Does LAKESIDE HEALTH AND WELLNESS have any serious inspection findings?

Yes, LAKESIDE HEALTH AND WELLNESS has 6 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 41 total deficiencies from recent inspections.

What are the staffing levels at LAKESIDE HEALTH AND WELLNESS?

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

Where is LAKESIDE HEALTH AND WELLNESS located?

LAKESIDE HEALTH AND WELLNESS is located in KEMP, TX. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does LAKESIDE HEALTH AND WELLNESS have?

LAKESIDE HEALTH AND WELLNESS has 124 certified beds.

Who owns LAKESIDE HEALTH AND WELLNESS?

LAKESIDE HEALTH AND WELLNESS is a for profit - corporation facility and is part of the ML HEALTHCARE chain.

How does LAKESIDE HEALTH AND WELLNESS compare to other nursing homes?

LAKESIDE HEALTH AND WELLNESS has a 1-star overall rating, which is below average compared to other nursing homes in TX. Families should carefully review inspection findings and consider alternatives.

LAKESIDE HEALTH AND WELLNESS

Name: LAKESIDE HEALTH AND WELLNESS
Address: 110 N STATE HWY 274, KEMP, TX, 75143, US
Telephone: (210) 479-2500
Rating: 1.0

110 N STATE HWY 274, KEMP, TX 75143 · (210) 479-2500

For profit - Corporation 124 Beds ML HEALTHCARE Data: November 2025 6 Immediate Jeopardy citations

Trust Grade

0/100

#1021 of 1168 in TX

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Last Inspection: October 2024

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

Overview

Lakeside Health and Wellness has received a Trust Grade of F, indicating significant concerns about the quality of care provided. They rank #1021 out of 1168 facilities in Texas, placing them in the bottom half, and #6 out of 6 in Henderson County, meaning there are no better local options. The facility's situation is worsening; issues increased from 12 in 2023 to 23 in 2024, raising serious red flags. Staffing is rated poorly with a turnover rate of 58%, which is around the Texas average, highlighting potential instability in care. Concerningly, they have incurred $83,033 in fines, suggesting ongoing compliance issues, and critical incidents include failures to prevent residents from being burned by hot coffee and not providing necessary rehabilitative services for multiple residents. While there is average RN coverage, the overall picture shows both significant weaknesses and a lack of reliable care.

Trust Score: F
In Texas: #1021/1168
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 58% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $83,033 in fines. Higher than 98% of Texas facilities. Major compliance failures.
Skilled Nurses: Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 41 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2023: 12 issues

2024: 23 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Texas average (2.8)

Significant quality concerns identified by CMS

Staff Turnover: 58%

12pts above Texas avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $83,033

Well above median ($33,413)

Moderate penalties - review what triggered them

Chain: ML HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (58%)

10 points above Texas average of 48%

The Ugly 41 deficiencies on record

6 life-threatening 1 actual harm

Oct 2024 19 deficiencies 1 Harm

SERIOUS (H)

Actual Harm - a resident was hurt due to facility failures

Incontinence Care (Tag F0690)

A resident was harmed · 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 a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 1 of 3 residents (Resident 30) reviewed for urinary catheters. The facility failed to properly anchor Resident #30's foley catheter to prevent pulling and tension of the foley catheter tubing which resulted in a tear in his penis 3.5 cm in length and an ER visit on [DATE]. This failure could place residents at risk of injury, urinary tract infections, and a decreased quality of life. Findings included: Record review of a face sheet dated [DATE] indicated Resident #30 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system), dementia (memory loss), benign prostatic hyperplasia (enlarged prostate blocks the flow of urine), and retention of urine. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #30 was able to make himself understood and understood others. The MDS assessment indicated Resident #30 had a BIMS score of 13, which indicated his cognition was intact. The MDS assessment indicated Resident #30 required substantial/maximal assistance with eating, toileting hygiene, dressing, and partial/moderate assistance with personal hygiene. The MDS assessment indicated Resident #30 had an indwelling catheter. Record review of Resident #30's care plan with a date initiated of [DATE] indicated he had an ADL self-care performance deficit related to dementia, hemiplegia (paralysis or weakness of one side of the body), limited mobility, and stroke and required assistance of one staff for bathing, bed mobility, dressing and personal hygiene. Resident #30's care plan indicated he had an indwelling catheter related to benign prostatic hyperplasia to check the tubing for kinks each shift, monitor for signs and symptoms of discomfort on urination and frequency, monitor/document for pain/discomfort due to catheter, monitor/record/report to doctor for signs and symptoms of urinary tract infection, pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of Resident #30's Order Summary Report dated [DATE] indicated: foley catheter care every shift and as needed with a start date of [DATE] secure catheter with leg strap with a start date of [DATE] urinary catheter with a start date of [DATE]. Record review of Resident #30's Clinical admission completed [DATE] indicated he had a foley catheter and his skin was within the normal limits. Resident #30's Clinical admission did not indicate any tears in his penis. Record review of Resident #30's Weekly Skin Observation completed on [DATE] and [DATE] by RN F did not indicate tears in his penis or any penile issues. Record review of Resident #30's progress notes indicated: [DATE] at 9:05 PM Responsible Party in facility to see resident earlier on tonight. Requested said nurse to assess his father. Resident noted /c (with) malodor to the groin area. His ureter was noted torn measuring 3.5cm in length (from tip of penis to shaft of penis). Foley catheter in place. Redness also noted to scrotum and inner right leg. No bleeding noted. Denies pain. No shock symptoms noted. Tear not noted fresh. Requested that [NAME] be called, which took place via conference call will both Rp/D.O.N. Resident with request of family member was sent out via ambulance to hospital. Message left via answering service for PCP regarding findings and transfer to hospital. Signed by Charge Nurse G. [DATE] at 1:32 AM Patient arrived back in facility from ER via transportation from family. Patient is stable with no complaints of any pain and is resting comfortably back in bed with call [sic] within reach. Patients family is very admit [sic] about making sure patient is changed frequently and peri care performed regularly. Patient came back with new orders from ER with Cephalexin (antibiotic) 50mg po BID for 7 days, Bacitracin (antibiotic ointment) BID to penis for 7 days, Clotrimazole antifungal cream to groin, referral for urologist for suprapubic catheter (tube that drains urine from the bladder from a small incision in the abdomen) consult. Signed by Charge Nurse Y. Record review of Resident #30's ER After Visit Summary dated [DATE] indicated reason for visit penis injury and hand injury and diagnoses of erosion of penis (breakdown of tissue at the catheter insertion site), sebaceous cyst (fluid filled lump under the skin) and tinea cruris (fungal skin infection). During an interview on [DATE] at 10:45 AM, Resident #30's family member was at his bedside. Resident #30's family member said approximately five months ago they had visited Resident #30 and noticed a bad odor. Resident #30's family member said upon inspection of Resident #30's penis and foley catheter they realized the odor was coming from his private area. Resident #30's family member said there was blood and they noticed he had a split penis. Resident #30's family member said the facility had not been providing Resident #30 foley catheter care like they were supposed to. Resident #30's family member said they spoke with the DON regarding the lack of care being provided to Resident #30 and that same night ([DATE]) Resident #30 was sent to the ER for evaluation. During an interview on [DATE] at 5:01 PM, RN F said he had provided care to Resident #30. RN F said when Resident #30 admitted to the facility he had not seen any issues with his foley catheter or penis. RN F said he remembered the incident when Resident #30 was sent to the ER for evaluation for his split penis. RN F said he remembered Resident #30's family member brought it up to the facility staff. RN F said prior to Resident #30's family member identifying the penile erosion he had performed assessments on Resident #30 and there were no issues with his penis or catheter. RN F said if a resident had penile erosion upon admission to the facility it should be documented on the skin assessments. During an attempted phone interview on [DATE] at 5:12 PM, Charge Nurse G did not answer the phone. During an attempted observation and an interview on [DATE] at 5:29 PM, Resident #30's family members were at bedside and informed the surveyor Resident #30 was deceased and they preferred not to be bothered. During an interview on [DATE] at 12:30 PM, the DON said Resident #30's family member contacted her and sent her a picture of Resident #30's penis. The DON said she called Resident #30's family member to address the situation and ensure the resident was okay. The DON said she instructed the staff to send Resident #30 to the ER for evaluation. The DON said she believed Resident #30 admitted to the facility with the penis erosion. The DON said she could not find documentation of it in Resident #30's electronic medical record. The DON said she would continue to search through Resident #30's assessments to see if it was documented (documentation that Resident #30 admitted to the facility with the penis erosion was not provided upon exit of the facility). The DON said she told Resident #30's family member the injury to his penis was probably due to the catheter strap that was securing his foley catheter was on him too tight. The DON said the staff were not giving foley catheter enough slack for when he sat up or got up to walk with therapy. The DON said the foley catheter not having enough slack was causing friction and pulling the foley catheter. The DON said the CNAs and the nurses should be ensuring residents with a foley catheter have it properly secured and that it has enough slack so it will not get pulled and to prevent injury. The DON said she believed after the incident she had done an in-service with the staff, but she was not sure. The DON said she remembered doing verbal teaching with the staff regarding Resident #30's foley catheter and ensuring it was not getting pulled. During a phone interview on [DATE] at 1:59 PM, the DON brought her cell phone to the surveyor and Resident #30's family member was on the phone. Resident #30's family member said when he noticed Resident #30's penile erosion he had freaked out because it was a traumatic thing. Resident #30's family member said a week later Resident #30 was taken to the urology clinic, and it was explained to him that penile erosion was a common thing for long-term catheter use. Resident #30's family member said upon admission to the facility Resident #30 did not have any physical signs of penile erosion. During an interview on [DATE] at 1:31 PM, the facility's policy regarding foley catheter care was requested from the Regional Compliance Nurse and not received upon exit of the facility. Record review of the CDC's Indwelling Urinary Catheter Insertion and Maintenance accessed on [DATE] indicated, .Properly secure catheters to prevent movement and urethral traction .Catheter securement devices act as an anchor to prevent tugging and pulling which can cause irritation and inflammation. When catheters are not secured in male patients, the tugging and pulling can cause pressure sores on the penis tip .

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of the face sheet, dated [DATE], revealed Resident #225 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), schizoaffective disorder, bipolar type (a mental illness that is generally characterized by a combination of schizophrenic and mood disorder symptoms), traumatic brain injury (brain injury that is caused by an outside force), and heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). The face sheet did not address Resident #225's preferred code status or advanced directive. Record review of the entry MDS assessment, dated [DATE], revealed Resident #225 recently admitted to the facility on [DATE] from an in-patient psychiatric facility. Record review of Resident #225's baseline care plan, dated [DATE], did not address her preferred code status or advanced directive. Record review of the order summary report, dated [DATE], revealed Resident #225 had no physician order for her preferred code status or advanced directive. During an interview on [DATE] beginning at 9:45 AM, the Social Worker stated a code status assessment was one of the first things completed on a resident who admitted to the facility. The Social Worker stated a code status assessment was completed on Resident #225, which indicated she requested a full code status at the facility. The Social Worker stated nursing staff was responsible to making sure a physician order was placed in the electronic medical record. The Social Worker stated nursing staff was also responsible for ensuring the code status was placed on the face sheet, which then showed on the resident status bar in the electronic medical record. During an interview on [DATE] beginning at 12:33 PM, LVN A stated when a new resident admitted to the facility, the orders were placed in the electronic monitoring system. LVN A stated admission orders should have included an order for the preferred code status. LVN A stated she was unsure the nurse who admitted Resident #225. LVN A stated the order for full code status could have been missed for Resident #225 because the order was not part of the admission batch orders and had to placed into the computer separately. LVN A stated the resident status bar in the electronic medical record was how the nursing staff quickly determined the resident's code status. LVN A stated it was important to ensure the preferred code status was placed in the physician orders and on the face sheet, which pulls to the resident status bar in the electronic medical record so the nursing staff could quickly determine the code status of Resident #225 in an emergency. During an interview on [DATE] beginning at 1:21 AM, the ADON stated the admitting nurse was responsible for making sure a physician order was placed in the electronic medical record for the preferred code status. The ADON stated the preferred code status should have also been placed on the face sheet, which would then show on the resident status bar in the electronic medical record. The ADON stated the resident status bar in the electronic medical record was what the nursing staff looked at to determine a resident's code status. The ADON stated she tried to audit new admission charts within 1 - 2 days but that was not always possible. The ADON stated she had not performed an audit on Resident #225's chart. The ADON stated it was important to ensure the preferred code status was placed in the physician orders and on the face sheet so the nursing staff could quickly determine the code status of a resident in an emergency. During an interview on [DATE] beginning at 1:31 PM, the Corporate Regional Nurse provided a policy on Do Not Resuscitate Order. The Regional Nurse stated that was the facility policy on advanced directives. During an interview on [DATE] beginning at 1:37 PM, the DON and Administrator were interviewed together. The DON stated code status should have been included in the admission orders and on the face sheet so the nursing staff could quickly identify the code status of a new resident. The Administrator stated new admissions were discussed in the daily clinical meeting and Resident #225's missing order should have been caught. The Administrator stated it was important to ensure the preferred code status was placed in the physician orders and on the face sheet to respect the resident's wishes. The DON stated it was important to ensure the preferred code status was placed in the physician orders and the face sheet so nursing staff could quickly determine the code status of a resident in an emergency. Record review of the Do Not Resuscitate Order policy, revised [DATE], revealed . A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident' legal surrogate, as permitted by State law) and placed in front of the resident's medical record .Use only state-approved DNR forms .in addition to the advanced directive and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency. State-specific forms include .physician orders for life-sustaining treatment . Based on interview, and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 2 of 23 residents reviewed for advanced directives. (Residents #66 and #225) 1. The facility failed to ensure Resident #66's OOH-DNR was completed accurately. 2. The facility did not ensure Resident #225 had a physician order for her preferred code status. 3.The facility did not ensure Resident #225's code status was readily available to facility staff. These failures placed the residents at risk of not having their end of life wishes honored. Findings included: 1. Record review of Resident #66's face sheet dated [DATE], indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included fracture of right lower leg, diabetes type 2 (long term condition in which the body has trouble controlling blood sugar and using it for energy), hypertension (high blood pressure), and dementia (memory loss). The face sheet indicated under the advance directive section **Code Status: DNR**). Record review of Resident #66's admission MDS assessment dated [DATE], indicated Resident #66 was able to make herself understood and understood others. The MDS assessment indicated Resident #66 had a BIMS score of 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #66 required partial/moderate assistance with toileting, showering, lower body dressing and putting on/taking off footwear. Record review of Resident #66's comprehensive care plan dated [DATE], indicated Resident #66 wished her code status to be DNR with interventions to discuss a code status at care plan conferences and to send a copy of DNR with resident to outside appointments/hospital transfers. Record review of Resident #66's physician's orders dated [DATE], indicated Resident #66 had an order for Code Status: DNR with a revised date of [DATE]. Record review of Resident #66's OOH-DNR dated [DATE], revealed the witnesses had only signed in the section where it indicated Two Witnesses. The witnesses had not signed at the bottom of the form under where the OOH-DNR form instructed . All persons who have signed above must sign below, acknowledging that this document has been properly completed. During an interview on [DATE], at 3:01 PM, the SW said she was responsible for ensuring the DNRs were completed. The SW said based on the DNR instructions the witnesses do no need to be sign at the bottom of the form. The SW said when she was trained, she was only informed the witnesses had to sign on the section where it indicated the two witnesses. During an interview on [DATE] at 11:48 AM, the DON said she was unsure of the how the DNR needed to be completed. The DON said the SW was responsible was for ensuring the DNRs were accurately completed. The DON said not having Resident #66's DNR accurately completed could cause the nurse to have confusion on what to do in a life-or-death situation. During an interview on [DATE] at 11:49 AM, the Administrator said the DNR form should be completed with whatever the form required. The Administrator said by not completing the form appropriately they were out of compliance with the form requirements. The Administrator said the SW was responsible for completing the DNRs correctly.

CONCERN (D)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 1 (Resident #22) of 23 residents reviewed for privacy and confidentiality. The facility failed to ensure MA R closed Resident #22's EMR before entering the supply room and leaving the medication cart unattended. This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others. Findings included: Record review of Resident #22's face sheet dated 10/16/2024, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (a group of diseases that result in too much sugar in the blood), bipolar disorder (a mental illness that causes extreme shifts in mood, energy, and activity level), and anxiety (a mental illness that causes excessive and uncontrollable feelings of fear or anxiety that can significantly impair a person's daily life). Record review of Resident #22's MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS indicated Resident #22 had a BIMS score of 10, indicating moderate cognitive impairment. The MDS indicated she was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. During an observation and interview on 10/16/24 at 9:19 a.m., the medication cart for hall 400 was open, turned toward the hall and Resident # 22's information was visible. There was no staff present. MA R came out of the supply room, and stated she was responsible for leaving the screen with Resident #22 's information open. MA R stated she quickly ran to the supply room and forgot to close the screen. MA R stated it was important to close the EMR screen to protect Resident #22's personal information. MA R stated there could be a risk to Resident #22 if seen her personal information. During an interview on 10/17/2024 at 10:07 a.m., the DON stated she expected the EMR screen to be locked and the resident's information to be kept confidential. The DON stated the nurse was responsible for ensuring the screen was kept locked when not in use. The DON stated by not keeping the screen locked was a privacy and confidentially issue. During an interview on 10/17/2024 at 10:35 a.m., the Administrator stated he expected the MAR screen to be closed when the nurses entered the resident's room or if they left the cart unattended. The Administrator stated it was a HIPPA violation and breech of resident information leaving the screen with resident information up and visible to others. The Administrator stated everyone was responsible for ensuring resident information was kept confidential. Record review of the facility's policy Statement of Resident Rights residents have the right to personal privacy and confidentiality of their personal and clinical records

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

Free from Abuse/Neglect (Tag F0600)

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 ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 23 residents (Resident #233) reviewed for abuse. The facility failed to ensure RN N did not verbally abuse Resident #233 on 09/21/2024. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 10/17/2024 indicated Resident #233 was a [AGE] year-old female admitted to the facility on [DATE] and discharged [DATE] with diagnoses which included displaced spiral fracture of shaft of right tibia (right fracture of the shin bone). Record review of the 5-day MDS assessment dated [DATE] indicated Resident #233 was able to understand others and was understood by others. The MDS assessment indicated Resident #233 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #233 required partial/moderate assistance with toileting, showering, and lower body dressing and supervision/touching assistance for upper body dressing and oral hygiene and was independent for eating. Record review of Resident #233's care plan with date initiated 09/20/2024 indicated she used anti-anxiety medications related to an anxiety disorder to monitor her every shift and as needed for safety. Record review of Resident #233's progress notes indicated, This nurse was with resident outside for a break. Resident relayed a nurse, yesterday called her a M'Fer when she asked her to lower the temperature of the room. Administrator, DON, Police and resident representative notified. Signed by LVN E. During an interview on 10/15/2024 at 3:09 PM, RN N said she was not an employee of the facility that she was employed through a staffing agency. RN N said she had never had any incidents with anybody at the facility. RN N said she did not know who Resident #233 was. RN N said she had never had any allegations of abuses against her, and she would never abuse or cuss at a resident. RN N said she had not been contacted by the facility regarding the allegation of abuse made against her. During an interview on 10/15/2024 at 5:50 PM, the Administrator said when there was an incident of allegations of abuse incident statements were obtained from the witnesses and perpetrators and the resident involved. The Administrator said he had not attempted to get a witness statement from RN N because she was an agency employee. The Administrator said because RN N was agency staff the DON or the Staffing Coordinator probably attempted to get her witness statement. During an interview on 10/16/2024 at 8:47 AM, LVN E said on 09/22/2024 Resident #233 reported to her that RN N had called her a mother fucker, after she asked her to change the temperature of the AC on 09/21/2024. LVN E said she reported it to RN D, the RN supervisor for the weekend, and to the Administrator, DON, and police. During an interview on 10/16/2024 at 9:00 AM, CNA H said he worked on 09/21/2024. CNA H said Resident #233 kept asking the staff to take her to smoke. CNA H said there were multiple staff at the nurses' station, and another staff (unable to recall who the staff was) told Resident #233 they would take her to smoke. RN N told Resident #233 the staff was doing her a mother fucking favor by taking her out to smoke. CNA H said he had not reported this to the Administrator, the abuse coordinator, because multiple staff heard the comment including RN D (CNA H was unable to recall the other staffs' names). CNA H said he believed RN D would handle the situation. CNA H said if there had not been other staff around, he would have reported it to the Administrator because it was verbal abuse. During an interview on 10/16/2024 at 9:13 AM, RN D said she was the RN supervisor the weekend that the incident with RN N and Resident #233 occurred. RN D said Resident #233 did not inform them immediately of the incident with RN N. RN D said Resident #233 notified LVN E the following day. RN D said Resident #233 told LVN E that she had called RN N into her room to adjust the AC 2 times and RN N had called her a mother fucker. RN D said this was the only incident between RN N and Resident #233 she was aware of. RN D said she had not heard RN N tell Resident #233 the staff was doing her a mother fucking favor by taking her out to smoke, and nobody reported this to her. RN D said if she would have heard this, she would have reported it to the abuse coordinator, the administrator, immediately to protect the residents. During an interview on 10/16/2024 at 9:42 AM, the Social Worker said Resident #233's discharge was unplanned, and Resident #233 had been moved to another facility because a nurse had told her I'm tired of turning the air up mother fucker. During an interview on 10/16/2024 at 9:55 AM, Resident #233 said she had asked RN N to adjust the AC for her. Resident #233 said RN N told her, I am getting tired of turning the fucking AC on and off, mother fucker. Resident #233 said RN N had also told her the nurse is doing you a mother fucking favor to take you to smoke. Resident #233 said it made her feel awful. Resident #233 said she did not want to take RN N's time up she knew she was busy. Resident #233 said she was scared of RN N's attitude because she did not know what she (RN N) was going to do next. During an interview on 10/16/2024 at 10:20 AM, the DON said she was notified of the incident that occurred where RN N called Resident #233 a mother fucker by the Administrator. The DON said she did not remember much about the investigation she just remembered that Resident #233 had transferred to a different facility the next day. The DON said she had not reached out to RN N to ask her what happened with Resident #233. The DON said she was not notified about RN N telling Resident #233 the staff was doing her a mother fucking favor by taking her out to smoke. The DON said that should have been reported, and RN N should have been sent home to ensure the residents were safe and did not have any emotional distress. The DON said the facility did a lot of training on abuse upon hire and the facility provided frequent in-services on abuse. The DON said for staff that was employed through an agency the agency did their abuse training and checked their backgrounds. The DON said they tried to in-service the agency staff when they gave in-services about abuse and agency staff were present in the facility at the time of the in-service. The DON said she was not sure if RN N had received any abuse training by the facility. During an interview on 10/16/2024 at 10:54 AM, the Administrator said on 09/22/2024 Resident #233 was outside with a facility nurse and Resident #233 reported to the facility nurse that an agency nurse called her a mother fucker when she asked her to lower the AC the day before, 09/21/2024. The Administrator said he was able to identify RN N, an agency nurse, by the description provided to him by Resident #233. The Administrator said he did an in-service with the staff; safe surveys were completed with residents who were interviewable and the police were notified. The Administrator said no other claims of verbal abuse were made by the residents. The Administrator said he notified the staffing agency he wanted RN N placed on the do not return list for the facility. The Administrator said he was not notified by CNA H or any of the staff who worked on 09/21/2024 of RN N telling Resident #233 the nurse was doing her a mother fucking favor by taking her out to smoke. The Administrator said he should have been notified immediately of the incident. The Administrator said they were continually monitoring for abuse and neglect daily and in-serviced the facility staff frequently on abuse and neglect. The Administrator said they also performed angel rounds where the department heads had room assignments and every morning they checked on the residents. The Administrator said safe surveys were completed on residents who were able to be interviewed when incidents that were reportable occurred. The Administrator said the abuse training for agency staff was completed by the staffing agency. The Regional Compliance Nurse was with the Administrator during the interview, and she said that when agency staff went to the facility to work there was a training packet the facility should have them complete. The training packet was specifically for agency staff, and it contained abuse training for them. The Regional Compliance Nurse said she did not know if the facility had completed this for RN N. The Administrator said he had reached out to the staffing agency RN N was employed by to get her abuse training, and he would check with human resourced to see if RN N had completed the packet. During an interview on 10/16/2024 at 11:11 AM, the Social Worker said she had done a safe survey with Resident #233 after the incident with RN N. The Social Worker said she had asked Resident #233 what happened with RN N, and Resident #233 said she had asked the nurse to adjust the AC and the nurse said I am tired of turning it up and down m fer. The Social Worker said Resident #233 was upset at the language used by RN N, but she had not said she did not feel safe in the facility. During an interview on 10/16/2024 at 3:35 PM, the Staffing Coordinator said she did not reach out to agency staff for statements. The Staffing Coordinator said she contacted the human resources department of the staffing agency for them to get a statement from the staff involved. The Staffing Coordinator said she had contacted the human resources from the staffing agency where RN N was employed for them to get a statement from her, and to notify them to place RN N on the do not return list for the facility. The Staffing Coordinator said she still had not received a statement from them. During an interview on 10/16/2024 at 3:41 PM, the human resources from the staffing agency said they were notified of the incident that occurred with RN N and Resident #233. They said they had reached out to RN N for a statement, but she still had not provided it. They said the facility had requested RN N be placed on the do not return list for the facility. Record review of the facility's Resident Abuse and Neglect Policy 2021, indicated, . Our Facility will not condone resident abuse by anyone, including associates {associates herein refer to covered individuals), staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals .c)Verbal abuse: may be considered to be a type of mental abuse. Verbal abuse is defined as any oral, written, or gestured communication or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. It is language that includes disparaging or derogatory terms to a resident or within their hearing distance, regardless of the resident's age, ability to comprehend., or disability .

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

Abuse Prevention Policies (Tag F0607)

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 implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 23 residents (Resident #233) reviewed for abuse. The facility failed to implement their policy on reporting abuse when CNA H did not immediately report RN N's verbal abuse towards Resident #233 on 09/21/2024. The facility failed to follow its policy when RN N did not complete abuse training. These failures could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life. Findings included: Record review of a face sheet dated 10/17/2024 indicated Resident #233 was a [AGE] year-old female admitted to the facility on [DATE] and discharged [DATE] with diagnoses which included displaced spiral fracture of shaft of right tibia (right fracture of the shin bone). Record review of the 5-day MDS assessment dated [DATE] indicated Resident #233 was able to understand others and was understood by others. The MDS assessment indicated Resident #233 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #233 required partial/moderate assistance with toileting, showering, and lower body dressing and supervision/touching assistance for upper body dressing and oral hygiene and was independent for eating. Record review of Resident #233's care plan with date initiated 09/20/2024 indicated she used anti-anxiety medications related to an anxiety disorder to monitor her every shift and as needed for safety. During an interview on 10/15/2024 at 3:09 PM, RN N said she was not an employee of the facility that she was employed through a staffing agency. RN N said she had never had any incidents with anybody at the facility. RN N said she did not know who Resident #233 was. RN N said she had never had any allegations of abuses against her, and she would never abuse or cuss at a resident. RN N said she had not been contacted by the facility regarding the allegation of abuse made against her. During an interview on 10/16/2024 at 9:00 AM, CNA H said he worked on 09/21/2024. CNA H said Resident #233 kept asking the staff to take her to smoke. CNA H said there were multiple staff at the nurses' station, and another staff (unable to recall who the staff was) told Resident #233 they would take her to smoke. RN N told Resident #233 the staff was doing her a mother fucking favor by taking her out to smoke. CNA H said he had not reported this to the Administrator, the abuse coordinator, because multiple staff heard the comment including RN D (CNA H was unable to recall the other staffs' names). CNA H said he believed RN D would handle the situation. CNA H said if there had not been other staff around, he would have reported it to the Administrator because it was verbal abuse. During an interview on 10/16/2024 at 9:13 AM, RN D said she was the RN supervisor the weekend that the incident with RN N and Resident #233 occurred. RN D said she had not heard RN N tell Resident #233 the staff was doing her a mother fucking favor by taking her out to smoke, and nobody reported this to her. RN D said if she would have heard this, she would have reported it to the abuse coordinator, the administrator, immediately to protect the residents. During an interview on 10/16/2024 at 9:55 AM, Resident #233 said RN N had told her the nurse is doing you a mother fucking favor to take you to smoke. Resident #233 said it made her feel awful. Resident #233 said she did not want to take RN N's time up she knew she was busy. Resident #233 said she was scared of RN N's attitude because she did not know what she (RN N) was going to do next. During an interview on 10/16/2024 at 10:20 AM, the DON said she did not remember much about the investigation she just remembered that Resident #233 had transferred to a different facility the next day. The DON said she had not reached out to RN N to ask her what happened with Resident #233. The DON said she was not notified about RN N telling Resident #233 the staff was doing her a mother fucking favor by taking her out to smoke. The DON said that should have been reported, and RN N should have been sent home to ensure the residents were safe and did not have any emotional distress. The DON said the facility did a lot of training on abuse upon hire and the facility provided frequent in-services on abuse. The DON said for staff that was employed through an agency the agency did their abuse training and checked their backgrounds. The DON said they tried to in-service the agency staff when they gave in-services about abuse and agency staff were present in the facility at the time of the in-service. The DON said she was not sure if RN N had received any abuse training by the facility. During an interview on 10/16/2024 at 10:54 AM, the Administrator said he was not notified by CNA H or any of the staff who worked on 09/21/2024 of RN N telling Resident #233 the nurse was doing her a mother fucking favor by taking her out to smoke. The Administrator said he should have been notified immediately of the incident. The Administrator said they were continually monitoring for abuse and neglect daily and in-serviced the facility staff frequently on abuse and neglect. The Administrator said they also performed angel rounds where the department heads had room assignments and every morning they checked on the residents. The Administrator said safe surveys were completed on residents who were able to be interviewed when incidents that were reportable occurred. The Administrator said the abuse training for agency staff was completed by the staffing agency. The Regional Compliance Nurse was with the Administrator during the interview, and she said that when agency staff went to the facility to work there was a training packet the facility should have them complete. The training packet was specifically for agency staff, and it contained abuse training for them. The Regional Compliance Nurse said she did not know if the facility had completed this for RN N. The Administrator said he had reached out to the staffing agency RN N was employed by to get her abuse training, and he would check with human resourced to see if RN N had completed the packet. During an interview on 10/16/2024 at 4:13 PM, the Administrator said the staffing agency had not sent him RN N's abuse training yet, and he did not have any abuse training RN N had completed at the facility. Abuse training from the staffing agency for RN N was not received upon exit of the facility. During an interview on 10/17/2024 at 12:55 PM, the Administrator said he expected for all the staff to be properly trained on abuse and neglect. The Administrator said human resources was doing the abuse and neglect training. The Administrator said it was important for the staff to complete abuse and neglect training to prevent abuse and neglect to the residents. During an interview on 10/17/2024 at 1:26 PM, Human Resources said she completed abuse training during orientation. Human Resources said she did not do anything with agency staff. Human Resources said the Staffing Coordinator completed a check off list with them, and the Staffing Coordinator kept up with it. Human Resources said it was important for abuse and neglect training to be completed so the residents were not abused and neglected, and this was the residents' home and if the staff see abuse or neglect, they needed to intervene appropriately. During an interview on 10/17/2024 at 1:35 PM, the Staffing Coordinator said prior to this week they did not have anything in place for the abuse and neglect training for agency staff. The Staffing Coordinator said sometimes agency staff would sign abuse and neglect in-services. The Staffing Coordinator said she did not have any abuse trainings for RN N. The Staffing Coordinator said it was important for the staff to complete abuse and neglect trainings so none of the residents were abused or neglected. Record review of the facility's Resident Abuse and Neglect Policy 2021, indicated, . Our Facility will not condone resident abuse by anyone, including associates {associates herein refer to covered individuals), staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. 2. Employee/Associates, consultants, and attending physicians shall report any suspected abuse or incidents of abuse to the community designated abuse coordinator promptly. In the absence of the Facility Abuse Coordinator, such reports may be made to the Director of Nursing Services and if not available then to the nurse supervisor on duty. In accordance with S.B. 9 failure to report, abuse is a misdemeanor. 3.The Administrator and Director of Nursing Services shall be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services shall be called at home or shall be paged and informed of such incident .c) Verbal abuse: may be considered to be a type of mental abuse. Verbal abuse is defined as any oral, written, or gestured communication or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. It is language that includes disparaging or derogatory terms to a resident or within their hearing distance, regardless of the resident's age, ability to comprehend., or disability . All new and existing team members·receive periodic in-service training relative to resident rights and our Facility's abuse prevention program policies and procedures 1. Associates are required to attend our Facility's resident rights and abuse prevention program and dementia management (communication & caring for the cognitively Impaired) in-service training sessions before having any resident contact .

