury. She said LVN A did not report it to anyone. She said she would have notified the MD. In an interview on 1/10/25 at 8:33 a.m., Resident #72's MD P said she was notified of Resident #72's incident from NP A on 12/6/24. She said NP A told her Resident #72 was hit by a car and his right foot and ankle were hurting. She said she ordered an x-ray. She said she would have liked to have been notified when the facility first became aware in order to know it occurred, what the findings were, and to determine the next steps. She said she would have recommended to monitor and be notified of any changes in swelling and pain and for the resident to be seen on the next visit. In an interview on 1/10/25 at 8:50 a.m., LVN O said (on 12/6/24) Resident #72 asked her for pain medicine. She said he reported his foot was hurting. She assessed his foot and saw no swelling, redness, warmth, and no apparent injury. She said the NP reported to her approximately 10-15 minutes later that Resident #72 said a car ran over him. LVN O said she was not previously aware of that allegation. She said she reported it to the next nurse but did not report it to the DON or Administrator because she thought they knew since it happened a couple of days ago. In an interview on 1/10/25 at 9:06 a.m., NP A said Resident #72, who was not her patient, reported to her (on 12/6/24) that his ankle was hurting, and he got hit by a car approximately 2 days ago. She said there was no apparent injury. She said she notified the MD, and ordered an x-ray on his ankle, foot, and tibia/fibula. Record review of the facility's Physician Notification policy updated March 2019 read in part, .The types of conditions which arise frequently are listed. This list is not inclusive .it is the responsibility of the nursing staff to observe the change, make an assessment, and notify the physician as indicated based on the assessment . The nurse will: recognize the condition change, monitor the patient, and continue to assess the condition and changes. Notify the physician, patient, and patient representative of any change in condition .

CONCERN (D)

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

Accident Prevention (Tag F0689)

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 received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #92) reviewed for accident hazards. The facility failed to ensure Resident #92 was supervised while smoking outside on the back patio on 1/8/25. These failures could place residents at risk for injuries. Findings included: Record review of Resident #92's face sheet dated 1/8/25 indicated a [AGE] year-old male readmitted on [DATE]. His diagnoses included diabetes mellitus, hypertension, disease of stomach and duodenum, schizophrenia, and peripheral vascular disease. Record review of Resident #92's annual MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #92's care plan dated 12/10/24 and revised on 1/8/25 revealed he was at risk for injury related to not complying with facility protocol for resident's smoking. Interventions were to educate the resident on the facility's tobacco/smoking policy and orient resident to smoking times and procedures. Record review of Resident #92's Smoking and Safety Evaluation dated 12/10/24 revealed he used tobacco products and followed the facility's policy on location and time of smoking. In an interview on 1/7/25 at 3:54 p.m., Resident # 92 said he was not a child and should be able to smoke on his own. He said facility staff removed smoking paraphernalia from him earlier today. He said he went out to smoke on his own sometimes. In an observation and interview on 1/8/25 at 3:16 p.m., of Resident #92 outside on the back patio. He pulled a cigarette and lighter out and began to smoke by himself. Approximately 4 minutes later at 3:20 p.m. CNA N escorted residents out to the back patio to smoke. Resident #92 was outside smoking in a non-smoking area. Resident #92 said he been outside for around 30 minutes and just started smoking 2-3 minutes prior to the staff coming outside. He said he borrowed a cigarette from a [NAME] and had his lighter on him in his bag. CNA N said this was her first time bringing the residents out to smoke and referred to a list of names, where Resident #92 was not listed. She said she did not notice if Resident #92 was smoking and did not provide a cigarette to him. In an interview on 1/10/25 at 4:07 p.m., the Administrator said she set out smoking times and hours for residents to smoke and provided a staff member to ensure safe smoking. She said no resident could smoke unsupervised. She said she has had problems with Resident #92 before regarding smoking and had taken 3 packs of cigarettes from him. She said there was no risk to Resident #92 smoking unsupervised because he was a safe smoker. She said there was a fire extinguisher available in the designated smoking area on the back wall and not the side of the building. Record review of the facility's smoking policy dated 1/4/24 read in part, .Policy: to maintain safety for residents who smoke . Procedure: 1. The center will designate a smoking area where smoking will be permitted. Smoking will be prohibited in any area other than the designated smoking area . 8. Residents are not permitted to retain in their possession any smoking paraphernalia like cigarettes, lighters, matches, tobacco, tobacco vaporizer products, etc. All smoking paraphernalia will be stored in the medication room . 12. When a resident smokes, it will be under the direct supervision of the staff. Direct supervision must be provided throughout the entire smoking period .

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

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 its medication error rates were not 5% or greater. The facility had a medication error rate of 6% based on 2 errors out of 29 opportunities which involved 2 of 8 residents (Resident #47 and #105) and 2 of 8 staff (MA D and LVN R) reviewed for medication administration. MA D handed Resident #47 (who did not self-administer) his eye drops, and the resident administered the wrong dose per physician orders on 1/8/25. MA D did not provide Resident #47 with instructions. LVN R crushed and administered Lansoprazole DR ODT (a delayed release medication used to treat heartburn and certain other conditions caused by too much acid in the stomach) to Resident #105 via PEG tube on 1/8/25. Delayed Release formulations should not be crushed. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: 1. In an observation on 1/8/25 at 8:08 a.m., MA D prepared Resident #47's medication for administration. MA D handed ultra lubricant eye drops to Resident #47 and did not give directions. Resident #47 inserted one drop in each eye. Record review of Resident #47's face sheet dated 1/10/25 revealed a [AGE] year-old male who readmitted on [DATE]. His diagnosis included unspecified disorder of eye and adnexa (accessory or adjoining anatomical parts,), cerebral infarction (stroke), hypertension (high blood pressure), and bladder disorder. Record review of Resident #47's annual MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated no cognitive impairment. He was independent with ADL care and needed setup or clean-up assistance with eating, oral hygiene, and shower/bathing. Record review of Resident #47's care plan dated 1/8/25 revealed the resident requested to self-administer his own eye drops and nasal spray. Interventions were to hold the medication and the cart and hand to the resident at the time of administration. Resident will have a good understanding of and return demonstration of how the medication is to be self-administered. Record review of Resident #47's Physician orders for January 2025 revealed an order for: Refresh Tears eye drops, instill 2 drops in both eyes three times a day for dry eye, order date 11/3/24. There were no orders for self-administration. Record review of Resident #47's Late Entry Nursing note- Self Administration of Medication effective 12/21/24 (created 1/8/25 at 10:26 a.m. by the Clinical Resource Nurse) revealed he was able to administer refresh eye drops. In an interview on 1/8/25 at 8:14 a.m., MA D said Resident #47 was supposed to apply two drops in each eye but only applied one in the left eye and two in the right eye. He said he did not give the resident directions for the eye drops because he was nervous. He said the resident refused for staff to administer his eye drops and he reported it to the nurses. He said the nurse said they would reach out to the MD but that had not happened yet. In interview on 1/10/25 at 1:23 p.m., the DON said nursing staff have to give directions to the resident. She said staff should not just give residents' their medication and expect them to know what to do.' In an interview on 1/10/25 at 3:00 p.m., the Clinical Resource Nurse said the self-administration of medication assessment for Resident #47 was completed on 1/8/25. 2. In an observation on 1/8/25 at 8:17 a.m., LVN R prepared Resident #47's medication for administration via g-tube. She retrieved Lansoprazole from the medication cart. The pharmacy label read Lansoprazole ODT 30 mg but the foil pouch read Lansoprazole DR ODT 30 mg. LVN R crushed the Lansoprazole DR and administered it along with the other medications to Resident #105 via g-tube. Record review of Resident #105's face sheet dated 1/10/25 revealed a [AGE] year-old male who admitted on [DATE]. His diagnosis included respiratory failure, gastrostomy status (presence of a surgical opening into the stomach), disease of stomach and duodenum, and chronic obstructive pulmonary disease. Record review of Resident #105's admission MDS assessment dated [DATE] revealed his cognitive skills for daily decision making were severely impaired. He required assistance from staff with ADL care. Record review of Resident #105's Physician orders for January 2025 revealed orders for: Lansoprazole 30 mg ODT give 1 tablet via g-tube related to disease of stomach and duodenum, order date 10/22/24, May crush medications or open capsules unless contraindicated, order date 11/1/2024. In an interview on 1/8/25 at 8:30 a.m.,,. LVN R said when preparing medication, she was trained to look at the label three times and verify the orders and patient. She said saw that the foil pouch read Lansoprazole DR ODT but she did not connect the dots between delayed release and not crushing. She said you could not crush enteric coated, extended or delayed release medications because the medication was intended to last longer and if crushed, there would be no lasting effect. She said there could be a risk of the resident not receiving the desired effect if crushed. She said she was not sure about the Lansoprazole DR ODT and would verify with the MD and pharmacy. In an interview on 1/8/25 at 8:40 a.m., LVN R said she called the pharmacy, and they said the Lansoprazole could be crushed. In an interview on 1/10/25 at 1:28 p.m., the DON said the facility had a do not crush list which included enteric coated and some delayed release medications. She said if staff were unsure of which medications to crush or not crush, they could call the pharmacy. In an interview on 1/10/25 at 4:13 p.m., the Administrator said staff should review the MD orders during medication administration. She said residents had to be instructed by the MA on what to do every time they administered the medication. Record review of document Oral Dosage Forms That Should Not Be Crushed 2016 provided by the facility revealed Prevacid Solutab (Lansoprazole) tablet was listed. Note: orally disintegrating do not swallow; dissolve in water only and dispense via dosing syringe of NG tube. Record review of the Prescribing information for Prevacid SoluTab (lansoprazole) Delayed-Release orally disintegrating tablet from the www.accessdata.fda.gov dated 9/2012 revealed Lansoprazole Solutab should not be broken or cut. For administration via a nasogastric tube, place a tablet in a syringe and draw up water, shake gently to allow for quick dispersal. Record review of the facility's undated Medication Administration policy read in part, .2. The 6 rights of medication administration a. right patient . b. Right drug . c. Right dose . d. Right dosage form . e. Right time . F. Right route . g. Right indication . 7. Eye medication administration . c. Resident may not administer their own eye drops unless self-administration assessment/order/care plan is filed . 9. Enteral tube medication administration . b. dilute liquids and crush and dilute tablets according to facility policy .

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

Medical Records (Tag F0842)