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

Report Alleged Abuse (Tag F0609)

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 ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 23 residents (Resident #233) reviewed for abuse reporting. The facility failed to ensure CNA H immediately reported RN N's verbal abuse towards Resident #233 on 09/21/2024 to the abuse coordinator or designee. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 10/17/2024 indicated Resident #233 was a [AGE] year-old female admitted to the facility on [DATE] and discharged [DATE] with diagnoses which included displaced spiral fracture of shaft of right tibia (right fracture of the shin bone). Record review of the 5-day MDS assessment dated [DATE] indicated Resident #233 was able to understand others and was understood by others. The MDS assessment indicated Resident #233 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #233 required partial/moderate assistance with toileting, showering, and lower body dressing and supervision/touching assistance for upper body dressing and oral hygiene and was independent for eating. Record review of Resident #233's care plan with date initiated 09/20/2024 indicated she used anti-anxiety medications related to an anxiety disorder to monitor her every shift and as needed for safety. During an interview on 10/15/2024 at 3:09 PM, RN N said she was not an employee of the facility that she was employed through a staffing agency. RN N said she had never had any incidents with anybody at the facility. RN N said she did not know who Resident #233 was. RN N said she had never had any allegations of abuses against her, and she would never abuse or cuss at a resident. RN N said she had not been contacted by the facility regarding the allegation of abuse made against her. During an interview on 10/16/2024 at 9:00 AM, CNA H said he worked on 09/21/2024. CNA H said Resident #233 kept asking the staff to take her to smoke. CNA H said there were multiple staff at the nurses' station, and another staff (unable to recall who the staff was) told Resident #233 they would take her to smoke. RN N told Resident #233 the staff was doing her a mother fucking favor by taking her out to smoke. CNA H said he had not reported this to the Administrator, the abuse coordinator, because multiple staff heard the comment including RN D (CNA H was unable to recall the other staffs' names). CNA H said he believed RN D would handle the situation. CNA H said if there had not been other staff around, he would have reported it to the Administrator because it was verbal abuse. During an interview on 10/16/2024 at 9:13 AM, RN D said she was the RN supervisor the weekend that the incident with RN N and Resident #233 occurred. RN D said she had not heard RN N tell Resident #233 the staff was doing her a mother fucking favor by taking her out to smoke, and nobody reported this to her. RN D said if she would have heard this, she would have reported it to the abuse coordinator, the administrator, immediately to protect the residents. During an interview on 10/16/2024 at 9:55 AM, Resident #233 said RN N had told her the nurse is doing you a mother fucking favor to take you to smoke. Resident #233 said it made her feel awful. Resident #233 said she did not want to take RN N's time up she knew she was busy. Resident #233 said she was scared of RN N's attitude because she did not know what she (RN N) was going to do next. During an interview on 10/16/2024 at 10:20 AM, the DON said she did not remember much about the investigation she just remembered that Resident #233 had transferred to a different facility the next day. The DON said she had not reached out to RN N to ask her what happened with Resident #233. The DON said she was not notified about RN N telling Resident #233 the staff was doing her a mother fucking favor by taking her out to smoke. The DON said that should have been reported, and RN N should have been sent home to ensure the residents were safe and did not have any emotional distress. The DON said the facility did a lot of training on abuse upon hire and the facility provided frequent in-services on abuse. During an interview on 10/16/2024 at 10:54 AM, the Administrator said he was not notified by CNA H or any of the staff who worked on 09/21/2024 of RN N telling Resident #233 the nurse was doing her a mother fucking favor by taking her out to smoke. The Administrator said he should have been notified immediately of the incident. The Administrator said they were continually monitoring for abuse and neglect daily and in-serviced the facility staff frequently on abuse and neglect. The Administrator said they also performed angel rounds where the department heads had room assignments and every morning they checked on the residents. The Administrator said safe surveys were completed on residents who were able to be interviewed when incidents that were reportable occurred. Record review of the facility's Resident Abuse and Neglect Policy 2021, indicated, . Our Facility will not condone resident abuse by anyone, including associates {associates herein refer to covered individuals), staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. 2. Employee/Associates, consultants, and attending physicians shall report any suspected abuse or incidents of abuse to the community designated abuse coordinator promptly. In the absence of the Facility Abuse Coordinator, such reports may be made to the Director of Nursing Services and if not available then to the nurse supervisor on duty. In accordance with S.B. 9 failure to report, abuse is a misdemeanor. 3.The Administrator and Director of Nursing Services shall be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services shall be called at home or shall be paged and informed of such incident .c) Verbal abuse: may be considered to be a type of mental abuse. Verbal abuse is defined as any oral, written, or gestured communication or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. It is language that includes disparaging or derogatory terms to a resident or within their hearing distance, regardless of the resident's age, ability to comprehend., or disability .

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement the baseline care plan that included the minimum healthcare information necessary to properly care for a resident including, but not limited to - initial goals based on admission orders and physician orders for 1 of 4 (Resident #225) residents reviewed for baseline care plans. The facility did not ensure Resident #225's preferred code status was addressed on the baseline care plan. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. The findings included: Record review of the face sheet, dated 10/16/2024, revealed Resident #225 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), schizoaffective disorder, bipolar type (a mental illness that is generally characterized by a combination of schizophrenic and mood disorder symptoms), traumatic brain injury (brain injury that is caused by an outside force), and heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). Record review of the entry MDS assessment, dated 10/10/2024, revealed Resident #225 recently admitted to the facility on [DATE] from an in-patient psychiatric facility. Record review of Resident #225's baseline care plan, dated 10/10/2024, did not address her preferred code status or advanced directive. During an interview on 10/17/2024 beginning at 9:45 AM, the Social Worker stated a code status assessment was one of the first things completed on a resident who admitted to the facility. The Social Worker stated a code status assessment was completed on Resident #225, which indicated she requested a full code status at the facility. The Social Worker stated she did not enter the code status onto the baseline care plan. The Social Worker stated the MDS Coordinator or nursing staff were responsible for completing the baseline care plan. During an interview on 10/17/2024 beginning at 1:16 PM, the MDS Coordinator stated the baseline care plan was completed as an IDT. The MDS Coordinator stated she was responsible for ensuring the baseline care plan was completed as she signed off on it. The MDS Coordinator stated the code status section on the baseline care plan auto populated from the face sheet. The MDS Coordinator stated she probably opened the baseline care plan assessment before the code status was filled out, so it did not auto populate. The MDS Coordinator stated she did not feel like it was important for the code status to have been included in the baseline care plan because the IDT discussed Resident #225's code status verbally. During an interview on 10/17/2024 beginning at 1:31 PM, the Corporate Regional Nurse stated the facility followed the Texas Administrative Code regarding baseline care plans. The Regional Nurse stated the facility did not have a policy specific to baseline care plans. During an interview on 10/17/2024 beginning at 1:37 PM, the DON and Administrator were interviewed together. The DON and Administrator stated the code status should have been included on the baseline care plan. The Administrator stated new admissions were reviewed in the daily clinical meeting. The Administrator stated the staff should have caught the error. The Administrator stated it was important to ensure the code staff was included in the baseline care plan to respect the resident's wishes. Record review of the Texas Administrative Code, Title 26, Part I, Chapter 554, Subchapter 1 revealed the facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must: .include the minimum healthcare information necessary to properly care for a resident, included: initial goals based on admission orders; physician orders .

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 1 of 4 residents reviewed for ADLs. (Resident #224) The facility failed to ensure Resident #224 was assisted with facial hair removal. These failures could place residents at risk of not receiving care or services, decreased quality of life, embarrassment, and decreased self-esteem. The findings included: Record review of the face sheet, dated 10/17/2024, revealed Resident #224 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of unspecified dementia without behaviors (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The face sheet further revealed Resident #224 was receiving hospice services. Record review of the admission MDS assessment, dated 10/09/2024, revealed Resident #224 had clear speech and was understood by others. The MDS revealed Resident #224 was able to understand others. The MDS revealed Resident #224 had a BIMS score of 3, which indicated severe cognitive impairment. The MDS revealed Resident #224 had no behaviors or refusal of care. The MDS revealed Resident #224 required partial/moderate assistance (helper does less than half the effort) with personal hygiene. The MDS revealed Resident #224 was receiving hospice services in the facility. Record review of the comprehensive care plan, initiated 10/15/2024, revealed Resident #224 had an ADL self-care performance deficit related to dementia. The interventions included: Ensure/promote resident self esteem and dignity while performing ADL care and Personal Hygiene: the resident requires 1 staff assist with personal hygiene and oral care. The comprehensive care plan further revealed Resident #224 was receiving hospice services. The interventions included: Adjust provision of ADLs to compensate for resident's changing abilities. Record review of the ADL task documentation for personal hygiene, dated 10/04/2024 to 10/16/2024 revealed Resident #224 required limited to extensive assistance. During an observation and interview on 10/14/2024 beginning at 11:38 AM, Resident #224 was laying in the bed with the head of her bed elevated slightly. Resident #224's had approximately 1-inch black and gray facial hairs to the sides of her mouth. Resident #224's eyes became wide, and she placed her hands up to cover her mouth when the surveyor asked if the staff assisted her with facial hair removal. Resident #224 stated the staff had not offered to help her remove it and she was unaware she had facial hair. Resident #224 stated she wanted help from the staff with removing her facial hair. Resident #224 stated she was embarrassed to have facial hair. During an observation on 10/15/2024 beginning at 10:43 AM, Resident #224 had approximately 1-inch black and gray facial hairs to the sides of her mouth. During an interview on 10/17/2024 beginning at 12:27 PM, Hospice CNA B stated she provided care for Resident #224 at the facility. Hospice CNA B stated she gave Resident #224 her baths and helped her make her bed. Hospice CNA B stated she only provided care to Resident #224 at the facility three times a week. Hospice CNA B stated the facility staff were responsible for providing care to Resident #224 when she did not come. Hospice CNA B stated she had not offered or asked Resident #224 if she wanted help removing her facial hairs. Hospice CNA B stated she had not noticed Resident #224's facial hairs. Hospice CNA B stated facial hair removal was not on the plan of care for the hospice, but it was something she could have assisted her with. Hospice CNA B stated it was important to ensure Resident #224 was assisted with facial hair removal because a woman wouldn't want facial hair. During an interview on 10/17/2024 beginning at 12:33 PM, LVN A stated the hospice CNAs did come to the facility and perform care for Resident #224. LVN A stated the facility staff also performed ADL care for Resident #224. LVN A stated facial hair removal is usually completed with bathing. LVN A stated if facility staff noticed facial hair, they should have asked if Resident #224 wanted help removing it. LVN A stated it was important to assist Resident #224 with facial hair removal to maintain her dignity. During an interview on 10/17/2024 beginning at 1:09 PM, CNA C stated she assisted females with facial hair removal if they asked her. CNA C stated she had not assisted Resident #224 with facial hair removal. CNA C stated she had not asked if she needed assistance. CNA C stated it was important to assist Resident #224 with facial hair removal to respect her rights and maintain her dignity. During an interview on 10/17/2024 beginning at 1:37 PM, the DON and Administrator were interviewed together. The DON stated she expected facial hair to be removed if the resident's asked. The DON stated CNA's and nurses were responsible for ensuring facial hair was removed. The Administrator stated the facility staff performed angel rounds daily, however, they were not trained specifically to look for facial hair. The DON stated if the facial hair was noticed they should have asked the resident if she wanted assistance with removing it. The Administrator stated it was important to ensure facial hair removal was offered to maintain her dignity. Record review of the Certified Nurse Aide Standards of Clinical Practice policy, updated 03/12/2019, revealed the CNA assists the resident in activities of daily living such as .bathing, grooming . Record review of the Activities of Daily Living (ADL), Supporting policy, revised March 2018, revealed appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for the facility's only resident with an enteral device (Resident #57). The facility failed to ensure LVN W checked Resident #57's gastrostomy placement (placement of the tube used for nutrition and medication administration) as ordered by the physician on 10/15/24. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk of health complications. Findings included: Record review of Resident #57's face sheet dated 10/17/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), essential hypertension (high blood pressure), congestive heart failure (heart does not pump blood as well as it should), gastrostomy status (surgical opening into the stomach for nutritional support and medication administration), and dysphagia (difficulty swallowing). Record review of Resident #57's quarterly MDS assessment dated [DATE], indicated Resident #57 was rarely/never understood and usually understood others. The MDS assessment indicated Resident #57 had short term and long-term memory problems. The MDS assessment indicated Resident #57 was dependent on staff with eating, oral hygiene, toileting, personal hygiene, and showers. The MDS assessment indicated Resident #57 had a feeding tube. Record review of Resident #57's comprehensive care plan dated 03/28/24, indicated Resident #57 required tube feeding related to dysphagia and swallowing problems. The care plan interventions indicated to check for tube placement and gastric contents/residual volume per facility protocol and record, resident needs total assistance with tube feeding and water flushes. Record review of Resident #57's order summary report dated 10/17/24, indicated he had the following orders: *Nothing by mouth (NPO) diet with an order start date of 05/22/24. *Confirm g-tube placement via auscultation of 10 mls of air. Hold if placement cannot be confirmed and notify MD/NP every 4 hours for enteral feeding with an order start date of 05/22/24. *Check gastric residual volume (GRV) every 4 hours and hold feeding if residuals are greater than 500mls. Return GRV to stomach and recheck in 4 hours. If enteral feedings were held for high GRV for 3 consecutive checks, notify the physician or NP for additional orders with an order start date of 06/14/24. *Do not cocktail medications with an order start date of 05/22/24. During an observation and interview on 10/15/24 at 11:20 AM, LVN W prepared Resident #57's morning medications by crushing all medications together. LVN W applied PPE and entered Resident #57's room to attempt to administer his medications. LVN W applied the syringe to Resident #57s gastrostomy tube and checked Resident #57's residual by pulling back on the syringe with no residual noted. LVN W did not confirm placement via auscultation as ordered by the physician. Surveyor intervened before medications were administered. LVN W said she did not remember if she could cocktail Resident #57's medications but that was what she had been doing. LVN W said she had not checked placement by auscultation as ordered because she had done it that morning. LVN W said she was responsible for ensuring medications were being administered as ordered by the physician. LVN W said by cocktailing medications Resident #57 was at risk for an adverse reaction. LVN W said by not checking placement as ordered, Resident #57 was at risk for his gastrostomy tube to be out of place. LVN W said she had been checked off on medication administration via the gastrostomy tube. During an interview on 10/16/24 at 4:28 PM, the DON said she did not have a medication administration via the gastrostomy tube competency skills check off for LVN W. During an interview on 10/17/24 at 11:32 AM, the DON said when peg tube medications were being administered, peg tube placement should be checked via auscultation and residual. The DON said medications should not be cocktailed because it could cause harm or cause a change in condition to the resident. The DON said medications should be crushed individually. The DON said LVN W was responsible for ensuring medications via the gastrostomy tube were administered as ordered by the physician. The DON said by not checking placement as ordered Resident #57's peg tube could be out of place. During an interview on 10/17/24 at 11:36 AM, the Administrator said he expected LVN W to administer medications as per the physician orders. The Administrator said the nurses should follow best practice and what they have been trained to do. The Administrator said by not administering medications as ordered there was a potential for harm or change in condition. The Administrator said the licensed individual administering the medications was responsible for ensuring the mediations were administered as ordered. Record review of the facility's policy Administering Medications through an Enteral Tube revised November 2018, indicated . The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. Preparation.1. Verify that there is a physician's medication order for this procedure . Follow the medication administration guidelines in policy entitled Administering Medications . 3. Administer each medication separately and flush between medications . Steps in the procedure . 3. Prepare the medication: a. check the label and confirm the medication name and dose with the MAR . 6. Verify placement of feeding tube . 9. Dilute medication: a remove plunger from syringe. Add medication and appropriate amount of water to dilute. b. dilute crushed (powdered) medication with at least 30mls of purified water (or prescribed amount) . 10. Administer each medication separately . 12. Administer medication by gravity flow . 13. If administering more than one mediation, flush with 15mls warm water (or prescribed amount) between medications.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 3 residents (Residents #43 and Resident #56) reviewed for respiratory care. 1. The facility failed to ensure Resident #56's oxygen concentrator was set at 2 liters per nasal cannula as ordered by the physician. 2. The facility failed to ensure Resident #43's oxygen concentrator was clean. These failures could place residents requiring respiratory care at risk for shortness of breath, respiratory distress, or complications. Findings included: 1. Record review of a face sheet dated 10/17/2024 indicated Resident #56 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #56 was usually able to understand others and was usually understood by others. The MDS assessment indicated Resident #56 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #56 required partial/moderate assistance for dressing, toileting and personal hygiene, substantial/maximal assistance with bathing. The MDS assessment indicated Resident #56 received oxygen therapy while a resident at the facility. Record review of Resident #56's care plan date initiated 08/30/2024 indicated she had chronic obstructive pulmonary disease with oxygen settings for oxygen via nasal cannula at 2-4 liters per minute continuously. Record review of Resident #56's Order Summary Report dated 10/17/2024 indicated oxygen at 2 liters per minute via nasal cannula every shift related to chronic obstructive pulmonary disease with a start date of 08/30/2024. During an observation on 10/14/2024 at 11:30 AM, Resident #56 was lying in bed wearing her oxygen via nasal cannula. Resident #56's oxygen was set between 3-4 liters per minute. During an observation and interview on 10/17/2024 at 10:50 AM, LVN A checked the settings on Resident #56's oxygen. LVN A said Resident #56's oxygen was set at 3 liters per minute and her order was for 2 liters per minute. LVN A said it was the nurse's responsibility to ensure the residents oxygen was set as ordered by the physician. LVN A said it was important for the oxygen to be set as ordered by the physician to follow the doctor's order and because a resident could get too much or not enough oxygen. 2. Record review of a face sheet dated 10/15/2024 indicated Resident #43 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side (right sided weakness and paralysis after unspecified disease affecting the brain) and chronic respiratory failure (condition where the lungs cannot supply enough oxygen or remove enough carbon dioxide from the blood). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #43 was able to make herself understood and understood others. The MDS assessment indicated Resident #43 had a BIMS score of 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #43 required partial/moderate assistance for toileting, bathing, and personal hygiene. The MDS assessment indicated Resident #43 received oxygen therapy while a resident at the facility. Record review of Resident #43's Order Summary Report dated 10/17/2024 indicated, oxygen at 2-4 liters per minute via nasal canula as needed for shortness of breath with a start day of 08/19/2024. Resident #43's orders did not indicate cleaning the oxygen concentrator. Record review of Resident #43's care plan date initiated 07/06/2024 indicated the resident has the potential for shortness of breath oxygen therapy per the doctor's orders. During an observation and interview on 10/14/2024 at 11:55 AM, Resident #43 was lying in bed wearing oxygen via nasal cannula. Resident #43's oxygen concentrator had white speckles on the outside of it with a layer of dust. The dust was layered on the back as well and there was a thick layer of built-up, gray, fuzzy material on the oxygen concentrator vents on the back. Resident #43 said the nurse changed out the humidifier and tubing, but she was not sure if they were cleaning the oxygen concentrator. During an interview on 10/16/2024 at 3:23 AM, RN D said she provided care to Resident #43. RN D said she had changed the water on Resident #43's oxygen concentrator, but she had not noticed it was dirty. RN D said she believed the Staffing Coordinator was responsible for cleaning the oxygen concentrators. RN D said it was important for the oxygen concentrators to be cleaned because the air was going to the residents' lungs, and they could get infections. During an interview on 10/16/2024 at 3:35 PM, the Staffing Coordinator said she was not responsible for cleaning the oxygen concentrators. The Staffing Coordinator said housekeeping, CNAs or the nurses should be cleaning the oxygen concentrators in the residents' rooms. During an interview on 10/17/2024 at 11:58 AM, the DON said anyone could wipe down an oxygen concentrator. The DON said angel rounds were completed daily to check the room and their cleanliness. The DON said the nurses should be checking the settings on the oxygen at least every shift. The DON said if they noticed the oxygen was not set per the doctor's order, they should correct the situation and ensure the resident was safe, assess the resident and notify the doctor. The DON said it was important for the oxygen to be set per the doctor's order because it could cage a respiratory change of condition and it could cause harm. During an interview on 10/17/2024 at 12:09 PM, the Administrator said the charge nurses should be checking the resident's oxygen settings because it could be too high or too low for them. The Administrator said it was important for the oxygen concentrators to be cleaned for a pleasant living environment free of dust and debris. The Administrator said the cleanliness of the concentrators should be checked on room rounds by the department heads. Record review of the undated facility's policy titled, Oxygen Administration, indicated, Purpose: A resident will receive oxygen therapy when ordered by a physician . 3. Obtain physician orders for oxygen administration. Orders should include the following: a. oxygen source to be used (concentrator, tank, etc.) b. method of delivery (cannula, mask, etc.) c. flow rate of delivery d. oxygen saturation monitoring parameters, if indicated . The policy did not address cleaning of the oxygen concentrator.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

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 ensure that residents were free of significant medication errors for 1 of 7 residents reviewed for pharmacy services. (Resident #57) The facility failed to ensure LVN W did not prepare to and attempt to administer Resident #57's metoprolol (blood pressure medication) his blood pressure was low on 10/15/24. The facility failed to ensure LVN W prepared and attempt to administer Resident #57's Eliquis (anticoagulant medication) on 10/15/24. These failures could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: Record review of Resident #57's face sheet dated 10/17/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), essential hypertension (high blood pressure), congestive heart failure (heart does not pump blood as well as it should), gastrostomy status (surgical opening into the stomach for nutritional support and medication administration), and dysphagia (difficulty swallowing). Record review of Resident #57's quarterly MDS assessment dated [DATE], indicated Resident #57 was rarely/never understood and usually understood others. The MDS assessment indicated Resident #57 had short term and long-term memory problems. The MDS assessment indicated Resident #57 was dependent on staff with eating, oral hygiene, toileting, personal hygiene, and showers. The MDS assessment indicated Resident #57 had a feeding tube. The MDS assessment indicated Resident #57 received anticoagulant and antiplatelet medications within the 7-day look back period. Record review of Resident #57's comprehensive care plan revised on 05/17/24, indicated Resident had a cerebral vascular accident affecting mobility, speech and cognition. The care plan interventions included to give medications as ordered by the physician. Record review of Resident #57's order summary report dated 10/17/24, indicated he had the following orders: *Do not cocktail medications with an order start date of 05/22/24. *May crush or open medications and mix each medication with 5mls of water. Give 5-10 mls water between each medication every shift for enteral administration with a start date of 05/22/24. *Apixaban 5mg give one tablet via g-tube two times a day for anticoagulant with an order start date of 05/22/24. *Entresto 24-26mg give one tablet via g-tube two times day for chronic heart failure hold if SBP less than 110 or DBP less than 60 with an order start date of 07/25/24. *Metoprolol tartrate 25mg give one tablet via g-tube two times a day for hypertension with an order start date of 05/22/24. Record review of Resident #57's nursing medication administration record for 10/01/24-10/31/24, indicated Resident #57 was scheduled to receive apixaban 5 mg one tablet, Entresto 24-25mg one tablet, and metoprolol 25mg one tablet via g-tube. The record indicated to not cocktail Resident #57's medications and to flush tube with 30mls of before and after medications every shift. The nursing administration record also indicated may crush or open medications and mix each medication with 5mls of water and to give 5-10mls of water between each medication every shift. During an observation of medication administration and an interview on 10/15/24 at 11:05 AM, LVN W obtained Resident #57's following medications: Vitamin C 500mg tablet, multivitamin tablet, thiamin 100mg tablet, aspirin 81 tablet, amiodarone 400mg tablet, metoprolol 25mg tablet, montelukast 10mg tablet, atorvastatin tablet and crushed all medications together in a pill crusher pouch. LVN W said she was not placing the Entresto 24-26mg tablet or the Eliquis 5mg tablet until she obtained Resident #57's blood pressure (Eliquis does not require a blood pressure reading for administration). LVN W obtained Resident #57's blood pressure with readings of 87/48 and pulse of 63. LVN W said she was not administering the Entresto tablet or the Eliquis tablet because Resident #57's blood pressure was low. LVN W and LVN Z applied PPE and entered Resident #57's room. LVN W had the pill crusher pouch with the crushed medications inside in her hand. LVN W obtained a 60 mls syringe, attached it to Resident #57's enteral feeding tube, and checked for residual by pulling back on the syringe. No residual noted. LVN W did not confirm placement via auscultation as ordered by the physician. LVN W then used the syringe and obtained over 60mls of water and flushed Resident #57's gastrostomy tube. LVN W then removed the stopper from the syringe, placed her pointer finger on the tip of the syringe, and poured the crushed medications from the pouch into the syringe. LVN W then applied the stopper to the top of the syringe, turned the syringe upside down, then inverted it into a cup with water, and added approximately 50mls of water into the syringe. LVN W then mixed the medications in the syringe by shaking it. LVN W was in the process of applying the syringe with medications to Resident #57's gastrotomy tube to administer them, when surveyor intervened before the medications were administered. LVN W said she did not remember if she could cocktail Resident #57's medications, but that was what she had been doing. LVN W said she had not checked placement by auscultation as ordered because she had done it that morning. LVN W said she should not have crushed Resident #57's metoprolol tablet with his medications since it was a blood pressure medication and Resident #57's blood pressure was low. LVN W said if she had administered the blood pressure medication Resident #57 was at risk for bis blood pressure bottoming out. LVN W said she did not place the Eliquis tablet in Resident #57's medications because she thought it was for his blood pressure. LVN W said failure to administer the Eliquis placed Resident #57 at risk of having a blood clot since Eliquis was a blood thinner. LVN W said she was responsible for ensuring medications were being administered as ordered by the physician. LVN W said by cocktailing medications Resident #57 was at risk for an adverse reaction. LVN W said by not checking placement as ordered, Resident #57 was at risk for his gastrostomy tube to be out of place. LVN W said she had been checked off on medication administration via the gastrostomy tube. LVN Z said the metoprolol, Entresto and amiodarone were the medications that should have been held and all should have had blood pressure parameters. During an interview on 10/17/24 at 11:32 AM, the DON said medications should not be cocktailed because it could cause harm or cause a change in condition to the resident. The DON said medications should be crushed individually and mixed with 5-10mls of water. The DON said Resident #57's blood pressure should have been assessed prior to preparing the medications. The DON said if a resident's blood pressure was low, then the blood pressure medications should be held. The DON said LVN W should have prepared the Eliquis to have been administered as it was an anticoagulant medication and not a blood pressure medication. The DON said LVN W was responsible for ensuring medications via the gastrostomy tube were administered as ordered by the physician. The DON said if Resident #57's received his blood pressure medication with his blood pressure being low he was at risk for his blood pressure to drop. During an interview on 10/17/24 at 11:36 AM, the Administrator said he expected LVN W to administer medications as per the physician orders. The Administrator said the nurses should follow best practice and what they have been trained to do. The Administrator said by not administering medications as ordered there was a potential for harm or change in condition. The Administrator said the licensed individual administering the medications was responsible for ensuring the mediations were administered as ordered. Record review of the facility's policy Administering Medications revised April 2019 indicated . Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders, including any required time frame . 7. Medications are administered within 1 hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 11. The following information is checked/verified for each resident prior to administering medications: .b. Vital signs, if necessary .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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During an observation and interview on 10/16/2024 at 9:19 a.m., MA R left the medication cart for hall 300 and 400 unlocked on hall 400 while in medication supply. MA R stated the medication cart should be locked. MA R stated she walked off to fast and forgot to lock the medication cart. MA R stated it was important to keep the medication cart locked so no one could take medication from the cart. MA R stated residents could take medication from the cart that was not theirs. During an interview on 10/17/2024 at 10:07 a.m., the DON stated she expected the staff to always lock the medication carts before walking away. The DON stated it was important to lock the medication carts for safety of the residents and visitors. The DON stated she would monitor by daily rounds. During an interview on 10/17/2024 at 10:07 a.m., the Administrator stated he expected staff to lock the medication cart. The Administrator stated the nursing staff were responsible for locking the medication carts before walking away. The Administrator stated it was important to lock the medication cart to ensure the safety of the drugs. The Administrator stated he would monitor by making rounds to ensure all medications carts were locked. Record review of the facility's policy titled, Administering Medication dated April 2019, revealer During administration of medication, the medication cart was kept closed and locked when out of sight of the medication nurse or aide . Based on observation, interview, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 3 of 6 medication carts (treatment cart, 300-400 hall medication cart, and 100-200 nurses' cart) reviewed for pharmacy services. 1. The facility failed to ensure RN D locked the 100-200 nurses' cart when she left it unattended at the nurses' station on 10/14/24. 2. The facility failed to ensure the MDS Coordinator locked the treatment cart when she left it unattended in the hallway on 10/16/24. 3. The facility failed to ensure medication cart for hall 300-400 was secured and unable to be accessed by unauthorized personnel. These failures could place residents at risk of not having the medication available due to possible drug diversion. Findings included: 1. During an observation and interview on 10/14/24 beginning at 10:31 PM, a medication cart was unlocked at the nurses' station. There were no facility staff at the nurses' station. RN D walked up to the nurses' station. RN D stated she was the nurse responsible for the unlocked medication cart. RN D stated medication carts should have been kept locked. RN D stated she forgot to lock the medication cart. RN D stated it was important to ensure medication carts were kept locked to prevent a drug diversion or adverse effects from taking the wrong medications. 2. During an observation and interview on 10/16/24 at 4:28 PM, the MDS Coordinator entered Resident #176's room to flush her PICC line. The MDS Coordinator completed the procedure and went to the treatment cart to obtain disinfectant wipes to clean Resident #176's bedside table. The MDS Coordinator did not lock the treatment cart when she went back inside Resident #176's room to disinfect Resident #176's bedside table and wash her hands. The MDS Coordinator said it was her responsibility to lock the carts when leaving them unattended because residents could get in and get medications.