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, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete for 1 of 8 residents (Resident #72) reviewed for medical records. LVN A failed to document in Resident #72's medical record the allegation made that a car ran over his foot while out of the facility and the assessment he conducted on the resident on an unknown date. This failure could place residents at risk of injury, hospitalization, or death. Findings include: Record review of Resident #72's face sheet revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnosis included multiple sclerosis and seizures. Record review of Resident #72's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #72's care plan dated 3/3/23 - Current revealed the resident was at risk for injury related to falls and was resistant to care. Record review of Resident #72's care plan initiated 12/9/24 revealed no documentation of his allegation that a car ran over his foot. In an interview on 1/8/25 at 4:30 p.m., LVN A said Resident #72 returned to the facility from the store late at night and told him someone hit him. He said the resident informed him the ambulance brought him back to the facility and nothing was wrong with him. LVN A said he assessed the resident, and he was normal with no pain. He said he did not report the incident to anyone and did not document because nothing was wrong. He said if something was wrong, he would have notified the MD. LVN A said he left to go home and was off work for the next few days. In an interview on 1/9/25 at 8:13 a.m., the DON said LVN A should have notified the MD, DON, and Administrator of what Resident #72 said. She said the resident could have been hurt and at risk for harm. In an interview on 1/9/25 at 10:46 a.m., LVN A said the facility recently switched electronic systems and he did not remember documenting anything. He said he did not document because nothing was wrong and the resident said things all the time. In an observation and interview on 1/9/25 at 11:52 a.m., of Resident #72, he shrugged his shoulder when asked if he had an incident where a car ran over his foot. He said he had normal pains. In an observation on 1/9/25 at 12:49 p.m., the Social Worker conducted a BIMS assessment on Resident #72 with a result of 14 of 15 which indicated no cognitive impairment. In an interview on 1/9/25 at 1:35 p.m., the Administrator said she was not aware Resident #72 said his foot was run over by a car until the Surveyors started investigating it. In an interview on 1/9/25 at 2:29 p.m., the DON said she expected staff to notify her of any incident to know what is going on and keep the residents safe. She said LVN A informed her (upon investigation) that Resident #72 said someone hit or ran over him with a car. She said LVN A assessed the resident and there was no redness, swelling or signs of injury. She said LVN A did not report it to anyone. She said the initial assessment (by LVN A) should have been documented. Record review of the facility's Charting and Documentation policy dated July 2017 read in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy: . 2. The following information is to be documented in the resident medical record: . e. events, incidents or accidents involving the resident .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessments for 2 of 8 residents (Resident #72 and #105) reviewed for care plans. The facility failed to care plan Resident #105's gastrostomy status nor tube feeding. The facility failed to care plan Resident #72s allegation that a car ran over his foot while out of the facility. This failure could place residents at risk of not receiving individualized care and services. Findings include: 1. Record review of Resident #105's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with diagnosis of gastrostomy status (opening into the stomach from the abdominal wall. Record review of Resident #105's admission MDS assessment dated [DATE] revealed a BIMS score could not be conducted due to medical conditions. According to the MDS, the resident had diagnoses of dysphagia (trouble swallowing) and gastrostomy. The MDS revealed Resident #105 was on a feeding tube (nutrition through a tube) while a resident. Record review of Resident #105's Care Plan from 10/8/24, did not mention the gastrostomy or tube feeding. Record review of Resident #105's chart revealed the following orders from MD P: - NPO diet, NPO texture, NPO consistency. Ordered on 11/26/24. - Enteral (through the intestine)-Check Tube Placement, every shift. Check tube for proper placement by auscultation (listening) of injected air or visual inspection of aspirated (sucked out) stomach contents prior to instilling medication, and/or initiating a feeding. Ordered on 11/26/24. - G Tube Site Care, every day shift. Check GT site daily for s/s of infection. Cleanse with Normal Saline or soap and water as appropriate. Apply dry dressing if drainage noted. Ordered on 11/26/24. - Enteral Feed Order, every shift. Isosource 1.5 at 60 ml/hr via feeding tube for 22 hours, to run continuously until total volume of 1320 ml administered. May remove for care and services. 2 hour bowel rest every 24hr. Ordered on 12/23/24. Record review of Resident #105's chart revealed an H&P dated 12/12/24 from NP M, which revealed the resident received a gastrostomy tube and started on tube feedings before he was admitted to the facility on [DATE]. Record review of Resident #105's nurse's note dated 12/13/24 by LVN C, revealed the resident was on g-tube feedings and tolerated them. In an observation on 1/7/25 at 9:38 a.m., Resident #105 was lying on his back in bed, with his g-tube running Isosource 1.5 at 60ml/hr. In an interview with MDS K on 1/10/25 at 9:15 a.m., he said he was responsible for comprehensive care plans triggered by the MDS. He said the acute care plans were done by the unit managers, and there were 2-3 of them. He said the unit manager would put the care plan in and then he would check to make sure the care plan made sense and had goals and interventions entered correctly. In an interview with the Clinical Resource Nurse on 1/10/25 at 12:52 p.m., she said the Unit Managers were responsible for the acute care plans. In an interview with the DON on 1/10/25 at 12:54 p.m., she said the Infection Preventionist updated the care plan regarding anything to do with infection control or antibiotics. She said there was not anyone specific who updated the care plans and that everyone was doing it since they were merging over to the new EMR system. She said there were care plans in the old system and care plans in the new system. She said as the resident's quarterly review came up they were merging the care plans over to the new system and they had a year to use the old system. The DON said all of the leadership team was updating the care plans and there was not one specific person. 2. Record review of Resident #72's face sheet revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnosis included multiple sclerosis and seizures. Record review of Resident #72's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #72's care plan dated 3/3/23 - Current revealed the resident was at risk for injury related to falls and was resistant to care. He also rejected or resisted care (taking medications/injections ADL assistance or eating), refused air mattress, and wound treatments. Interventions were to talk to resident about reasons for refusal of care and potential risks and identify times/approaches/staff that result in least resistance. When care is refused, remind resident of potential risk. Coax but do not force compliance. Record review of Resident #72's care plan initiated 12/9/24 revealed no documentation of his allegation that a car ran over his foot or any other behaviors. Record review of Resident #72's nursing note dated 12/6/24 written by LVN O revealed the resident complained of right foot pain due to a car running over his foot 2 days ago. No swelling noted, no warmth to touch, no bruising on right foot. Resident medicated for pain, NP notified, and new order received for right foot x ray stat. Record review of Resident #72's Radiology report dated 12/6/24 revealed no fractures to right ankle, foot, or tibia and fibula. In an interview on 1/8/25 at 4:30 p.m., LVN A said Resident #72 returned to the facility from the store late at night and told him someone hit him. He said the resident informed him the ambulance brought him back to the facility and nothing was wrong with him. LVN A said he assessed the resident, and he was normal with no pain. He said he did not report the incident to anyone and did not document because nothing was wrong. He said if something was wrong, he would have notified the MD. LVN A said he left to go home and was off work for the next few days. In an observation and interview on 1/9/25 at 11:52 a.m., of Resident #72, he shrugged his shoulder when asked if he had an incident where a car ran over his foot. He said he had normal pains. In an interview on 1/9/25 at 12:28 p.m., the Social Worker said she was unaware of the alleged incident with Resident #72. She said she would have care planned it, determined what happened, reviewed medications, and tried to prevent it from happening again. In an observation on 1/9/25 at 12:49 p.m., the Social Worker conducted a BIMS assessment on Resident #72 with a result of 14 of 15 which indicated no cognitive impairment. In an interview on 1/9/25 at 1:35 p.m., the Administrator said she was not aware Resident #72 said his foot was run over by a car until the Surveyors started investigating. She said the incident should have been care planned, staff in-serviced, and education provided to the resident. She said Resident #72 did go in and out the facility and she warned him before to be careful. She said he was not deemed incompetent and had the right to make the decision to go out. In an interview on 1/9/25 at 2:29 p.m., the DON said she was not aware that Resident #72 said someone ran over him and did not see the nurses note until the Surveyor showed her. She said the facility recently switched electronic systems and the note was not originally there, once the resident readmitted on [DATE] it showed up. She said the incident should have been care planned so facility staff know what accusations were made when he was out of the building. She said even though he said he was run over; he was alert and oriented and the facility could not force him to stay but could continue to monitor for pain and talk to him about being careful. In an interview on 1/10/25 at 8:50 a.m., LVN O said (on 12/6/24) Resident #72 asked her for pain medicine. She said he reported his foot was hurting. She assessed his foot and saw no swelling, redness, warmth, and no apparent injury. She said the NP reported to her approximately 10-15 minutes later that Resident #72 said a car ran over him. LVN O said she was not previously aware of that allegation. She said she reported it to the next nurse but did not report it to the DON or Administrator because she thought they knew since it happened a couple of days ago. In an interview on 1/10/25 at 9:06 a.m., NP A said Resident #72, who was not her patient, reported to her (on 12/6/24) that his ankle was hurting, and he got hit by a car approximately 2 days ago. She said there was no apparent injury. She said she notified the MD, and ordered an x-ray on his ankle, foot, and tibia/fibula. In an interview on 1/10/25 at 9:15 a.m., MDS K said he was unaware of the incident where Resident #72 alleged his foot was ran over by a car. He said one of the Unit Managers would have updated the care plan. He said the incident was not discussed in morning meeting. He said if aware, he would have made sure psych services were implemented to ensure his mind was right and reviewed his medications. In an interview on 1/10/25 at 9:30 a.m., Unit Manager T said the MDS K and MDS R primarily updated care plans, but she was able to do them if asked. She said LVN W did staffing and oversaw falls and incidents on the care plans. She said if facility staff asked her to do a care plan she would because she was a nurse, but she did not really have anything to do with them. She said she was just notified of the incident with Resident #72 today and no one said anything to her about his foot being ran over. She said she did not recall discussing the incident in morning meeting. She said she would have put something in place, monitored him for pain, determine what happened, and educate him on safety. In an interview on 1/10/25 at 12:20 p.m., the Administrator said MDS K and MDS R updated the care plans. Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated March 2022 read in part, .a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation . 1.The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment and no more than 21 days after admission . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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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 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 1 of 1 facility and 2 of 16 residents (Resident #217 and Resident #218) reviewed for infection control. 1. The facility failed to establish and provide documentation for a water management program as part of the infection control program. 2. The facility failed to ensure Housekeeper L wore the appropriate PPE for contact precautions when she was cleaning the room for Resident #217. 3. The facility failed to ensure LVN S wore appropriate PPE when administering IV medication to Resident #218 on 1/8/25 who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes). This failure could place residents at risk of exposure to Legionnaires' disease (a serious type of lung infection caused by Legionella bacteria which can live in standing water within facility water systems), and other infectious diseases due to improper infection control practices. Findings include: 1. In an interview on 1/9/25 at 2:15 p.m., Maintenance V said he had worked at the facility for 18yrs. He said he did not have a policy or protocol for checking for water-borne pathogens. He said he checked the backflow from the city water, with the Fire Marshall once a year. He said he also checked the water heater temperatures once a day, but he did not know anything about a Water Management Program or about Legionella. In an interview on 1/9/25 at 2:17 p.m., the ADON, who was the Infection Preventionist, said they had never had any residents who had Legionnaire's Disease. In an interview on 1/9/25 at 2:18 p.m., the Clinical Resource Nurse, said there was a policy on water-borne illness, and she would call Maintenance V's boss and ask him about it. In an interview on 1/10/25 at 12:24 p.m., the ADON/Infection Preventionist said she had been with the facility since August 2024. She said she did not know anything about a policy/procedure on water-borne illness or water management. She said that would be maintenance's department. In an interview on 1/10/25 at 12:54 p.m., the DON said that she had heard of legionella bacteria, but she did not know anything about a policy or procedure on Water Management. She said she would check with the Administrator. In an interview on 1/10/25 at 4:14 p.m., the Administrator, said she did not know there was supposed to be a Water Management System. She said she thought she had heard about it a few years ago but was not for sure. She said she would get it fixed right away. 2. Record review Resident #217's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of urinary tract infection, respiratory failure (not enough oxygen in the blood), severe sepsis with shock (severe infection throughout the body that is starting to shut down organs), type 2 diabetes (body does not produce insulin or resists it), aphasia (trouble speaking), dysphagia (trouble swallowing), COPD (chronic lung disease that reduces airflow and makes breathing difficult), tracheostomy (opening in the neck to provide an airway to the lungs), gastrostomy (opening into the stomach from the abdominal wall), and pressure ulcer of the sacrum (tailbone). Record review of Resident #217's admission MDS assessment dated [DATE] revealed a BIMS could not be conducted due to medical conditions. The MDS revealed she was dependent (the helper does all of the effort or the assistance of 2 or more helpers is required) with all ADLs. The MDS indicated the resident had an indwelling catheter (tube into the bladder to drain urine) and was always incontinent of bowel. Resident #217 was on a feeding tube (nutrition through a tube into the stomach) and had an unstageable (not stageable due to coverage of wound bed by dead skin or infection) pressure ulcer. Record review of Resident #217's care plan dated 12/10/24 revealed a Focus: Resident is at risk for infection related to Candida Auris (resistant fungal infection), tracheostomy, and g tube and she needed to be on Enhanced Barrier Precautions (Initiated: 12/11/24, Revised: 12/11/24). Interventions: Educate resident/RP on infection control practices. Focus: Resident requires tube feeding (Initiated: 12/10/24, Revised: 12/10/24). Interventions: Provide local care to G-tube site as ordered. Focus: Resident has Stage 4 pressure ulcer to sacrum (Initiated: 12/26/24, Revised: 12/26/24). Interventions: Administer treatments as ordered. Focus: Resident has a tracheostomy (Initiated: 12/10/24, Revised: 10/10/24). Interventions: Oxygen via trach collar at 5L continuously. Record review of Resident #217's Physician Orders revealed the following order from MD P: - Contact Isolation, every shift. Follow facility policy-Use contact precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Ordered on 1/7/25. In an observation of Resident #217 on 1/7/25 at 10:44 a.m., there was a contact isolation sign on her door with PPE outside the room. The resident was lying on her left side with her eyes closed. She had a tracheostomy with 10L of oxygen, a foley catheter, and a gastrostomy tube. In an observation of Resident #217 on 1/8/25 at 9:39 a.m., her door was open, and Housekeeper L was in her room cleaning without any PPE on. There was still a contact isolation sign on Resident #217's door. In an interview with the Housekeeping Supervisor on 1/8/25 at 9:41am, she said when there was a contact isolation sign on the door, everyone including housekeeping had to wear a gown and gloves into the room. She said Housekeeper L was new and had just started the day before and did not know. In an interview using Spanish translator services with Housekeeper L on 1/8/25 at 9:45am, she said she thought she only wore a gown if she was going to touch the resident. She said she started at the facility in November 2024 and her trainer did not wear a gown into any of the rooms. She said she could not read the isolation sign because it was in English, and she could not read English. She said she did not know any of the signs said she had to wear a gown. Once the surveyor explained cross contamination Housekeeper L voiced understanding and the importance of wearing a gown. 3. Record review of Resident #218's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of infection and inflammatory reaction due to internal left knee prosthesis, enterococcus (a large group of lactic acid bacteria), type 2 diabetes (body does not make insulin or resists it), anemia (not enough iron), and pressure ulcer of unspecified site. Record review of Resident #218's admission MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated normal cognition. The MDS revealed she had recent knee replacement surgery. She had an unstageable pressure injury presenting as a deep tissue injury, surgical wound, and was receiving IV medication. Record review of Resident #218's care plan dated 1/3/25, did not have the IV antibiotics, the surgical wound, or the isolation precautions on it. Record review of Resident #218's hospital records from 1/1/25 revealed she had a revision of her left total knee replacement and now had a surgical site infection with Enterococcus Faecalis (type of bacteria), which would require several weeks of IV antibiotics. Record review of Resident #218's chart revealed a nursing note from 1/2/25 that revealed the resident admitted with a diagnosis of infected left knee due to arthroplasty, she had a left knee incision and a PICC (flexible tube that's inserted into a vein in the arm and threaded into a large vein near the heart) to her RUE line for IV antibiotics. Record review of Resident #218's Physician Orders revealed the following orders from MD P: - Ampicillin Sodium Injection Solution 2 GM (type of antibiotic), 2 grams intravenously every 8 hours related to direct infection of left knee in infectious and parasitic diseases. Ordered on 1/3/25. - Ceftriaxone Sodium Injection Solution 2 GM (type of antibiotic), 2 grams intravenously every 12 hours related to direct infection of left knee in infectious and parasitic diseases. Ordered on 1/3/25. - IV-Flush SASH Method, every shift related to infection and inflammatory reaction due to internal left knee prosthesis. Ordered on 1/4/25. - Wound Treatment-Dry Dressing, every day shift, every Mon, Wed, Fri. Cleanse SDTI to Lt heel with Normal Saline or Skin Cleanser, Pat dry, apply skin prep and cover with dry dressing. Ordered on 1/6/25. - Wound Treatment-Dry Dressing, every day shift, every Mon, Wed, Fri. Monitor surgical dressing to LLE. DO not remove dressing wrap with kerlex and ace wrap, notify MD of any changes. Ordered on 1/6/25. In an interview and observation of Resident #218 on 1/7/24 at 10:35 a.m., the resident was sitting in a recliner in her room with a brace on her left leg. There was not an isolation sign on her door. A PICC line was seen on her RUA. She said she was there for an infection of her left knee and was on IV antibiotics. In an observation and interview on 1/8/25 at 9:06 a.m., LVN S administered Resident #218's Ampicillin IV via her PICC line. She wore gloves but did not wear a gown. She said enhanced barrier precautions was used for residents with an artificial opening such as a PEG tube and PICC line. She said she wore gloves but did not wear a gown. She said she had training on EBP but there was no PPE cart present in the resident's room. In an interview and observation of Resident #218 on 1/8/25 at 9:35 a.m., staff were putting an Enhanced Barrier Precaution sign on her door and PPE outside of her room. The resident said the facility had just added the sign to the door and they had not been wearing any PPE before. In an interview with the ADON/Infection Preventionist on 1/10/25 at 12:24 p.m., she said Enhanced Barrier Precautions was for any resident with artificial openings, PICC lines, catheters, or g-tubes. She said staff were expected to wear gloves and gowns with ADL care, transfers, when giving g-tube meds or IV meds, and whenever providing up close and personal care, including therapists. She said when a resident was on contact isolation, everyone needed to wear gloves, gowns, and a face shield if coming in contact with something that might splash. She said that included family, doctors, housekeeping, everyone. The Infection Preventionist said contact isolation was for residents that had MDROs like ESBL of the urine or any kind of bugs in wounds. She said if a staff member did not wear PPE into a contact isolation room, the staff member could get an infection and could transfer it to another resident. She said if staff did not wear PPE in an EBP room they could spread infections to other residents. She said she provided training on infection control and had an in-service this week and in December. In an interview with the DON on 1/10/25 at 12:54 p.m., she said she expected staff to stop and look at the isolation signs before going in and touching the patient, so they knew how to suit up. She said if someone did not wear PPE and went into a EBP room they could spread infection to and from the resident. She said if someone went into a contact isolation room without PPE, they could get an infection. The DON said for contact isolation everyone had to wear PPE, including housekeeping. Record review of the facility's policy and procedure on Infection Control (revised November 2017) read in part: The facility must establish an infection prevention and control program (IPCP) that must include: A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases .An individual Infection Control Surveillance Report designed to identify possible communicable diseases or infections before they can spread to other persons in the facility must be completed by the nurse manager or designee upon the occurrence of any infection and reported to the Director of Nursing Services . Record review of the facility's policy and procedure on Legionella Surveillance and Detection (Revised September 2022) read in part: Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Legionnaire's disease is included as part of our infection surveillance activities. Legionella can grow in parts of building water systems that are continually wet .and certain devices can spread contaminated water droplets via aerosolization. Legionellosis outbreaks are generally linked to locations where water is held or accumulates and pathogens can reproduce .As part of the infection prevention and control program, all cases of pneumonia that are diagnosed in residents> 48 hours after admission are investigated for possible Legionnaire's diseases .If pneumonia or Legionnaire's disease is suspected, the nurse will notify the physician or practitioner immediately. Residents who have signs and symptoms of pneumonia may be placed on transmission-based (droplet) precautions .Diagnosis of Legionnaire's disease is based on a culture of lower respiratory secretions and urinary antigen testing .If Legionella is detected in one or more residents, the infection preventionist will: initiate active surveillance for Legionnaire's disease, notify the water management team, notify the local health department, and notify the administrator and the director of nursing services.