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 residents (Resident #14) reviewed for hospice services. The facility did not ensure Resident #14's hospice records were a part of their records in the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings included: Record review of the face sheet, dated 10/17/2024, revealed Resident #14 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of parkinsonism (clinical syndrome characterized by the four motor symptoms found in Parkinson's disease: tremor, bradykinesia (slowed movements), rigidity, and postural instability). The face sheet further revealed Resident #14 received hospice services. Record review of the quarterly MDS assessment, dated 10/01/2024, revealed Resident #14 had clear speech and was understood by others. The MDS revealed Resident #14 was able to understand other. The MDS revealed Resident #14 had a BIMS score of 11, which indicated moderately impaired cognition. The MDS revealed Resident #14 received hospice services at the facility. Record review of the comprehensive care plan, revised 06/02/2023, revealed Resident #14 had a terminal prognosis and was receiving hospice services. Record review of the order summary report, dated 10/17/2024, revealed Resident #14 had an order, which started on 05/01/2024, for hospice services. Record review of Resident #14's hospice binder, accessed on 10/16/2024, revealed no certification of terminal illness. The hospice binder further revealed the plan of care and medication were not updated since 08/22/2024. During an interview on 10/16/2024 beginning at 10:17 AM, Hospice RN AA stated every other week after the plan of care meetings the hospice nurse was responsible for dropping off the updated paperwork. Hospice RN AA stated the hospice nurse dropped off the paperwork and placed it in the binder and the facility nurse signed off on a paper that it was dropped off. Hospice RN AA stated she was covering for the hospice nurse that usually came because she was on vacation. Hospice RN AA stated Resident #14's hospice binder did not contain the updated information. Hospice RN AA stated it was important to ensure the facility had the updated hospice documentation and plan of care to ensure continuity of care and communication with the facility. During an interview on 10/17/2024 beginning at 12:33 PM, LVN A stated the hospice nurses were responsible for leaving the documentation in the hospice binders at the nurses' station. LVN A stated she never received paperwork from the hospice company. LVN A stated she only signed the tablets used by the hospice company to verify they were at the facility. LVN A stated she did not have to sign a paper to verify the documentation was placed in the hospice binder. During an interview on 10/17/2024 beginning at 1:37 PM, the Corporate Regional Nurse stated she did not have a policy that stated the facility had to check the hospice binder to make sure the paperwork was current and up to date. During an interview on 10/17/2024 beginning at 1:37 PM, the DON and Administrator were interviewed together. The DON and Administrator were unsure who was responsible for ensuring the facility had the most updated information from the hospice company. The Administrator stated typically Admissions then Medical Record would have been responsible. The DON stated it was important to ensure the facility had access to the updated hospice paperwork for coordination or continuity of care.

CONCERN (D)

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

Deficiency F0943 (Tag F0943)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property for 1 of 6 (RN N) employees reviewed for staff training. The facility failed to ensure RN N received abuse training. This failure could place residents at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training. Findings included: During an interview on 10/16/2024 at 10:20 AM, the DON said the facility did a lot of training on abuse upon hire and the facility provided frequent in-services on abuse. The DON said for staff that was employed through an agency the agency did their abuse training and checked their backgrounds. The DON said they tried to in-service the agency staff when they gave in-services about abuse and agency staff were present in the facility at the time of the in-service. The DON said she was not sure if RN N had received any abuse training by the facility. During an interview on 10/16/2024 at 10:54 AM, the Administrator said they were continually monitoring for abuse and neglect daily and in-serviced the facility staff frequently on abuse and neglect. The Administrator said the abuse training for agency staff was completed by the staffing agency. The Regional Compliance Nurse was with the Administrator during the interview, and she said that when agency staff went to the facility to work there was a training packet the facility should have them complete. The training packet was specifically for agency staff, and it contained abuse training for them. The Regional Compliance Nurse said she did not know if the facility had completed this for RN N. The Administrator said he had reached out to the staffing agency RN N was employed by to get her abuse training, and he would check with human resourced to see if RN N had completed the packet. During an interview on 10/16/2024 at 4:13 PM, the Administrator said the staffing agency had not sent him RN N's abuse training yet, and he did not have any abuse training RN N had completed at the facility. Abuse training from the staffing agency for RN N was not received upon exit of the facility. During an interview on 10/17/2024 at 12:55 PM, the Administrator said he expected for all the staff to be properly trained on abuse and neglect. The Administrator said human resources was doing the abuse and neglect training. The Administrator said it was important for the staff to complete abuse and neglect training to prevent abuse and neglect to the residents. During an interview on 10/17/2024 at 1:26 PM, Human Resources said she completed abuse training during orientation. Human Resources said she did not do anything with agency staff. Human Resources said the Staffing Coordinator completed a check off list with them, and the Staffing Coordinator kept up with it. Human Resources said it was important for abuse and neglect training to be completed so the residents were not abused and neglected, and this was the residents' home and if the staff see abuse or neglect, they needed to intervene appropriately. During an interview on 10/17/2024 at 1:35 PM, the Staffing Coordinator said prior to this week they did not have anything in place for the abuse and neglect training for agency staff. The Staffing Coordinator said sometimes agency staff would sign abuse and neglect in-services. The Staffing Coordinator said she did not have any abuse trainings for RN N. The Staffing Coordinator said it was important for the staff to complete abuse and neglect trainings so none of the residents were abused or neglected. Record review of the facility's Resident Abuse and Neglect Policy 2021, indicated, .All new and existing team members·receive periodic in-service training relative to resident rights and our Facility's abuse prevention program policies and procedures 1. Associates are required to attend our Facility's resident rights and abuse prevention program and dementia management (communication & caring for the cognitively Impaired) in-service training sessions before having any resident contact .

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 3 residents (Resident #8, Resident #22, and Resident #15) reviewed for pharmacy services. The facility failed to ensure MA V accurately reconciled Resident #8's narcotic medication log when she administered Resident #8's morphine (controlled medication used for pain) tablet on 10/15/24. The facility failed to ensure MA V accurately reconciled Resident #22's narcotic medication log when she administered Resident 22's pregabalin (controlled medication used to treat pain caused by nerve damage) tablet on 10/15/24. The facility failed to ensure LVN W accurately reconciled Resident #15's narcotic medication log when she administered Resident #15's Norco (controlled medication used for pain) tablet on 10/15/24. These failures could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: 1. Record review of Resident #8's face sheet dated 10/17/24, indicated Resident #8 admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), depression (persistent feeling of sadness and loss of interest), essential hypertension (high blood pressure), sciatica (pain radiating along the sciatic nerve, which runs down one or both legs from the lower back), and chronic obstructive pulmonary disease (a chronic lung disease that limits airflow and causes ongoing respiratory symptoms). Record review of Resident #8's admission MDS assessment dated [DATE], indicated Resident #8 was able to make herself understood and usually understood others. The MDS assessment indicated Resident #8 had a BIMS score of 11, indicating her cognition was moderately impaired. The MDS assessment indicated Resident #8 received scheduled pain medication and had received an opioid (narcotic) medication within the 7-day look back period. Record review of Resident #8's comprehensive care plan revised on 09/10/24, indicated Resident #8 had the potential for pain related to sciatica left side and history of angina pectoris (chest pain). The care plan interventions to anticipate the resident's need for pain relief and respond immediately to any complaints of pain. Record review of Resident #8's order summary report dated 10/17/24, indicated she had an order for Morphine Sulfate ER 15mg give one tablet by mouth two times a day for pain with an order start date of 08/20/24. Record review of Resident #8's medication administration record for 10/01/24-10/31/24, indicated Resident #8 received morphine sulfate 15mg twice a day. During an observation on 10/15/24 at 09:01 AM, MA V prepared Resident #8's morning medications. MA V opened the narcotic box located on the medication cart and removed one tablet of morphine 15mg from the medication card and added it to the rest of Resident #8's morning medications. MA V proceeded to administer Resident #8's medications. MA V failed to document the administration of the morphine tablet on Resident #8's narcotic record. 2. Record review of Resident #22's face sheet date 10/17/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included left femur fracture, bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (persistent feeling of sadness and loss of interest), fibromyalgia (long-term condition that involves widespread body pain and tiredness), and osteoarthritis (occurs when flexible tissue at the ends of the bones wears down). Record review of Resident #22's admission MDS assessment dated [DATE], indicate Resident #22 was able to make herself understood and understood others. The MDS assessment indicated Resident #22 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #22 received scheduled pain medication. Record review of Resident #22's comprehensive care plan revised 10/08/24, indicated Resident #22 had a potential for pain related to fibromyalgia, left femur fracture, osteoarthritis of bilateral knees, and chronic pain syndrome. The care plan interventions included to anticipate the residents need for pain relief and respond immediately to any complaint of pain. Record review of Resident #22's order summary report dated 10/17/24, indicated Resident #22 had an order for pregabalin 100mg give one capsule by mouth three times a day for pain with a start date of 09/21/24. Record review of Resident #22's medication administration record dated 10/01/24-10/31/24, indicated Resident #22 received pregabalin morning, midday and at bedtime. During an observation on 10/15/24 at 09:36 AM, MA V prepared Resident #22's morning medications. MA V opened the narcotic box located on the medication cart and removed one tablet of pregabalin 100mg from the medication card and added it to the rest of Resident #22's morning medications. MA V proceeded to administer Resident #22's medications. MA V failed to document the administration of the pregabalin tablet on Resident #22's narcotic record. During an interview on 10/15/24 at 3:30 PM, MA V said she was responsible for documenting on the resident's narcotic record when a narcotic medication was administered but had not since the surveyor was observing the medication pass. MA V said was going to sign off when she completed the medication pass with the surveyor. MA V said not documenting the narcotic medication was administered could cause a discrepancy or a medication error, since someone will not know the resident had already received the narcotic medication. 3. Record review of Resident #15's face sheet dated 10/17/24, indicated an [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (a chronic lung disease that limits airflow and causes ongoing respiratory symptoms), malignant neoplasm of prostate (prostate cancer), and dementia (memory loss). Record review of Resident #15's quarterly MDS assessment dated [DATE], indicated Resident #15 was able to make himself understood and usually understood others. The MDS assessment Resident #14 had a BIMS score of 14, indicating his cognition was intact. The MDS assessment indicated Resident #15 received scheduled pain medication and PRN pain medications during the 5-day look back period. Record review of Resident #15's comprehensive care plan dated 05/17/24, indicated Resident #15 had the potential for pain related to fracture of right humerus (upper arm fracture) and diabetic neuropathy (nerve damage that occurs with diabetes. The care plan interventions indicted to evaluate the effectiveness of pain interventions. Record review of Resident #15's nursing medication administrator record for 10/01/24-10/31/24, indicated Resident #15 had an order for Norco 10-325mg tablet give one tablet every 6 hours as needed for pain with a start date of 07/24/25. During an observation and interview on 10/15/24 at 3:38 PM, this surveyor performed a random controlled drug count with LVN W of the 300-400 hall nurses' cart. During the drug count LVN W said Resident #15 had 16 tablets of Norco 10/325 mg remaining in the medication card. Surveyor observed 15 tablets of Norco 10/325mg remaining in the medication card. LVN W said she had administered Resident #15 a Norco tablet before lunch. LVN W said she should have signed off on the narcotic record when she administered the Norco tablet to Resident #15, but she was busy with other residents and did not. LVN W said not documenting the Norco being administered to Resident #15 placed Resident #15 at risk for his medication count to be off and could cause a medication error since someone else would not have known he had already received the medication. LVN W said the nurse that administered the narcotic medication was responsible for ensuring the appropriate documentation was completed when administering a narcotic medication. During an interview on 10/17/24 at 11:42 AM, the DON said she expected when narcotic medications were administered the narcotic record should be signed off as soon as the medication was removed from the medication card to ensure the count remained accurate. The DON said by not signing off on the narcotic record mistakes can happen, drug diversion or a medication error. The DON said the person administering the medications was responsible for documenting when a narcotic medication was administered and removed from the narcotic card. During an interview on 10/17/24 at 11:45 AM, the Administrator said when narcotic medications were administered the narcotic record should be signed off for medication accountability. The Administrator said by not signing off the narcotic record when narcotic medications were administered mistakes could happen. The Administrator said there was a risk for drug diversion and medication error as medications could be given again. The Administrator said the licensed person administering the narcotic medication was responsible for documenting it as administered on the narcotic log. Record review of the facility's policy Controlled Substances revised April 2019 indicated . 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift 10. Upon administration a. the nurse administering the medication is responsible for recording: 1. Name of the resident receiving the medication; 2. Name, strength, and dose of medication; 3. Time of administration; 4. Method administration; 5. Quantity of the medication remaining; and 6. Signature of nurse administering medication .

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

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 that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 18.75%, based on 12 errors out of 64 opportunities, which involved 2 of 7 residents (Resident #18 and Resident #57) reviewed for medication administration. The facility failed to ensure LVN W administered Resident #57's scheduled morning medications as prescribed on 10/15/24. The facility failed to ensure MA X administered Resident #18's multivitamin with minerals and Reglan as prescribed on 10/15/24. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #57's face sheet dated 10/17/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), essential hypertension (high blood pressure), congestive heart failure (heart does not pump blood as well as it should), gastrostomy status (surgical opening into the stomach for nutritional support and medication administration), and dysphagia (difficulty swallowing). Record review of Resident #57's quarterly MDS assessment dated [DATE], indicated Resident #57 was rarely/never understood and usually understood others. The MDS assessment indicated Resident #57 had short term and long-term memory problems. The MDS assessment indicated Resident #57 was dependent on staff with eating, oral hygiene, toileting, personal hygiene, and showers. The MDS assessment indicated Resident #57 had a feeding tube. The MDS assessment indicated Resident #57 received anticoagulant and antiplatelet medications within the 7-day look back period. Record review of Resident #57's comprehensive care plan revised on 05/17/24, indicated Resident had a cerebral vascular accident affecting mobility, speech and cognition. The care plan interventions included to give medications as ordered by the physician. Record review of Resident #57's order summary report dated 10/17/24, indicated he had the following orders: *Nothing by mouth (NPO) diet with an order start date of 05/22/24. *Do not cocktail medications (do not mix all medications together and administer) with an order start date of 05/22/24. *Flush tube with 30 mls before and after meds every shift for enteral feedings with an order start date of 05/22/24. *May crush or open medications and mix each medication with 5mls of water. Give 5-10 mls water between each medication every shift for enteral administration with a start date of 05/22/24. *Amiodarone 400mg give one tablet via g-tube two times a day for abnormal heart rhythm with an order start date of 05/22/24. *Apixaban 5mg give one tablet via g-tube two times a day for anticoagulant (blood thinner) with an order start date of 05/22/24. *Aspirin 81mg give one tablet via g-tube two times a day for anticoagulant with an order start date of 05/22/24. *Entresto 24-26mg give one tablet via g-tube two times day for chronic heart failure hold if SBP less than 110 or DBP less than 60 with an order start date of 07/25/24. *Lipitor 40mg give one tablet via g-tube one time a day for hyperlipidemia (high cholesterol) with an order start date of 05/23/24. *Metoprolol tartrate 25mg give one tablet via g-tube two times a day for hypertension (high blood pressure) with an order start date of 05/22/24. *Montekulast 10mg give one tablet via g-tube one time a day for asthma with an order start date of 05/23/24. *Multivitamin with minerals give one table via g-tube one time a day for supplement with an order start date of 05/23/24. *Thiamine 100mg give one tablet via g-tube one time a day for supplement with an order start date of 05/23/24, *Vitamin C oral liquid give 500mg via g-tube in the morning for supplement 5mls equal 500mg with an order start date of 06/13/24. Record review of Resident #57's nursing medication administration record for 10/01/24-10/31/24, indicated Resident #57 was scheduled to receive Aspirin 81mg one tablet, Lipitor 40mg one tablet, montelukast 10mg tablet, multiple vitamin with minerals one tablet, thiamine 100mg one tablet, vitamin C 500mg, amiodarone 5 mg tablet, apixaban 5 mg one tablet, entresto 24-25mg one tablet, and metoprolol 25mg one tablet via g-tube. The record indicated to not cocktail Resident #57's medications and to flush tube with 30mls of water before and after medications every shift. The nursing administration record indicated to not cocktail medications every shift. The nursing administration record also indicated may crush or open medications and mix each medication with 5mls of water and to give 5-10mls of water between the administration of each medication every shift. During an observation of medication administration and an interview on 10/15/24 at 11:05 AM, LVN W obtained Resident #57's following medications: Vitamin C 500mg tablet, multivitamin tablet, thiamin 100mg tablet, aspirin 81 tablet, amiodarone 400mg tablet, metoprolol 25mg tablet, montekulast 10mg tablet, atorvastatin tablet and crushed all medications together in a pill crusher pouch. LVN W said she was not placing the entresto 24-26mg tablet or the Eliquis 5mg tablet until she obtained Resident #57's blood pressure (Eliquis does not require a blood pressure reading for administration). LVN W obtained Resident #57's blood pressure with readings of 87/48 and pulse of 63. LVN W said she was not administering the Entresto tablet or the Eliquis tablet because Resident #57's blood pressure was low. LVN W and LVN Z applied PPE and entered Resident #57's room. LVN W had the pill crusher pouch with the crushed medications inside in her hand. LVN W obtained a 60 mls syringe, attached it to Resident #57's enteral feeding tube, and checked for residual by pulling back on the syringe. No residual noted. LVN W did not confirm placement via auscultation as ordered by the physician. LVN W then used the syringe and obtained over 60mls of water and flushed Resident #57's gastrostomy tube. LVN W then removed the stopper from the syringe, placed her pointer finger on the tip of the syringe, and poured the crushed medications from the pouch into the syringe. LVN W then applied the stopper to the top of the syringe, turned the syringe upside down, then inverted it into a cup with water, and added approximately 50mls of water into the syringe. LVN W then mixed the medications in the syringe by shaking it. LVN W was in the process of applying the syringe with medications to Resident #57's gastrotomy tube to administer them, when surveyor intervened before the medications were administered. LVN W said she did not remember if she could cocktail Resident #57's medications, but that was what she had been doing. LVN W said she had not checked placement by auscultation as ordered because she had done it that morning. LVN W said she should not have crushed Resident #57's metoprolol tablet with his medications since it was a blood pressure medication and Resident #57's blood pressure was low. LVN W said if she had administered the blood pressure medication Resident #57 was at risk for bis blood pressure bottoming out. LVN W said she did not place the Eliquis tablet in Resident #57's medications because she thought it was for his blood pressure. LVN W said failure to administer the Eliquis placed Resident #57 at risk of having a blood clot since Eliquis was a blood thinner. LVN W said she was responsible for ensuring medications were being administered as ordered by the physician. LVN W said by cocktailing medications Resident #57 was at risk for an adverse reaction. LVN W said by not checking placement as ordered, Resident #57 was at risk for his gastrostomy tube to be out of place. LVN W said she had been checked off on medication administration via the gastrostomy tube. LVN Z said the metoprolol, Entresto and amiodarone were the medications that should have been held and all should have had blood pressure parameters. 2. Record review of Resident #18's face sheet dated 10/17/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), gastritis (inflammation of the stomach lining), ulcerative colitis (inflammatory bowel disease that causes inflammation and ulcers in the colon and rectum), gastro-esophageal reflux disease (chronic acid reflux in the esophagus) and protein-calorie malnutrition (not enough protein and calories in diet). Record review of Resident #18's quarterly MDS assessment dated [DATE], indicated Resident #18 was able to make herself understood and understood others. The MDS assessment Resident #18 had a BIMS score of 11, indicating her cognition was moderately impaired. Record review of Resident #18's comprehensive care plan dated 09/03/24, indicated Resident #18 had GERD with the potential for heartburn and reflux. The care plan interventions included to give medications as ordered. Record review of Resident #18's order summary report dated 10/17/24, indicated Resident #18 had the following orders: *Multiple vitamin-minerals give one tablet by mouth one time a day for supplement with an order start date of 07/25/24. *Reglan 5mg tablet give 5mg by mouth before meals related to nausea with vomiting with an order start date of 07/18/24. Record review of Resident #18's medication administration record for 10/01/24-10/31/24, indicated Resident #18 was to receive multiple vitamin with minerals one tablet between 6a-10a and Reglan 5mg one tablet before meals at 07:00 AM, 11:30 AM, and 4:30 PM. During an observation of medication administration on 10/15/24 at 10/15/24 at 08:36 AM, MA X administered the following medications to Resident #18: *Losartan 100mg- 1 tablet *Carvedilol 6.25mg- 1 tablet *B-complex plus vitamin C- 1 tablet *Eliquis 5mg- 1 tablet *Fluticasone 50mcg- 2 sprays in each nostril *Multivitamin- 1 tablet *Hydrochlorothiazide 12.5mg- 1 tablet *MiraLAX 17gms *Active liquid protein- 30mls *methocarbamol 500mg- 1 tablet *Reglan 5mg- 1 tablet Review of medication reconciliation on 10/16/24 revealed Resident #18 had physician's orders for multivitamin with minerals by mouth daily. MA X failed to administer the ordered multivitamin with minerals as she administered a multivitamin tablet. Resident #18 also had an order for Reglan 5mg one tablet before meals and was scheduled for 07:00 AM. MA X failed to administered Resident #18's ordered Reglan before meals as ordered by the physician and within the one hour before and one hour after the prescribed time frame since medication was administered at 08:36 AM, 36 minutes late. During an observation and interview on 10/16/24 at 11:57 AM, MA X opened the 100-200 hall medication cart and took out the multivitamin bottle. MA X said the multi-vitamin with minerals bottle was not on the medication cart. MA X said Resident #18 should have received the multivitamin with minerals tablet as prescribed by the physician. MA X said they had an hour before and an hour after the prescribed time frame to administer a medication. MA X said Resident #18's Reglan was given over an hour from the prescribed time frame. MA X said if the medication was ordered before meals, then it should have been given before meals. MA X said it was necessary to administer the medication before meals because administering it after meals could cause the medication not to work as well. MA X said she was responsible for ensuring medications were being administered as ordered. MA X said she had been checked off on medication administration competency. During an interview on 10/16/24 at 4:28 PM, the DON said she did not have a medication administration via the gastrostomy tube competency skills check off for LVN W or medication administration competency skills check off for MA X. During an interview on 10/17/24 at 11:32 AM, the DON said when peg tube medications were being administered, peg tube placement should be checked via auscultation and residual. The DON said medications should not be cocktailed because it could cause harm or cause a change in condition to the resident. The DON said medications should be crushed individually and mixed with 5-10mls of water. The DON said Resident #57's blood pressure should have been assessed prior to preparing the medications. The DON said if a resident's blood pressure was low, then the blood pressure medications should be held. The DON said LVN W should have prepared the Eliquis to have been administered as it was an anticoagulant medication and not a blood pressure medication. The DON said LVN W was responsible for ensuring medications via the gastrostomy tube were administered as ordered by the physician. The DON said if Resident #57's received his blood pressure medication with his blood pressure being low he was at risk for his blood pressure to drop. The DON said by not checking placement as ordered Resident #57's peg tube could be out of place. The DON said she expected MA X to have administered Resident #18's medications as ordered by the physician. The DON said failure to administer the medications as ordered, placed the resident at risk for medications not to work effectively. The DON said MA X was responsible for ensuring medications were administered as ordered. The DON said competencies should be completed annually and since MA X and LVN W did not have the required competencies mistakes could happen. The DON said she was responsible for ensuring staff was competent in providing the required care to the residents. During an interview on 10/17/24 at 11:36 AM, the Administrator said he expected LVN W and MA X to administer medications as per the physician orders. The Administrator said the nurses should follow best practice and what they have been trained to do. The Administrator said by not administering medications as ordered there was a potential for harm or change in condition. The Administrator said the licensed individual administering the medications was responsible for ensuring the mediations were administered as ordered. Record review of the facility's policy Administering Medications through an Enteral Tube revised November 2018, indicated . The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. Preparation.1. Verify that there is a physician's medication order for this procedure . Follow the medication administration guidelines in policy entitled Administering Medications . 3. Administer each medication separately and flush between medications . Steps in the procedure . 3. Prepare the medication: a. check the label and confirm the medication name and dose with the MAR . 6. Verify placement of feeding tube . 9. Dilute medication: a remove plunger from syringe. Add medication and appropriate amount of water to dilute. b. dilute crushed (powdered) medication with at least 30mls of purified water (or prescribed amount) . 10. Administer each medication separately . 12. Administer medication by gravity flow . 13. If administering more than one mediation, flush with 15mls warm water (or prescribed amount) between medications. Record review of the facility's policy Administering Medications revised April 2019 indicated . Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders, including any required time frame . 7. Medications are administered within 1 hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 11. The following information is checked/verified for each resident prior to administering medications .b. Vital signs, if necessary .