May 2024 1 deficiency 1 IJ (1 affecting multiple)

CRITICAL (K) 📢 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

Pressure Ulcer Prevention (Tag F0686)

Someone could have died · 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 identify and ensure that residents received the necessary treatment and services, to promote healing and prevent infection for 2 of 9 residents (CR#1 and Resident #2) reviewed for pressure ulcer in that: -The facility failed to identify and treat pressure sore on CR#1's penis, left foot 5th toe, Right Toe Digit 1, great -The facility failed to provide CR#1 with an air mattress for 20 days with multiple diagnoses of Stage 4 pressure ulcers. -The facility failed to initiate precautions for pressure sores when an order was not obtained for air mattress. -The facility failed to prevent progression of the CR#1's Stage 4 Sacral Pressure Ulcer that was not getting better and enlarged from 6x6.2x0.4 cm on 2/27/24 to 10.7x8.9x0.4 cm on 4/15/24, had odor and exhibited signs of infection. -Resident #2's Pressure wounds dressing was not changed as per physician's orders. An Immediate Jeopardy (IJ) was identified on 5/2/24 at 3:46 p.m. While the IJ was lowered on 5/5/244 at 4:27 p.m., to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy at a scope of pattern while the facility continued to monitor the implementation of effectiveness of their plan of removal. These failures placed residents with multiple Stage 4 pressure ulcers and those who are at risk of developing wounds at risk of hospitalization, surgeries, sepsis infection, a decline in health, and pain. Findings included: CR #1 Record review of Resident#1's face sheet dated 4/24/24 revealed he was a [AGE] year-old male admitted to the facility initially on 2/2/24 and readmitted on [DATE] with a diagnosis of pain, type 2 diabetes, elevated white blood cell count, pressure ulcer of right lower back unspecified stage, and pressure ulcer of sacral region, unstageable. Record review of CR#1's comprehensive MDS dated [DATE] revealed a BIMS score of 8 indicating moderately impaired cognition. CR#1 required substantial maximal assistance for eating, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear and personal hygiene. CR #1 was dependent on staff for rolling left and right, sitting to lying, lying to sitting on side of bed, and sitting to standing and chair/bed-to-chair was not attempted due to medical condition or safety concerns. CR#1 could not attempt toilet/transfer, tub shower transfer, car transfer and walk 10 feet due to CR#1's current illness. CR#1 had diagnosis of local infection of the skin and subcutaneous tissue, pressure ulcer of unspecified site, Pressure ulcer of sacral region, unstageable, hypertension (high blood pressure), neuralgia and neuritis, and diabetes insipidus. Record review of CR#1's Care plan dated 4/24/24 revealed, CR#1 had an indwelling foley catheter related to impaired skin integrity. He was at risk for skin impairment related to acute skin impairment, impaired mobility, muscle weakness and incontinence with interventions as administer medications as ordered, follow facility policies/protocols for the prevention/treatment of skin breakdown, and monitor nutritional status. CR#1 was identified for a pressure area: Stage: unstageable, Right heel with the goal to have skin remain clean and dry and area will heal over the next 90 days. The interventions included: Encourage by mouth and fluid intake within dietary limits, keep family/responsible party and MD informed of CR#1's progress, assist with turn/repositioning every two hours and prn, Use padding between pressure areas and positioning devices for proper body alignment. Provide pressure relieving device for bed and wheelchair. Monitor labs and report and report to MD, and Dietary consult for proper nutrition resolve pressure area. CR#1 had a stage 4 pressure ulcer Sacrum with interventions such as Drawsheet to be used when positioning patient, Notify physician of abnormal labs, Obtain lab work as ordered, Use of suspension devices, pillows, and /or wedges to reduce pressure on heels and pressure points, and Provide Wound Care as directed by physician order. CR#1 also had stage 3 pressure ulcer (12,16) right ischium with interventions such as: Patients who rely on nursing staff for positioning will be turned and repositioned every 2 hours and as needed, Perform nutritional screening, Adjust diet/supplements as indicated to reduce the risk of skin breakdown, Pressure redistribution support cushion in chair/wheelchair, Pressure redistribution support surface mattress on the bed, Provide Wound Care as directed by physician Order, Use of suspension devices, pillows, and /or wedges to reduce pressure on heels and pressure points, Obtain lab work as ordered, Notify physician of abnormal labs, and Drawsheet to be used when positioning patient. Record review of CR#1's Physician Orders dated 4/30/24 revealed the following orders: *2/20/24 Nectar thickened liquids, puree *2/21/24 Weekly head to toe 1 time weekly *Wound Supplement (30ml) Oral one time daily dated 2/22/24 *Supplement pass (120 cc) Oral one time daily dated 3/1/24 and discontinued 4/8/24 *3/7/24 Wound Treatment- Santyl 3 times daily *3/12/24 Wound Treatment-Collagen 1 Time Daily *3/12/24 Wound Treatment- Santyl 3 times weekly *3/13/24 Wound Treatment- Collagen 1 Time daily discontinued 3/27/24 *3/13/24 Wound Treatment- Collagen 1 Time daily *3/13/24 Wound Treatment- Santyl 3 times weekly *3/15/24 Pre-Wound Treatment- Pain intensity Score-Can verbalize 1 time daily *3/15/24 Post Wound Treatment- Pain intensity Score- Can verbalize 1 Time daily * *3/27/24 Wound Treatment- Santyl 1 Time Daily *3/27/24 Podus Boot (S) 1 time daily *4/11/24 Initiate IV Access 1 Time Daily *4/11/24 IV Dressing Change Every 1 Week Further review of CR#1's orders did not reveal orders for an air mattress. Record review of CR#1's February 2024 TAR dated 2/20/24- 2/29/24 revealed: Wound Treatment-Dry Dressing by Shift Starting 2/20/24 Discontinued 2/21/24 Cleanse Wound to Sacrum with normal saline or skin. Cleanser. Pat Dry. Cover with Dry Dressing. Wound Treatment- Apply Betadine Three Times Weekly Starting 2/21/24 Order date 2/21/24 Discontinued 3/6/24. Clean wound to right heel with normal saline pat dry, apply betadine and cover with dry dressing. RP Aware Wound Treatment-Collagen Three Times Weekly Staring 2/21/24 Order [NAME] 2/21/24 Discontinued 3/6/24. Notes: Clean wound o sacrum with normal saline pa dry apply collagen and cover with dry dressing. RP aware. Wound Treatment-Collagen Three Times Weekly Staring 2/21/24 Order [NAME] 2/21/24 Discontinued 3/12/24. Notes: Clean wound o sacrum with normal saline pat dry apply collagen and cover with dry dressing. RP aware. Wound Treatment- Apply Betadine Three Times Weekly Starting 2/21/24 Order Date 2/21/24. Discontinued 3/6/24. Notes: clean wound to right heel with normal saline pat dry apply betadine and cover with dry dressing. RP aware. Wound Treatment- Collagen Three Times Weekly Starting 2/21/24 Order Date: 2/21/24 Discontinued: 3/6/24 Notes: Clean wound to sacrum with normal saline pat dry apply collagen and cover with dry dressing. RP aware. Wound Treatment- Collagen Three Times Weekly Starting 2/21/24 Order Date: 2/21/24 Discontinued: 3/12/24 Notes: Clean wound to right Ischium with normal saline pat dry apply collagen and cover with dry dressing. RP aware. Wound Treatment- Collagen Three Times Weekly Starting 3/6/24 Order Date: 2/21/24 Discontinued: 3/12/24 Notes: Clean wound to sacrum with normal saline pat dry apply collagen and calcium alginate cover with dry dressing. RP aware. Wound Treatment- Santyl Three times weekly Starting 3/7/24 Order date 3/6/24. Discontinued 3/12/24. Notes: clean wound to right heel with normal saline pat dry apply Santyl and cover with dry dressing. RP aware Wound Treatment Collagen One time daily starting 3/13/24 Order date 3/12/24 Discontinued 3/27/24. Notes: Clean wound to sacrum with normal saline pat dry apply collagen and calcium alginate cover with dry dressing. RP aware Wound Treatment- Collagen One time daily Starting 3/13/24 order date: 3/12/24 discontinued 3/27/24 Notes: Clean wound to sacrum with normal saline pat dry apply collagen and calcium alginate cover with dry dressing. RP aware. Wound Treatment-Collagen One time daily starting 3/13/24 order date: 3/12/24 Completed. Notes: clean wound to right ischium with normal saline pat dry apply collagen and cover with dry dressing. RP aware. Wound Treatment-Santyl Three times Weekly Starting 3/13/24 Order date: 3/12/24 Completed. Notes: clean wound to right heel with normal saline pat dry apply iodosorb and cover with dry dressing every other day. RP aware. Podus Boot(s) One time daily Starting 3/27/24 Order Date: 3/27/24 Completed Notes: Apply heel protector boots daily RP aware. Wound Treatment-Santyl One time daily Starting 3/28/24 Order Date: 3/27/24 Completed Notes: Clean wound to sacrum with normal saline pat dry apply Santyl and calcium alginate cover with dry dressing. RP aware Record review of CR#1's Wound Evaluation & Management Summary dated 2/27/24 revealed the following 1.Site 1-Stage 4 Pressure Wound Sacrum Full thickness: *Wound size 6x6.2x0.4cm, *Surface Area: 37.20 cm, *Exudate: Light serosanguinous, *granulation tissue: 100%, *Wound progress: not at goal .Dressing treatment plan .Alginate calcium apply once daily for 20 days. Collagen sheet apply once daily for 30 days, Secondary Dressings: Gauze island with bdr apply once daily for 9 days, *Plan of Care Reviewed and Addressed: .Float heel in bed; off-load wound; Cleanse with wound cleanser at time of dressing change; Group 2 Mattress; Pressure Off-loading boot; multi vitamin once daily by mouth; Vitamin C 500mg Twice daily by mouth. 2.Site 2-Stage 4 Pressure Wound of the Left heel full thickness: Wound Size 5x6x0.2 cm. This visit's measurements are noted by the clinician to be exactly the same as the previous visit. *Surface Area: 30.00 cm, *Exudate: Light Serous, Thick adherent devitalized necrotic tissue: 80%, granulation tissue: 20%, *Wound progress: not at goal .Dressing Treatment Plan: Primary dressing(s) Santyl apply every two days for 20 days, Secondary dressing(s): gauze island with bdr apply every two days for 9 days. *Plan of Care reviewed and addressed: Float heel in bed; off-load wound; Cleanse with wound cleanser at time of dressing change; Group 2 Mattress; Pressure off-loading boot; Multi vitamin once daily by mouth; Vitamin C 500mg twice daily by mouth. Site 2: Surgical Excisional debridement procedure: Remove necrotic tissue and establish the margins of viable tissue. *Consent for procedure: Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 02/17/2024 to the patient who indicated agreement to proceed with the procedure(s). *Procedure note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to surgically excise 3.0cm² of devitalized tissue and necrotic muscle level tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 80 percent to 70 percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. 3.Stage 3 Pressure wound of the right ischium . Record review of CR#1's Wound Evaluation & Management Summary dated 4/9/24 revealed: Stage 4 Pressure Wound Sacrum full thickness: *Wound size 8.9x6.8x0.4 cm, *Surface Area: 60.52 cm, *Peri wound radius: Surrounding DTI (Purple/Maroon), *Exudate: Moderate Serous, thick adherent devitalized necrotic tissue: 10%, *Slough: 10%, *Granulation tissue: 80%, *Wound progress: Exacerbated due to generalized decline of patient. Dressing treatment plan: primary dressing(s) Alginate calcium apply once daily for 30 days; Santyl apply once daily for 9 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 23 days. Plan of care reviewed and addressed: Float Heels in Bed; Off-Load Wound; Cleanse with wound cleanser at time of dressing change; Group-2 Mattress; Pressure Off-Loading Boot; Multivitamin Once Daily PO; Vitamin C 500mg Twice daily PO. SITE 1: surgical excisional debridement procedure: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to surgically excise 9.08cm² of devitalized tissue and necrotic muscle level tissues along with slough and biofilm were removed at a depth of 0.4 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 20 percent to 5 percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. Record review of CR#1's Local hospital labs dated 4/15/24 revealed WBC 26.7, Hemoglobin 8.1, Sedimentation rate 58, Platelet count 504, Procalcitonin 2.53 and lactic acid was 2.3. Record review of CR#1's WOUND EVALUATION & MANAGEMENT SUMMARY dated 4/15/24 revealed: Appetite-Fair .Bed- Group 1 .Stage 4 Pressure Wound Sacrum full thickness- *Wound size 10.7 x 8.9 x 0.4 cm, *Surface area: 95.23 cm, *Exudate: Light serous, Thick adherent devitalized necrotic tissue: *100%, Wound progress: Exacerbated due to generalized decline of patient. Expanded evaluation performed: The progress of this wound and the context surrounding the progress were considered in greater depth today. Impaired nutritional status discussed with patient, family, nursing staff, and/or dietitian. *Dressing treatment plan: Primary Dressing(s) Sodium hypochlorite solution (Dakin's) apply once daily for 30 days: 0.25% soaked gauze. Secondary Dressing(s) Gauze Island w/ bdr apply once daily for 17 days. Plan of care reviewed and addressed- *Recommendations: Float Heels in Bed; Off-Load Wound; Cleanse with wound cleanser at time of dressing change; Group-2 Mattress ; Pressure Off-Loading Boot ; Multivitamin Once Daily PO ; Vitamin C 500mg Twice daily PO. SITE 1: Surgical excisional debridement procedure indication for procedure Remove Necrotic Tissue and Establish the Margins of Viable Tissue, Remove Thick Adherent Eschar and Devitalized Tissue. Consent for procedure: Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 02/06/2024 to the patient who indicated agreement to proceed with the procedure(s). Procedure note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 19.05cm² of devitalized tissue and necrotic muscle level tissues were removed at a depth of 0.5 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 100 percent to 80 percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. Record review of CR#1's Local Hospitalist History & Physical dated 4/16/24 at 7:26 am by Physician revealed, . previous admissions for infected decubitus ulcers who was discharged last from our facility 2/2nd after debridement of decubitus ulcer and was continued on IV antibiotics for 2 weeks who presents this time from SNF [facility] with leukocytosis. Reportedly patient was placed again IV antibiotics through mid-line in facility. He was found to have significantly elevated WBCs so he was sent to the ER. In our ER he was found to have WBCs 26.7, Anemia with Hgb of 8.1, Lactic acid of 2.3 so he was referred for admission for further evaluation. Spoke with CR#1's family member who reported that patient has been declining recently in facility. She noted to have worsening wounds and worsening mental status. She reported very poor po intake for over the last 2 months. She reported being angry at the facility for not doing enough for him. Assessment and Plan revealed, 1. Sepsis: Secondary to pneumonia and suspected infected sacral decubitus ulcer. Continue IV fluid and IV antibiotics. Admit to tele. Close monitor to VS and wbc's 2. Gram negative pneumonia: Left lower lobe. empiric broad spectrum antibiotics Will add and suction. Pulmonary hygiene, 3. Multiple decubitus ulcers presented on admission: Possible infected sacral decubitus, Continue antibiotics. surgical eval for possible need for debridement, 4. Significant leukocytosis: Secondary to sepsis. Monitor. 