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 23 residents (Resident's #6, #14, and #39) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #6, Resident #14, and Resident #39, who complained the food was served cold, was bland, and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: During an interview on 10/14/2024 at 3:03 p.m., Resident #14 stated the food was okay, but it was too cold most of the time. During an interview on 10/14/2024 at 3:25 p.m., Resident #6 stated the food had no taste and was overcooked most of the time. During an interview on 10/14/2024 at 3:36 p.m., Resident #39 stated the food was not good, very bland. During an observation and interview on 10/15/2024 at 1:03 p.m., a lunch tray was sampled by [NAME] U and four surveyors. The sample tray consisted of beef stew, which was bland but hot, lettuce which was warm, and carrot cake that was bland. [NAME] U agreed that the food was bland, and the lettuce was warm. During an interview on 10/15/2024 at 2:15 p.m., [NAME] U stated she had just started working at the facility two weeks ago. [NAME] U stated she was responsible for ensuring the food was appropriate temperature and tasted good. [NAME] U stated it was important to ensure food was served at the appropriate temperature and tasted good, so the residents enjoyed eating it and the food did not make them sick. During an observation and interview on 10/16/2024 at 12:57 p.m., a lunch tray was sampled by the Dietary Manager and four surveyors. The sample tray consisted of rotisserie chicken, which was dry, yellow squash, which was bland, steamed rice, which was bland and over cooked, fruit crisp. The Dietary Manager agreed the food was bland and stated she adds seasoning packets on the trays. The Dietary Manager it was hard to please everyone with as many different diets the residents were on. During an interview on 10/16/2024 at 2:30 p.m., the Dietary Manager stated she had received food complaints. The Dietary Manager stated she expected the food to have been served at the appropriate temperatures, looked good, and tasted good. The Dietary Manager stated it was important to ensure the food was served at the correct temperature, looked good, and tasted good so the food did not make the residents sick and so they would not lose weight. During an interview on 10/17/2024 at 10:35 a.m., the Administrator stated he has a test tray about once a week, and they have been bland. The Administrator stated he expected dietary staff to ensure food was served at appropriate temperatures and was appetizing. The Administrator stated it was important to ensure food was served at correct temperatures, looked good, and tasted good so the residents would eat it and get the proper nutrition. The Administrator stated he would monitor by getting a test tray three days a week and making daily rounds. Record review of the policy Test Tray, dated 10/01/2018, revealed .The facility recognized the importance of routine quality assurance monitoring to ensure that its residents are provided food that is appealing, palatable and served at the correct temperature

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure hair restraints were worn appropriately by dietary staff. 2. The facility failed to ensure the dishwasher was in correct temperature range of 120 during wash cycle. 3. The facility failed to ensure chemical test strips were used for dishwasher. These failures could place residents at risk for foodborne illness. Findings include: During an observation in the kitchen on 10/14/2024 at 10:20 a.m., revealed [NAME] U was not wearing a hair restraint appropriately while preparing the lunch meal. [NAME] U's hair was visible outside of the hairnet in the back approximately four inches. During an observation in the kitchen on 10/14/2024 at 10:28 a.m., revealed dietary aide S was not wearing a hair restraint appropriately while preparing the lunch meal. Dietary aide S's hair was visible outside of the hairnet in the back approximately three to four inches. During an observation in the kitchen on 10/14/2024 at 10:30 a.m., revealed dishwasher temperature to be 115 during wash cycle and dietary aide S could not find correct chlorine test strips for the dishwasher. During an interview on 10/14/2024 at 11:15 a.m., Dietary aide S stated she did not realize she had hair uncovered. Dietary aide S stated it was important to cover your hair to keep it out of the food. Dietary aide S stated the harm to the resident was they would not want to eat food that had hair in it and lose weight. Dietary aide S stated the temperature for the dishwasher should be above 120 and it was 115. Dietary aide S stated it was important for the dishwasher to be at the correct temperature to sanitize the dishes. Dietary aide stated she uses test strips to check the dishwasher sanitation. Dietary aide S stated if the dishwasher was not at the right temperature residents could get sick. During an interview on 10/14/2024 at 11:45 a.m. the Maintenance Employee T stated the dishwasher was a low temp machine and the temperature should be at 120 during the wash cycle. Maintenance Employee T stated it was important for the dishwasher to be at 120F to kill bacteria. Maintenance Employee T stated the harm was resident could become sick from food borne illnesses. During an interview on 10/14/2024 at 1:15 p.m., [NAME] U stated she did not realize her hair was not covered. [NAME] U stated it was important to wear hairnets correctly to keep hair out of the food. [NAME] U stated the residents would not enjoy eating food with hair in it. During an interview on 10/16/2024 at 2:30 p.m., the Dietary Manager stated she expects staff to keep all hair covered. The Dietary Manager stated hairnets were important to ensure no hair got into the food. The Dietary Manager stated if hair was in the food the residents may not want to eat. The Dietary Manager stated she had shown the dietary staff several times where the test strips were and how to use them. The Dietary Manager stated it was important to make sure the dishes were sanitized to prevent cross contamination. During an interview on 10/17/2024 at 10:35 a.m., the Administrator stated he expected the dishwasher to reach the correct temperature for sanitation and the dietary staff to use the correct chlorine test strip. The Administrator stated it was important to monitor the temperature to verify the correct sanitation. The Administrator stated he would monitor by making daily rounds. Record review of the facility's policy Mechanical Cleaning and Sanitation of Utensils, dated 10/01/2018, revealed If a machine that uses chemicals for sanitizing is in use, follow the guidelines .The temperature of the wash water must be at least 120 F A test kit or other devices that accurately measure the parts per million concentration of the solution must be available and used

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Resident #43 and Resident #176) and 2 of 4 clean linen carts (Hall 300 and Hall 400 clean linen carts) in the facility reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure the MDS Coordinator applied PPE prior to flushing Resident #176's PICC line on 10/16/2024 2. The facility failed to ensure CNA M changed her gloves and performed hand hygiene and did not touch the wipes container with dirty gloves while providing incontinent care to Resident #43 on 10/14/2024. 3. The facility failed to ensure Hospice Aide L did not carry unbagged, dirty linen in her hand down the hall on 10/16/2024. 4. The facility failed to ensure CNA K did not leave a bag with trash and an unbagged bed pad on the floor in Resident #43's room after providing incontinent care on 10/16/2024. 5. The facility failed to ensure the clean linen carts on Hall 300 and Hall 400 were covered. These failures could place residents at risk for cross-contamination and the spread of infection. Findings included: 1. Record review of Resident #176's face sheet dated 10/17/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (a brain dysfunction caused by various disease toxins in the body), essential hypertension (high blood pressure), pneumonia (lung infection), and chronic obstructive pulmonary disease (lung condition caused by damage to the airways that limit airflow). Record review of Resident #176's admission MDS assessment dated [DATE], indicated Resident #176 was able to make herself understood and understood others. The MDS assessment indicated Resident #176 had a BIMS score of 11, indicating her cognition was moderately impaired. The MDS assessment indicated Resident #176 received IV medications and had an IV access on admission and while a resident at the facility. The MDS assessment indicated Resident #176 had a PICC line on admission. Record review of Resident #176's comprehensive care plan dated 10/08/24, indicated Resident #176 was on antibiotic therapy related to UTI, CRE (carbapenem-resistant enterobacterales, bacteria that is resistant to most antibiotics) noted in urinalysis. The care plan interventions included to administer antibiotic medications as ordered by the physician. Record review of Resident #176's comprehensive care plan dated 10/09/24, indicated Resident #176 was on enhanced barrier precautions (EBP) related to risk for MDRO due to indwelling medical device PICC line. The care plan interventions included for enhanced barrier precautions to be utilized during ADLs but not limited to: dressing, bathing, transferring, providing hygiene, changing linens/briefs or when toileting, care of indwelling medical device and wound care of chronic wounds. Record review of Resident #176's order summary report dated 10/17/24, indicated Resident #176 had an order for normal saline flush use 10mls IV every 8 hours for PICC line with an order start date of 10/01/24. Resident #176 also had an order for contact isolation precautions strict isolation required in which all care, therapy, dining, and other services were provided in private room related to an active infection. Record review for Resident #176's nursing medication administration record for 10/01/24-10/31/24, indicated Resident #176 had been receiving 10mls of normal saline flushes to her PICC line 3 times a day. During an observation and interview on 10/16/24 at 4:28 PM, the MDS Coordinator entered Resident #176's room to flush her PICC line. The MDS Coordinator did not apply PPE before entering Resident #176's room. The MDS Coordinator said she should have worn PPE before she went inside Resident #176's room and provided care due to Resident #176 being on contact precautions. The MDS Coordinator said by not applying PPE prior to providing care placed her at risk for getting blood spilled on her and was an infection control issue. The MDS Coordinator said it was her responsibility to ensure PPE was worn when providing care to residents that were on isolation. During an interview on 10/17/24 at 11:16 AM, the ADON said she expected the MDS Coordinator to have worn PPE prior to flushing Resident #176's PICC line to ensure she did not get anything around the PICC line. The ADON said failure to not use PPE was an infection control issue and the nurse was responsible for ensuring PPE was worn when providing care. During an interview on 10/17/24 at 11:46 AM, the DON said she expected her staff to wear PPE when providing care to a resident who was contact isolation. The DON said by the staff not wearing the appropriate PPE when providing care placed the residents at risk for spread of infection. The DON said everyone that provided care to a resident on isolation was responsible for ensuring PPE was worn. During an interview on 10/17/24 at 11:49 AM, the Administrator said he expected the staff to wear PPE when providing care to a resident on isolation. The Administrator said by not using PPE there was a potential to spread infection. The Administrator said everyone providing care to a resident on isolation was responsible for ensuring PPE was worn. 2. Record review of a face sheet dated 10/15/2024 indicated Resident #43 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side (right sided weakness and paralysis after unspecified disease affecting the brain) and chronic respiratory failure (condition where the lungs cannot supply enough oxygen or remove enough carbon dioxide from the blood). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #43 was able to make herself understood and understood others. The MDS assessment indicated Resident #43 had a BIMS score of 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #43 required partial/moderate assistance for toileting, bathing, and personal hygiene. The MDS assessment indicated Resident #43 received oxygen therapy while a resident at the facility. Record review of Resident #43's care plan date initiated 07/06/2024 indicated she had an ADL self-care performance deficit related to a stroke with right sided weakness. Resident #43's care plan indicated she required assistance of one staff member for personal hygiene and toilet use. Resident #43's care plan indicated the resident had the potential for bowel incontinence related to decreased mobility to provide peri care after each incontinent episode. During an observation on 10/14/2024 starting at 11:15 PM, CNA M provided incontinent care to Resident #43. CNA M applied gloves and removed Resident #43's brief. CNA M placed the packet of wipes on Resident #43's bed. CNA M wiped Resident #43's front peri area and then turned her on her side. CNA M removed the dirty brief and disposed of it. CNA M touched the wipes container with her dirty gloves and removed more wipes from the wipes container. CNA M wiped Resident #43's buttocks. CNA M grabbed the clean brief with her dirty gloves. CNA M failed to change gloves and perform hand hygiene prior to touching the clean brief and applying it. CNA M applied the clean brief and clen bed pad. CNA M applied cream to Resident #43's buttocks with one hand. CNA M then removed the glove that she had applied the cream on Resident #43's buttock and kept the other glove on. CNA M finished fastening the clean brief with one dirty, gloved hand and repositioned Resident #43 in the bed. CNA M touched Resident #43's remote with her dirty glove and opened the drawers to her nightstand. CNA M placed the packet of wipes on top of Resident #43's nightstand. CNA M then gathered the dirty linens and trash to exit the room. CNA M removed her other glove and disposed of it. CNA M took the dirty linens, trash, and the wipes container and exited the room. CNA M returned the wipes container to the linen cart in the hallway and disposed of the dirty linen and trash and performed hand hygiene. CNA M said gloves should be changed and hand hygiene performed after removing the dirty brief and before applying the clean brief. CNA M said she should not have repositioned Resident #43 and touched her nightstand and wipes container with her dirty gloves. CNA M said she was in a hurry and that was why she had not performed appropriate glove changes and hand hygiene. CNA M said she was not sure what the correct way to use the wipes was. CNA M said she had asked other staff at the facility how she should take the wipes into the room and had not received a clear response. CNA M said taking the wipes container into the room and placing it on the bed and on the nightstand and then returning it to the linen cart was a risk for cross contamination. CNA M said not performing hand hygiene and glove changes during incontinent care placed the residents at risk for urinary tract infections. During an observation on 10/16/2024 at 1:42 PM, Hospice Aide L was observed walking to the end of the hall wearing gloves, in one hand she was carrying a bed pad with sheets rolled up in the middle. Hospice Aide L disposed of the dirty linens in the dirty linen closet at the end of the hall. Hospice Aide L said the bed pad and sheets she was carrying were dirty, and they should have been carried down the hall in a bag. Hospice Aide L said she did not have any bags in the room where she provided care. Hospice Aide L said dirty linens should be carried in a bag to prevent cross contamination and for infection control. During an observation and interview on 10/16/2024 at 1:55 PM, there was a clear bag with dirty wipes and a dirty brief in it on top of a bed pad on the floor in the entry to Resident #43's room. Resident #43 said she did not know it had been left there that she was changed after lunch. CNA K said she had left the trash and bed pad there because there were lunch trays on the hall when she changed Resident #43. CNA K said the bed pad was used to place under Resident #43 while she provided incontinent care, but it was not wet and that was why she did not bag it. CNA K said the trash and linens should not be left on the floor in the residents' rooms because it was gross. During an interview on 10/17/2024 at 12:19 PM, the DON said during incontinent care the CNAs should ensure they used proper incontinent care and infection control standards. The DON said gloves should be changed and hand hygiene performed when touching the dirty and then touching the clean. The DON said it was important for incontinent care to be performed appropriately, gloves to be changed and hand hygiene performed during incontinent care to prevent urinary tract infections. The DON said wipes should either be pulled and placed in a clean container or bag prior to entering the resident's room and the container or bag taken into the resident's room or the wipes container taken into the room and left in the room. The DON said it was important not to take the wipes container into the resident's room and then take it out of the room because of cross contamination and for infection control. The DON said the dirty linen should be bagged prior to leaving the room. The DON said after incontinent care the trash and dirty linen should be disposed of properly, not left in the resident's room. The DON said it was important for the dirty linen to be bagged and disposed of and for the trash to be disposed of for infection control and to prevent cross contamination. The DON said she tried to pop in and observe the CNAs provide incontinent care at least once a week. During an interview on 10/17/2024 at 12:50 PM, the Administrator said he expected for the staff to follow the policies and procedures they were trained on. The Administrator said the nursing department was responsible for ensuring the CNAs performed proper incontinent care and disposed of linens and trash properly. The Administrator said it was important for the infection control policies and procedures to be followed to decrease the risk of infection. 3. During an observation on 10/14/2024 at 10:30 p.m., a clean linen cart was on hall 400 with the cover open. During an observation on 10/14/2024 at 10:50 p.m., a clean linen cart was on hall 300 with cover was open. During an interview on 10/14/2024 at 10:40 p.m., CNA O stated the clean linen cart cover should be closed. CNA O stated it was important to keep the cover closed so the clean linens would not get contaminated. CNA O stated the failure would be the residents could get rashes or urinary tract infection if the linens became contaminated. During an interview on10/14/2024 at 10:55 p.m., CNA M stated the clean linen cart cover should be closed. CNA M stated it was important to keep the cover closed to prevent the residents from getting things from the cart. CNA M stated the failure would be if the residents touch the clean linens, it could cause infections. During an interview on 10/14/2024 at 11:06 p.m., RN Q stated the clean linen cart cover should be closed. RN Q stated the CNAs were responsible for closing the cover when they are done. RN Q stated the charge nurse was responsible for making sure the CNAs do their jobs. RN Q stated it was important to keep the cover closed for infection control. RN Q stated the failure was the linens could become soiled. During an interview on 10/17/2024 at 10:07 a.m., the DON stated she expected the staff to close the cover to the clean linen cart when not being used because that was part of infection control. The DON stated it was important to keep the cover closed for infection control. The DON stated there could be potential harm to the residents. The DON stated she would monitor by in-service and making rounds. During an interview on 10/17/2024 at 10:35 a.m., the Administrator stated he expected the staff to close the clean linen cart cover when not in use. The Administrator stated it was important to close the cover, so the clean linens did not get debris on them. The Administrator stated he would assume there was no harm to the resident by leaving the cover to the clean linens open. The Administrator stated he would monitor by making rounds. Record review of the policy Linens, undated, revealed .Staff members will follow the community's protocols for handling linens, and linens will be processed, transported, stored, and handled properly. Record review of the facility's policy Administering Medications revised April 2019 indicated . Medications are administered in a safe and timely manner, and as prescribed . 25. Staff follows established community infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Record review of the facility's policy Isolation-Categories of Transmission-Based Precautions revised October 2018, indicated . Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents .Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the residents environment . 4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room . 5. Staff and visitors will wear disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed . During an interview on 10/17/2024 at 1:31 PM, the policy for incontinent care was requested and the Regional Compliance Nurse provided the policy titled, Basic Standards for Clinical Procedures, last revised July 2017. The policy indicated, Appropriate care is taken to put forth the resident's right to privacy and dignity, as well as the resident's health and safety are protected during the performance of any clinical care or procedure . j. Apply appropriate Personal Protective Equipment (gloves, gown, mask, etc.) as required by the procedure . c. Based upon the type of procedure and work surface: Clean and sanitize the resident's the area as needed and discard any used supplies. Remove any equipment and clean as appropriate. d. Remove soiled linens and place in an appropriate receptacle. e. Remove personal protective equipment and discard appropriately .

Sept 2024 2 deficiencies 2 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · 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 ensure residents were free from abuse for 1 of 7 residents (Resident #1) reviewed for resident abuse. 1.The facility failed to ensure Resident # 1, was free from physical abuse on 04/03/2024, when CNA A used excessive rubbing force across Resident #1's chest while providing a shower which resulted in a 5 cm superficial laceration (cut or tear in the skin) across her chest at the level of the 2-3rd rib with surrounding ecchymosis (bruising), tenderness, and closed fractures of the 2nd and 3rd rib. 2.The facility failed to protect Resident #1 by not ensuring CNA A did not continue to provide care to Resident #1 after the shower room incident on 04/03/2024. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 04/03/2024 and ended on 04/04/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress. The findings included: Record review of a face sheet dated 09/20/2024 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), contracture of muscle of the left and right forearm, muscle weakness, dependence of a wheelchair, rheumatoid arthritis of hands (chronic swelling of the small joints), speech and language deficits following cerebrovascular disease (weakness on one side of the body). Record review of the quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 12, which indicated mild cognitive deficit. Resident #1 required maximum assistance for ADLs such as toileting, showering and dressing. Record review of a care plan revised on 11/09/2023 titled ADL assistance indicated Resident #1 had an ADL self-deficit and required maximum assistance with dressing, toileting and showering. The interventions for Resident #1 included: Transfer - The resident required mechanical lift - Hoyer Lift with 2 staff assistance for transfers. Record review of Incident Report dated 04/03/2024 indicated Resident #1 experienced a 1.5 x 1.5 x .5 cm laceration across her chest while in the shower room on 04/03/2024. Record review of the hospital Encounter Summary for Resident #1 dated 04/04/2024 documented the Final Diagnosis: abrasion to skin, closed fracture of multiple ribs of right side, assault. Assessment: 5 cm linear (a line) superficial laceration across anterior chest at level of 2-3rd rib. Piece of skin separated down middle of laceration, attached to right side of laceration, no jagged edges. Surrounding ecchymosis (discoloration of the skin resulting from bleeding underneath, typically caused by bruising) and tenderness. Medical Decision Making: [AGE] year-old female presents with primary history of cerebrovascular accident with residual left sided deficits (wheelchair bound at baseline) who suffered unfortunate traumatic skin tears to her chest yesterday evening at the hands of her CNA. The CNA is new, currently training, and seemingly became too aggressive while giving the patient a bath. Per patient, bath water was too hot, and she was scrubbing her too aggressively. Skin tear to middle chest noted. Chest X-Ray suggestive of Right sided rib fracture. Will clean skin tear thoroughly and apply dermabond. (skin adhesive). Of greater concern is the possibility of elder abuse. Patient and [family member] would like to discharge. Medically ready, just waiting on Social Worker for assault case. [family member] and patient would like to leave and will file report outpatient. During an interview on 09/17/2024 at 11:10 AM, Resident #1 said she reminded CNA A that she did not want her hair washed, but the CNA A did not acknowledge her. Resident #1 said CNA A proceeded to use the shower hose and sprayed the water in her face. Resident #1 repeated she did not want her hair wet because she used the salon for her hair care. CNA A squeezed soap onto Resident #1's chest area and rubbed aggressively back and forth. Resident #1 told CNA A to stop because she was hurting her. CNA A continued to rub the front of Resident #1's body aggressively. Resident #1 attempted to kick at CNA A to get CNA A away from her. CNA A turned the water back on and sprayed Resident #1 all over her face again. Resident #1 stated she was yelling for CNA A to stop. Resident #1 said that CNA C entered the shower room and Resident #1 said to CNA C, I did not want my hair wet/washed. Resident #1 said that CNA C said, no, you just don't like our color and turned and left the shower room. Resident #1 said she noticed blood on the washcloth laying on the floor and asked CNA A where the blood was coming from. CNA A never responded to Resident #1. Resident #1 said she did not recall anything that hurt besides the rubbing on her chest area with the washcloth by CNA A and the water spraying hard on her face. Resident #1 stated that LVN D entered the shower room and asked what happened. Resident #1 said CNA A was yelling, she done that to herself. Resident #1 said LVN D told CNA A to leave the shower room. Resident #1 said LVN D dried her off and put her gown on. Resident #1 said several towels that were laying on the floor were stained with blood. Resident #1 said LVN D pushed her on shower chair into the hallway where CNA A, CNA B, and CNA C were standing. Resident #1 stated CNA A was talking loudly and kept repeating, she did that to herself and pulled the shower hose out of my hand and the showerhead hit her. Resident #1 said she tried to talk but CNA A kept talking over her and interrupted her several times. Resident #1 said LVN D told the CNAs to put her back into her bed because she had to call the administrator. Resident #1 said she was scared when CNA A and CNA B placed her back in her bed. Resident #1 said she asked CNA A not to hurt her. Resident #1 said she was scared of new staff and requested not to be in the shower room with new staff. Resident #1 said she did not utilize the same shower room where the incident with CNA A happened because it made her anxious and scared to go in there. During an interview on 09/17/2024 at 11:58 AM, CNA B said she was training CNA A as a new employee to the facility. CNA A had previously worked at the facility through a staffing agency. CNA B was going to shower Resident #1, but CNA A insisted on doing the shower by herself and was arguing about it in front of Resident #1. CNA B said she did not want to argue in front of Resident #1. CNA B said everything seemed fine, and she left CNA A and Resident #1 alone in the shower room. CNA B said a different resident on the hall needed help, so she went into that resident's room. CNA B stated when she come out of the other resident's room (located closer to the nurse's desk), she heard some yelling from the shower room. CNA B said she notified LVN D of the yelling. CNA B said LVN D left the nurses' desk and headed toward the shower room. CNA B said she was in the hallway outside of the shower room when LVN D brought out Resident #1, and Resident #1 was bleeding from the chest area. CNA B said LVN D asked Resident #1 what happened, but CNA A was yelling and talked over Resident #1. CNA B said Resident #1 was bleeding from her chest area and was very upset, crying, and short of breath. CNA B said LVN D instructed her and CNA A to place Resident #1 back in the bed while she called for the ambulance due to the excessive bleeding. CNA B said Resident #1 was very quiet and scared during the transfer process. CNA B said when they were in Resident #1's room, CNA A never said anything more to Resident #1. CNA B said after CNA A left the room, she remained with Resident #1. CNA B said Resident #1 cried and told her she was so scared. CNA B said Resident #1 said she had told CNA A not to wash her hair or get her hair wet, but she continued to spray her in the face area. CNA B stated Resident #1 explained CNA A was rubbing her chest with the washcloth so hard and it was hurting her, and CNA A would not stop when she asked her to. CNA B said Resident #1 kept repeating I was so scared. CNA B stated Resident #1 always wanted her showers just not her hair washed because she used the hair salon. CNA B stated CNA A left the facility soon after the incident occurred. CNA B stated EMS took Resident #1 to the hospital. CNA B said the police came but CNA A had already left the facility at that time. CNA B said in-services for abuse and neglect and how to respond to certain behaviors such as aggression were started with the working staff the same night the incident occurred. CNA B said if a resident requested the staff to stop, the staff should honor the resident's request. CNA B said if a resident refuses care, you could ask the resident later, get assistance from another staff member to see if the resident was more open to them, notify the family and get their help but you would not continue the process because that would be abuse. CNA B said if she witnessed abuse, she would always separate the people having the altercation and be sure no contact had occurred. CNA B said she did not understand why LVN D sent CNA A back to assist with Resident #1's transfer after this incident occurred. CNA B stated that prior to Resident #1's shower she had discussed with CNA A that Resident #1 did not get her hair washed during the shower. CNA B stated she had not experienced any episodes of aggression from Resident #1 while providing care to her or giving her showers. CNA B stated Resident #1 did not refuse her showers or care. CNA B stated Resident #1 would not be able to grab or hold the showerhead hose due to the contracture (a permanent or temporary shortening of muscles, tendons, and other soft tissues that causes joint stiffen and limited movements) of her hands and limited movement. During an interview on 09/17/2024 at 2:29 PM, LVN D said she was the charge nurse for Resident #1 on 04/03/2024. LVN D said CNA B was scheduled to orient CNA A. LVN D said she was at the nurses' desk when she was alerted by CNA B that she heard yelling. LVN D said she immediately went down to the shower room and opened the door, and she saw several towels laying on the floor with blood stains. LVN D said she asked Resident #1 what happened. LVN D said Resident #1 was immediately interrupted by CNA A yelling she did that to herself repeatedly. LVN D said she told CNA A to get out of the shower room, and she dried off and dressed Resident #1. LVN D said Resident #1 was still bleeding profusely. LVN D said she rolled Resident #1 into the hallway where CNA A continued to yell out, she pulled the shower hose and the shower head hit her. LVN D said that CNA C was being mouthy about skin color but could not recall what was said. LVN D said Resident #1 said, I don't get my hair washed in the shower and you sprayed me hard. LVN D said she told two CNAs to place Resident #1 back in the bed. LVN D said she could not recall who she told because everything became a blur. LVN D said she would not have told CNA A to put Resident #1 back in bed because you would separate them to protect the resident, but it was all a blur at that point. LVN D said she had to call the administrator first and he told her to immediately remove CNA A from the facility. LVN D said she had to get CNA A from another resident's room where she was providing incontinent care and told her to leave. LVN D said that she called 911 after she attempted to steri-strip the area to prevent bleeding. LVN D said EMS examined the shower hose and shower head and did not find any type of tissue on it. LVN D said the police came and filed a report. LVN D said in-services for abuse and neglect and how to respond to certain behaviors such as aggression was completed for the staff working. Attempted telephone call on 09/17/2024 at 02:43 PM to CNA A, unable to reach or leave a message due to no voice mail had been set up. During an interview on 09/18/2024 at 10:34 AM, Resident # 1's family member stated she had received a call on the GrandPad (tablet) from Resident #1. The family member stated Resident #1 was crying during the call. Resident #1's family member stated that CNA B was in the room and had assisted Resident #1 to make the call. The family member stated that during the call she saw EMS arrive to Resident #1's room. Resident #1's family member stated when she arrived at the facility Resident #1 was in the ambulance. The family member stated she went into the facility and took pictures of the shower room, shower hose and shower head, and the blood stain towels that were on the floor. Resident #1's family member said LVN D said CNA C stated that Resident #1 and CNA A were fighting over the shower head. Resident #1 family member asked CNA C if she had observed Resident #1 and CNA A fighting, and CNA C responded no. Resident #1's family member said that CNA C said, I don't have to talk to you. Resident #1's family member said Resident #1 was interviewed multiple times by different staff at the hospital and the story never changed. Resident #1's family member said she told CNA A not to get her hair wet, but CNA A refused to listen or acknowledge her and continued and sprayed her roughly with the water. CNA A then placed a large amount of soap on Resident #1's chest area and rubbed her aggressively with a washcloth. Resident #1 's family member stated Resident #1 said she asked CNA A to stop because it hurt but CNA A did not stop and proceeded to rinse her with hot water. Resident #1 stated she tried to kick at CNA A to get away from her, but CNA A backed up and no contact was made. Resident #1's family member stated that Resident #1 had limited range of motion of her upper extremities and only uses her thumb and index finger on the left and cannot pick up anything with the right hand. Resident #1's family member stated she had provided the pictures with the time stamp from the camera in Resident #1's room to the police and the facility. Resident #1's family member stated she had also provided a detailed timeline of the events that took place in Resident #1's room from the camera pictures. Resident #1 's family member stated at 07:33 PM CNA A, CNA B, and CNA C come into Resident #1's room and got Resident #1 for her shower. Resident #1's family member further stated that at 07:55 PM on the camera, CNA A and CNA B placed a brief on Resident #1 after they transferred her back in bed. Attempted telephone call on 09/18/2024 at 11:31 AM to CNA A, unable to reach or leave a message due to no voice mail had been set up. Record review of CNA C's written witness statement dated 04/03/24 at 7:50 PM indicated, heard yelling from CNA A and she opened the door to the shower room and seen CNA A's clothes were wet and the skin tear around Resident #1's neck. CNA C asked Resident #1 what happened? But Resident #1 started yelling for me to shut up and tried to kick me. By that time, I helped CNA A roll her out of the shower room and CNA B went a got the LVN D. LVN D questioned CNA B while she (CNA C) and CNA A helped Resident #1 to bed. Then I left out to do the other patient During an interview on 09/18/2024 at 11:40 AM, CNA C said on 04/03/2024 was her first shift as the facilities employee. CNA C said she had previously worked at the facility through a staffing agency. CNA C said she heard yelling from the shower room from the hallway. CNA C said she opened the shower room door and seen CNA A and Resident #1 tugging the shower head back and forth between each other. CNA C said she saw CNA A's clothes were wet. CNA C said she did not enter the shower room. CNA C said she got LVN D because Resident #1 was yelling at her. CNA C said CNA B did not want to shower Resident #1. CNA C said CNA B told CNA A to shower Resident #1 after Resident #1 told her she did not want the black girl to shower her. CNA C said Resident #1 had refused in the hallway. CNA C said after the incident occurred in the shower room, she and CNA B put Resident #1 back in the bed and dressed her alone. CNA C said she was educated on abuse and neglect and proper reactions to aggressive behaviors. CNA C said it was important to separate and not allow any contact with the alleged victim to keep them safe from abuse. CNA C said she had never come back to the facility after the night that the incident occurred. Attempted telephone call on 09/18/2024 at 02:45 PM to CNA A, unable to reach or leave a message due to no voice mail had been set up. During an interview on 09/18/2024 at 3:00 PM, the DON stated when she arrived at the facility CNA A had already left. The DON stated Resident #1 was at the hospital. The DON stated she had examined the shower head and shower hose for bodily tissue or blood but seen no indication of either. The DON stated she was unsure who placed Resident #1 back to bed after the incident in the shower room occurred. The DON stated she had been educated on abuse and neglect after the incident as well as aggressive behaviors and how to respond. The DON stated that the perpetrator or alleged perpetrator should immediately be removed from the facility and not allowed access to residents pending the investigation to ensure no harm to the alleged victim or other resident occurs. During an interview on 09/19/2024 at 08:23 AM, the Administrator stated that he had re-enacted the scenario and agreed Resident #1 had pulled the shower hose from CNA A and caused the shower head to hit her in the chest resulting in the laceration and fracture of the ribs. The Administrator stated Resident #1 could have pulled the shower hose with the use of her one finger and limited arm movement. The Administrator said CNA A was being an ass and spraying the water crazily and Resident #1 wanted CNA A to stop. CNA A did not stop as Resident #1 had requested. The Administrator stated he had tried to get the hall camera's video as requested by the police, but the video only saves for 10 days, and he was not able to get it timely from the IT (information technology) department. The administrator stated that he was not aware that LVN D had sent CNA A back into the room to transfer Resident #1 into bed after the incident had occurred. The Administrator stated if CNA B said that she and CNA A had transferred Resident #1 back into the bed after the shower room incident then that would be true because CNA B was as honest as the day is long. The Administrator said in-services on abuse and neglect, aggressive behavior and appropriate responses, and once an alleged perpetrator is identified there should be no access to the alleged victim or any resident to prevent harm and provide safety. The Administrator said he expected all staff to follow the Abuse and Neglect Policy. The Administrator said CNA A was terminated on 04/03/2024. The Administrator said CNA C was also terminated and had not worked at the facility after the incident on 04/03/2024. The Administrator said he expected CNA A would not have provided any more resident care and left the facility immediately to prevent further possibilities of abuse. The Administrator stated CNA A and CNA C come back to the facility on [DATE] for interviews by the police department. The Administrator stated the family of Resident #1 filed charges on CNA A. Record review of grievances from January 2024 to September 2024 did not reveal any abuse concerns related to CNA A or CNA C. Record review of the facility's policy and procedure, titled Reporting Abuse and Neglect Policy, dated 2021, indicated .Our facility will protect residents from harm during investigations of abuse allegations. 1. During abuse investigations, residents will be protected from harm by the following measure: Employees accused of participating in the alleged abuse will be immediately re-assigned to duties that do not involve resident contact or will be suspended without pay until the findings of the investigation have been reviewed and a determination made by the Administrator/designee. a)Should the team member(s) be reassigned to non-resident care duties, such assignment will not be in any part of the building which the resident frequents. b)If the alleged abuse involves the resident's family member or visitor, such persons(s) will not be permitted to have unsupervised visits with the resident. c)If the alleged abuse involves another resident, please see Resident-to- Resident . The Administrator was notified on 09/19/2024 at 01:43 p.m., that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Residents #1 in an IJ situation on 04/03/2024. The facility had corrected the noncompliance on 04/04/2024 by the following: - Termination of CNA A who was responsible for the abuse - Written counseling of the LVN D the education on the Abuse and Neglect Policy - Safe surveys of 15 residents in the facility - 100% staff in-service on abuse and neglect and proper responses to aggressive behaviors - QAPI sign in sheet dated 05/01/2024 completed with Administrator, DON, Infection Preventionist, Medical Director, Floor Staff Representative, and Director of Maintenance with opportunities of improvement with Abuse Policy attached. Record review of Inservice dated 04/03/2024 indicated education to all staff was completed on the Abuse and Neglect Policy, Resident Rights, and Resident's with Combative Behavior. Record review of LVN D's written counseling dated 04/04/2024. Record review of CNA A's termination notice dated 04/04/2024. Interviews on 04/20/2024 from 08:30 AM - 10:48 AM of the sampled residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) revealed no abuse occurred. All staff interviewed (LVN E, CNA F, LVN G, LVN H, LVN J, CNA K, CNA L, CNA M, LVN N, LVN P, CNA Q, RN R, 2 ADONs, Activity Director, Social Worker, MDS Coordinator, Staffing Coordinator on 09/20/2024 08:30 AM - 10:48 AM verbalized any allegation of abuse should be reported to the administrator immediately. They verbalized understanding of the types of abuse and the facility's obligation to report abuse to HHS within 2 hours and removing the alleged perpetrator from the victim or any potential victims immediately. The noncompliance was identified as PNC. The noncompliance began on 04/03/2024 and ended on 04/04/2024. The facility had corrected the noncompliance before the survey began.