5. Lactic acidosis: Secondary to above. Monitor. 6. Chronic Anemia: Likely anemia of chronic disease. Monitor. 7. Possible UTI associated with indwelling foley catheter POA: Exchange foley. Empiric antibiotics. Follow cx 8. History of dysphagia: Speech eval. He was placed on pureed last hospitalization. 9. Acute Metabolic encephalopathy: Likely secondary to pneumonia and sepsis. Record review of CR#1's Hospital assessment dated [DATE] at 2:08 pm revealed: #1 Sacrum: Pt with extensive stage IV pressure ulcer with ~100% black necrotic tissue / bone exposed / foul odor / + undermining / + stringy slough. This site would benefit from surgical consult. #2 (R) Ischium: Unstageable. Site with 100% soft brownish yellow slough coverage / foul odor. This site would benefit from surgical consult. #3 (L) Ischium: Superficial skin breakdown / 100% red/pink tissue. #4 (R) heel: 100% stringy yellow slough coverage / max foul odor / max drainage amount. This site would benefit from surgical consult. Support surface/specialty bed recommendation: Low air loss replacement with bed frame. Recommended consults: General surgeon, RN and Attending MD notified of recommendation. Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/24 at 8:20 pm revealed: Assessment and Documentation: *Head to Toe skin assessment completed. Yes, *Skin integrity intact. No, Wound 01/27/24 Diabetic Ulcer Right Heel (Active) First Assessment Date/First Assessment Time: 01/27/24 1651, Primary Wound Type: Diabetic Ulcer Orientation: Right Location: Heel. Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM revealed, Current Dressing Status Clean, dry, and intact, Wound 01/27/24 Pressure Injury Midline Sacrum (Active). First Assessment Date/First Assessment Time: 01/27/24 1651, Primary Wound Type: Pressure Injury Orientation: Midline, Location: Sacrum Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM revealed: Current Dressing Status Clean, dry, and intact, Wound 01/27/24 Pressure Injury Left Ischium (Active), First Assessment Date/First Assessment Time: 01/27/24 1651, Primary Wound Type: Pressure Injury Orientation: Left Location: Ischium Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM, Current Dressing Status Clean, dry, and intact, Wound 01/27/24 Pressure Injury Right Ischium (Active), First Assessment Date/First Assessment Time: 01/27/24 1651, Primary Wound Type: Pressure Injury Orientation: Right Location: Ischium Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM, Current Dressing Status Clean, dry, and intact, wound 04/16/24 Other (comment) Penis (Active), First Assessment Date/First Assessment Time: 04/16/24 0830, Present on Original admission: Yes, Primary Wound Type: Other (comment) Location: Penis. Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM, Wound Base Appearance Red, Peri-wound Assessment Induration; Red, Urethral Catheter Other (Comment) 16 Fr. (Active) Placement Date/Time: 04/16/24 1800 Present on admission: NO Reason for Insertion: (c) Healing of open sacral or perineal wounds in incontinent patients Inserted/Placed by: (c) Catheter Type: (c) Other (Comment) Tube Size : Catheter . Assessments 4/16/2024 8:20 PM Already in place, Site Assessment Edema, Collection Container Standard drainage bag to dependent drainage, Securement Method Securing device, Daily Review of Reason for Continuing Urinary Catheterization Healing of open sacral or perineal wounds in incontinent patients. Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/24 at 8:20 pm revealed: Dorsal (foot); Left Description (Comments): left foot 5th toe, Assessments Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM, Primary Dressing Open to air, Wound 04/16/24 Other (comment) Dorsal (foot); Right Toe D1, great (Active) Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/24 at 8:10 pm revealed: First Assessment Date/First Assessment Time: 04/16/24 0810 pm, Present on Original admission: Yes, Primary Wound Type: Other (comment) Orientation: Dorsal (foot); Right Location: Toe D1, great Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM revealed, Wound Base Appearance Slough, Primary Dressing Open to air First assessment dated [DATE] at 8:30 pm revealed, Present on Original admission: Yes Primary Wound Type: Other comment) Location: Penis Assessments 4/16/2024 8:20 PM Wound Base Appearance Red, Peri-wound Assessment Induration; Red Urethral Catheter Other (Comment) (Active) Record review of CR#1's Local Hospital PT Wound Care Evaluation dated 4/16/24 at 9:50 am revealed Principal Problem: . *Skin Integrity: Diabetic Ulcer Right Heel: Wound appearance: necrotic; slough; pink; tan, exposed structures: Bone necrosis, Wound 6.5x5.5x2 cm, Surface area 35.75 cm^2, Wound volume 71.5 cm^3, drainage amount: large, drainage odor: maximum, drainage description: yellow . *Pressure Injury Midline Sacrum (Active), Stage 4, Wound appearance: Necrotic; Black; Brown; Slough, Exposed structures: Bone; Bone necrosis, Shape: irregular, Peri-wound assessment: pink, Wound 9.5x 7x 3.5 cm, Wound surface area 66.5 cm^2, Wound volume 232.75 cm ^3, drainage amount: moderate, drainage odor: Maximum, drainage description: Brown; Black . Pressure Injury Left Ischium (Active):Wound appearance: Red; Pink; Slough, Peri-wound assessment: pink; Maceration, Wound 5x 3.5 cm, Wound surface area 17.5 cm^2, drainage amount: scant, drainage description: serosanguineous; serous. Pressure Injury Right Ischium (Active): Wound appearance: slough; tan; pink, Peri-wound assessment: Pink, Wound 3.8 x 3.5 x0.2 cm, Wound Surface area 13.3 cm ^2, Wound volume 2.66 cm^3, drainage amount: small, drainage odor: minimal. Incision Buttocks (Active), Wound 4/16/24 Penis (Active): wound appearance: red, Peri-wound assessment: Induration, 4/16/24 Dorsal foot-Left (Active): Peri-wound assessment: clean; intact, drainage amount: none, drainage odor: none. 4/16/24 Dorsal Left foot (Active): Peri-wound assessment: clean; intact. 4/16/24 Dorsal right toe D1, great (Active): Current dressing status: Absent, Wound appearance: slough. Wound 4/16/24 Abrasion Upper Back (active): Peri-wound assessment: clean, dry and intact. In an observation and attempted interview on 4/30/24 at 9:15 am with CR#1 at the Local Hospital observation revealed CR #1 was seen lying in the bed with a fall mat at bedside. CR#1 appeared to have difficulty responding due to speech difficulty. In an interview on 4/30/24 at 9:25 a.m. at Local Hospital with RN she stated CR#1 had a lot of pressure sores and he had been in the hospital for 14 days. She stated a lot of the pressure sores were unstageable on hips, right heel, and his sacrum. She stated the sore on the sacrum is unstageable and the hospital did debridement on the sacrum and the right heel. In a record review and interview on 4/30/24 at 9:46 am with RN, Quality & Patient Safety Dept. of CR#1's hospital records she stated CR#1 admitted to the local hospital on 2/2/24 and had been admitted to the hospital the first time on 1/26/24 and discharged on 2/2/24 to the Nursing facility. She stated CR#1 had multiple decubitus ulcer present on admission on [DATE] on the heel, sacrum and buttocks and re-admitted to the hospital on [DATE]. She stated CR#1 was admitted for pneumonia of left lung, and sepsis secondary to pneumonia, Wbc 26.7, additional pressure ulcers on his scrotum, dorsal left foot, dorsal right foot, right toe, penis, abrasion to upper back and sacrum. She stated record review of pressure ulcer and observation of the pictures revealed large pressure sore, much worse from when he was discharged from the hospital. In a record review and interview on 4/30/24 at 11:02 am of CR#1's local hospital records with BSN, Wound Ostomy Nurse he stated CR#1's ulcer of the right heel could be from the eschar coming off and it was still unstageable. He stated they keep the eschar stable because they did not know the underlying condition of the patient. He stated he did not know the underlying condition of the patient, but it was usually due to sepsis, and/or high blood pressure. He stated CR#1 had sacral debridement on 1/31/24, 4/24/24 surgery on right foot, incision and partial calcinatory with skin biologic. CR#1 was found to have severe protein malnutrition and was diabetic. He stated the dietician met with him on 4/19/24 and CR#1 was tolerating the pureed food. He stated they are discussing whether CR#1 would get an ostomy and PEG tube for optimum healing, but he was receiving nutrition supplements. The Wound Ostomy Nurse stated the type of dressing was important to see how CR#1's wound was being cared for. He stated CR#1's right heel opened up because the Nursing home added Santyl. He stated if CR#1 had poor circulation then you do not want to debride the wound. He stated sepsis was infection to the bloodstream that can lead to multiple organ failure. He did have elevated lactic acid, but it went down. He stated the Nutrition pays a big part of his wound and if he was not getting any nutrition supplements that was huge, no peg, no ostomy and off-loading was the key. He stated if CR#1 was not turning or repositioning that can get bad fast. He stated CR#1 required strict turning and support surface. In a record review and interview on 4/30/24 at 11:46 am at Local Hospital Physician she stated the wounds getting better depends on a lot of things like nutrition, and wound care. She stated CR#1 did not have a feeding tube, and she did not know how much nutrition he was getting. She stated Albumen was 1.7 and pre albumen. She stated CR#1's albumen had increased to 1.4 and CR#1 needed air fluidized. She stated CR#1 was on a specialty bed and was being turned. CR#1 was having contamination of stool and they could not account for what happened to him for the 2 months. He was in the nursing facility. In an interview on 4/30/24 at 7:50 pm with CR#1's family member she stated on 4/15/24, she popped into the Nursing facility unannounced to see CR#1 and on this day, she walked into CR#1's room and his room door was left almost closed. She stated she walked in the room and noticed that CR#1 was laying on his side and he was bare bottom, no diaper on, no depend on, not covered, and she freaked out. She stated there was a fly in the room and her eyes noticed on CR#1's bottom and she saw bone. She stated she went into the hallway asking where the nurse was and there was no one in the hallway. She stated the caregiver said she was changing CR#1 and she had to go get the diaper. CR#1's family member asked the CNA shouldn't she already have the diaper if she was changing him. CR#1's family member stated the CNA said she went to go get the wound nurse. She stated she told the CNA that there was a fly in the room and flies carry disease. She stated she noticed an IV in CR#1's arm and no one told her anything. She stated she holds his Medical Power of Attorney and she spoke with the DON. CR#1's family member stated the in-house Doctor came twice a month and the Doctor mentioned CR#1's wbc was high. She said there were antibiotics is in CR#1's arm and she said she would rather CR#1 go to the hospital to find out what type of infection he is fighting or what he has. CR#1's family member stated she told the nursing facility this at around 11 am or 11:30 am on 4/15/24. CR#1's family member stated the DON did not want to call 911 and said they gave CR#1 antibiotics. CR#1's family member stated before she gave CR#1 a needle they were supposed to call her. She said the DON went to her computer and there was no note. She stated the DON apologized and said someone was supposed to call her. She said she did not give any kind of consent to go to the hospital by 911. CR#1's family member stated the DON did not want to call the ambulance and said the only time they call if it's a dire situation, but she said CR#1 has an infection and they don't know what it is. She stated it was 7 pm and she was waiting, and she was crying and could not even look at CR#1. CR#1 stated she went to her car and called another family member, and it was overwhelming, and they just did not care. CR#1's family member stated the nursing facility wanted to call local transportation company and when CR#1 was checked into the hospital, they took pictures of the wounds. She stated CR#1's bed sore on his bottom, and his foot was a Stage 4 where the bone was exposed. She stated when CR#1 got to the hospital he had pneumonia, he was severely dehydrated and malnutrition. CR#1's family member stated the facility just said that CR#1 was not eating, but it was their job to find another way to get him to eat. She stated they should have called her to ask if she wanted them to do a feeding tube, but no one called her. She stated when CR#1 got to the hospital they said he was 144 lbs and he had to have 2 bags of blood, 2 surgeries this week on both bed sores because they were infected with sepsis. She stated CR#1 was in the hospital for 2 weeks and CR#1 also had a pressure sore on his penis and scrotum that they found on 4/15/24 and she has the pictures the hospital took. She stated when CR#1 got to the facility before he was eating, and he just dropped a lot of weight. She stated CR#1 was found turned over with nothing on his bottom, the curtain was not pulled back, the door was almost closed, and the IV was in his arm. She said the facility did not come to her with the 2nd care plan until she went to talk with them on 4/15/24 and they said maybe you can put him on hospice or maybe put him on a feeding tube on that day. She stated the DON did not ask her about a feeding tube until 4/15/24. In an interview on 4/30/24 at 2:33 pm with the Wound care Nurse she stated CR#1 admitted , left and went home and came back the next day long-term. She stated CR#1 was bed bound, admitted with wounds, and was a total assist resident. She stated CR#1 admitted with a wound to the sacrum, heels, and ischium. She stated the Wound Care Doctor saw CR#1 every week. She stated the sacrum wound was not improving any, but the ischium was. She stated the wound was beefy red until a week or so before his last stay. She stated the day of CR#1 being transferred to the hospital the Wound Care Doctor just gave orders to try to turn the wound around. The Wound Care Nurse stated CR#1 had 2 family members, but they were aware of what was going on. She stated the other Doctor made rounds that day on 4/15/24 and she does not put a clean dressing on a soiled body, so she put the button (call light) on and waited for the CNA and she came and started gathering materials to do incontinent care. She stated she was rounding with the Doctor and the CNA called her and she went downstai[TRUNCATED]

Oct 2023 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

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 program (PASARR) to the maximum extent practicable for two of seven residents (Resident #3 and Resident #41) reviewed for PASRR. -Resident #3 and Resident #41 had a diagnosis of mental illness while living at the facility, and the facility did not coordinate with the appropriate, State-designated authority. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health. Findings include: Resident #3 Review of Resident #3's face sheet dated 10/27/23 revealed Resident #3 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included the following: Schizophrenia (a serious a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), Major Depressive Disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), Other Specified Eating Disorder (any of a range of mental conditions in which there is a persistent disturbance of eating behavior and impairment of physical or mental health), Obsessive Compulsive Disorder (a long-lasting disorder in which a person experiences uncontrollable and recurring thoughts (obsessions), engages in repetitive behaviors (compulsions), or both), Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), and Type 2 Diabetes Mellitus (impaired utilization of blood sugar). Review of Resident #3's MDS assessment, dated 3/16/2023, revealed sections A-1500 Preadmission Screening and Resident Review (Has the resident been evaluated by Level II PASRR and determined to have a serious mental illness and//or mental retardation or a related condition?) was answered NO. Section A- 1510. Level II PASRR conditions was left blank. Section I- Active Diagnoses of the MDS revealed resident to have anxiety disorder, depression (other than bipolar), and schizophrenia . Review of Resident #3's MDS dated [DATE] revealed a BIMS score of 11, indicating minimal cognitive impairment. Review of Resident #3's PASRR Level I screening (PL1) dated 8/20/2021 revealed Resident #3 screened negative for mental illness. Review of Resident #3's clinical records revealed there was no documented request to have Resident #3 further evaluated by local authorities for mental illness due to her diagnoses of schizophrenia and major depressive disorder. Resident #41 Record review of Resident #41's Face Sheet dated 10/25/2023 revealed a [AGE] year-old man admitted on [DATE]. The face sheet documented his diagnoses included cerebrovascular disease (conditions that affect blood flow to the brain), dysphagia (difficulty swallowing), hemiplegia (paralysis of one side of the body), cerebellar stroke syndrome (blocked blood vessel or bleeding causing a complete interruption to a portion of the cerebellum), hypertension (high blood pressure), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), hypothyroidism (condition resulting from decreased production of thyroid hormones), anxiety disorder (fear characterized by behavioral disturbances), hyperlipidemia (high cholesterol), major depressive disorder (disorder having episodes of psychological depression), bipolar disorder (mental illness characterized by extreme mood swings), insomnia (trouble falling and/or staying asleep), conversion disorder (condition in which a person experiences blindness, paralysis or other nervous system symptoms that cannot be explained by illness or injury), and psychotic disorder (mental disorders that cause abnormal thinking, perceptions, and loss of reality)with hallucinations (false perception of objects involving the senses). Record review of Resident #41's diagnoses report dated 10/25/2023, revealed his bipolar disorder and conversion disorder with seizures were identified as an active diagnosis on 3/27/2017. The report documented his anxiety, major depressive disorder, psychotic disorder, and insomnia were all diagnosed on [DATE]. Record review of Resident #41's quarterly MDS dated [DATE] with an ARD of 9/9/2023 revealed a BIMS score of six, indicating a significant cognitive impairment. The MDS documented he had no potential indicators of psychosis, behaviors affecting others, behaviors affecting others, and/or wandering behaviors. Per the MDS, Resident #41 required limited one person assistance with bed mobility, transfers, walking, locomotion, dressing, toileting, and personal hygiene. The MDS revealed he was diagnosed with anxiety disorder, depression, bipolar disorder, and psychotic disorder. The MDS documented Resident #41 was prescribed and administered an antidepressant medication. Record review of Resident #41's undated Care Plan revealed a focus on his medications for depression and insomnia with interventions including monitoring for mood or behavior problems, medication administration, monitoring for side effects of the medications, assessing the effectiveness of the medications, and provision of a psychiatric consultation as needed. Record review of Resident #41's medication report dated 10/25/2023 revealed by prescriptions for Zoloft (medication used to treat depression, panic attacks, obsessive compulsive disorder, and/or social anxiety disorder) 50mg tablet one time daily, Melatonin (over the counter medication used to treat insomnia) 3mg tablet one tablet at bedtime, Trileptal (medication used to treat seizure disorders) 150mg tablet one tablet every twelve hours, and Neurontin (medication used to prevent and control seizures) 300mg capsule one capsule every twelve hours. Record review of Resident #41's PASRR Level 1 Screening document dated 5/17/2023 revealed a no answer to questions C0100 which read Is there evidence or an indicator this is an individual that has a Mental Illness. The facility did not provide any additional PASRR documentation for Resident #41's later MI diagnoses. Record review of Resident #41's Psychiatric Initial assessment dated [DATE] revealed he was evaluated for depression. The assessment documented he endorsed symptoms of sad moods and fatigue. Per the assessment, Resident #41 would continue his use of Zoloft and Trileptal. The assessment revealed the Zoloft was used to treat his depression and the Trileptal was used to decrease possible aggression and/or self-harm behaviors, decrease psychotic symptoms, and avoid inpatient treatment. On10/24/23 at 09:05 AM, during an attempted interview, the Resident #41 appeared agitated and upset, he was unable to communicate effectively. Observation on 10/26/2023 at 11:04 AM, revealed Resident #41 was lying in his bed. Resident #41 got up and sat down in a chair. Resident #41 was unable to communicate effectively. Resident #41's responses to all questions were yes, no, or everything. Resident #41 wrote on a notebook but while the words were legible, they were unintelligible. Resident #41 appeared to be in a better mood and pointed to religious pictures on his wall and smiled. Resident #41 also pointed out the religious music coming from his computer and smiled. Interview on 10/26/2023 at 8:54 AM with the Admin, she said they had no other documentation for PASRR for Resident #3, Resident #41, or Resident #47 other than their original PASRR 1 documents. The Admin said she did not know why there was no other documentation related to PASRR for those residents, or if their new diagnoses should have triggered a new PASRR, but they had no other PASRR information. The Admin said those diagnose fell through the cracks. Interview on 10/26/2023 at 9:12 AM, with the MDS RN and the MDS LVN revealed the MDS RN had been employed since April of 2023 and the MDS LVN had been employed since March of 2022. The MDS LVN said his primary duties were to complete the MDS assessments and care plans. The MDS RN said her primary duties were to complete the skilled nursing resident and Medicare resident MDS assessments. The MDS LVN said they did not complete the PASRR assessments or have any responsibility for PASRR. The MDS LVN said PASRR was completed by the facility's SW. Interview on 10/26/2023 at 9:33 AM, with the SW revealed she had been employed by the facility as the Director of Social Services for one year. The SW said her primary duties included discharge planning and coordination, care plan meeting coordination, PASRR, responding to resident concerns, and scheduling appointments with the podiatrist, psychiatrist, optometrist, and/or dentist for residents. The SW said she receives the PASSR 1 from the admitting facility for a resident, and she uploaded the completed PASSR 1 into the electronic system. The SW said [NAME] County then reviewed the PASSR 1 to determine if a resident qualified for additional services provided by the county. The SW said she had just learned that if a resident who admitted to the facility with a negative PASRR 1 was diagnosed with a qualifying concern, that resident should have a new PASRR 1 completed. The SW said she would be reviewing the diagnoses for all the residents in the facility to determine if any required a new PASSR 1 due to new qualifying diagnoses. The SW said she completed an online training related to PASRR in the past, but the training did not present any materials related to a resident with a new qualifying diagnoses. The SW said she still should have been aware that residents required a new PASRR 1 with a new qualifying diagnosis. The SW said if a resident who had a qualifying diagnosis did not have a new PASRR 1 completed, that resident would not receive services they were entitled to. The SW said the policy and procedure she adhered to was when she received the PASRR from the admission team provided her the PASRR information she uploaded it to the electronic system. The SW said that was the extent of her understanding of the facility's PASRR policy and procedure. The SW said she was going to review all the current residents' diagnoses for any qualifying diagnoses, and she would create new PASRR 1's for those residents. Resident #41 may have a qualifying diagnosis, but she was unsure. The SW said Resident #3 had a qualifying diagnosis. The SW said she would be reviewing all residents so she would determine if any residents had any qualifying diagnoses. Interview on 10/27/23 at 3:05 PM, DON B said the PASRR came from the hospital and the Social Worker put in the information. DON B said if there was another psych diagnosis, the facility would have to conduct another PASRR 1. Record review of the facility's undated PASRR policy revealed the PASRR was required to ensure residents with MI, ID, or DD were properly cared for. The policy documented the purpose of the PE was to evaluate residents to determine if they had MI, ID, or DD, the correct setting for the resident's care, and what services could be provided to the resident. Per the policy, if a resident was positive for MI, ID, or DD, the policy must contact the LIDDA and/or the LMHA within two days and schedule an IDT meeting with them to discuss specialized services for the resident within two days of notification of the diagnosis. The policy revealed a PASRR positive resident should begin receiving the therapeutic services within three business days of approval from HHSC. The policy documented the facility should update and print the Positive PASRR list and review it at least weekly, with positive PASRR residents reviewed at each weekly care coordination meeting with all IDT members present. .

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 F0790 (Tag F0790)