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Abuse Prevention Policies (Tag F0607)

Someone could have died · 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 implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to implement their abuse polices by not ensuring CNA A did not continue to provide care to Resident #1 after CNA physically abused Resident #1 in the shower room on 04/03/2024. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 04/03/2024 and ended on 04/04/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse. Findings included: Record review of the facility's policy and procedure, titled Reporting Abuse and Neglect Policy, dated 2021, indicated .Our facility will protect residents from harm during investigations of abuse allegations. 1. During abuse investigations, residents will be protected from harm by the following measure: Employees accused of participating in the alleged abuse will be immediately re-assigned to duties that do not involve resident contact or will be suspended without pay until the findings of the investigation have been reviewed and a determination made by the Administrator/designee. a)Should the team member(s) be reassigned to non-resident care duties, such assignment will not be in any part of the building which the resident frequents. b)If the alleged abuse involves the resident's family member or visitor, such persons(s) will not be permitted to have unsupervised visits with the resident. c)If the alleged abuse involves another resident, please see Resident-to- Resident . Record review of a face sheet dated 09/20/2024 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), contracture of muscle of the left and right forearm, muscle weakness, dependence of a wheelchair, rheumatoid arthritis of hands (chronic swelling of the small joints), speech and language deficits following cerebrovascular disease (weakness on one side of the body). Record review of the quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 12, which indicated mild cognitive deficit. Resident #1 required maximum assistance for ADLs such as toileting, showering and dressing. Record review of a care plan revised on 11/09/2023 titled ADL assistance indicated Resident #1 had an ADL self-deficit and required maximum assistance with dressing, toileting and showering. The interventions for Resident #1 included: Transfer - The resident required mechanical lift - Hoyer Lift with 2 staff assistance for transfers. Record review of the hospital Encounter Summary dated 04/04/2024 documented the Final Diagnosis: abrasion to skin, closed fracture of multiple ribs of right side, assault. Assessment: 5 cm linear (a line) superficial laceration across anterior chest at level of 2-3rd rib. Piece of skin separated down middle of laceration, attached to right side of laceration, no jagged edges. Surrounding ecchymosis and tenderness. Medical Decision Making: [AGE] year-old female presents with primary history of cerebrovascular accident with residual left sided deficits (wheelchair bound at baseline) who suffered unfortunate traumatic skin tears to her chest yesterday evening at the hands of her CNA. The CNA is new, currently training, and seemingly became too aggressive while giving the patient a bath. Per patient, bath water was too hot, and she was scrubbing her too aggressively. Skin tear to middle chest noted. Chest X-Ray suggestive of Right sided rib fracture. Will clean skin tear thoroughly and apply dermabond. (skin adhesive). Of greater concern is the possibility of elder abuse. Patient and daughter would like to discharge. Medically ready, just waiting on Social Worker for assault case. Daughter and patient would like to leave and will file report outpatient. During an interview on 09/17/2024 at 11:10 AM, Resident #1 said she reminded CNA A that she did not want her hair washed, but the CNA A did not acknowledge her. Resident #1 said CNA A proceeded to use the shower hose and sprayed the water in her face. Resident #1 repeated she did not want her hair wet because she used the salon for her hair care. CNA A squeezed soap onto Resident #1's chest area and rubbed aggressively back and forth. Resident #1 told CNA A to stop because she was hurting her. CNA A continued to rub the front of Resident #1's body aggressively. Resident #1 attempted to kick at CNA A to get CNA A away from her. CNA A turned the water back on and sprayed Resident #1 all over her face again. Resident #1 stated she was yelling for CNA A to stop. Resident #1 said that CNA C entered the shower room and Resident #1 said to CNA C, I did not want my hair wet/washed. Resident #1 said that CNA C said, no, you just don't like our color and turned and left the shower room. Resident #1 said she noticed blood on the washcloth laying on the floor and asked CNA A where the blood was coming from. CNA A never responded to Resident #1. Resident #1 said she did not recall anything that hurt besides the rubbing on her chest area with the washcloth by CNA A and the water spraying hard on her face. Resident #1 stated that LVN D entered the shower room and asked what happened. Resident #1 said CNA A was yelling, she done that to herself. Resident #1 said LVN D told CNA A to leave the shower room. Resident #1 said LVN D dried her off and put her gown on. Resident #1 said several towels that were laying on the floor were stained with blood. Resident #1 said LVN D pushed her on shower chair into the hallway where CNA A, CNA B, and CNA C were standing. Resident #1 stated CNA A was talking loudly and kept repeating, she did that to herself and pulled the shower hose out of my hand and the showerhead hit her. Resident #1 said she tried to talk but CNA A kept talking over her and interrupted her several times. Resident #1 said LVN D told the CNAs to put her back into her bed because she had to call the administrator. Resident #1 said she was scared when CNA A and CNA B placed her back in her bed. Resident #1 said she asked CNA A not to hurt her. Resident #1 said she was scared of new staff and requested not to be in the shower room with new staff. Resident #1 said she did not utilize the same shower room where the incident with CNA A happened because it made her anxious and scared to go in there. During an interview on 09/17/2024 at 11:58 AM, CNA B said LVN D instructed her and CNA A to place Resident #1 back in the bed while she called for the ambulance due to the excessive bleeding. CNA B said Resident #1 was very quiet and scared during the transfer process. CNA B said when they were in Resident #1's room, CNA A never said anything more to Resident #1. CNA B said after CNA A left the room, she remained with Resident #1. CNA B said Resident #1 cried and told her she was so scared. CNA B said Resident #1 said she had told CNA A not to wash her hair or get her hair wet, but she continued to spray her in the face area. CNA B stated Resident #1 stated CNA A was rubbing her chest with the washcloth so hard, and it was hurting her, and CNA A would not stop when she asked her to. CNA B said Resident #1 kept repeating I was so scared. CNA B said in-services for abuse and neglect and how to respond to certain behaviors such as aggression were started with the working staff the same night the incident occurred. CNA B said she did not understand why LVN D sent CNA A back to assist with Resident #1's transfer after this incident occurred. During an interview on 09/17/2024 at 2:29 PM, LVN D said she was the charge nurse for Resident #1 on 04/03/2024. LVN D said she was at the nurses' desk when she was alerted by CNA B that she heard yelling. LVN D said she immediately went down to the shower room and opened the door, and she saw several towels laying on the floor with blood stains. LVN D said she asked Resident #1 what happened. LVN D said Resident #1 was immediately interrupted by CNA A yelling she did that to herself repeatedly. LVN D said she told CNA A to get out of the shower room, and she dried off and dressed Resident #1. LVN D said Resident #1 was still bleeding profusely. LVN D said she rolled Resident #1 into the hallway where CNA A continued to yell out, she pulled the shower hose and the shower head hit her. LVN D said that CNA A was being mouthy about skin color but could not recall what was said. LVN D said Resident #1 said, I don't get my hair washed in the shower and you sprayed me hard. LVN D said she told two CNAs to place Resident #1 back in the bed. LVN D said she could not recall who she told because everything became a blur. LVN D said she would not have told CNA A to put Resident #1 back in bed because you would separate them to protect the resident, but it was all a blur at that point. LVN D said she had to call the administrator first and he told her to immediately remove CNA A from the facility. LVN D said she had to get CNA A from another resident's room where she was providing incontinent care and told her to leave. LVN D said in-services for abuse and neglect and how to respond to certain behaviors such as aggression was completed for the staff working. Attempted telephone call on 09/17/2024 at 02:43 PM to CNA A, unable to reach or leave a message due to no voice mail had been set up. During an interview on 09/18/2024 at 10:34 AM, Resident #1's family member further stated that at 07:55 PM on the camera, CNA A and CNA B placed a brief on Resident #1 after they transferred her back in bed. Attempted telephone call on 09/18/2024 at 11:31 AM to CNA A, unable to reach or leave a message due to no voice mail had been set up. Record review of the CNA C's written witness statement dated 04/03/24 at 7 :50 PM indicated, heard yelling form CNA A and she opened the door to the shower room and seen CNA A's clothes were wet and the skin tear around Resident #1's neck. CNA C asked Resident #1 what happened? But Resident #1 started yelling for me to shut up and tried to kick me. By that time, I helped CNA A roll her out of the shower room and CNA B went a got the LVN D. LVN D questioned CNA B while she (CNA C) and CNA A helped Resident #1 to bed. Then I left out to do the other patient During an interview on 09/18/2024 at 11:40 AM, CNA C said 04/03/2024 CNA C said after the incident occurred in the shower room, she and CNA B put Resident #1 back in the bed and dressed her alone. CNA C said she was educated on abuse and neglect and proper reactions to aggressive behaviors. CNA C said it was important to separate and not allow any contact with the alleged victim to keep them safe from abuse. CNA C said she had never come back to the facility after the night that the incident occurred. Attempted telephone call on 09/18/2024 at 02:45 PM to CNA A, unable to reach or leave a message due to no voice mail had been set up. During an interview on 09/18/2024 at 3:00 PM, the DON stated when she arrived at the facility CNA A had already left. The DON stated Resident #1 was at the hospital. The DON stated she had examined the shower head and shower hose for bodily tissue or blood but seen no indication of either. The DON stated she was unsure who placed Resident #1 back to bed after the incident in the shower room occurred. The DON stated she had been educated on abuse and neglect after the incident as well as aggressive behaviors and how to respond. The DON stated that the perpetrator or alleged perpetrator should immediately be removed from the facility and not allowed access to residents pending the investigation to ensure no harm to the alleged victim or other resident occurs. The DON said LVN D should have told CNA A to not provide any resident care immediately. During an interview on 09/19/2024 at 08:23 AM, the Administrator he was not aware that LVN D had sent CNA A back into the room to transfer Resident #1 into bed after the incident had occurred. The Administrator stated if CNA B said that she and CNA A had transferred Resident #1 back into the bed after the shower room incident then that would be true because CNA B was as honest as the day is long. The Administrator said in-services on abuse and neglect, aggressive behavior and appropriate responses, and once an alleged perpetrator is identified there should be no access to the alleged victim or any resident to prevent harm and provide safety. The Administrator said he expected all staff to follow the Abuse and Neglect Policy. The Administrator said CNA A was terminated on 04/03/2024. The Administrator said CNA C was also terminated and had not worked at the facility after the incident on 04/03/2024. The Administrator said he expected CNA A would not have provided any more resident care and left the facility immediately to prevent further possibilities of abuse. Record review of grievances from January 2024 to September 2024 did not reveal any abuse concerns related to CNA A or CNA C. The Administrator was notified on 09/19/2024 at 01:43 p.m., that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Residents #1 in an IJ situation on 04/03/2024. The facility had corrected the noncompliance on 04/04/2024 by the following: - Termination of CNA A who was responsible for the abuse - Written counseling of the LVN D the education on the Abuse and Neglect Policy - Safe surveys of 15 residents in the facility - 100% staff in-service on abuse and neglect and proper responses to aggressive behaviors - QAPI sign in sheet dated 05/01/2024 completed with Administrator, DON, Infection Preventionist, Medical Director, Floor Staff Representative, and Director of Maintenance with opportunities of improvement with Abuse Policy attached. Record review of Inservice dated 04/03/2024 indicated education to all staff was completed on the Abuse and Neglect Policy, Resident Rights, and Resident's with Combative Behavior. Record review of LVN D's written counseling dated 04/04/2024 regarding the procedures of the Abuse and Neglect Policy. Record review of CNA A's termination notice dated 04/04/2024. Interviews on 04/20/2024 from 08:30 AM - 10:48 AM of the sampled residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) revealed no abuse occurred. All staff interviewed (LVN E, CNA F, LVN G, LVN H, LVN J, CNA K, CNA L, CNA M, LVN N, LVN P, CNA Q, RN R, 2 ADONs, Activity Director, Social Worker, MDS Coordinator, Staffing Coordinator on 09/20/2024 08:30 AM - 10:48 AM verbalized any allegation of abuse should be reported to the administrator immediately. They verbalized understanding of the types of abuse and the facility's obligation to report abuse to HHS within 2 hours and removing the alleged perpetrator from the victim or any potential victims immediately. The noncompliance was identified as PNC. The noncompliance began on 04/03/2024 and ended on 04/04/2024. The facility had corrected the noncompliance before the survey began. The noncompliance was identified as PNC. The noncompliance began on 04/03/2024 and ended on 04/04/2024. The facility had corrected the noncompliance before the survey began.

Jul 2024 2 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

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 observation, interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 3 of 6 residents reviewed for pharmacy services. (Resident #2, Resident #3, Resident #4) 1. The facility failed to ensure Resident #2 was administered her Nifedipine (medication to treat high blood pressure and chest pain) on 4/12/24 when it was available in the facility's emergency kit. 2. The facility failed to ensure MA D administered Resident #3 only her ordered medication and did not administer Trazodone (anti-depressant medication) and Ativan (anti-anxiety medication) without orders on 6/25/24. 3. The facility failed to ensure MA C administered Resident #4 her amlodipine (medication to high blood pressure and chest pain) on 7/18/24. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings Include: 1. Record review of the face sheet dated 7/17/24 indicated Resident #2 was an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including dementia, atrial fibrillation (irregular, often rapid heart rate commonly caused by poor blood flow), and hypertension (elevated blood pressure). Record review of the MDS dated [DATE] indicated Resident #2 was understood by others and understood others. The MDS indicated Resident #2 did not have a BIMS score. Record review of the care plan last revised 7/10/24 indicated Resident #2 had hypertension with the potential for abnormal blood pressure, impaired vision, headache, and stroke with interventions including give anti-hypertensive medications as ordered. Record review of the physician orders dated 7/17/24 indicated Resident #2 had an order for Nifedipine Extended Release 30mg 1 tab daily for hypertension starting 3/13/24. Record review of the MAR dated April 2024 indicated Resident #2 did not received her Nifedipine 30mg. Record review of Medication Error report dated 4/12/24 indicated Resident #2's Nifedipine was not administered due to not being available. The Medication Error report indicated the immediate action taken by the facility was Resident #2's vital signs were obtained, and notification was made to the nurse practitioner, responsible party, and pharmacy. Record review of the undated emergency kit's Active Inventory list indicated the emergency kit contained Nifedipine Extended Release 30mg, quantity of 10. During an interview on 7/17/24 at 10:20 a.m. the DON said an MA or nurse can obtain medication from the emergency kit. The DON said the emergency kit should be utilized for new medication orders and medications that are not available due to not being delivered from the pharmacy at the time the medication is due. During an interview on 7/17/24 at 12:25 p.m. MA E said she worked 6:00 a.m. to 2:00 p.m. as a medication aide at the facility. MA E said she did not remember the incident on 4/12/24 with Resident #2 not receiving her Nifedipine due to the medication not being available. MA E said only a nurse can access the emergency kit. MA E said if the facility was out of a medication and pharmacy has not delivered the medication the nurse could pull the medication from the emergency kit. MA E said it was important to ensure residents received their medication because it was ordered from the doctor for them to maintain quality of life. MA E said Resident #2 was a resident they had to watch her medication and give them carefully because she would notify her family if she was not receiving her medications. During an interview on 7/18/24 at 9:14 a.m. Resident #2 said she had not had any issues with her medications including getting the wrong medications, not receiving medications, or medications not being on time. 2. Record review of the face sheet dated 7/17/24 indicated Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stroke, hypertension (elevated blood pressure), alcohol dependence, and tachycardia (rapid heart rate). Record review of the MDS dated [DATE] indicated Resident #3 was rarely/never understood by others and sometimes understood others. The MDS indicated Resident #3 did not have a BIMS score. Record review of the physician orders dated 7/17/24 indicated Resident #3 did not have an order for Ativan (a medication to relieve anxiety) or Trazodone (a medication to treat depression). Record review of the Medication Error report dated 6/25/24 indicated MA D notified the nurse she gave Resident #3 Ativan 1mg and Trazodone 100mg by mistake. The Medication Error report indicated immediate action taken by the facility was Resident #3's vital signs were obtained, and assessment was completed, and Resident #3 was encouraged to drink fluid. Record review of the nursing progress note dated 6/25/24 at 7:29 p.m. indicated MA D notified the nurse she gave Resident #3 Ativan 1mg and Trazodone 100mg by mistake. The progress note indicated Resident #3's vital signs were withing normal limits. The progress note indicated the nurse practitioner, DON, and resident's family were notified. During an interview on 7/17/24 at 1:05 p.m. MA D said she worked part-time at the facility as of 7/1/24 and had not worked any shifts since moving to part-time status. MA D said on 6/25/24 while passing medication she had popped out Resident #5's Ativan and Trazodone, put the medication in a medication cup, and placed the medication in her medication cart. MA D said she then started preparing Resident #3's evening medication. MA D said while preparing Resident #3's medication she received a phone call from the ADON. MA D said when she took the call, she placed Resident #3's medication in her medication cart. MA D said when she returned to the cart, she grabbed Resident #5's medication instead of Resident #3's medication and administered it to Resident #3. MA D said she realized immediately she had made a medication error and reported it to the charge nurse. MA D said the charge nurse went to assess Resident #3 and found her stable. MA D said the night nurse reported Resident #3 stable. MA D said she should not have pre-prepared Resident #5's medication and should not have left the medication in her medication cart. MA D said she was educated regarding medication administration, not leaving medication in the medication cart, and not pre-preparing medications. 3. Record review of the face sheet dated 7/18/24 indicated Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, hypertension (elevated blood pressure), atrial fibrillation (irregular, often rapid heart rate commonly caused by poor blood flow), and stroke. Record review of the MDS dated [DATE] indicated Resident #4 usually understood others and was usually understood by others. The MDS indicated Resident #4 had a BIMS of 13 and was cognitively intact. Record review of the physician orders dated 7/18/24 indicated Resident #4 had an order for amlodipine 2.5mg 1 tab daily for hypertension starting 5/2/24. During an observation on 7/18/24 at 10:17 a.m. MA C administered medications to Resident #4. MA C obtained Resident #4's blood pressure prior to administering her medications. During the medication pass the surveyor watched MA C put medications in the med cup and then reviewed medication bottles and cards. MA C administered the following medications to Resident #4: 1. Fexofenadine 180 mg 1 tablet 2. B-Complex Vitamin 1 tablet 3. Aspirin 81mg 1 tablet 4. Multivitamin 1 tablet 5. Magnesium Oxide 400mg 2 tablets 6. Vitamin D3 25mcg 1 capsule 7. Esomeprazole Magnesium 20 mg 1 tablet 8. Sertraline 50mg 1 ½ tablet 9. Coreg 6.25mg 1 tablet 10. Ranolazine 500 mg 1 tablet 11. Gabapentin 100mg 1 capsule 12. Eliquis 5mg 1 tablet 13. Metformin 500mg 1 tablet 14. Oxybutynin 5mg 1 tablet During an interview and observation on 7/18/24 at 10:36 a.m. MA C said she had handed the surveyor all the medication bottles and med cards after placing the medication in the med cup. MA C said she would show the surveyor all the medications she had administered by pulling the cards from the medication cart. MA C pulled all Resident #4's prescription medication cards and she laid three cards aside and the other 7 cards were what she confirmed she had administered to Resident #4. Observation of the 3 medication cards MA C said she did not administer was performed and Amlodipine 2.5mg was one of the 3 medications. MA C said she had administered the Amlodipine 2.5 mg medication and she must have not handed the surveyor the card to examine during the medication pass. MA C said she had been passing medications for 10 years and knew what she was doing. The surveyor explained what she witnessed and what MA C had confirmed regarding the medications, medications pass, and medication cards. MA C said she must have misunderstood the surveyor's question because she knew what she was doing, she had given Resident #4 the Amlodipine and that was why she had signed it off on the MAR. During an interview on 7/18/24 at 12:20 p.m. the DON said she expected staff to follow physician orders when administering medication. The DON said staff should not set-up medication ahead of time. The DON said if a medication was not available, she expected staff to look for the medication in the overflow and if it was still not found to pull the medication from the E-kit if available or call the pharmacy. The DON said the importance of ensuring residents received their prescribed medication was the treat their help condition and prevent harm. During an interview on 7/18/24 at 12:41 pm the Administrator said he expected medication to be administered as ordered and within 1 hour before or 1 hour after the scheduled time. The Administrator said medications should not be preprepared. The Administrator said if a medication was not available, he expected staff to obtain the medication from the e-kit or call the pharmacy. The Administrator said the importance of administering medications was following the physician's orders. Record review of the facility's Administering Medications policy revised April 2019 indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with the prescriber orders, including any required time frame .9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. if necessary, verifying resident identification and other community personnel. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication .23. If the medication is withheld, refused or not available on the med cart, the Medication Aide or Licensed Nurse should immediately notify the supervisor, as physician notification may need to occur OR the E-kit [emergency kit] checked for the medication .27. Medication ordered for a particular resident may not be administered to another resident, unless permitted by state law and community policy, and approved by the director of nursing services .

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 staff (CNA A and CNA B) observed for infection control. 1. The facility failed to ensure CNA A did not wipe Resident #1's vaginal area with a wipe visibly soiled by feces during incontinent care on 7/17/24. 2. The facility failed to ensure CNA B performed hand hygiene between glove changes, before exiting resident room, and prior to re-entering a resident room. 3. The facility failed to ensure CNA A and CNA B emptied the trash in Resident #1's room which had dirty gloves visibly soiled with feces following incontinent care and prior to exiting the resident's room. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: 1. During an observation on 7/17/24 at 10:50 a.m. CNA A wiped Resident #1's vaginal area and between her labia (folds of skin around the vaginal opening) with disposable wipes. Resident #1 had had a bowel movement. The disposable wipe was observed to be visibly soiled with feces when CNA A wiped between Resident #1's labia. CNA A folded the wipe with feces on it and then wiped between Resident #1's labia with the same disposable wipe. Resident #1 then rolled to her side and CNA B was wiping her bottom. CNA B ran out of disposable wipes, disposed of the visibly soiled with feces gloves in a trash can in the resident's room, did not perform hand hygiene and exited the room. CNA B returned to the room with more disposable wipes, did not perform hand hygiene, donned clean gloves, and continued cleaning Resident #1's bottom. When the CNAs finished with the incontinent care and exited the room the trash can with the soiled gloves was not emptied. During an interview on 7/17/24 at 11:06 a.m. CNA A said when she wiped Resident #1's vaginal area she did notice feces on the wipe. CNA A said she should have disposed of the wipe and used a clean wipe instead of folding the wipe with feces on it and reusing it to wipe between Resident #1's labia. CNA A said the importance of not using a visibly soiled wipe was to prevent infections. During an interview on 7/17/24 at 11:07 a.m. CNA B said hand hygiene should be performed before and after providing care to a resident and before entering and when exiting a resident room. CNA B said she realized after the fact she had exited the room and re-entered the room without performing hand hygiene. CNA B said the importance of performing proper hand hygiene was to prevent the spread of bacteria and infections. During an interview and observation on 7/17/24 at 11:08 a.m. CNA A and CNA B said they were not aware they left any dirty gloves in the rooms. CNA A and CNA B went back in the resident's room with the surveyor and observed the dirty gloves in the trash. CNA A and CNA B both said they should have removed the trash bag with the dirty gloves in it. CNA A and CNA B both said the importance of removing all dirty items after performing incontinent care was to prevent cross contamination and infections. During an interview on 7/18/24 at 12:20 p.m. the DON said if a staff member was performing incontinent care and a disposable wipe became visibly soiled with feces, she would expect the staff member to dispose of the wipe prior to wiping the resident in their pelvic/urethra area. The DON said the importance of disposing of visibly soiled wipes was infection control. The DON said she expected staff to perform hand hygiene before and after care, before donning and after doffing gloves, and before entering or exiting a resident room. The DON said the importance of proper hand hygiene was infection control and to prevent cross-contamination. The DON said dirty gloves should not be left in a resident room after care for safety and infection control. During an interview on 7/18/24 at 12:41 p.m. the Administrator said he expected staff to perform hand hygiene before and after care, before donning and after doffing gloves, and before entering or exiting a resident room. The Administrator said the importance of hand hygiene was infection control. Record review of the facility's Basics of Care for the Resident Who Had Urinary Incontinence Competency Check-Off revised June 2021 indicated, Steps of Process: 1. Perform hand hygiene and don gloves .5. Cleanse the inner legs and outer peri area along the outside of labia, using a clean area of washcloth or wipe for each swipe of peri area. Visibly soiled gloves and washcloths or wipes exchanged for clean ones. 6. Cleanse outer skin folds from front to back, using a clean area of washcloth or wipe for each swipe of peri area. Visibly soiled gloves and washcloths or wipes exchanged for clean ones. 7. Cleanse inner labia from front to back, using a clean area of washcloth or wipe for each swipe of peri area. Visibly soiled gloves and washcloths or wipes exchanged for clean ones .16. Doff and dispose of gloves. 17. Perform Hand Hygiene . Record review of the facility's Handwashing/Hand Hygiene policy revised August 2019 indicated, This community considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents .g. Before handling clean or soiled dressings, gauze pads, etc.h. Before moving from a contaminated body site to a clean body site during resident care .i. After contact with a resident's skin .j. After contact with bloody or bodily fluids .m. After removing gloves .8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace handwashing/hand hygiene .

Sept 2023 12 deficiencies 4 IJ (4 affecting multiple)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

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 lacked supervision to prevent accident hazards and failed to ensure that an environment was free from accident hazards for 3 of 6 residents reviewed for accident hazards. (Resident #249, Resident #42, and Resident #41). 1. The facility failed to ensure safety measures were in place to prevent Resident #249 and Resident #42 from obtaining an injury from hot coffee. 2. The facility failed to implement measures to prevent other coffee spills with burns. 3. The facility failed to monitor the temperatures of hot liquids served to residents. 4. The facility failed to identify residents at risk for coffee burns. 5. The facility failed to ensure Resident #249 and Resident #41 had new fall interventions implemented with each subsequent fall. An Immediate Jeopardy (IJ) situation was identified on 09/14/23. While the IJ was removed on 09/15/23 at 6:47 p.m., the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for diminished quality of life, accidents, and injury. Findings included: 1.Record review of Resident #249's face sheet, dated 09/05/23 indicated Resident #249 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), and anxiety (feelings of nervousness, panic and fear). Record review of Resident #249's quarterly MDS assessment, dated 06/15/23, indicated Resident #249 was understood and usually understood others. Resident #249's BIMs score was 11, which indicated she was moderately cognitively impaired. Resident #249 required total assistance with bathing, extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, and set-up assistance with eating. Record review of Resident #249's comprehensive care plan dated 09/16/22 indicated Resident #249 had an ADL self-care performance deficit related to activity intolerance and limited mobility. The interventions of the care plan were for staff to provide Resident #249 with assistance with eating and personal hygiene. Resident #249's care plan failed to address how many staff were needed to assist with eating prior to 06/07/23. Record review of Resident #249's file revealed a hot liquid assessment had not been completed. Record review of the coffee machine temperature log indicated start date of 09/11/23. Record review of Resident #249's incident report dated 08/15/23 at 6:30 a.m., revealed Resident #249 spilled coffee on her lap and had redness to both of her inner and top thighs. No swelling or tenderness to the area. Silvadene cream was applied to the area. Resident #249's clothes were changed and she was assisted back to the dining room. Hospice was notified. Record review of Resident #249's nurse note dated 08/15/23 at 5:40 a.m., signed by LVN N revealed LVN N was notified that Resident #249 had spilled her coffee onto her lap and had redness noted on both of her thighs (inner and top) area. No swelling or tenderness to the area. Silvadene was applied to the area. Resident #249's clothes were changed and she was assisted back to the dining room. Hospice was notified and the hospice nurse said she would notify the family and the physician. Record review of Resident #249's nurse's note dated 08/15/23 at 5:40 a.m., did not indicate any notification to the physician, nurse managers, or administrator. During an observation and interview on 9/11/23 at 3:58 p.m., the dietary manager obtained a cup from the cabinets and coffee temped the coffee in the dining room. The coffee temperature was 160 degrees F. The dietary manager said she does temp the coffee daily but does not log the temperatures. There were 6 residents sitting at the dining table closest to the coffee machine. During an interview on 09/13/23 at 4:54 p.m., LVN N said she was notified by an unknown staff member that Resident #249 had spilled coffee on herself. She said she went to assess Resident #249 and noted redness to both the inner and top thighs. LVN N said she applied Silvadene cream, changed Resident #249's clothes, and assisted her back to the dining room. LVN N said she did not notify the physician but she knew Silvadene was for burns, so she applied the cream. LVN N said she should have notified the physician but she did not. LVN N said she does not recall notifying the administrator about the burn on Resident #249 but believed she notified the DON. During an interview on 09/14/23 at 8:41 a.m., the administrator said he does not report burns unless they were major burns. He said the nursing department would have weekly meetings and if the DON felt something was not a significant event (such as an unknown injury), then she would not notify him. The administrator said he was not aware of Resident #249's coffee burn which occurred on 08/15/23 therefore he could not speak of any injuries or not. During an interview on 09/14/23 at 10:43 a.m., the facility NP said he does not recall receiving a call about Resident #249's burn. He said if any resident had a wound or skin issues, he would have the facility staff call the wound care physician. During an interview on 09/14/23 at 11:15 a.m., the facility wound care doctor said he was unaware of any staff calling him about a burn. He said if they had called, he would have instructed them to wipe the area with a cool towel to stop the burning and then apply Silvadene cream. During an interview on 09/15/23 at 12:16 p.m., the ADON said they were supposed to do a hot liquid assessment on admission and quarterly. She said they were important for the safety of residents who drink coffee. The ADON said the hot liquids were part of the required UDAs (Assessments and Evaluations) and was a team effort between her and the DON to complete. She said the coffee pots were only on during meal service and were supposed to be monitored by nursing staff. The ADON said she was unaware if any interventions were put into place after Resident #42 and Resident #249 obtained burns from the hot coffee. She said they now have things in place to prevent further coffee injuries. During an observation and interview on 09/15/23 at 1:06 p.m., observed coffee pots were still on in the dining room. Housekeeper DD came into the dining room and verified by pulling the coffee level down with the coffee dispensed. He said as far as he knew the coffee stayed on all the time and residents were allowed to get coffee at any time. During an interview on 09/15/23 at 1:40 p.m., the DON said hot liquid assessments were supposed to be done on admission and quarterly. The DON said she was responsible for ensuring the hot liquid assessment had been completed. She said prior to today (09/15/23) they did not have a plan in place to ensure staff were completing the hot liquid assessments. She said the hot liquid assessment was done to ensure residents who drank coffee or hot liquids were safe. During an interview on 09/15/23 at 7:01 p.m., the administrator said he was unaware of how often hot liquid assessments needed to be completed. He said during this survey process he realized that some of the UDAs had not been triggering as they should. He said they educated Resident #42 about her coffee spill but were unaware of any interventions put in place for Resident #249 coffee spill. He said they have implemented staff going up and down the hallways monitoring during mealtimes and alerting nurses if any concerns. He said they have completed the hot liquid assessments and educated staff on hot coffee spills. The administrator said since they had completed the hot liquid assessments, he felt the residents were safer. 2. Record review of Resident #42's face sheet dated 09/14/23 indicated she was a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of fractured left shoulder and arm, high blood pressure, kidney failure, anxiety, and depression. Record review of Resident #42's MDS dated [DATE] indicated she had a BIMS score of 15 which indicated she was cognitively intact. The MDS also indicated she required supervision of 1 person with bed mobility, transfers, eating, and toileting. Record review of Resident #42's care plan initiated on 08/11/23 indicated she had actual impairment to skin integrity of the right upper thigh related to a burn due to coffee spill with interventions to avoid scratching, keep hands, and body parts from excessive moisture, and to monitor, document, report as needed. Record review of Resident #42's incident report dated 08/10/23 indicated she was in the dining room attempting to carry coffee for herself and 2 other residents when she dropped the cups of coffee causing it to spill on her right upper thigh. Record review of Resident #42's hot liquid screening dated 09/15/23 after surveyor intervention indicated she may have hot liquid as served without safety measures. During an interview on 09/11/23 at 04:23 PM Resident #42 said she remembered spilling coffee on her. She said that she was in the dining room on that day, and she just dropped the coffee on her. Resident #42 said the coffee was always self-serve. She said she had not had any other issues with coffee outside of that incident on 08/10/23. During an interview on 09/14/23 at 08:42 AM the DON said she was aware of Resident #42's coffee burn. She said Resident #42 went to the coffee pot and attempted to carry 3 cups of coffee and spilled the coffee before anyone could get to her. The DON said there was some redness on her right upper thigh, and it was gone within 2 hours of the assessment. She said Resident #42 told her she was fine. The DON said no residents were allowed to get coffee on their own. She said Resident #42 retrieved cups from under the cabinet. The DON said the facility started monitoring to ensure the residents did not get into the coffee themselves, but it was not documented. The DON said the coffee pot was turned off at certain times of the day so that it was not hot, and the nurses and aides were made aware to monitor, but no documentation. She said she thought In-services were provided at that time but would look for them. The DON said the Administrator monitors incidents, so he was aware of the coffee burn incident. She does not know if the kitchen checks the coffee daily, but the coffee had a regulator, so the temperatures of the coffee did not fluctuate. The DON said hot liquid assessments were supposed to be completed and the purpose of the assessment was to promote safety with hot liquids. With the assessments not being completed it placed residents at risk for unsafe coffee. During an interview on 09/15/23 at 12:37 PM the ADON said the hot liquid assessments were to be completed on admission and quarterly. The ADON said the assessments were important because a lot of residents like coffee and the assessments are needed for the resident's safety. She said the DON and ADON were responsible for ensuring they were completed. She said Resident #42 let everyone know about the incident with her coffee spill. The ADON said the incident for the coffee was placed in the nurse's note and the nurse aides were also notified by word of mouth. She said the dietary staff were responsible for checking the temperatures of the coffee. The ADON said 160 was too hot for coffee. The ADON said at the time of the burn incident on 08/10/23 the facility provided education to the resident and the staff but not documented. She said the residents were not allowed to make their own coffee. The ADON said they made sure that there were staff members in the dining room when residents started to come into the dining room. She said the nurses and nurse aides were responsible for monitoring when the first resident came into the dining room. The ADON said the coffee pot does not always stay on, but the coffee pot is turned on at the time of meal service. 3. Record review of Resident #249's quarterly MDS assessment, dated 06/15/23, indicated Resident #249 was understood and usually understood others. Resident #249's BIMs score was 11, which indicated she was moderately cognitively impaired. Resident #249 required total assistance with bathing, extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, and set-up assistance with eating. Record review of Resident #249's comprehensive care plan, dated 06/07/23 indicated Resident #249 had an actual fall on 5/20/23,05/21/23, and 06/02/23. The interventions of the care plan were for staff to determine and address causative factors of the fall, lock the wheelchair beside the bed even when the resident was not in her wheelchair, provide activities that promote exercise and strength building, provide nonskid socks at bedtime, and continue interventions on the at-risk plan. Record review of Resident #249 falls revealed she had a fall on 06/28/23, 07/24/23, 07/25/23, and 08/19/23. No injuries were noted from unwitnessed falls on 06/28/23, 07/24/23 and 07/25/23. Resident #249 had a witnessed fall on 08/19/23 at 12:20 pm and obtained an abrasion to her forehead, a small hematoma to mid-forehead, and a minor abrasion to her right knee. Record review of Resident #249 nurse notes dated 08/19/23 at 12:20 pm documented by the DON indicated, that Resident #249 was sitting at the nurses' station with RN CC and leaned forward and fell out of her wheelchair causing an abrasion to her forehead, a small hematoma to mid-forehead, and a minor abrasion to her right knee. During an interview on 09/13/23 at 11:03 p.m., RN R said when a resident had a fall they would fill out several forms on the computer, start neuros, notify the family and physician. She said if a resident required an immediate intervention such as fall mats, low bed, or nonskid socks then the nurses would put those things in place otherwise the nursing managers would put an intervention in place. During an interview on 09/15/23 at 12:16 p.m., the ADON said she had never attended a care plan meeting. She said when a resident had a fall the nurses would assess for any changes and notify the DON, family, and the physician. She said the nurses would put interventions if needed in the plan of care or risk management in the computer system. The ADON said without interventions in place they could fall again. During an interview on 09/15/23 at 8:17 PM the MDS nurse said the last care plan related to falls for Resident #249 was 06/02/23. She said she was unaware why her fall care plan had not been updated. The MDS nurse said she and the interdisciplinary team met weekly and everyone played a part in updating care plans. The MDS nurse said she was ultimately responsible for ensuring care plans had been updated and residents had interventions after each fall. The MDS nurse said the care plan should be updated for continuity of care. During an interview on 09/15/23 at 1:40 p.m., the DON said the nurses were responsible for updating the care plan and putting interventions in place. She said they were supposed to put interventions in the UDAs or plan of care. The DON said she reviewed care plans in their meetings and could not say why Resident #249's care plan had not been updated after each fall. The DON said when a resident had a fall, intervention should be implemented to prevent further falls. During an interview on 09/15/23 at 7:01 p.m., the administrator said he knew things should be care planned but was unaware if Resident #249 had falls care planned. He said Resident #249 was at risk for falls. The administrator said nursing was responsible for ensuring care plans were updated as needed. He said care plan updates were important because they were a part of the resident's care and could potentially prevent other falls. 4) Record review of a face sheet dated 9/13/2023 indicated Resident #41 was a [AGE] year-old female who was admitted on [DATE] with the diagnosis of dementia, muscle wasting and atrophy (loss of muscle) to right lower leg, muscle wasting and atrophy to left lower leg, and generalized muscle weakness. Record review of an Annual MDS dated [DATE] indicated Resident #41 was usually understood and usually understands. The MDS indicated Resident #41's BIMS score was 3 indicating severe cognitive deficiet. The MDS indicated Resident #41 required limited assistance of one staff with bed mobility, transfers, dressing, toielting, and personal hygiene. The MDS indicated Resident #41 required supervision of one staff with walking in the room, and walking in the cooridor. The MDS indicated Resident #41 had one fall with an injury (except major). Record review of a comprehensive care plan dated 9/20/2023 indicated Resident #41 had an ADL deficit and required transfer assistance of one staff and she required use of a wheelchair for locomotion. The care plan indicated Resident #41 was at risk for falls related to confusion, incontinence, and psychoactive medications the goal was Resident #41 would not sustain a serious injury. The intervention noted indicated Resident #41's call light would be within reach and ensure the bed was locked in the lowest position. The comprehensive care plan dated 4/19/2023 and revised on 8/08/2023 indicated Resident #41 had falls on 4/19/2023, 4/20/2023, 6/21/2023, 6/28/2023, and 8/3/2023. The goal of the care plan was Resident #41 would resume normal activities without further incident. The care plan interventions implemented on 4/19/2023 monitor and report as needed changes in mental status, new onset of confusion, sleepiness, agitation, and inability to maintain posture, implement neurological checks per facility protocol, provide activities to promote exercise and strength when possible, and a physical therapy consult. The care plan failed to mention interventions implemented for falls occurring after 4/19/2023. Record review of facility incident reports provided for 4/19/2023 - 8/31/2023 indicated: *4/19/2023 LVN N documented she was called to the nurses' station where Resident #41 was found face down on the floor. Resident #41's injuries included a hematoma below the left knee, a bruise forming on her forehead, and abrasion and swelling of her nose. The incident report indicated Resident #41's pain was rated at a 9 out of 10. Resident #41 was sent to the emergency room. The incident report indicated Resident #41 was oriented. The incident report indicated predisposing physiological factors were confusion, gait imbalance, and impaired memory. The incident report indicated the predisposing situation factor was ambulating without assistance. The incident and accident report provided failed to mention any interventions implemented for Resident #41. *4/20/2023 LVN N documented she was informed Resident #41 fell to her knees in the hallway. The incident indicated Resident #41's injury was an abrasion to her left knee. The incident report indicated Resident #41's mental status was oriented. The incident report indicated Resident #41's predisposing factors were confusion, gait imbalance, and impaired memory. The incident report indicated the predisposing situation factors included ambulating without assistance. The incident report provided failed to mention any interventions implemented for Resident #41. *6/21/2023 LVN N documented Resident #41 was ambulating in the hallway with this nurse and Resident #41 tripped while walking. The incident report indicated she was assisted to a wheelchair, then her reclining chair, and was found to have no injuries. The incident report indicated Resident #41's mental status was oriented to person, place, and situation. The incident report indicated Resident #41 predisposing factors were drowsy, and gait imbalance. The incident report provided failed to mention any interventions implemented for Resident #41. *6/27/2023 LVN O documented Resident #41 was standing at the nurses' station and lost her balance. The incident report indicated Resident #41 fell and landed on her left shoulder and hit her left temporal area. The incident report indicated Resident #41 was crying and complained of pain rated at an 8 out of 10 and was hurting all over. The incident report indicated Resident #41 was sent to the emergency room. The incident report indicated Resident #41's mental status was oriented to person only. The incident report indicated Resident #41's predisposing physiological factors included confusion, current UTI, gait imbalance, and impaired memory. The incident report indicated Resident #41's predisposing situation included ambulating without assistance. The incident report provided failed to mention any interventions implemented for Resident #41. *8/03/2023 at 11:25 a.m., LVN N documented Resident #41 was being assisted up from the floor in the hallway by 4 staff members to a wheelchair. The incident report indicated Resident #41 had an abrasion and bruising to her left knee. The incident report indicated Resident #41 had an x-ray ordered. The incident report indicated Resident #41 was oriented. The incident report indicated Resident #41's predisposing physiological factors included gait imbalance and impaired memory. The incident report indicated Resident #41's predisposing situation factors included ambulating without assistance. The incident report provided failed to mention any interventions implemented for Resident #41. *8/31/2023 at 2:26 p.m., LVN O documented Resident #41 was found lying on the floor on multiple blankets by the cleaning staff. Resident #41 was asked if she fell, and she replied yes. The incident report indicated Resident #41's family was asked to review the camera footage to evaluate if Resident #41 fell but the family indicated Resident #41 was not in view of the camera. The incident report indicated Resident #41 had no injuries. The incident report indicated Resident #41's mental status was oriented to person only. The incident report indicated Resident #41's predisposing physiological factor was confusion. The incident report indicated Resident #41's predisposing situation factors included ambulating without assistance and being a wanderer. The incident report failed to mention any interventions implemented for Resident #41. *8/31/2023 at 8:30 p.m., LVN O documented Resident #41 was found on the floor attempting to cover herself with a blanket. The incident report indicated Resident #41 was unable to describe how she ended up on the floor. The incident report indicated Resident #41 had no injuries. The incident report indicated Resident #41's predisposing factors included she had confusion. The incident report indicated Resident #41's predisposing situation was ambulating without assistance, and she was a wanderer. Record review of a Fall Interventions in-service dated 5/15/2023 provided by the DON indicated: *Universal fall precautions: Universal fall precautions are called universal because they apply to all patients regardless of fall risk. Universal fall precautions revolve around keeping the patient's environment safe and comfortable. *Familiarize the patient with the environment *Have the patient demonstrate call light use. *Maintain call light within reach. *Keep the patient's personal possessions within patient safe reach. *Have sturdy handrails inpatient bathrooms, room, and hallway. *Place the hospital bed in low position when a patient is resting in bed; raise bed to a comfortable height when the patient is transferring out of bed. *Keep hospital bed brakes locked. Keep wheelchair wheel locks in locked position. *Keep nonslip, comfortable, well-fitting footwear on the patient. *Use night lights or supplemental lighting. *Keep floor surfaces clean and dry. Clean up all spills promptly. *Keep patient care areas uncluttered. *Follow safe patient handling practices. *Involve resident/patient/family to discuss appropriate interventions. *Anticipate toileting needs and incontinence management. *Use of positioning devices; frequent change in position. *Keep personal items within reach. *Manage behavior symptoms by knowing *Diversional activity program of resident/patient preference *Verify transfer code and safety measures by looking on the CNA care Kardex in the computer system. Record review of a fall risk evaluation dated 9/08/2023 indicated Resident #41 has had 3 or more falls in the past three months, she had intermittent confusion, ambulatory and continent, no dropping of the blood pressure from lying to standing and her vision was adequate. The fall risk indicated she had had no changes in condition during the last 14 days and no recent hospitalizations, her gait was normal, and takes 3-4 medications. 5. Risk of falls area had no focus, no goal and no interventions marked. Section Clinical Suggestions there were no options coded. The fall risk assessment copy did not indicate the assessor. During an interview on 9/14/2023 at 9:10 a.m., CNA B said she was unaware of Resident #41 having a history of falls. CNA B said she was not aware of any fall prevention interventions for Resident #41. CNA B said she was assigned to care for Resident #41. During an interview on 9/15/2023 at 12:15 p.m., the ADON said the fall process included: after a fall the nurse completes an assessment including vital signs, neurological checks initiated and a pain assessment. The ADON said the nurse managers were notified. The ADON said interventions were implemented and placed in the Kardex POC (Point of Care) system such as a fall mat. The ADON said the fall care plan should reflect interventions with each fall. The ADON said implementing fall interventions after falls could prevent other falls. The ADON said Resident #41 was a high fall risk. The ADON said the interventions were monitored through rounds. During an interview on 9/15/2023 at 1:57 p.m., the DON said the fall process included the nurses completing a physical assessment, completing the risk assessment report, notification of the family, doctor, and management nurses. The DON said with fractures or head injuries both the administrator and she was notified. The DON said new interventions were placed in the care plan, the point of care (Kardex) and through broad stream in-servicing. The DON said Resident #41 was a high fall risk. During an interview on 9/15/2023 at 7:08 p.m., the Administrator said when a resident had a fall, he expected an incident report to be completed, to determine if the result of the fall was a physical change. The Administrator said the care plan should be updated by the nurses. The Administrator said sometimes being creative was required to implement new interventions. The Administrator said Resident #41 was a fall risk. Record review of a Falls Clinical Protocol dated March 2018 indicated: 1. They physician will help identify individuals with a history of falls and risk factors for falling c. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underling cause. 2. In addition, the nurse shall assess and document/report the following: g. frequency and number of falls since last physician visit; i . All current medications, especially those associated with dizziness or lethargy. 3.b. After a first fall, the staff (and physician, if possible) should watch the individual rise from a chair without using his or her arms, walk several paces, and return to sitting. If the individual has no difficulty or unsteadiness, additional evaluation may not be needed. If the individual has difficulty or is unsteady in performing this test, additional evaluation should occur. 4.a. Falls often have medical causes; they are not just a nursing issue. Cause Identification: 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Monitoring and Follow-Up: 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. 5. As needed, and after an appropriately thorough review, the physician will document any uncorrectable risk factors and underlying causes . Record review of a Falls and Fall Risk, Managing policy dated March 2018 indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 4. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. Record review of facility policy, Food Holding dated June 1, 2019, indicated, To ensure that all food served by the facility is of good quality and safe for consumption all food will be held and served according to the state and US food code and HACCP guidelines. A food sample temperature chart reveals coffee should be between 160 and 180 degrees. This was determined to be an Immediate Jeopardy (IJ) situation on 09/14/23 at 2:14 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 09/14/23 at 2:24 a.m. and requested a Plan of Removal (POR). The Plan of Removal (POR) was accepted on 09/15/23 at 4:20 p.m. and indicated the following: Immediate action: Facility failed to implement measures to prevent other coffee spills with burns. 1. Resident #249 was admitted on [DATE] with diagnoses of dementia, anxiety, and heart failure. 2. Resident #42 was admitted on [DATE] with the diagnoses of Dementia, anxiety, hypertension, and depression. 3. All residents will have a hot liquid screening tool completed by the nursing admin to be completed. Completion Date: 9/14/2023 4. Residents identified at risk will have relevant adaptive devices (lids, vinyl apron, [NAME] cups, etc.) initiated based on hot fluid screening tool completed on 09/15/2023. Staff to document in E.H.R. when resident refuses to use relevant adaptive devices. Completion Date: 9/15/2023 5. Newly admitted /re-admitted residents will have hot liquid screening tool completed at time other admission/readmission assessments are being completed and if identified at risk and any relevant adaptive equipment within 24 hours. 6. Care plans will be updated by the Facility MDS Nurse and Regional Support MDS nurse as needed to reflect any changes in hot liquid status based on new hot liquid screening conducted 09/15/2023. Completion Date: 9/15/2023 7. In-service initiated for hot liquid by nursing administration (DON, ADON, MDS Nurse) and staff (Lic. And non-lic. Direct Care staff, Therapy, Dietary) will be in-serviced prior to the next scheduled shift starting 9/15/2023. Policy includes steps to do when Hot Liquid Spill Occurs, from resident skin check, to temping the liquid/food item, to completing a Hot Liquid Screening Tool (PCC UDA), to updating care plan, Nutrition management adding relevant adaptive item if need identified. Completion Date: 9/15/2023 8. DON In serviced Staff on 8/15/[TRUNCATED]

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

Deficiency F0825 (Tag F0825)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability, or services of a lesser intensity as set forth at §483.120(c) for 14 of 15 residents (Resident #33, Resident #28, Resident #6, Resident #8, Resident #100, Resident #17, Resident #45, Resident #149, Resident #15, Resident #2, Resident #41, Resident #27, Resident #12, and Resident #99) for residents observed for specialized rehabilitative services. The facility failed to provide Resident #33 with physician ordered physical therapy from the admission date of [DATE]. The facility failed to provide Resident #99 with physician ordered physical therapy from the admission date of [DATE]. The facility failed to implement Resident #99's physical therapy evaluation recommendations of 5 times weekly for 4 weeks. The facility failed to ensure therapy services were provided as ordered for Resident #33, Resident #28, Resident #6, Resident #8, Resident #100, Resident #17, Resident #45, Resident #149, Resident #15, Resident #2, Resident #41, Resident #27, Resident #12, and Resident #99 consistently from [DATE] until [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 9:10 AM. While the IJ was removed on [DATE] at 2:59 PM, the facility remained out of compliance at potential harm that is not immediate jeopardy with a scope identified as a pattern due to the facility's need to complete in-service training, daily validation of physical therapy staff, weekly monitoring of staff knowledge of the abuse and neglect policy and evaluate the effectiveness of the corrective systems. These failures could place residents who had orders for physical therapy at risk of not having their rehabilitation needs met and possibly resulting in serious impairment likely to occur as a result of decline in physical abilities. Findings included: 1.Record review of Resident #33's face sheet dated [DATE] indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of fracture of left femur, falls, anxiety, high blood pressure, and pain. Record review of Resident #33's MDS dated [DATE] indicate she had a BIMS score of 13 which meant she had mildly impaired cognition. The MDS also indicated that Resident #33 required limited assist of 1 staff for bed mobility, dressing, and toileting, limited assist of 2 staff for transfers, and extensive assist of 1 staff for bathing. The MDS also indicate Resident #33 had 0 minutes of physical therapy in the last 7days. Record review of Resident #33's physician orders dated [DATE] indicated the order for PT to evaluate and treat that started on [DATE]. Record review of Resident #33's care plan last revised on [DATE] indicated she had ADL self-performance deficit with a goal to improve current level of function and an intervention to have therapy services as indicated. Record review of Resident #33's therapy notes dated [DATE]-[DATE] indicated resident only had a physical therapy evaluation and plan of treatment on [DATE] and no other treatments until after surveyor intervention on [DATE], [DATE] and [DATE]. During an interview on [DATE] at 06:15 PM the Administrator said the facility did not have a policy on therapy services, but he had a therapy services agreement. During an observation and interview on [DATE] 10:47 AM Resident #33 was lying in bed. She said she was unaware the facility did not have a physical therapist but had expected to receive physical therapy services when she agreed to come to the facility. She said she had been completing some type of therapy. During an interview on [DATE] at 02:40 PM the Director of Rehab said she had been the Director of Rehab since January of 2023. She said she was responsible for staffing the physical therapists in the facility. The Director of Rehab said the physical therapist last hired had been out of the facility since [DATE]. She said [DATE] was supposed to be the first date of work but his licensed were expired. The Director of Rehab said the physical therapist worked [DATE], and [DATE], and missed work on [DATE], related to medical issues. The Director of rehab said residents who had physical therapy orders were evaluated by a telehealth physical therapist and they had a prn PT that was supposed to come in, but never came. She said none of the residents with physical therapy orders had been seen for physical therapy treatment. She said she had text several workers that said they would come in to work as physical therapist but did not show on the day they were scheduled to treat. The Director of Rehab said she had talked to her boss, the Regional Director of operations, repeatedly to notify her that there had been no physical therapist in the building. She said the facility held a level of care meeting weekly with the regional director of operations included on the call. She said in that meeting the therapy minutes were discussed. She said she talked to the administrator about the problem several times and he was aware of the facility not having a physical therapist. The Director of Rehab said when residents had admitted to the facility it was not discussed that the facility did not have a physical therapist in the facility to treat when services were ordered. She said it was important for the residents to receive the physical therapy treatments if ordered to ensure they reach their rehabilitation goals. The Director of Rehab said residents not receiving therapy they had ordered could have caused continued weakness or gait problems. She said she did not think they would decline because she was provided extra occupational therapy when she treated residents. She said she did not see the difference in the resident getting PT and OT except the treatment plan. The Director of Rehab said the occupational therapists treat the residents daily. She said she saw the facility not having a physical therapist as a failure but not in failure in treatment. When asked why she thought that she had been notifying her boss and the administrator of the lack of a physical therapist, they never assisted in getting a physical therapist in the facility, on [DATE] after surveyor intervention, the facility had a physical therapist that came in the building to treat all residents with physical therapy orders, She started to get upset and cry and said she did not know. During an interview on [DATE] at 03:09 PM the Regional Director of Operations said the facility had had a physical therapist periodically. She said the full-time physical therapist had an un-foreseen diagnosis and been out of the building since [DATE]. She said Telehealth were performed for evaluations on residents that had orders for physical therapy. The Regional Director of Operations said she was made aware on [DATE] of there being residents who had not received further treatments. She said the Director of Rehab notified her by phone. The Regional Director of Operations said the Director of Rehab had notified her about call-ins in august but not since [DATE]. She said she did not know no residents with physical therapy ordered were not receiving physical therapy. She said with the resident not getting physical therapy as ordered, if could have caused a negative effect on their mobility and bed mobility. The Regional Director of Operations said she spoke with the facility administrator today about the issues. She said the Director of Rehab was responsible for staffing the physical therapy in facility, and she did not have a monitoring tool to ensure the ordered therapy was staffed and being completed. The Regional Director of Operations said the facility held weekly calls where she was aware that physical therapy did not have a full-time physical therapist, but as a regional she did not always attend the meetings about the visits. She said the facility did not communicate to the residents and families as they admitted that they could not provide physical therapy services. During an interview on [DATE] at 03:46 PM the DON said she said she was not aware that the facility did not have a physical therapist in the building. She said she thought the physical therapist telehealth were being completed for evaluations when they received new physician orders for physical therapy, and a physical therapy assistant was completing the in-house treats. The DON said she just found out when the administrator notified her of the investigations on [DATE]. The DON said it was important for the residents to receive the physical therapy services if they have orders. She said the risk to the residents not receiving the physical therapy treatments as ordered was decreased mobility, weight loss, or an exacerbation of what the residents had admitted to the facility for. The DON said the rehab company was responsible for ensuring the physical therapist was in the facility as scheduled to treat all residents with physical therapy orders. She said she did not attend any of the meetings that therapy had for level of care or to discuss minutes in therapy. During an interview on [DATE] at 07:00 PM the Administrator said he expected the therapy services to be provided. He said the Director of Rehab was responsible for ensuring the residents with Physical therapy orders receive the treatment ordered and would expect every day a validation to ensure the therapy was provided and to be continued as a component in their morning clinical meetings. The risk to the resident was a risk for time delay in healing. The Administrator said as a non-clinician he could not say the physical mobility would have a declined, but he could say that the residents could be more upset by not receiving the therapies ordered. 2.Record review of a face sheet dated [DATE] indicated Resident #99 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of wedge compression fracture of the third lumbar vertebra (fracture of the lower spine), heart failure, and a heart attack. Record review of the Baseline Care Plan dated [DATE] indicated in the summary section Resident #99 admitted to the facility for therapy and skilled nursing care. The baseline care plan summary also indicated Resident #99's plan was to discharge home at prior level of functioning with home health services. Record review of consolidated physician orders dated [DATE] indicated Resident #99 was ordered on [DATE] physical therapy to evaluate and treat as indicated. Record review of the admission MDS dated [DATE] indicated Resident #99 was understood and understands others. The MDS indicated Resident #99's BIMS score was 10, indicating her cognition was moderately impaired. The MDS indicated Resident #99 was extensive assistance of two staff for bed mobility, and transfers. Resident #99 required extensive assistance of one staff for dressing, toileting, bathing, and personal hygiene. The MDS indicated Resident #99 did not receive any minutes of physical therapy and received 38 minutes of occupational therapy over the last 7 days. Record review of a Physical Therapy Evaluation and Treatment indicated Resident #99 was evaluated for on [DATE] for the start of the certification period of [DATE] - [DATE]. The physical therapy evaluation indicated Resident #99 had compression fractures of her lower back, lack of coordination, abnormal gait and mobility and muscle weakness. The evaluation indicated Resident #99 would receive physical therapy 5 times a week for 4 weeks. The goal of the physical therapy plan indicated Resident #99 would be able to return home. The physical therapy plan indicated Resident #99 demonstrated good rehab potential as evidenced by the ability to follow multi-step directions. During an observation and interview on [DATE] at 12:45 p.m., Resident #99 was eating her noon meal. Resident #99 said she had not had physical therapy since she arrived. Resident #99 said she was walking before her admission. Resident #99 said she could not walk now. During an interview on [DATE] at 10:59 a.m., Resident #99's family member indicated Resident #99 had admitted to the facility specifically for physical therapy. Resident #99's family member further said they chose this facility because they accepted her insurance as the payor source. The family member said she had gone to the Administrator; then the DON and she sent me to the SW with no resolution as to why the resident had just laid there with no physical therapy. Resident #99's family member said she was so upset she discharged Resident #99 and took her to a hospital her physician advised an hour away from the facility. During an interview on [DATE] at 3:44 p.m., the DOR said the physical therapist assistant had not worked since [DATE]. The DOR said she has had a physical therapist sporadically but not on regular basis. The DOR said she had reached out to the RDO of the therapy group and had not had the position filled. The DOR said she provided occupational therapy which overlapped with the physical therapy. The DOR said she had not provided the recommended physical therapy as the physical therapist indicated was needed for Resident #99 to reach her goals. The DOR said the Administrator and the RDO of the therapy company was aware there was not a physical therapist to provide treatments. During an interview on [DATE] at 12:15 p.m., the ADON said she was unaware the residents with ordered physical therapy was not receiving the physical therapy. The ADON said she could not say if a resident would have a negative outcome due to not receiving physical therapy, but she indicated a resident would have to stay longer in the nursing facility to meet their goals. During an interview on [DATE] at 1:40 p.m., the DON said she was not notified of not having a physical therapist on site to provide physician ordered therapy treatment. The DON said neglect could be not providing services. The DON said abuse and neglect could continue without prevention and investigation. During an interview on [DATE] at 7:15 p.m., the Administrator said he had reviewed the residents who had not received their ordered therapy and had found no residents had suffered a decline in their function. The Administrator said but if it had been him who had not received the ordered physical therapy he would have been upset as well. The Administrator said he was expected to follow the facility policies. The Administrator said to always put the residents first by abiding by the abuse policy. The Administrator said when the abuse policy was not followed there was a risk for the resident not to be advocated for. 3. Record review of the face sheets and physical therapy evaluations and treatments for the residents on service the month of [DATE] and [DATE] indicated: Resident #33 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received no physical therapy treatments until after surveyor intervention on [DATE] by PT W, [DATE] by PT W and [DATE] by PTA XX . Resident #28 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 3 treatments of physical therapy on [DATE] by PT W, [DATE], and [DATE] by PTA YY. Resident #6 re-admitted to the facility on [DATE] and facility had an order for physical therapy evaluation, but no evaluation nor treatments were found. Resident #8 re-admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 1 treatment on [DATE] and 1 treatment after surveyor intervention on [DATE] by PT W. Resident #100 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 1 treatment after surveyor intervention on [DATE] by PT W. Resident #17 re-admitted to the facility on [DATE] and had a physical therapy evaluation completed showed incomplete and resident received 1 treatment after surveyor intervention on [DATE] PT W. Resident #45 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 1 treatment after surveyor intervention on [DATE] by PT W. Resident #99 admitted to the facility on [DATE] and discharged AMA on and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received no therapy treatments Resident #149 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 1 physical therapy treatment after surveyor intervention on [DATE] by PT W. Resident #15 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 3 times a week for 30 days and received physical therapy treatments twice weekly on [DATE], [DATE] by PTA ZZ, [DATE], [DATE] by PTA YY, [DATE], [DATE] by PTA BBB, [DATE], [DATE], and [DATE] by PT W after surveyor intervention. Resident #2 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 4 physical therapy treatments on [DATE], [DATE] by PT W, [DATE],[DATE] by PTA YY, and 1 treatment after surveyor intervention on [DATE] by PT W. Resident #41 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 3 times a week for 30 days and received no physical therapy treatments. Resident #27 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 5 physical therapy treatments on [DATE] by PT W, [DATE], [DATE] by PTA BBB, [DATE], [DATE] by PTA YY and 1 treatment after surveyor intervention on [DATE] PT W. Resident #12 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 3 times a week for 4 weeks and received 3 physical therapy treatments on [DATE] by PT W, [DATE], [DATE] by PTA YY, and 1 treatment after surveyor intervention on [DATE] by PT W. Record review of the Therapy Services Agreement for Lakeside Health and Wellness dated [DATE] indicated This Therapy Services Agreement (Agreement) is made by and between . 1. Services: a. Therapy and Related Services . i.physical, occupational, and speech therapy services, including clinical supervision of such services, in accordance with physician's orders and the applicable plan of care ii.clinical oversight, subject to Customer's direction, of (A) overall caseload and documentation support and (B) focused clinical communication, including interaction with local referral sources . The Administrator was notified on [DATE] at 10:35 AM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on [DATE] at 10:41 AM. The facility's Plan of Removal was accepted on [DATE] at 07:27 AM and included: 825 - The facility failed to provide the services of physical therapy. Resident #33 admitted to the facility with a repaired femur fx on [DATE].Physical therapy was ordered on [DATE] and no services were provided. Resident #99 admitted to the facility on [DATE] with orders to receive physical therapy. Facility failed to provide physical therapy to residents #33 and #99. This failure has the potential to affect all residents with orders for physical therapy. 1. Resident #99 discharged AMA to hospital. Resident #33 was immediately assessed for any negative outcome as a result of not having physical therapy. 2. All residents with orders for physical therapy evaluated by licensed physical therapist, in-person on [DATE]. 3. All residents with orders for physical therapy to begin face-to-face treatments as ordered by licensed physical therapy staff as of [DATE]. 4. Contract Rehab provider to provide schedule of in-person physical therapy coverage over the next 30 days. Additional oversight hired that is licensed P.T. as of 9/14 to start to validate contractor has physical therapist in building and will subcontract to provide therapy backup. 5. Continuous physical therapy staff presence in facility will be validated and monitored by administrator daily. 6. IF no physical therapists occurs (not available to treat), facility will not admit residents with physical therapy orders until a physical therapists is available to treat. 7. Continuous Presence of in-person physical therapy will be reviewed monthly with medical director at facility QAPI meeting. Facility had the responsibility to protect residents from neglect that could cause regression and decline in ADL function. 1. All residents with orders for physical therapy to begin face-to-face treatments as ordered by licensed physical therapy staff as of [DATE]. 2. Contract Rehab provider to provide schedule of in-person physical therapy coverage over the next 30 days. Additional oversight hired that is licensed P.T. as of 9/14 to start to validate contractor has physical therapist in building and will subcontract to provide therapy backup. 3. Continuous physical therapy staff presence in facility will be validated and monitored by administrator daily. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of face-to-face physical therapy treatments performed for all residents who had physical therapy orders completed on [DATE] by a licensed physical therapist. Record review of the [DATE] and the [DATE] schedule which included a physical therapist assistant to treat Monday through Friday. Interviews of staff on [DATE] between 10:47 AM and 02:55 PM (Dietary Manager, CNA EE, LVN FF, LVN GG, RN G, Housekeeping Supervisor, Dietary [NAME] HH, CNA II, Social Worker, Comfort aide S, RN F, Dietary [NAME] P, CNA JJ, RN DD, LVN N, LVN LL, ADON, Maintenance Manager, Administrator, DON, MDS Nurse, CNA MM, Housekeeping aide KK, Activity Director, RN NN, Dietary aide OO, LVN O, CNA T, Marketing Director, Housekeeping aide PP, Housekeeping aide QQ, Business Office Manager, RN Q, People Operations, Receptionist, Staffing Coordinator AA, MA C, Rehab Director, Regional Director of Operations, COTA RR, PTA SS) were performed. During the staff interviews the staff were able to correctly identify the types of abuse and neglect definition. The staff were able to indicate who the Abuse coordinator was as well as when and who to report abuse and neglect. During an interview with the Administrator on [DATE] at 01:10 PM he said that he had measuress in place to monitor and validate to ensure there were therapists in the facility daily to ensure ordered treatments were completed. During an observation on [DATE] at 02:30 PM PT VV was in the therapy gym providing treatments. On [DATE] at 02:59 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at potential harm that is not immediate jeopardy with a scope identified as a pattern due to the facility's need to complete daily validation of physical therapy staff by the Administrator and to evaluate the effectiveness of the corrective systems.