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 or obtain from an outside source routine dental service to meet 1 of 8 residents (Resident #34) reviewed for dental services. The facility failed to provide dental services for Resident #34 who had loose teeth and a diagnosis of periodontal disease. This failure placed resident at risk for infection and unwanted hospitalization. Findings include: Record review of Resident #34's face sheet revealed a [AGE] year old male admitted to the NF on 12/23/2022 with diagnoses that included the following: adult neglect or abandonment, adult physical abuse, open-angle glaucoma (vision loss), chronic pain syndrome, hypertension (elevated blood pressure), and periodontal disease (gum disease). Record review of Resident #34's MDS dated [DATE] revealed that resident had a BIMS score of 15 indicating that resident cognition was intact. Record review of Resident #34's Nursing admission assessment dated [DATE] revealed that resident ate independently, good appetite, oral mucosa (inside surface of the mouth) intact, resident has own teeth no dentures, no active infection, and no specialized diet. Record review of Resident #34's Care Plan dated 09/14/2023 revealed that Resident #34 was being care planned for periodontal disease with an intervention that included schedule dental evaluation; arrange for follow-up care as indicated. Record review of Resident #34's History & Physical dated 12/27/2022 revealed that resident had dental caries (oral disease). Record review of Resident #34's Physician Orders revealed an order dated 12/27/2022 for a regular diet. Further review revealed an order dated 12/27/2022 may have dental care. Record review of Resident #34's weights revealed resident weight upon admission dated 12/23/2022 revealed 142lbs. with last weight documented on 03/01/2023 weight of 146lbs. Further review revealed that from the month of April 2023 to present resident refused to be weighed. Observation on 10/24/23 at 10:27 a,m,, Resident #34 was in room sitting up on the side of his bed. Further observation was made resident top front teeth were crooked and appeared to be rotten. Interview on 10/26/23 at 10:58 a.m., Resident #34 said he had a few loose teeth. Further interview with resident said sometimes it hurt for him to chew pending on the texture of the food and therefore chewed on the side of his mouth at times. Resident said he was admitted to the NF in December of 2022 and had not been seen by a Dentist. Resident #34 said the NF had not asked him if he wanted to see the Dentist. Interview on 10/26/23 at 11:55 a.m., the SW said the NF had a dental provider but would have to see what insurance Resident #34 had. After the SW reviewed Resident #34's insurance and reviewed the list of residents being seen by the Dentist the SW said Resident #34 was not on the list to be seen by the Dentist. The SW said she would have to search for a dental provider that accepted Resident #34's insurance. The SW said she went by what the NF provided to her of what residents needed to be seen by the Dentist. The SW said conditions that would warrant a resident to be seen by the Dentist was if the resident was experiencing tooth pain, loose teeth, etc. The SW said she could not say why Resident #34 had not been assessed by the Dentist. Interview on 10/27/23 at 8:04 a.m., the MDS LVN said the resident (s) care was discussed in the morning meetings. The MDS LVN said he did not know who done Resident #34's care plan. The MDS LVN said he knew resident was being care planned for periodontal disease and refusing ADL's. The MDS LVN said when he assessed the residents upon admission, he also assessed their mouth as well. Interview on 10/27/23 at 9:35 a.m., DON A said she worked at the sister facility as the DON and was helping the facility out. DON A said all residents care were discussed in the morning meetings with all disciplinaries being present including the SW. DON A said if Resident #34 had not been thoroughly assessed, it would be missed. DON A said the nurses will only report to the doctor if the resident is complaining about something such as pain. DON A said the nurses was not thinking critically on the importance of dental care regarding periodontal disease. DON A said she had spoken with the NP regarding periodontal disease. DON A said the NP said that when a resident has periodontal disease and not being followed by dental services, it placed the resident at risk for weight loss as well as infections that could get into the blood stream which could affect the resident heart. Interview on 10/27/23 at 2:54 p.m., DON B said residents that are admitted to the NF are assessed for dental services by doing an assessment regarding oral health such as loose teeth, pain etc. DON B said a resident with the diagnosis of periodontal disease the NF should have attempted to have resident assessed by the Dentist. DON B said periodontal disease placed Resident #34 at risk for infections of some kind. Record review of a clinical note for Resident #34 dated 10/27/2023 documented by the NF SW revealed in part . Resident #34 has dental appointment scheduled . for Monday 10/30/2023 at 11:00am. Facility will provide transportation . Record review of the NF Policy on Routine Dental Care revised April 2007 revealed in part . each resident will receive routine dental care. The Nursing care staff will conduct ongoing health assessments to ensure that each resident receives adequate oral hygiene . .

CONCERN (F) 📢 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 most or all residents

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Based on interview, record review and observation, the facility failed to ensure each resident was provided with food prepared by methods that conserve nutritive value, flavor, and appearance and is nourishing, palatable, attractive and at a safe and appetizing temperature for 1 of 1 kitchens in the facility. -The facility failed to ensure the dessert cook prepared food according to the recipe and utilized all ingredients in the specified amounts which resulted in residents receiving food that did not have nutritive value and flavor. This failure had the potential to affect all facility residents who consumed food from the facility's kitchen. Findings include: Record review of the Week- at- a Glance Fall-Winter 23-24 Week 2 Menu revealed the lunch served on 10/24/23: Fried Chicken Steamed Broccoli Macaroni and Cheese Fruit Crisp Observation on 10/24/23 at 12:24 PM revealed approximately 25 residents in the upstairs dining area with fruit crisp on their lunch tray. No alternative dessert observed. Observation on 10/24/23 at 12:50 PM of a regular texture and a pureed texture test trays for the lunch meal period revealed both included a fruit crisp dessert except it was presented in pureed form on the pureed tray. Observed the crisp on the regular tray consisted of blueberry pie filling with 15 pieces of oats sprinkled on top and a few more pieces of raw oats suspended in the filling. Interview on 10/24/23 at 1:10 PM with the DM. He said that the dessert on the lunch test tray was a fruit crisp, and he said it was the same dessert that was served to the residents for lunch. He said that the DA C had started to prepare the wrong dessert because she thought she supposed to be making blueberry cobbler. He said when DA C realized she was making the wrong dessert, she threw out the crust and tried to hurry and make the crisp. He said he was not present that morning when DA C was making the dessert. Interview on 10/24/23 at 1:30 PM with DA C. She said that she prepared a blueberry crisp for lunch on 10/24/23. She said it was a crisp because it had oats on top, and she baked it in the oven. She said that she prepared the dessert by spraying a pan with butter, pouring in the blueberry filling, and sprinkling the fruit with oats and sugar. She said she could not confirm how much of which ingredient she used. She said that she is aware there is a recipe, but she did not follow it because she did not have all the ingredients. She said the crisp was supposed to have been made with apples, but she did not have any apples and substituted for blueberry. She said that she did not make the topping per recipe because she did not have flour or brown sugar, and she said, to be honest half the oven is not heating like it should. DA C said if she were to prepare a dish but happened to be out of an ingredient, she would prepare a close substitution. She said failure to provide close substitutions could be that the residents don't get all the nutrition they are supposed to get. Observation on 10/24/23 at 1:45 PM revealed a large container of flour and 7 bags of brown sugar in the dry storage area. Observed 4 1lb sticks of margarine in walk-in- refrigerator. Record review of Crisp (Fruit Filling) recipe revealed the following ingredients were needed to make this dish: 2 #10 cans of Pie Filling, 3 cups of All Purpose Flour, 2 Cups of brown sugar, 1 quart of oatmeal, 2.5 cups of margarine. Interview on 10/24/23 at 1:45 PM with the DM. He confirmed with visual inspection and said that the facility had all the necessary ingredients to make the fruit crisp according to the recipe. He said that the oven works fine. He said failure to follow the recipes could result in residents receiving a lower quality or less appetizing food product as well as not getting all the nutrients they should get from that prepared food item. Interview on 10/24/23 3:00 PM, the Administrator said kitchen staff are expected to follow the recipe to ensure residents receive adequate nutrition. Interview on 10/26/23 at 11:10 am DA D. She said she has been working in her position for 3 months. She said that she follows a recipe to prepare her desserts and the cooks provide guidance as well. She said it is important to follow the recipe to make sure the residents get what they are supposed to. She said she received training upon hire and the cooks are readily available to provide guidance. Record review of Use of Recipes Policy dated September 15, 2006 read in part, . Recipes are to be used when preparing menu items . Procedure: . 3. Cooks are expected to use and follow the recipes provided . 5. Any problems the cooks have with recipes should be discussed with the Dietary Services Manager so that they can be resolved . .

Aug 2022 6 deficiencies

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

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 that residents received the necessary treatment and services, to promote healing and prevent infection for 1 of 3 residents (Resident #88) reviewed for pressure ulcer in that: -Resident #88's Stage Ill Pressure wound dressing was not changed as per physician's orders. -Treatment nurse failed to transcribe wound care doctor order for Resident #88 dated 7/26/22 until 8/2/22. -Treatment nurse failed to follow up with wound care doctor's recommendation for supplements for Resident #88. These failures could place residents with wounds or who are at risk of developing wounds placing them at risk of infection, a decline in health, pain, and hospitalization. Findings included: Record review of Resident #88's face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), end stage renal disease (final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), Pressure ulcer of sacral region, stage 3 (skin injuries that occur in the sacral region of the body, near the lower back and spine) and type 2 diabetes mellitus with diabetic chronic kidney disease. Record review of Resident #88's Quarterly MDS dated [DATE] revealed she had a BIMS of 06 out of 15 indicating severely impaired cognitively. Resident required extensive assistance from staff with personal hygiene, toilet use, dressing, transfer, and bed mobility. Further review of Section M0150: is this resident at risk of developing pressure ulcers/injures? Coded-blank. M0210: Unhealed pressure ulcers/injuries: coded-blank. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Coded-blank. Record review of MDS correction to prior assessment dated [DATE] revealed Section M0150: is this resident at risk of developing pressure ulcers/injures? Coded-Yes. M0210: Unhealed pressure ulcers/injuries: coded-Yes. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Coded -1. G. Unstageable-Deep tissue injury: 1. Number of unstageable pressure injuries presenting as deep tissue injury. Coded- 2. 2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry. Coded- 2. Record review of Resident #88's care plan initiated 6/20/22 revealed the following: Problem: Stage 3 pressure ulcer to sacrum Goal: The size of ulcer will decrease with evidence of healing over the next 30 days. Interventions: Perform treatments per order, if no improvement x2 weeks report to MD. Perform nutritional screening. Adjust diet/supplements as indicated to reduce the risk of skin breakdown. Record review of Resident #88's Wound Evaluation & Management Summary dated 7/26/22 read in part: .Wound Size (L x WxD): 8 x 9.7 x 0.2 cm. Primary Dressing(s) Drain sponge apply once daily for 23 days; ABD pad apply once daily for 23 days; Santyl apply once daily for 23 days. SITE 1: SURGICAL EXCISIONAL DEBRIDEMENT PROCEDURE: Remove Necrotic Tissue and Establish the Margins of Viable Tissue. PLAN OF CARE REVIEWED AND ADDRESSED Recommendations: Zinc sulphate 220mg once daily PO for 14 days; Vitamin C 500mg twice daily PO . Record review of Resident#88's Wound Evaluation & Management Summary dated 8/2/22 read in part: .Wound Size (L x WxD): 8 x 9.7 x 0.2 cm. Primary Dressing(s) Drain sponge apply once daily for 23 days; ABD pad apply once daily for 23 days; Santyl apply once daily for 23 days. SITE 1: SURGICAL EXCISIONAL DEBRIDEMENT PROCEDURE: Remove Necrotic Tissue and Establish the Margins of Viable Tissue. PLAN OF CARE REVIEWED AND ADDRESSED Recommendations: Zinc sulphate 220mg once daily PO for 14 days; Vitamin C 500mg twice daily PO . Record review of Resident#88's physician order dated 7/22/22 revealed an order for wound Treatment- Collagen four times weekly. Note: Clean wound to sacrum with ns pat day apply collagen and cover with dry dressing rp aware. This order was discontinued on 08/02/22. Record review of Resident#88's physician order dated 8/2/22 revealed an order for wound Treatment- Santyl one time daily. Note: Clean wound to sacrum with ns pat day apply Santyl and cover with dry dressing rp aware. Record review of Resident#88's physician order dated 8/2/22 revealed an order for multivitamin with minerals tablet (1 tab) one time a day via g-tube. Record review of Resident#88's physician order dated 8/2/22 revealed an order for Vitamin C 500 mg tablet (1 tab) two times a day oral. Record review of Resident#88's physician order dated 8/2/22 revealed an order for wound supplement (30 ml) one time daily via g-tube. Record review of Resident#88's physician order dated 8/3/22 at 3:50pm entered by the Treatment Nurse revealed an order for Wound Treatment - Dry Dressing PRN. May use ABD pad for wound treatment as needed for excessive drainage rp aware Record review of Resident #88's nurses notes dated 8/02/22 written by the Treatment nurse read in part: .Pt readmitted from the hospital. Pt lying in bed denies pain and discomfort. Pt has stg 3 to sacrum. Wound bed red with serous drainage . Observation and attempted interview on 8/3/22 at 9:23 a.m., revealed Resident #88 was resting in his bed. Resident was not on an air mattress. He was alert and well groomed. Resident did not respond to the questions asked about his pressure ulcer. Observation on 8/3/22 at 9:45a.m., revealed Treatment Nurse providing wound care for Resident #88. The Treatment Nurse was assisted by LVN AA. The Treatment Nurse gathered the supplies at the treatment cart in the hallway before bringing them into Resident #88's room. Prior to initiation of the treatment, Resident #88 was assisted on to his right side. Continued observation revealed an open area of approximately 8.0 centimeters in diameter. The Treatment nurse cleansed the wound with normal saline, pat dried, applied a nickel-thick layer of Santyl to wound bed and covered it with one dry 4x4 gauze and dry border dressing. The Treatment nurse did not use ABD pad as ordered by the physician. In an interview on 8/3/22 at 12:27p.m., with the Treatment Nurse, she said she printed the wound evaluation this morning. She said I don't use ABD pad. Only use 4x4 or 6x6 protected dry dressing. She said she used 6x6 dry dressing this morning during wound care on Resident #88. She said ABD pad were used on surgical site and heavy drainage. Treatment nurse reviewed wound evaluation dated 8/2/22 with the Surveyor. Treatment nurse said, wound care doctor specifically said ABD pad. I didn't see that when I reviewed it this morning. She said, wound care doctor can recommend nutrition supplements, but we feel it's better to use our own protocol. She said, our protocol for stage lll and lV nutrition intervention included multivitamin with mineral, vitamin C and liquid 30cc wound healing supplement. In an interview on 8/4/22 at 10:01a.m., with the DON, she said Resident #88 did not have excessing drainage. She said her, and the treatment nurse called the wound care doctor yesterday evening (8/3/22) and got the prn order to use ABD for excessing drainage. The DON reviewed wound evaluation dated 7/26/22 and 8/2/22 with the Surveyor. The DON said wound care doctor recommended certain meds: zinc, protein, and multivitamin. She said the facility had their own nutrition protocol, but the Treatment nurse should have called the Resident's doctor and see if he wanted to add wound care doctor's recommended supplements for 14 days for wound healing. This Surveyor explained that the resident was re-admitted on [DATE] with stage 3 pressure ulcer and that the treatment nurse did not follow facility's nutrition protocol and wound care doctor's orders for Santyl on 7/26/22 Zinc Sulphate/Vitamin C. The DON said she would have to ask Treatment nurse why she failed to follow up with wound care doctor's orders/recommendations. She said she started 7 weeks ago at this facility. She said she was responsible to oversee the Treatment Nurse. When asked how she monitor staff to ensure they are implementing care planned interventions. How did she monitor the resident's wound progress and how did she determine the appropriate interventions. The DON said she had not been spot checking or reviewing the wound evaluations with the treatment nurse to make sure the orders were being following. The DON said, I thought Treatment nurse knew what she was doing. I will have to watch her now. In an interview on 8/4/22 at 2:48p.m., with the Treatment Nurse, she said she was the certified wound care nurse. Surveyor reviewed wound evaluation dated 7/26/22 with the Treatment Nurse. She said she did not know wound care doctor saw Resident #88 on 7/26/22. This is the first time I am seeing this wound evaluation. She said the wound care doctor came to the facility every Tuesday and sent the wound evaluation by every Wednesday. She said she failed to enter vitamins orders and change order from collagen to Santyl until 8/2/22. She said I overlooked orders and didn't put it in. It's error on my part. She said the DON did not spot check/review wound evaluations with her. She said she had done a competency check off with previous DON. She said it was important to match wound care doctor order and need for vitamins for wound healing. In an interview on 8/4/22 at 3: 19p.m., with the DON, she said she did not have a chance to do competency check off with the Treatment nurse because the Treatment nurse came to the facility at different times as she worked at this facility and their sister facility. She said she would do in service with the Treatment nurse to follow physician order to prevent wounds from deteriorating. At this time policy on following physician orders was requested. Record review of facility's Skin policy dated July 2022 read in part: .19. The Director of Nursing or designee will audit and verify system compliance weekly including prevention-focused rounding and education as appropriate . Record review of facility's pressure ulcer protocol dated June 2022 read in part: .This protocol contains suggested interventions. You should work with the patient's attending physician to implement this nutrition protocol by obtaining any necessary physician's orders. Guidelines: Stage lll and lV: Suggested interventions: a. multivitamin with minerals once per day. B. Vitamin C 500 mg BID. C. Wound Healing supplement (30cc) once per day . No policy on following physician orders were provided on exit.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

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 pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs for 1 (Residents #193) of 18 residents reviewed for pharmacy services. The facility failed to ensure Resident #193's hospital discharge medication order was followed, give two times a day (BID) instead of three times a day (TID) Pantoprazole (Protonix, reduces gastric acid secretion) 40 mg tablet enteric coated (delayed release). This failure could place all residents at risk of not receiving medications as per hospital discharge order and had the potential to cause adverse reactions, medication overdosing, and worsening of medical condition. Findings Included: Record review of Resident #193's clinical record revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of gastroesophageal reflux disease with esophagitis (inflammation of the esophagus) without bleeding, cerebral infarction, hemiplegia (complete loss of strength one side) and hemiparesis (weakness on one side) following stroke and type 2 diabetes mellitus. Record review of Resident #193's Baseline Care Plan dated 7/23/22 revealed he was alert and cognitively intact with initial goals established bed in lowest position and meeting date discussed. He required limited assistance with 1 staff most ADLs and gait belt transfer assist. Record review of Resident #193's Hospital discharge order dated 7/23/22 revealed, give two times a day (BID) Pantoprazole (Protonix) 40 mg tab by mouth, enteric coated (delayed release=DR), for gastroesophageal reflux disease with esophagitis, without bleeding. Record review of Resident #193's Physician Order dated August 2022 revealed, give three times a day (TID) Pantoprazole (Protonix) DR 40 mg tab by mouth, for gastroesophageal reflux disease with esophagitis, without bleeding, start date 7/23/22. Record review of MAR dated August 2022, revealed Resident #193 received three times a day (TID) Pantoprazole (Protonix) DR 40 mg tab by mouth, for gastroesophageal reflux disease with esophagitis, without bleeding, start date 7/23/22. Interview on 8/04/22 at 11:30 am, the weekend Supervisor stated she asked the Nurse Practitioner regarding the administered order of TID Protonix DR 40 mg tab of Resident #193, instead of BID Protonix DR 40 mg tab according to hospital discharge order. She said the NP stated the problem, Resident #193's hospital discharge order was not followed to give two times a day (BID), and not three times a day (TID) Protonix delayed release (DR) 40 mg tab. She added admitting charge nurse calls MD regarding if either to continue with hospital discharge orders or not, and then former DON and former unit manager would go through to verify if the MD orders correspond with hospital discharge orders and accurate. Interview on 8/04/22 at 11:40 am, The DON stated the NP responded to discontinue TID Protonix DR 40 mg and decreased to BID Protonix DR 40 mg tab according to Resident #193's Hospital discharge order. The DON stated Resident #193's Hospital discharge order was not followed, and moving forward she will verify the physician orders next day if accurate and correspond with Hospital discharge orders together with weekend supervisor. The DON stated she was also assigned to reconcile monthly physician orders with the weekend supervisor. She stated she will follow-up on the issues on pharmacy services and she will be monitoring them. She stated she just started last month, and she cannot answer for previous DON. Record review of the facility policy titled Medications dated November 2017 revealed, upon admission including re-admission of each Resident, the physician orders for the Resident must be reviewed and reconciled by the charge nurse and the DON or designee for accuracy in the Electronic Medical Record. Record review of the facility policy titled, Safe Medication Assistance and Administration, revised date 07/2015, revealed initiations, dosage changes . will be coordinated with the prescriber and discussed as needed to ensure staff and/or the person served has a clear understanding of the order.

CONCERN (E)

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

MDS Data Transmission (Tag F0640)

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 complete and transmit a resident assessment within the required time frame for 3 of 18 residents (CR#1 & Resident #20 ) reviewed for data completion and transmission in that: 1 - CR #1 did not have a Discharge MDS completed within the required timeframe. - CR#1 did not have a Discharge MDS transmitted within the required timeframe. 2- The facility failed to ensure Resident #20's annual MDS was transmitted within 14 days of being completed and instead was transmitted 23 days after the assessment reference date. 3-The facility failed to ensure Resident #32's annual MDS was transmitted within 14 days of being completed and instead was transmitted 23 days after the assessment reference date. These failures could place residents at risk of not having their assessments completed and transmitted timely. Findings Included: CR #1 1 Record review of CR #1's admission sheet revealed he was a 69- year- old male who admitted to the facility on [DATE] and discharged on 05/19/22 (Death in facility). His diagnoses included cerebral infraction (Brain diseases), dementia, insomnia (inability to sleep), Type 2 Diabetes Mellitus (Chronic condition that affects the way the body processes blood sugar), and hypertension (high or elevated blood pressure). Record review of CR #1's MDS assessment revealed a discharge MDS was started on 05/19/22 but was not completed and transmitted. There was no RN signature of when it was completed and transmitted. Resident #20 2 Record review of Resident #20's face sheet dated 08/03/22 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Cerebral Palsy (a condition that affect movement and muscle tone or posture) essential hypertension, Paraplegia, bipolar disorder, muscle weakness and lack of coordination. Record review of Resident #20's annual MDS with ARD date of 03/16/22 was signed as completed on 04/12/22 which was 28 days after the ARD Day, 14 days past due. 3-Resident # 32 Record review of Resident #32's face sheet dated 08/03/22 revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included congestive heart failure, chest pain, Chronic obstructive pulmonary disease (lungs disease) and Parkinson's disease. Record review of Resident #32's annual MDS with ARD date of 11/12/21 was signed as completed on 12/20/21 which was 26 days after the ARD Day 12 days past due. Interview with the DON on 08/03/22 at 10:00 AM, She said the MDS staff can answer any question regarding MDS. During an interview with MDS staff on 08/04/22 at 9:00AM, he said he would look but came back and said the MDS for CR #1 was not completed. He said would complete the MDS and transmit it. He said he was not at the facility during the time of Resident death at the facility. He said he was not at the facility when both MDS were done and there was a time when someone else was doing the MDS. He said it was his responsibility to ensure that all MDS were done timely and notify the RN for review and signatures. Record review of the Facility provided policy dated November 2017 titled Patient care Management system 12 Assessment did not address timely data transmission of the MDS

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

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 ensure the assessment accurately reflected the resident's status for 4 of 18 residents (Resident's #20, #28 , #32, and #88) whose assessments were reviewed for accuracy in that:. -1.Resident's #20, #28, and #32, and Resident #88 were not assessed for their dentures on their annual assessment. -2 Resident #88 was not assessed for his Unhealed pressure ulcers/injuries. This failur could place residents at risk of inaccurate assessment and not having their needs met. Findings included: Resident #20 1 Record review of Resident #20's face sheet dated 08/03/22 revealed he was a 64 -year-old male admitted to the facility on [DATE]. His diagnoses included Cerebral Palsy (a condition that affect movement and muscle tone or posture) essential hypertension, Paraplegia, bipolar disorder, muscle weakness and lack of coordination. Record review of Resident #20's Annual MDS, with ARD date of 03/16/22 and completed 04/12/22, revealed his BIMSs score was coded as 15 out of 15 indicating he was cognitively intact. He was assessed as total assist on his ADL assessment. Review of section L oral\denture status check all that apply was checked as none of the above were present indicating that the resident had his natural teeth. Observation and interview on 08/03/22 at 2:40 PM, revealed Resident #20 was in bed, alert and oriented. Observation during conversation revealed he had no teeth in his mouth. When asked if he had dentures, he said yes and pointed to his dentures on his nightstand. He said he did not wear them because he was about to sleep. 2 Resident # 28 Record review of Resident #28's face sheet dated 08/03/22 revealed she was a 103 -year -old female admitted to the facility on [DATE]. Her diagnoses included Osteoarthritis (degenerative joint disease), hypertension, Pain in right hip, left shoulder and gait abnormality. Record review of Resident # 28's Annual MDS, dated [DATE] and completed 01/6/22, revealed her BIMS score was coded as 6 out of 10 indicating she was moderately impaired. cognitively. Review of section L oral\denture status was checked as none of the above were present indicating the resident had her natural teeth. Observation and interview on 08/03/22 at 12:40 PM, revealed Resident #28 was in bed. She was alert and oriented. Observation revealed she had no teeth in her mouth. Interview at this time, she said she had no teeth and lost all her teeth over the years. 3 Resident # 32 Record review of Resident #32's face sheet dated 08/03/22 revealed he was a 64-year- old male who admitted to the facility on [DATE]. His diagnoses included congestive heart failure, chest pain, Chronic obstructive pulmonary disease (lungs disease) and Parkinson's disease. Record review of Resident #32's annual MDS with ARD dates of 11/12/21 was signed as completed on 12/20/21 revealed his BIMS score was coded 13 out of 15 indicating he was cognitively intact. Review of section L oral\denture status check all that apply was checked as none of the above were present indicating the resident had his natural teeth. Observation and interview on 08/03/22 at 1:50PM, revealed Resident #32 was in bed. He was alert and oriented. Observation revealed he had no teeth in his mouth. In an interview. He said he had no teeth but had dentures. He pointed to his dentures on his bed side table. He did not indicate why he did not have them on. 4 Resident # 88 Record review of Resident #88's face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), end stage renal disease (final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), Pressure ulcer of sacral region, stage 3 (skin injuries that occur in the sacral region of the body, near the lower back and spine) and type 2 diabetes mellitus with diabetic chronic kidney disease. Record review of Resident #88's Quarterly MDS dated [DATE] revealed he had a BIMS of 06 out of 15 indicating severely impaired cognitively. Resident required extensive assistance from staff with personal hygiene, toilet use, dressing, transfer, and bed mobility. Further review of Section M0150: is this resident at risk of developing pressure ulcers/injures? Coded-blank. M0210: Unhealed pressure ulcers/injuries: coded-blank. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Coded-blank Record review of Resident #88's Wound Evaluation & Management Summary dated 7/26/22 read in part: .Wound Size (L x WxD): 8 x 9.7 x 0.2 cm. Primary Dressing(s) Drain sponge apply once daily for 23 days; ABD pad apply once daily for 23 days; Santyl apply once daily for 23 days. SITE 1: SURGICAL EXCISIONAL DEBRIDEMENT PROCEDURE: Remove Necrotic Tissue and Establish the Margins of Viable Tissue. PLAN OF CARE REVIEWED AND ADDRESSED Recommendations: Zinc sulphate 220mg once daily PO for 14 days; Vitamin C 500mg twice daily PO . Record review of Resident#88's Wound Evaluation & Management Summary dated 8/2/22 read in part: .Wound Size (L x WxD): 8 x 9.7 x 0.2 cm. Primary Dressing(s) Drain sponge apply once daily for 23 days; ABD pad apply once daily for 23 days; Santyl apply once daily for 23 days. SITE 1: SURGICAL EXCISIONAL DEBRIDEMENT PROCEDURE: Remove Necrotic Tissue and Establish the Margins of Viable Tissue. PLAN OF CARE REVIEWED AND ADDRESSED Recommendations: Zinc sulphate 220mg once daily PO for 14 days; Vitamin C 500mg twice daily PO . Record review of Resident #88's nurses notes dated 8/02/22 written by the Treatment nurse read in part: .Pt readmitted from the hospital. Pt lying in bed denies pain and discomfort. Pt has stg 3 to sacrum. Wound bed red with serous drainage . In an interview on 8/4/22 at 11:02 a.m., with the Treatment nurse, she said Resident#88 was re-admitted on [DATE] from the hospital with stage 3 pressure ulcer on sacrum. She said the Wound care doctor came to the facility on 8/2/22 and did the initial wound evaluation. She said Resident#88 did not have any other wounds/deep tissue injuries. In an interview with the MDS coordinator on 08/03/22 at 4:00PM, he said he was responsible for ensuring that the MDS accurately reflect resident's condition. He looked at all 3 MDS and said they MDS should have been coded as no natural teeth on section L of the MDS and not none of the above. He said he completed the MDS by gathering information from all disciplines. to complete the MDS. He said he was not at the facility when these MDS were completed. In an interview and record review on 8/4/22 at 12:05p.m., with the MDS coordinator , he said the MDS was completed and accepted on 7/28/22. He said Resident #88's wound assessments were not captured under wound tab in Matrix by nursing until 7/28/22. He said when the residents re-admit he usually looked at hospital records to capture resident's condition/needs, but the medical records had not uploaded hospital records in matrix yet. He said he read nurses notes that resident was re-admitted with wounds, so he made correction on 8/3/22. He said it was important have accurate MDS so the paperwork would match the resident's condition and receive the proper care resident needed. Record review of Facility's provided policy dated November 2017 titled Patient care Management system 12 Assessment did not address Accuracy of MDS assessment. The MDS Coordinator said the facility uses the RAI manual set by CMS.