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Administration (Tag F0835)

Someone could have died · This affected multiple residents

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Based on interviews, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being for 48 of 48 residents reviewed. The administrator failed to follow the abuse and neglect policy. The administrator failed to collaborate with the regional director of the rehab company to ensure therapy services were provided as ordered. The administrator failed to monitor the director of rehab services to ensure the proper staff were available to provide physical therapy as ordered by the physician. The IP failed to ensure interventions were put in place to prevent an increase in UTIs. An Immediate Jeopardy (IJ) situation was identified on 09/14/23. While the IJ was removed on 09/15/23 at 6:47 p.m., the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at an increased risk for abuse, further abuse, increased anxiety, emotional distress, depression, neglect, and retaliation. Findings included: 1.Record review of physical therapy orders for Residents #99, # 33, #28, #6, #17, 170, #45, #149, #15, #2, #41, #27 and #12 were reviewed and they were not receiving therapy as ordered. During an interview on 9/12/2023 at 3:44 p.m., the DOR said the physical therapist assistant had not worked since July 31, 2023. The DOR said she has had a physical therapist sporadically but not regularly. The DOR said she had reached out to the RDO of the therapy group and had not had the position filled. The DOR said she had not provided the recommended physical therapy as the physical therapist indicated was needed for Resident #99, # 33, #28, #6, #17, 170, #45, #149, #15, #2, #41, #27 and #12 to reach their goals. The DOR said the Administrator and the RDO of the therapy company were aware there was not a physical therapist to provide treatments. During an interview on 09/12/23 at 4:55 p.m., the administrator said he was aware physical therapy had a staffing issue at some unknown point but thought it was resolved. During an interview on 09/13/23 at 03:09 PM the Regional Director of Operations said the facility had had a physical therapist periodically. She said the full-time physical therapist had an un-foreseen diagnosis and been out of the building since August 15, 2023. She said Telehealth were performed for evaluations on residents that had orders for physical therapy. The Regional Director of Operations said she was made aware on 09/12/23 of there being residents who had not received further physical therapy by the Director of Rehab. The Regional Director of Operations said the Director of Rehab had notified her about call-ins in august but not since 9/1/23. She said she did not know no residents with physical therapy ordered were not receiving physical therapy. She said the Director of Rehab was responsible for staffing the physical therapy in facility. The Regional Director of Operations said the facility held weekly calls where she was aware that physical therapy did not have a full-time physical therapist, but as a regional, she did not always attend the meetings about the visits. She said with the residents not getting physical therapy as ordered, if could have caused a negative effect on their mobility and bed mobility. 2.Record review of the facility's quality assessment and assurance process for UTIs dated 05/12/23, revealed a performance improvement process was put into place on 05/12/23 and no other updates were put in place until mentioned by the surveyor on 09/14/23. During an interview on 09/15/23 at 12:16 p.m., the ADON said when she identified the facility had an increase of UTIs back in May 2023, they started doing random peri-care checkoffs and hand washing. She said she did notice some decrease in the number of UTIs and felt her plan of action was effective. She said she tried to update the infection log daily but at least weekly. She said she did notice last month (August 2023) had an increase in UTIs. She said she had not implemented anything on paper but had started doing peri care, handwashing, and verbal communication with staff. She said she was responsible for ensuring staff was following the infection control policy. She said part of her process as the infection preventionist was to review the UA results, look to see if they meet the Mcgeers criteria (used for retrospectively counting true infections, to meet the criteria for definitive infection, more diagnostic information (e.g., positive laboratory tests) is often necessary), and educate facility staff and hospice as needed. She said it was important to push fluids and perform good peri care and handwashing to prevent UTIs. Record review of the Therapy Services Agreement for [facility] Health and Wellness dated 02/16/2021 indicated This Therapy Services Agreement (Agreement) is made by and between . 1.Services: a. Therapy and Related Services .i.physical, occupational, and speech therapy services, including clinical supervision of such services, in accordance with physician's orders and the applicable plan of care ii.clinical oversight, subject to Customer's direction, of (A) overall caseload and documentation support and (B) focused clinical communication, including interaction with local referral sources . Record review of the Resident Abuse and Neglect Policy section H. RECOGNIZING SIGNS AND SYMPTOMS OF ABUSE/NEGLECT dated 2021 indicated, Our Facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all team members are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing immediately. The following are some examples that include but are not limited to and may be abuse/neglect signs and symptoms that should be promptly reported to determine if they meet the current state/federal reporting requirements. All suspicions shall be reported . Record review of the Resident Abuse and Neglect Policy section L. STAFF RESPONSIBLE FOR COORDINATING/IMPLEMENTING ABUSE PREVENTION dated 2021 indicated, The Administrator Facility Abuse Coordinator assumes the responsibility for the overall coordination and implementation of our community's abuse prevention program policies and procedures. POLICY INTERPRETATION AND IMPLEMENTATION The Administrator has the overall responsibility for coordination and implementation of our Facility's abuse prevention program policies and procedures . Record review of facility policy, Infection Control dated August 2016, indicated The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. 1. Coordination and Oversight. a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). c. The infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include: 7. Prevention of Infection a. Important facets of infection prevention include: (I) identifying possible infections or potential complications of existing infections; (2) instituting measures to avoid complications or dissemination.3) educating staff and ensuring that they adhere to proper techniques and procedures. (4) enhancing screening for possible significant pathogens. This was determined to be an Immediate Jeopardy (IJ) situation on 09/14/23 at 2:14 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 09/14/23 at 2:24 a.m. and requested a Plan of Removal (POR). The Plan of Removal (POR) was accepted on 09/15/23 at 4:20 p.m. and indicated the following: Immediate action: The facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 1. Administrator to receive Abuse and Neglect education/in-service to be provided to on 9/13/2023 by Director of Resident Care & Education (RN Regional). Completion Date: 9/13/2023 2. Director of Resident Care & Education (RN Regional) to perform weekly random Q&A validation on what constitutes neglect, and examples of abuse and neglect. Findings will be shared with the SVP of Operations (Supervisor of Administrator) 3. Regional Rehab Director (contracted provider), Subcontractor Therapy Oversight PT to review with Administrator therapy staffing schedule weekly. The schedule will be shared with SVP of Operations (Supervisor of Administrator). 4. SVP of Operations in-serviced Administrator & DON on the oversight by SVP Operations and by Therapy subcontractor. Completion Date: 9/14/2023 5. DOR (Dir. of Rehab) to inform Administrator daily re: physical therapy discipline onsite and no later than noon, to allow a backup plan to be put in motion of notifying Regional Rehab Dir. and the Subcontractor Oversight Therapist. 6. In Weekly Clinical Care (SOC) meetings DOR to report changes in therapy frequency treatment plans and let DON and Administrator know if this differs from order and goals and if rationale is documented in resident E.H.R. 7. Continuous Presence of in-person physical therapy will be reviewed monthly with medical director at facility QAPI meeting. 8. DON/ADON to review residents with UTI's and MDS nurse(s) to update/revise care plans with interventions and update orders as needed to reduce potential for re-occurrence. Completion Date: 9/15/2023. During interviews and record reviews on 09/15/2023 from 4:20 p.m. until 6:40 p.m., the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ. Record review of in-service abuse, neglect, and reporting with administration staff dated 09/13/23. Record review of therapy schedule for September and October 2023 revealed they had a physical therapist scheduled. Record review of rehab reporting requirements dated 09/14/23 starting 09/15/23, signed by SVP administrator, facility administrator, and DON. Record review of care plans for 3 residents with current UTIs all updated 09/14/23 for Resident #11, #14, and #26. During an interview on 09/15/23 at 3:00 p.m., the ADON said she had been trained on the infection control process by the regional nurse which included a PowerPoint overview about infection and the process for infection control meeting and things needed to be done to prevent further infections. During an interview on 09/15/23 at 4:40 p.m., the director of rehab said she was to report her staffing to the administrator daily by noon. She said if someone were to call in sick, she would notify her regional director or designate. She said she would be attending standards of care (SOC) meetings weekly and if there had been a change in therapy such as missed visits, or a resident refusing therapy, she needed to have justification and notify the administrator. She said she had given the administrator a tentative schedule through October 2023. During a telephone interview on 09/15/23 at 6:18 p.m., the regional nurse said she would be doing weekly Microsoft team calls with the facility and asking questions about what abuse is, who is the abuse coordinator, and what were examples of abuse and neglect. She said staff could use their phones or facility computers. She said she had a Microsoft team meeting this morning (09/15/23) about abuse and infection control issues. During an interview on 09/15/23 at 6:41 p.m., the administrator said as part of their plan of removal he would be receiving updates on therapy services daily. He said he would be attending all meetings to ensure things were not missed. He said it was important to receive therapy as ordered and he was responsible for ensuring residents were receiving therapy as ordered. He said he had training on reporting, and he said everything he was supposed to report would be reported and investigations. The administrator said the risk to the resident was for the resident not being advocated for and placed them at risk for abuse and neglect to continue. On 09/15/2023 at 6:47 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that was not in immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Infection Control (Tag F0880)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of a face sheet dated [DATE] indicated Resident #250 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included encephalopathy(brain disease, damage, or malfunction), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem-solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the baseline care plan dated [DATE] indicated Resident #250 required one person assistance with personal hygiene, toilet use, dressing, and bathing. Resident #250's baseline care plan indicated he was always incontinent of bowel and bladder. Record review of Resident #250's electronic health record on [DATE] indicated he did not have a completed MDS assessment. During an observation and interview on [DATE] starting at 3:50 PM, Agency CNA A put on gloves and cleaned Resident #250's front genital area. Agency CNA A did not perform hand hygiene prior to putting on gloves to begin providing resident care. After Agency CNA A cleaned Resident #250's front genital area, she turned him on his side, and wiped his buttocks clean because he had had a small bowel movement. Agency CNA A then applied the clean brief and fastened it. Agency CNA A did not change gloves or perform hand hygiene prior to applying the clean brief. Agency CNA A with the dirty gloves repositioned Resident #250 in his bed and covered him up. After this, Agency CNA A grabbed Resident #250's remote control with the dirty gloves and adjusted the bed for him. Agency CNA A removed her gloves and took the trash out of the room and disposed of it. Agency CNA A did not perform hand hygiene after removing her gloves. Agency CNA A said she did not perform hand hygiene prior to the start of care, after removing her gloves, and after providing care because she forgot about that part. Agency CNA A said it was important to perform hand hygiene before and after patient care and after removing her gloves to prevent the spread of germs. Agency CNA A said she had not been checked off on incontinent care. Agency CNA A said not changing her gloves could cause the spread of infection and lead to urinary tract infections with E. Coli. Agency CNA A said she was responsible for providing proper incontinent care and performing hand hygiene. was her first day at this facility. Agency CNA A said she was not a facility employee. Agency CNA A said she was agency staff and today. 3. Record review of a face sheet dated [DATE] indicated Resident #17 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included cellulitis of the left lower limb (bacterial infection of the skin to the left lower leg), type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes blood sugar), and malignant neoplasm of the endometrium (cancer that originated in the uterus). Record review of the care plan with the date initiated of [DATE] indicated Resident #17 had an ADL self-care performance deficit and required assistance of 1 staff for personal hygiene and assistance of 2 staff for toileting. Record review of the comprehensive MDS assessment dated [DATE], indicated Resident #17 was able to make herself understood and understood others. The MDS assessment indicated Resident #17 had a BIMS of 13, which indicated her cognition was intact. The MDS assessment indicated Resident #17 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. During an observation and interview on [DATE] at 10:54 AM, Agency CNA B provided incontinent care to Resident #17. Agency CNA B did not wash her hands prior to providing incontinent care. Agency CNA B applied gloves and took off Resident #17's brief. Agency CNA B cleaned Resident #17's front genital area and turned Resident #17 on her side. Agency CNA B cleaned Resident #17's buttocks because she had a bowel movement and applied a clean brief. Agency CNA B did not change gloves or perform hand hygiene prior to applying the clean brief on Resident #17. Agency CNA B applied barrier cream to Resident #17's buttocks with her dirty gloves. Agency CNA B took off her gloves and put on new gloves. Agency CNA B did not perform hand hygiene prior to putting on the new gloves. Agency CNA B finished fastening Resident #17's brief. Agency CNA B took off her gloves and washed her hands. Agency CNA B said she did not perform hand hygiene prior to the start of care and in between glove changes because she was nervous. Agency CNA B said she should have changed gloves and performed hand hygiene prior to applying the clean brief. Agency CNA B said she did not do it because she was nervous and forgot. Agency CNA B said it was important to perform hand hygiene while providing incontinent care and to change gloves to prevention cross-contamination. Agency CNA B said she was checked off on incontinent care that morning by the Staffing Coordinator. Agency CNA B said she was agency staff not a facility employee. During an interview on [DATE] at 12:13 PM, the ADON said she expected incontinent care to be done correctly. The ADON said she expected the CNAs to perform hand hygiene before and after providing incontinent care, to change their gloves when going from dirty to clean, and in between glove changes. The ADON said not performing incontinent care correctly or hand hygiene could lead the resident to obtain a urinary tract infection and E. coli (bacteria commonly found in stool). The ADON said everyone was responsible for ensuring incontinent care was being performed correctly. During an interview on [DATE] at 01:37 PM, the DON said she expected incontinent care to be performed as per policy. The DON said she expected the CNAs to perform hand hygiene before and after providing incontinent care, to change their gloves when going from dirty to clean, and in between glove changes. The DON said not performing incontinent care correctly could lead to infection control issues. During an interview on [DATE] at 06:51 PM, the Administrator said he expected the clinical department to follow their policy when providing incontinent care. The Administrator said he expected the CNAs to perform hand hygiene before and after incontinent care and change their gloves after going from dirty to clean if that was what the policy indicated. The Administrator said he presumed infection could happen if improper incontinent care or hand hygiene were performed. Based on observation, interview, 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 hospitalization related to infections for 1 of 13 residents reviewed (Resident #16) for urinary tract infection (an infection in any part of the urinary system) and 4 of 6 residents reviewed for (Resident #250, Resident #17, Resident#35 and Resident #9) infection control practices. *The facility had 13 urinary tract infections for the month of [DATE]. 7 of 13 residents had Escherichia coli (E. coli- bacteria in urine) in their urine culture and Resident #16 was admitted to the hospital with sepsis(a serious condition that happens when the body's immune system has an extreme response to an infection) for UTI's. *The facility failed to provide employee in-services related to handwashing, peri-care, and/or catheter care. *The facility failed to ensure the agency staff were competent with peri-care, handwashing, and/or catheter *The IP failed to ensure the hospice services were following antibiotic stewardship. *Agency CNA A failed to perform hand hygiene and change her gloves while providing incontinent care to Resident #250. *Agency CNA B failed to perform hand hygiene and change her gloves while providing incontinent care to Resident #17. *CNA M failed to perform proper incontinent care for Resident #35. *CNA TT failed to perform proper incontinent care for Resident #9. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 6:47 p.m., the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for infection and hospitalization. Findings included: 1.Record review of Resident #16's face sheet, dated [DATE] indicated Resident #16 was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), and hypertension (high blood pressure). Record review of Resident #16's significant change in status MDS assessment, dated [DATE], indicated Resident #16 was understood and usually understood others. Resident #16's BIMs score was 01, which indicated she was cognitively severely impaired. Resident #16 required extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, limited assistance with bathing, and set-up assistance with eating. The MDS indicated she had a UTI in the last 30 days. Record review of Resident #16's comprehensive care plan, dated [DATE] indicated Resident #16 had an ADL self-care performance deficit related to confusion, dementia, and fatigue. activity intolerance and limited mobility. The interventions of the care plan were for staff to provide assistance with toilet use. Record review of Resident #16's hospital records dated [DATE] revealed a diagnosis of UTI with sepsis (occurs when your body has a life-threatening response to an infection). During an interview on [DATE] at 9:19 a.m., RN Q said he had noticed Resident #16's urine with an odor and dark in color and increased agitation. He said he had obtained an order to collect a urine sample on [DATE]. He said Resident #16 had a severe UTI and ended up in the hospital. He said she was placed on hospice service when she returned from the hospital. Record review of the facility's [DATE] monthly infection control data log revealed 13 residents who had UTIs of which 7 who had E. coli. Residents #1, #3, #11, #13, #27 and #199. Resident #16 was sent to the hospital on [DATE] with sepsis. Record review of in-service dated [DATE] revealed infection control: handwashing must be performed prior to starting and when finished with any task with residents, e.g.: peri care. Record review of the facility's quality assessment and assurance process for UTIs dated [DATE] revealed a performance improvement process was put into place on [DATE] and no other updates were put in place until mentioned by the surveyor on [DATE]. During an interview on [DATE] at 10:43 a.m., the facility NP said he knew the facility had quite a few UTIs last month but was not aware of how many. He said he had 3 more today ([DATE]). He said he recalled the facility asking for a UA for Resident #16. He said he gave orders for an antibiotic but was waiting on the culture to ensure he had her on the proper antibiotics. He said but before he could get the culture results back Resident #16 was admitted to the hospital on the ICU floor with sepsis and encephalopathy. He said sepsis was caused by an infection in the body. The facility NP said he was not sure what the facility had in place to prevent UTIs but said hygiene, nutrition, good peri care, and hydration played an important part in preventing UTIs. During a phone interview on [DATE] at 1:53 p.m., the medical director said he was not aware of all the UTIs the facility had last month. He said the facility usually notified the NP because he made rounds and would update him as needed. He said he was aware Resident #16 was in the hospital for sepsis and other comorbidities. He said she expired this morning ([DATE]). He said when a person becomes septic it could become a life-threatening medical situation because of the infection in a person's body. During an interview on [DATE] at 12:16 p.m., the ADON (who was the IP) said when she identified the facility had an increase of UTIs back in [DATE], they started doing random peri-care checkoffs and hand washing. She said she did notice some decrease in the number of UTIs and felt her plan of action was effective. She said she tried to update the infection log daily but at least weekly. The ADON said she was supposed to have her infection report completed by the 11th of each month. She said she did notice last month ([DATE]) had an increase in UTIs. She said she had not implemented anything on paper but had started doing peri care, handwashing, and verbal communication with staff. She said she was responsible for ensuring staff was following the infection control policy. She said nurse management had started doing peri care and handwashing check-offs Monday through Friday and increasing hydration. The ADON indicated the Hospice providers provide the facility with the prescribed antibiotic orders and did not report them to her. The ADON said the hospice providers treated according to signs and symptoms and did not obtain laboratory analysis. She said part of her process as the infection preventionist was to review the UA results, look to see if they meet the Mcgeers criteria (used for retrospectively counting true infections, to meet the criteria for definitive infection, more diagnostic information (e.g., positive laboratory tests) is often necessary), and educate facility staff and hospice as needed. She said it was important to push fluids and perform good peri care and handwashing to prevent UTIs. During an interview on [DATE] at 1:40 p.m., the DON said sepsis was a serious condition. She said the ADON was responsible for the infection control system. She said the ADON updated the infection control log at least weekly, but they talked about the residents who were placed on the infection log daily. The DON said it was important to update the infection control log so they could track and trend residents who had infections. She said when they noticed a pattern, they would implement an intervention as a team. During an interview on [DATE] at 3:00 p.m., the ADON said she had been trained on the infection control process by the regional nurse which included a PowerPoint overview about infection and the process for infection control meeting and information needed to be done to prevent further infections. During an interview on [DATE] at 7:01 p.m., the administrator said he expected nurses to inform the physician of any UA results and for the physician to prescribe whatever medication was needed. He said the DON and IP nurse should ensure UTIs were monitored and treated. He said residents who had UTIs should have good nutrition, increased fluids, and good peri care provided. He said it was important to track and trend infections to get to the root cause of infections. He said he was aware a diagnosis of sepsis was dangerous and could be life-threatening. 4. Record review of a face sheet dated [DATE] indicated Resident #9 was an [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with the diagnoses of high blood pressure and anxiety. Record review of an MDS dated [DATE] indicated Resident #9. The MDS was not scored for the BIMS score. The MDS indicated Resident #9 required extensive assistance for toileting and personal hygiene. Record review of the comprehensive care plan dated [DATE] and revised on [DATE] indicated Resident #9 was incontinent of bowel and bladder. The goal was Resident #9's risk for septicemia was minimized via prompt recognition and treatment of symptoms of a UTI. The interventions included clean peri-area with each incontinence episode, and monitor/document for s/sx UTI. During an observation and interview on [DATE] at 10:44 a.m., CNA TT and CNA M both washed their hands prior to care. The brief was removed downward. CNA M wiped one wipe on the left side and one wipe on the right side and one wipe down the middle of Resident #9's perineal area. CNA M did not cleanse the labia majora and labia minora. Resident # 9 was rolled to the right and she was cleansed on the buttocks three times wiping toward the perineal area instead of away. CNA M said she had wiped Resident #9 the wrong direction, wiping towards the perineal area. CNA M said she did not open Resident #9's labias to cleanse them. CNA M said not cleansing the labias and not wiping in the wrong direction could cause infections. Record review of an undated CNA Profieciency Check Off Perineal Care indicated CNA TT was proficient in the skill of incontinent care. During an interview on [DATE] at 12:15 p.m., the ADON said she had done random check offs for pericare. The ADON said pericare should be done properly by wiping the resident from front to back only. The ADON said she checked the CNAs off on pericare using a manikin as well on residents. The ADON said pericare should be done properly in order to prevent infections. The ADON said she had not provided written in-services for handwashing and incontinent care. During the interview the ADON was asked to provide the skills check off for CNA M but one was not provided. During an interview on [DATE] at 1:40 p.m., the DON she expected incontinent care to be performed according to the check offs. The DON said the check offs had every step to ensure the task was completed correctly. The DON said she expected the incontinent care to be performed from front to back and to open the labia for cleansing. During an interview on [DATE] at 6:51 p.m., the Administrator said he expected the clinical department to follow the policy and procedures related to incontinent care. The Administrator said expected CNAs to change gloves to ensure universal precautions were met. The Administrator said the DON was responsible for ensuring incontinent care was performed correctly 5. Record review of a face sheet dated [DATE] indicated Resident #35 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of diabetes, and high blood pressure. Record review of an Annual MDS indicated Resident #35 understands and was understood. The MDS indicated Resident #35 had a BIMS score of 15 indicated her cognition was intact and had no memory problems. The MDS indicated Resident #35 required extensive assistance of two staff with toileting, and extensive assistance of one staff for personal hygiene. Record review of the comprehensive care plan dated [DATE] indicated Resident #35 required assistance with her ADLs. The MDS indicated Resident #35 required 1 staff assistance with personal hygiene. During an observation and interview on [DATE] at 10:56 a.m., CNA M washed her hands prior to beginning care. CNA TT washed her hands. CNA TT opened Resident #35's brief and rolled the brief down. CNA TT wiped down once on the left side and once down the right side and once down the middle. CNA TT failed to open the labias majora and cleanse the labias minora. CNA TT assisted Resident #35 to roll to the right. CNA TT then wiped the buttocks three times from front to back using a different wipe for each cleaning wipe. CNA TT said she failed to properly cleanse the labia areas. CNA TT said not cleaning the labias well could cause infections. Record review of the facility's policy titled, Handwashing/Hand Hygiene, revised [DATE], indicated, This facility considers hand hygiene the primary means to prevent the spread of infections . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents . d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites) . h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids . m. After removing gloves . The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections Record review of a Perineal Care policy and procedure dated February 2018 indicated the purpose of this procedure was to provide cleanliness and comfort to the reisdent, to prevent infections and skin irraitiation, and to observe the resident's skin condition. Steps in the Procedure 8. a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. 1. Seperate the labia and wash downward from front to back. (if the rsidnet has an indewelling catheter, gently wash the juncture of the buting from the urethra down the catheter about 3 inches. Gently rinse and dry the area). c. Ask the residen to turn on hers [NAME] with her top leg slightly bent, if able. d. Rinse the wash cloth and apply soap or skin cleansing agent. e. Wash the rctal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. f. Rinse and dry thoroughly. 10 Remove gloves and discared into designated container. The policy does not mention any other glove changes. Record review of facility policy, Infection Control dated [DATE], indicated The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. 1.Coordination and Oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). c. The infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include: (2) whether antibiotic usage patterns need to be changed because of the development of resistant strains. (3) whether information about culture results or antibiotic resistance is transmitted accurately and in a timely fashion; and (4) whether there is appropriate follow-up of acute infections. d. The committee meets regularly, at least quarterly, and consists of team members from across disciplines, including the Medical Director. 5. Data Analysis a. Data gathered during surveillance is used to oversee infections and spot trends. b. One method of data analysis is by manually calculating the number of infections per 1000 resident days as follows: ( I) The infection preventionist collects data from the nursing units, and categorizes each infection by body (2)To adjust for differences in bed capacity or occupancy on each unit, and to provide a uniform basis for comparison, infection rates can be calculated as the number of infections per I 000 patient days(a patient day refers to one patient in one bed for one day), both for each unit and for the entire facility; (3) Monthly rates can then be plotted graphically or otherwise compared side-by-side to allow for trend comparison; and 7. Prevention of Infection a. Important facets of infection prevention include: (I) identifying possible infections or potential complications of existing infections; (2) instituting measures to avoid complications or dissemination. (3) educating staff and ensuring that they adhere to proper techniques and procedures. (4) enhancing screening for possible significant pathogens. On [DATE] at 2:14 p.m. the Administrator was notified an Immediate Jeopardy (IJ) situation was identified due to the above failures. The Administrator was provided with the IJ template on [DATE] at 2:24 a.m. and requested a Plan of Removal (POR). The Plan of Removal (POR) was accepted on [DATE] at 4:20 p.m. and indicated the following: Immediate action: The facility failed to provide employee in-services related to handwashing, peri-care, and/or catheter. 1. DON to conduct 1:1 in-service and skills validation with CNA-A. Completion Date: [DATE]. 2. Nursing administration (DON, ADON) to conduct in-service and competency checkoff with all direct care staff and agency staff currently working in building on re: handwashing, peri-care and catheter care starting [DATE] and Complete Date; [DATE]. 3. Agency staff will have skills competency completed prior to start of next shift start on [DATE] and ongoing due to potential for different agency staff scheduled. 4. Nursing administration (DON) & Dir. of Resident Care Services & Education (regional RN) to provide power point training Incontinent Care Without Contamination to include how to perform step by step with pictures (male & female) and checklist on performing incontinent care to staffing agency to provide to agency staff and facility to provide power point training at Nurses station to review prior to start of shift for any future agency assigned to provide care within the facility. Completion Date: [DATE] 5. Dir. of Resident Care Services & Education (Regional RN) to complete in-service with Hospice Agency Lead RN re: antibiotic stewardship and partnering with facility on ABT Stewardship. Completion Date: [DATE]. 6. Dir. of Resident Care Services & Education (Regional RN) reviewed current residents with active UTI (3), E.H.R. orders were reviewed for treatment interventions and Care plans and POC tasks updated by Regional MDS nurse for interventions to reduce potential for re-occurrence. Any of residents listed in August of the (13) and Sept. (3) with completion of ABT's will be reviewed as well for treatment interventions and Care plans and POC tasks updated. Ongoing monitoring of other residents to occur in weekly clinical review meeting DON, MDS Nurse and ADON has with Dir. of Resident Care Services & Education (Regional RN). Completion Date: [DATE] On [DATE]the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews on [DATE] from 4:20 p.m. to 6:40 p.m., on all three shifts (2p-10p, 6a-2p, & 2p-10p) with the administrator, DON, ADON, LVN O, LVN U, MA C, CNA U, CNA X, CNA Y, and CNA W revealed they had completed in-services on hand washing, peri-care with or without a catheter, and Hoyer lift. Staff were able to verbally explain how they should wash their hands, how to perform proper peri care, and how to safely transfer a resident who requires a Hoyer lift for transfers. Record review of CNA A one-on-one in-service and skills validation for proper peri care dated [DATE]. Record review of in-service dated [DATE] on handwashing, peri care, and catheter care. Record review of the orientation document dated [DATE] over hand washing, peri-care with or without a catheter, and Hoyer lift was signed by 4 (CNA U, CNA X, CNA Y, and CNA W) agency staff on duty on [DATE] during the 2p-10p shift. Record review of a updated PowerPoint on hand washing, peri care, incontinent care without contamination, skin care, and peri care on males and females with or without catheters signed by (7) 2-10 staff/agency on [DATE]. (LVN O and LVN U (2p-10p),1 MA: MAC (6a-2p), 4 CNAs CNAU, CNAX, CNAY, and CNAW). Record review of an in-service dated [DATE] related to antibiotic stewardship policy, Mcgeers criteria, antibiotic prescribing, infection control policy and procedure , and interventions to initiate when trending was identified was signed by hospice RN Z. Record review of in-service dated [DATE] given by the corporate nurse via Microsoft Teams or verbally was signed by the DON, ADON, MDS, RN Q, RN R, RN CC, RN D, LVN F, LVN BB, LVN O, LVN U, and LVN N related to antibiotic stewardship policy, Mcgeers criteria, antibiotic prescribing, infection control policy and procedure, and interventions to initiate when trending was identified. During a phone interview on [DATE] at 6:18 p.m., the corporate nurse said did an education with the DON/nurse managers and hospice this morning via TEAMS. She said the first part of the in-service was ABT stewardship, tracking and trending education, a new map and how to color code so they can see issues more easily, monitoring the infection control log daily, weekly and monthly, and looking to see if they meet McGeer's criteria, education on what kind of things they would do for trends, such as check-offs on hand hygiene and peri care and explained to hospice nurses about assessing signs and symptoms. She said the 2nd part involved the DON, infection preventionist, and nursing and it included glove changes, male and female care, with or without a catheter and procedure of incontinent care. She said the facility should have copies of everything she went over. The cooperate RN said the contracted agencies were aware of their expectations. On [DATE] at 6:47 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that was not in immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