CONCERN (E)

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

Drug Regimen Review (Tag F0756)

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 ensure all drug regimen irregularities identified by the licensed pharmacist were reported to the attending physician and acted upon in order, to minimize or prevent adverse consequences to the extent possible for 2 (Residents #47, #88) of 18 Residents reviewed for drug regimen review. -The facility failed to report Pharmacist consultant recommendation to update appropriate indication of use for Lamictal (neuroleptic) for anxiety. Neuroleptics (Antipsychotic) are not considered an appropriate use for anxiety due to the risk of side-effects vs benefits for this dx., to physician. -The facility failed to report Pharmacist consultant recommendation of duplicate therapy for Resident #47 Nystop (Nystatin, treats antifungal infection) for candidiasis of skin and nails, to physician. - The facility failed to report Pharmacist consultant recommendation on 7/22/22 for Protonix and Prevacid active-duplicate therapy for Resident #88, to the physician. These failures could place residents receiving medication, who required monthly Medication Regimen Reviews and place them at risk for medication errors, unnecessary medications and incorrect administration. Findings included: Resident #47 Record review of Resident #47's clinical record revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses of anxiety disorder, candidiasis of skin and nails, congestive heart failure, non-Alzheimer's dementia and HTN. Record review of Pharmacist consultant recommendation/ MRR, dated 7/22/22, revealed Resident #47 Nystop (Nystatin, treats antifungal infection) BID order was a duplicate order. Further review read, Please update diagnosis to appropriate indication of use for Lamictal (neuroleptic) for dx. anxiety. Neuroleptics (Antipsychotic) are not considered an appropriate use for anxiety in our setting, due to the risk of side-effects vs benefits for this dx. Please review for discontinue via taper off. Record review of Resident #47's Physician Order dated August 2022 revealed, give Lamictal 25 mg 2 tabs BID for dx. anxiety disorder, start date 6/10/22. Nystatin 100,000 unit /gm topical cream 1 application BID, for candidiasis skin and nail, start date 6/10/22. Nystop 100,000 unit/gm topical powder apply small amount BID, for candidiasis skin and nail, start date 7/14/22. Record review of MAR dated August 2022 revealed Resident #47 received Lamictal 25 mg 2 tabs BID for dx. anxiety disorder, start date 6/10/22. Nystatin 100,000 unit /gm topical cream 1 application BID, for candidiasis skin and nail, start date 6/10/22. Nystop 100,000 unit/gm topical powder apply small amount BID, for candidiasis skin and nail, start date 7/14/22. Interview on 8/04/22 at 11:30 am, the weekend supervisor stated the former DON or designee former unit manager reviewed the Consultant Pharmacist recommendations to follow-up with the Physician. She said that moving forward they will have the MD folders at the front receptionist desk for MD/NP to sign the physician letter/MRR, since it takes time if sent out, and to receive it back. Interview on 8/04/22 at 11:40 am, the DON stated she was currently designated to follow-up on the monthly Pharmacist MRR with weekend supervisor. She stated Resident #47's MRR on 7/22/22 was not done and moving forward she will ensure Pharmacist recommendations followed through within 72 hrs and reported to MD, and order carried out. She stated she will be working on the process and ensure the physician letter was given personally to MD/ NP if present in the facility. She said she will be monitoring them and have the physician letter at the front desk and signed by MD/NP. The DON stated she was also assigned to reconcile monthly physician orders with the weekend supervisor. She stated she will follow-up on the issues on pharmacy services and she will be monitoring them. She stated she just started last month, and she cannot answer for previous DON. Resident #88 Record review of Resident #88's face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), end stage renal disease (final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), Pressure ulcer of sacral region, stage 3 (skin injuries that occur in the sacral region of the body, near the lower back and spine) and type 2 diabetes mellitus with diabetic chronic kidney disease. Record review of Resident #88's Quarterly MDS dated [DATE] revealed she had a BIMS of 06 out of 15 indicating severely impaired cognitively. Resident required extensive assistance from staff with personal hygiene, toilet use, dressing, transfer, and bed mobility. Record review of Resident #88's care plan initiated 6/20/22 revealed the following: Potential for Gastro-Intestinal disturbance r/t: _X__Gastric Ulcers PEPTIC ULCERS Goal: Resident's s/s will be relieved/resolved during the next 90 days. Interventions: Administer meds as ordered by MD. Observe and report to MD any adverse s/e of medications. Monitor and record non-compliance with specified diet. Monitor and record increase in s/s and report to MD. Record review of Resident #88's physician order dated 6/27/22 revealed an order for pantoprazole 40 mg tablet, delayed release 1 Time Daily for gastrostomy status, - type 2 diabetes mellitus with diabetic chronic kidney disease, - mild protein-calorie malnutrition. Record review of Resident #88's physician order dated 6/14/22 revealed an order for Prevacid 30 mg capsule, delayed release (1 Tab. Daily) Capsule, delayed release (enteric coated) oral continuous. Record review of Consultant Pharmacist's Medication Regimen Review for Resident #88 dated 7/22/22 read in part: .Protonix and prevacid both active-duplicate therapy please ask MD to DC one . Record review of Resident #88's MAR dated August 2022 revealed Resident received pantoprazole 40 mg tablet, delayed release 1 Time Daily for gastrostomy status, - type 2 diabetes mellitus with diabetic chronic kidney disease, - mild protein-calorie malnutrition and Prevacid 30 mg capsule, delayed release (1 Tab. Daily) Capsule, delayed release (enteric coated) oral continuous. In an interview and record view on 8/4/22 at 10:01a.m., with the DON, the DON reviewed Medication regimen review dated 7/22/22 with the Surveyor. The DON said it's not been done. Will call the doctor now. We were in process of doing and y'all showed up. She said she and the ADON were responsible for completing the drug regimen review. She said she received the report from the pharmacist on 7/23/22 and started working on it right away and sent the letters to the doctor for them to sign. She said now the process will be that she will hold the letters and wait for doctor to come to the facility to sign the letters. She said the doctor comes every Friday to the facility. She said it was important to follow pharmacist recommendation to make sure residents were receiving the right medication and if there were duplicate order to take them off the resident's medical record. She said she reviewed resident's orders at the time of admission and then monthly. Record review of the facility policy titled Medications dated November 2017 revealed, recommendations made in a Consultant Pharmacist Report must be reviewed and corrections initiated within 2 business days of the visit. Any change in orders must be entered in the EMR for each recommendation approved by the physician.

CONCERN (E)

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

Deficiency F0757 (Tag F0757)

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 ensure each resident's drug regimen was free from unnecessary medications for 2 of 18 residents reviewed for medications. (Resident # 193 and # 47) The facility failed to ensure Resident #193's hospital discharge medication order was followed, give two times a day (BID) instead of three times a day (TID) Pantoprazole (reduces gastric acid secretion) 40 mg tab delayed release. The facility's Pharmacist consultant recommended on 7/22/22 to please update dx to appropriate indication of use for Lamictal (neuroleptic). Neuroleptics (Antipsychotic) are not considered an appropriate use for anxiety due to the risk of side-effects vs benefits for this dx. Resident #47 received a duplicate therapy for candidiasis of skin and nail, Nystatin 100,000 unit /gm topical cream, and Nystop 100,000 unit/ gm topical powder applied BID. These failures could place residents at risk of serious harm due to side effects, adverse reactions from the medication and receiving unnecessary medications. Findings included: Resident #193 Record review of Resident #193's clinical record revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of GERD with esophagitis (inflammation of the esophagus) without bleeding, cerebral infarction, hemiplegia (complete loss of strength one side) and hemiparesis (weakness on one side) following stroke and type 2 diabetes mellitus. Record review of Resident #193's Baseline Care Plan dated 7/23/22 revealed he was alert and cognitively intact with initial goals established bed in lowest position and meeting date discussed. He required limited assistance with 1 staff most ADLs and gait belt transfer assist. Record review of Resident #193's Hospital discharge order dated 7/23/22 revealed, give two times a day (BID) Pantoprazole (Protonix) 40 mg tab by mouth, enteric coated (delayed release=DR), for gastroesophageal reflux disease with esophagitis, without bleeding. Record review of Resident #193's Physician Order dated August 2022 revealed, give three times a day (TID) Pantoprazole (Protonix) DR 40 mg tab by mouth, for gastroesophageal reflux disease with esophagitis, without bleeding, start date 7/23/22. Record review of MAR dated August 2022 revealed Resident #193 received three times a day (TID) Pantoprazole (Protonix) DR 40 mg tab by mouth, for gastroesophageal reflux disease with esophagitis, without bleeding, start date 7/23/22. Interview on 8/04/22 at 11:30 am, the weekend Supervisor stated she asked the Nurse Practitioner regarding the administered order of TID Protonix DR 40 mg tab of Resident #193, instead of BID Protonix DR 40 mg tab according to hospital discharge order. She said the NP stated the problem, Resident #193's hospital discharge order was not followed to give two times a day (BID), and not three times a day (TID) Protonix delayed release (DR) 40 mg tab. She added admitting charge nurse calls MD regarding if either to continue with hospital discharge orders or not, and then the former DON and former unit manager would go through to verify if the MD orders correspond with hospital discharge orders and accurate. Interview on 8/04/22 at 11:40 am, The DON stated the NP responded to discontinue TID Protonix DR 40 mg and decreased to BID Protonix DR 40 mg tab according to Resident #193's Hospital discharge order. The DON stated Resident #193's Hospital discharge order was not followed and moving forward she will verify the physician orders next day if accurate and correspond with Hospital discharge orders together with weekend supervisor. The DON stated she was also assigned to reconcile monthly physician orders with the weekend supervisor. She stated she will follow-up on the issues on pharmacy services and she will be monitoring them. She stated she just started last month, and she cannot answer for previous DON. Resident #47 Record review of Resident #47's clinical record revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of anxiety disorder, candidiasis of skin and nails, congestive heart failure, non-Alzheimer's dementia and HTN. Record review of Pharmacist consultant recommendation/ MRR, dated 7/22/22, revealed Resident #47 Nystop (Nystatin, treats antifungal infection) BID order was a duplicate order. Further review read, Please update diagnosis to appropriate indication of use for Lamictal (neuroleptic) for dx. anxiety. Neuroleptics (Antipsychotic) are not considered an appropriate use for anxiety in our setting, due to the risk of side-effects vs benefits for this dx. Please review for discontinue via taper off. Record review of Resident #47's Physician Order dated August 2022 revealed, give Lamictal 25 mg 2 tabs BID for dx. anxiety disorder, start date 6/10/22. Nystatin 100,000 unit /gm topical cream 1 application BID, for candidiasis skin and nail, start date 6/10/22. Nystop 100,000 unit/gm topical powder apply small amount BID, for candidiasis skin and nail, start date 7/14/22. Record review of MAR dated August 2022 revealed Resident #47 received Lamictal 25 mg 2 tabs BID for dx anxiety disorder, start date 6/10/22. Nystatin 100,000 unit /gm topical cream 1 application BID, for candidiasis skin and nail, start date 6/10/22. Nystop 100,000 unit /gm topical powder apply small amount BID, for candidiasis skin and nail, start date 7/14/22. Interview on 8/04/22 at 11:30 am, the weekend supervisor stated the former DON or designee former unit manager reviewed the Consultant Pharmacist recommendations to follow-up with the Physician. She said that moving forward they will have the MD folders at the front receptionist desk for MD/NP to sign the physician letter/MRR, since it takes time if sent out, and to receive it back. Interview on 8/04/22 at 11:40 am, the DON stated she was currently designated to follow-up on the monthly Pharmacist MRR with weekend supervisor. She stated Resident #47's MRR on 7/22/22 was not done and moving forward she will ensure Pharmacist recommendations followed through within 72 hrs and reported to MD, and order carried out. She stated she will be working on the process and ensure the physician letter was given personally to MD/ NP in the facility. She said she will be monitoring them and have the physician letter at the front desk and signed by MD/NP. The DON stated she was also assigned to reconcile monthly physician orders with the weekend supervisor. She stated she will follow-up on the issues on pharmacy services and she will be monitoring them. She stated she just started last month, and she cannot answer for previous DON. Record review of the facility policy titled Medications dated November 2017 revealed, recommendations made in a Consultant Pharmacist Report must be reviewed and corrections initiated within 2 business days of the visit. Any change in orders must be entered in the EMR for each recommendation approved by the physician. Upon admission including re-admission of each resident, the physician orders for the resident must be reviewed and reconciled by the charge nurse and the DON or designee for accuracy in the Electronic Medical Record. Record review of the facility policy titled, Safe Medication Assistance and Administration, revised date 07/2015, revealed initiations, dosage changes .will be coordinated with the prescriber and discussed as needed to ensure staff and/or the person served has a clear understanding of the order.

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). Review inspection reports carefully.
• 16 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $11,009 in fines. Above average for Texas. Some compliance problems on record.

Bottom line: Mixed indicators with Trust Score of 61/100. Visit in person and ask pointed questions.

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About This Facility

What is Ashford Gardens's CMS Rating?

CMS assigns ASHFORD GARDENS an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Texas, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Ashford Gardens Staffed?

CMS rates ASHFORD GARDENS's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 45%, compared to the Texas average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Ashford Gardens?

State health inspectors documented 16 deficiencies at ASHFORD GARDENS during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 15 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 Ashford Gardens?

ASHFORD GARDENS is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CANTEX CONTINUING CARE, a chain that manages multiple nursing homes. With 202 certified beds and approximately 139 residents (about 69% occupancy), it is a large facility located in HOUSTON, Texas.

How Does Ashford Gardens Compare to Other Texas Nursing Homes?

Compared to the 100 nursing homes in Texas, ASHFORD GARDENS's overall rating (4 stars) is above the state average of 2.8, staff turnover (45%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Ashford Gardens?

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 Ashford Gardens Safe?

Based on CMS inspection data, ASHFORD GARDENS 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 4-star overall rating and ranks #1 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 Ashford Gardens Stick Around?

ASHFORD GARDENS has a staff turnover rate of 45%, which is about average for Texas nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Ashford Gardens Ever Fined?

ASHFORD GARDENS has been fined $11,009 across 1 penalty action. This is below the Texas average of $33,189. 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 Ashford Gardens on Any Federal Watch List?

ASHFORD GARDENS 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: 202
Avg. Residents: 139
Occupancy: 69.1%
Ownership: For profit - Corporation
Chain: CANTEX CONTINUING CARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
4-Star Rating: +30
1 Immediate Jeopardy citation: -12
16 Deficiencies: -5
Fines ($11,009): -2
Final Score: 61/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 675423