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 ensure that all alleged violations involving abuse were reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #249) of 6 residents reviewed for reporting allegations of abuse. The facility failed to report Resident #249's allegation of abuse to HHS. This failure could place the residents at risk for further potential abuse due to unreported allegations of abuse, and neglect. Findings included: Record review of Resident #249's face sheet, dated 09/05/23 indicated Resident #249 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), and anxiety (feelings of nervousness, panic, and fear). Record review of Resident #249's quarterly MDS assessment, dated 06/15/23, indicated Resident #249 was understood and usually understood others. Resident #249's BIMS score was 11, which indicated she was moderately cognitively impaired. Resident #249 required total assistance with bathing, extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, and set-up assistance with eating. Record review of Resident #249's comprehensive care plan, dated 09/16/22 indicated Resident #249 had an ADL self-care performance deficit related to activity intolerance and limited mobility. The interventions of the care plan were for staff to provide Resident #249 with assistance with eating and personal hygiene. Record review of Resident #249's nurse's note documented by LVN N on 08/15/23 revealed, Resident's family member attempted to contact nursing staff again during the 2-10 shift Oncoming 10-6 Charge Nurse answered the phone and the family member requested to speak to 2-10 Charge Nurse. 10-6 Charge Nurse advised her a report needed to be given and then contact would be made. The family member advised, If she doesn't call me back then I will be calling the police because there were some things that have taken place up there during her shift that were illegal. The family member was advised the 2-10 Charge Nurse would attempt contact with her after giving the report and the call was ended. Local Police Department arrived at the facility shortly after the phone call. The family member concerns were raised to law enforcement included: allegations of abuse of Resident #249 from staff members (none specifically named and no specific circumstance or reasoning as to why abuse was suspected) and complaints of (2) video cameras being removed from Resident #249's room. The officer was directed to Resident#249's room so he could perform a welfare check related to family members abuse allegations. The resident was observed resting in bed . The sitter was in the room and had a private conversation with the Peace Officer. The Peace Officer advised matter would be investigated further regarding monitoring devices and there were no obvious physical signs and/or symptoms of abuse had occurred .The Peace Officer advised they would be contacting the family member regarding findings. 09/15/23 at 6:56 PM DON (on call) and Administrator were both informed of situation as it was occurring. During an interview on 09/14/23 at 8:41 a.m., the administrator said he was not aware of any allegations of neglect or abuse that were not reported. He said if he were aware, he would report. He said the first thing he does when he becomes aware of an allegation situation was to ensure the safety of the resident. He said he would talk with the resident in which the allegation was made. He said if the resident was not able to communicate about the allegation, he would interview staff and family. The administrator said if any perpetrator were named, they would be suspended pending investigation. He said he had cameras around the facility so he would review the film if needed. He said he would have the nurses assess the resident for any injuries and notify the physician. He said he may have a social worker or psychological service talk with the resident if needed. He said then he would fill out the self-report to the state of Texas. He said he had 2 hours to report physical abuse and 24 hours to report verbal abuse then follow up with a 5-day report of what occurred or did not occur. During an interview on 09/15/23 at 1:16 p.m., LVN N said the family member was upset because she did not answer her phone call, so she called the police and they said we were abusing Resident #249. I did inform the administrator of the situation. During an interview on 09/15/23 at 12:16 p.m., the ADON said the administrator and the DON made the decisions on reporting or not reporting abuse. She said she knew things needed to be reported in a certain timeframe. She said it was important to report abuse for the safety of the resident. During an interview on 09/15/23 at 1:40 p.m., the DON said if someone verbalizes abuse or allegations of abuse it should be reported to HHS. She said the administrator was the overseer of reporting or not reporting. She said she does not recall any abuse or allegations of abuse on Resident #249. She said she or the ADON usually reads the nurse's notes and the 24-hour reports daily. The DON said it was important to report and investigate abuse to prevent further abuse from occurring. During an interview on 09/15/23 at 7:01 p.m., the administrator said he should follow their policy on reporting abuse or neglect. He said even if he had doubts about a situation such as abuse or neglect, he should report and then investigate. He said he had read Resident #249's nurse's note and he said he did not feel he needed to report this situation because he had a grievance on the cameras. He said the family member had a misunderstanding about the cameras. He said he never spoke to the family member because she would not speak with him but he had the business office manager call her about the cameras. Record review of facility policy, Resident Abuse and Neglect dated 2021, indicated, Reporting Abuse to State Agencies: All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities are individuals as may be required by law and per the current state/federal reporting requirements. POLICY INTERPRETATION AND IMPLEMENTATION 1. Should an alleged/suspected violation of mistreatment, neglect, or abuse be reported, the Facility Abuse Coordinator Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a) The State licensing/certification agency responsible for surveying/licensing the Facility. b) The Resident's Representative (Sponsor) of Record. c) Law enforcement officials. d) The Resident's Attending Physician; and e) The Facility Medical Director. 2. Verbal notices to the above agencies will be made as soon as possible but no later than within 24 hours of the occurrence of such incident or sooner based upon current state requirements and such notice will be submitted by telephone. Notices will include as a minimum: a) The name of the resident. b) The number of the room in which the resident resides. c) The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.). d) The date and time the alleged event occurred. e) The name(s) of all persons involved in the alleged incident; and f) The immediate action taken by the community.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team for 1 of 15 residents (Resident #40) reviewed for care planning. The facility failed to ensure Resident #40 had a person-centered care plan for activities. This failure could place residents at risk for social isolation, depression, and a decreased psychosocial well-being. Findings included: Record review of a face sheet dated 9/15/2023 indicated Resident #40 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of legal blindness, depression, and anxiety. Record review of an admission MDS dated [DATE] indicated Resident #40 was understood, and usually understands. The MDS indicated Resident #40's vision was severely impaired with no vision or sees only light, colors, or shapes. The MDS indicated Resident #40's BIMS score was 9 indicating his cognition was moderately impaired. Record review of Resident #40's care area summary failed to reflect Resident #40's need for an activity care plan. Record review of the comprehensive care plan dated 8/14/2023 indicated there was not an activity care plan. During an interview on 9/12/2023 at 4:45 p.m., Resident #40 said he enjoyed playing his guitar and being outside. During an interview on 9/13/2023 at 10:04 a.m., the AD said she has contacted the Talking book program for Resident #40 approximately a week ago but has not heard back yet. The AD said Resident #40 was out of the facility all day on Monday, Wednesday, and Fridays. The AD said Resident #40 enjoyed his playing his guitar and enjoyed outside. The AD said she completed activity care plans, and she believed Resident #40 had an activity care plan. During an interview on 9/15/2023 at 12:15 p.m., the ADON said she was only familiar with what she care planned and could not speak to what the AD director was expected to care plan. The ADON said she would believe Resident #40 would need a specialized activity care plan related to his vision loss and ability to participate in vision required activities. During an interview on 9/15/2023 at 1:55 p.m., the DON said the AD was responsible for care plans related to activity needs of the residents. The DON said Resident # 40 was at a vision disadvantage. The DON said Resident #40 could experience a decrease in the enjoyment of life. The DON said it was important to establish an activity care plan to implement activities a resident would enjoy. During an interview on 9/15/2023 at 6:51 p.m., the Administrator said every resident must have a care plan. The Administrator said the care plan directed the resident's care. The Administrator said he was unaware Resident #40 had an activity care plan. Record review of a Care Planning-Interdisciplinary Team policy dated September 2013 indicated the facility's care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for reach resident. 1. The comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS).

CONCERN (D)

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

Deficiency F0773 (Tag F0773)

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 promptly notify and follow-up with the ordering physician regarding laboratory results outside of clinical reference range for 1of 1 residents reviewed for laboratory services. (Resident #41). The facility failed to implement timely treatments for Resident #41's urinary tract infections. This failure could place residents at risk for urinary tract infections as well as any other urinary/incontinence issues. Findings included: Record review of a face sheet dated 9/13/2023 indicated Resident #41 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of dementia, and the need for assistance with personal care. Record review of an Annual MDS dated [DATE] indicated Resident #41 usually understood and was understood by others. Record review of the MDS indicated Resident #41's BIMS score was 3 indicating she had severely impaired cognition. The MDS indicated Resident #41 required limited assistance of one staff with toilet use and personal hygiene. The MDS indicated Resident #41 was frequently incontinent of urine and bowel. Record review of the comprehensive care plan dated 8/16/2023 indicated Resident #41 was receiving antibiotic therapy for a urinary tract infection. The goal of the care plan was Resident #41 would be free of any discomfort or adverse side effects of antibiotic therapy. The interventions included to administer antibiotic therapy mediations as ordered by the physician, monitor side effects, and effectiveness. Record review of a laboratory urinalysis collected on 11/18/2023 at 2:00 p.m., indicated Resident #41 had a urinary tract infection which resulted on 11/20/2022 and was reported on 11/20/2022 at 5:17 p.m. The urinalysis revealed an urinary tract infection plus pathogens detected. The bacterial pathogens detected on the urinalysis were escherichia coli at 93,000 and klebsidella pneumonia at 13,000,000. Record review of the consolidated physician orders dated November 1- November 30, 2022, indicated Resident #41 had ordered on 11/22/2022 Levaquin 500 milligrams one by mouth at bedtime for 7 days for a urinary tract infection . Record review of a medication administration record dated November 2022 indicated Resident #41 was administered Levaquin 500 mg by mouth at bedtime for 7 days related for a urinary tract infection starting on 11/22/2022. Record review of a laboratory urinalysis collected on 1/01/2023, received on 1/02/2023, indicated Resident #41 had an urinary tract infection plus pathogens detected. The urinaylysis indicated Resident #41's urinalysis had 580,000,000 escherichia coli present. Record review of the consolidated physician orders dated January 1 - January 31, 2023, indicated Resident #41 was ordered Macrobid 100 milligrams by mouth twice daily for 7 days for a urinary tract infection on 1/07/2023. Record review of the January 2023 medication administration record indicated Resident #41 was administered Macrobid 100 milligrams by mouth two times daily for 7 days started on 1/07/2023. During an interview on 9/15/2023 at 12:15 p.m., the ADON said she expected the nursing staff to send the urine cultures to the nurse practitioner promptly upon receipt. The ADON said she expected when the nurse's received the orders from the physician or designee the order was acted on normally within an hour. The ADON said the facility had a medication kit to obtain medications promptly for administration. The ADON said she was the IP but was not in the roll during the period of these infections. The ADON said residents could develop sepsis (severe infection) without timely treatment. During an interview on 9/15/2023 at 2:03 p.m., the DON said she expected as soon as the culture and sensitivity was received the nurses should obtain orders for treatment. The DON said she expected the physician's order to be implemented as ordered. The DON said she and the ADON were responsible for the infections and treatment oversight. The DON said a resident would be at risk for the infection worsening and developing sepsis (a severe infection). During an interview on 9/15/2023 at 7:12 p.m., the Administrator said he was not a clinician, but he would comment with common knowledge of infections. The Administrator indicated he expected the physician to be informed of the infections upon the receipt of the laboratory results. The Administrator said he expected the order to be implemented as soon as possible. The Administrator said the infections could worsen without timely treatment.

CONCERN (D)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review , the facility failed to provide food that was palatable for 1 of 15 resident (Resident #18) reviewed for palatable food and 1 of 1 test trays. The facility failed to provide palatable food served at an appetizing taste to Resident #18 who complained of the food not tasting good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: During an interview on 9/11/2023 at 10:04 a.m., Resident #18 said the food could be better as far as flavor. Resident #18 had not spoken to anyone regarding the food. Resident #18 ate in her room. During an observation and interview on 9/12/2023 at 12:45 p.m., a lunch tray was sampled tby the DM and 4 surveyors. The sample tray consisted of Mexican rice, chicken fajita, fajita vegetables, and apple sauce. The DM said the rice was gooey with hard bits throughout. The DM said the fajita vegetables tasted bland. The DM said the cook boiled the rice before placing on the steam table. During an interview on 9/15/2023 at 2:12 p.m., the DON said she expected the meals to be pleasing to the residents. The DON said she expected the foods to be cooked well so the residents would like it. The DON said she was unaware the rice was gooey and had hard bits throughout. During an interview on 9/15/2023 at 6:05 p.m., the DM said the cook was responsible for ensuring the food was palatable by following the recipes. During an interview on 9/15/2023 at 7:22 p.m., the Administrator said palatable food was important to prevent loss of appetite and weight loss. The Administrator said the DM was responsible for ensuring the meals were appetizing. A food palatability policy was requested but not provided on 9/15/2023.

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to accommodate residents' food preferences for 1 of 2 residents (Resident #23) reviewed for preference. The facility failed to honor Resident #23's preferences for a vegan diet. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of Resident #23's face sheet, dated 09/05/23 indicated Resident #23 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Diabetes mellitus (a group of diseases that affect how the body uses blood sugar), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), and anxiety (feelings of nervousness, panic, and fear). Record review of Resident #23's quarterly MDS assessment, dated 09/02/23, indicated Resident #23 was understood and understood others. Resident #23's BIMs score was 13, which indicated she was cognitively intact. Resident #23 required supervision assistance with eating. The MDS indicated she was on a therapeutic diet. Record review of Resident #23's physician orders dated 09/15/23, revealed Reduced Concentrated Sweet (RCS), regular texture, vegan, and lactose intolerant provide any kind of beans/lentils at all meals if available. Serve two times vegetable portion, May request meals at times for low salt diet, 1800 CC fluid restriction. Record review of Resident #23's comprehensive care plan, dated 04/04/23 indicated Resident #23 diet was RCS regular texture, regular consistency, vegan, and lactulose intolerant. Two times veggies portions and peanut butter and jelly sandwich on each meal tray. The interventions of the care plan were for staff to serve Resident #23 diet as ordered, offer substitutes as requested, and provide supplements or snacks as indicated. During an observation and interview on 09/11/23 at 11:38 a.m., Resident #23 was in the dining room and then left the dining room. Resident #23 had macaroni, cornbread, and tomatoes on her plate. Resident #23 may have consumed about 25% of her meal. Resident #23's tray card read vegan, lactulose intolerance, and 1800ml fluid restriction. Another resident sitting at Resident #23's table and stated she did not like cheese, so she left the dining room. Resident #23 was in her room sitting in a chair beside her bed eating crackers and drinking a Dr Pepper. Resident #23 was upset. She said she did not like her menu choice for lunch today (09/11/23) so she asked for beans, but the staff told her they did not have any beans. She said her family member had offered to bring beans, but she did not know what happened to them. She said she was a vegan and would like more vegan choices, she said she was tired of receiving the same meals over and over. Resident #23 said she does eat meat and dairy at times only because of the food choices she had. During an interview on 09/12/23 at 12:50 p.m., the dietary manager said Resident #23 was a vegan but does eat meats occasionally. She said they gave her the regular vegetable portion size for each meal and a peanut butter and jelly sandwich. She said sometimes Resident #23 would request a regular meal. She said she does not have a vegan diet on her order guide, but she had asked the food representative some time ago but never followed up. She said her family member had tried to bring beans and other food items in the past but explained that they could not accept outside food. She said she had told nursing staff they needed to warm up any outside food if she requested it. During a phone interview on 09/12/23 at 1:18 p.m., the dietitian called back and stated she had visited with Resident #23, and she was a vegan. She said they have had long conversations about her diet, she believed the last conversation was last month (August 2023). She said Resident #23 should be receiving 2 times portions of vegetables with each meal. She said Resident #23 had been known to ask for meats at meals and even cake and was given at her request. She said Resident #23 had orders for protein shakes at med pass times to help with her protein needs. She said she does not remember Resident #23 saying anything about dislikes of the food. She said it was important to provide residents with their meal preferences. During a phone interview on 09/12/23 at 5:36 p.m., a family member called back and said she had attempted to bring beans or other foods that could be warmed up but to her knowledge, the food was not used. She said they purchase Resident #23 outside food at times and provide her with snacks. She said she had talked with the dietary manager and administration about her diet choice. She said at home she would eat plant-based meats such as meatless meatballs and TV dinners. She said they have a bigger variety of vegan meals in grocery stores. She said she felt they could provide Resident #23 with more vegan choices. During a phone interview on 09/13/23 at 5:22 p.m., The food manager from the facility distributor stated they have a vegan diet menu. She said they usually worked with the cooperate dietitians to help residents with their food choices. She said they have plant-based products such as bean burgers. She said she did not see any request for a vegan menu from the facility. During an interview on 09/15/23 at 12:16 p.m., the ADON said residents have choices of meals and they offer an alternate meal for each meal. She said Resident #23 said she was a vegan but often eats non-vegan food. She said she had never talked to Resident #23 about her likes or dislikes because the dietary manager had, but felt it was a team effort to ensure all residents received the foods they liked. During an interview on 09/15/23 at 1:40 p.m., the DON said all residents should have choices of the food being served. She said the dietary manager was responsible for interviewing residents about their meal preferences. She said she was not aware of any plant-based products served in the kitchen. She said if residents had the food they liked, eating would be more enjoyable. During an interview on 09/15/23 at 7:01 p.m., the administrator said he was aware Resident #23 was a vegan. He said at times she would request the regular meal served. He said he was not aware if the facility had a vegan ordering guide. He said he felt it was important to offer Resident #23 her preference for food choices. He said not serving Resident #23 her food preference could cause her to not enjoy her meals or lose weight. The administrator said the dietary manager and dietitian would produce a plan to meet her needs. Record review of the facility policy, Menu planning dated June 1, 2019, indicated, The facility believes that nutrition is an important part of maintaining the well-being and health of its residents and is committed to providing a menu that is well balanced, nutritious and meets the preference of the resident population. Modifications for resident population and preference may be made as appropriate.

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

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 obtain the most recent plan of care specific to each resident for 3 of 3 residents (Resident #'s 4, 38, and 249) reviewed for hospice services. The facility failed to obtain Resident #38's, Resident # 4's and Resident #249's most recent hospice plan of care. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings included: 1. Record review of Resident #38's face sheet date 09/14/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #38's diagnoses included diabetes (a group of diseases that result in too much sugar in the blood), urine retention (a condition in which all the urine from the bladder cannot be emptied), anxiety, congestive heart failure (a long-term condition in which the heart can't pump blood well enough to meet the body's needs), and chronic kidney disease stage 4 (kidneys are moderately or severely damaged and are not working as well as they should to filter waste from the blood). Record review of Resident #38's comprehensive care plan revised on 07/17/23, indicated she had a terminal prognosis and was admitted to hospice with interventions to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Record review of Resident #38's quarterly MDS assessment dated [DATE], indicated she had clear speech, was usually understood, and usually understood others. The MDS indicated Resident #38 had a BIMS score of 14 indicating her cognition was intact. The MDS indicated Resident #38 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS indicated Resident #38 received hospice care within the last 14 days of the look back period. Record review of Resident #38's order summary report dated on 09/14/23, indicated she had an order to admit to hospice and to call them with any concerns, questions on change in condition with an order start date of 06/02/23. Resident #38 also had an order for Colace (stool softener) 100mg one capsule by mouth daily with a start date of 08/14/23 and an order for simethicone 80mg one tablet by mouth three times a day as needed with a start date of 08/22/23. Record review of Resident #38's hospice binder revealed the last hospice care plan was dated 06/02/23. There was not a recent plan of care update noted in the facility hospice binder or the Resident #38's EMR. The hospice care plan did not reflect Resident #38's orders for Colace 100mg one capsule by mouth daily or simethicone (used to relieve painful symptoms of extra gas in the stomach and intestines) 80mg one tablet by mouth three times a day as needed. 2. Record review of Resident #4's face sheet dated 09/14/23, indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses protein calorie malnutrition (lack of protein and calories to meet the nutritional needs), anxiety, diabetes mellitus (a group of diseases that result in too much sugar in the blood), and cerebral infarction (stroke). Record review of Resident #4's admission MDS assessment dated [DATE], indicated she had clear speech, was able to make herself understood and was able to understand others. The MDS indicated Resident #4's had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS indicated Resident required extensive assistance with bed mobility, transfers, locomotion, dressing, eating, toileting, and personal hygiene. The MDS indicated resident received hospice care while a resident and not a resident within the last 14 days of the look back period. Record review of Resident #14's comprehensive care plan revised on 07/12/23 indicated she had a terminal prognosis and was on hospice care with interventions to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Record review of Resident #4's order summary report dated 09/14/23, indicated she had an order for hospice with a start date of 07/03/23. Resident #4 also had an order for Risperdal (used to treat certain mental or mood disorders) 1mg one tablet by mouth two times a day with an order start date of 09/07/23. Record review of Resident #4's EMR on 09/14/23 indicated the last updated hospice plan of care provided to the facility was dated 08/14/23. There was not a recent plan of care updated noted in Resident #4's EMR. The hospice plan of care indicated Resident #4 was receiving Risperdal 1mg one tablet by mouth daily and did not reflect the current order of Risperdal 1mg one tablet by mouth twice a day. During an interview on 09/13/23 at 10:55 AM, RN D said she had not seen or received any hospice documentation. RN D said the hospice company did sign in the hospice chart on the days they came to the facility. RN D said she had looked in Resident #4's EMR and the last plan of care for Resident #4 that she found was dated 08/14/23. RN D said they usually communicated with the hospice nurse regarding new orders, issues, or changes. RN D said the hospice residents should have had their hospice chart updated for coordination of care. RN D said not having the hospice chart updated could cause them to not provide the same care for the residents. During an interview on 09/13/23 at 02:23 PM, Hospice RN E said she had not brought any of Resident #4's hospice updates in months. The Hospice RN said she rarely brought any hospice notes to the facility. The Hospice RN said if there was anything the facility needed then the hospice director could fax them over. The Hospice RN said she believed the hospice director was responsible for faxing over the updated plan of care. The Hospice RN said she communicated well with the facility staff every time she did a visit. The Hospice RN said not providing the facility with the most recent plan of care could cause poor coordination of care. 3. Record review of Resident #249's face sheet, dated 09/05/23 indicated Resident #249 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), and anxiety (feelings of nervousness, panic, and fear). Record review of Resident #249's quarterly MDS assessment, dated 06/15/23, indicated Resident #249 was understood and usually understood others. Resident #249's BIMs score was 11, which indicated she was moderately cognitively impaired. Resident #249 required total assistance with bathing, extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, and set-up assistance with eating. Record review of Resident #249's comprehensive care plan, dated 09/05/22 indicated Resident #249 had a terminal diagnosis and was under hospice care. The interventions of the care plan were for staff to keep her environment quiet and calm, and work cooperatively with the Hospice team to ensure the residents' spiritual emotional, intellectual, physical, and social needs are met. Record review of Resident #249's EMR on 09/14/23 did not reveal a hospice plan of care. The facility failed to have coordination of care for Resident #249 by having available hospice physician orders, hospice plan of care, including frequency of visits by the hospice staff. During an interview on 09/14/23 at 9:46 a.m., the hospice director said her staff does not leave any paperwork at the facility. She said her nurses charted in their EMR computer system. She said if the facility requested paperwork, they would send it. She said each resident on their hospice service should have a binder. She said the binder contained the resident's diagnosis, plan of care, recertifications, and a sign-in sheet for hospice staff. She said they had a clinical meeting every 2 weeks and updated the resident plan of care. She said her staff were responsible for bringing updates to the facility. She could not say when Resident #249's care plan had been updated. During a telephone interview on 09/14/23 at 9:55 a.m., hospice LVN UU said Resident #249 had been discharged from their services but when she was on their service, she had a binder at the nurses' station. She said the binder contained recertifications, a plan of care, a sign-in sheet, and a vital signs sheet. She said she did not leave any of her assessments during her visit. She said she would verbally communicate with the charge nurse if she had any new orders or concerns. During an interview on 09/15/23 at 12:13 PM, the ADON said she expected the hospice to provide them with updates. The ADON said she was unsure of who was responsible for ensuring the hospice charts were up to date. The ADON said it was important to keep the hospice plan of care updated for coordination of care as things could get missed. During an interview on 09/15/23 at 12:16 p.m., the ADON said hospice usually provided us with updates when they made their rounds. She said they bring paperwork on each visit. She said when she was the charge nurse, she would monitor the hospice books but was not sure who was supposed to monitor hospice books. She said it was important for the hospice and the facility to have good communication for the continuity of care for each resident on service. During an interview on 09/15/23 at 01:37 PM, the DON said she received hospice updates quarterly. The DON said the hospice staff did sign in when they came to the facility, and they attended the care plan meetings. The DON said the resident's care plan was updated every two weeks with any changes. The DON said updated their own care plans as they received verbal hospice updates. The DON said the hospice nurses usually brought the hospice updates and gave them to the charge nurse or they placed them in the resident's hospice book. During an interview on 09/15/23 at 01:40 p.m., the DON said all residents on hospice service had a binder at the nurses' station. She said the binder had the resident's diagnosis and plan of care. She said hospice does not chart in their system. She said the hospice companies had their own charting system She said the hospice companies usually communicated with her on each visit. She said she expected hospice to update the resident plan of care as needed. The DON was asked to provide Resident #249's hospice book but she could not locate the book. During an interview on 09/15/23 at 06:51 PM, the Administrator said any time the hospice care was updated it was communicated directly to the DON. The Administrator said he did not know if the hospice staff handed anything to his staff. The Administrator said not providing hospice updates could cause disagreement with the plan of care or cause to provide two different types of care. The Administrator said each hospice company sent their updates as per their policy. Record review of the facility's policy titled, Hospice Program, revised July 2017, indicated, . In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: a. Determining the appropriate hospice plan of care . a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services; . Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident; ( . Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. 14. The coordinated care plan will reflect the resident's goals and wishes, as stated in his or her advance directives and during ongoing communication with the resident or representative, including: a. palliative goals and objectives; b. palliative interventions; and c. medical treatment and diagnostic tests. 15. The coordinated care plan shall be revised and updated as necessary to reflect the resident's current status .

CONCERN (D)

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

Deficiency F0940 (Tag F0940)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 7 of 21 employees (RN F, RN G, Speech Therapist, Occupational Therapist, CNA H, CNA K, and CNA L) reviewed for required trainings. The facility failed to ensure RN F, RN G, CNA H, CNA K and CNA L received restraint and HIV training upon hire. The facility failed to ensure the Speech Therapist received HIV training annually. The facility failed to ensure the Occupational Therapist received restraint and HIV training annually. These failures could place residents at risk for the inappropriate use of restraints and exposure to HIV. Findings included: Record review of the employee files revealed there was no HIV or restraint training completed upon hire for the following staff: *RN F (hire date 08/16/23), *RN G (hire date 07/05/23), *CNA H (hire date 02/15/23), *CNA K (hire date 03/17/23), and *CNA L (hire date 03/17/23). . Record review of the employee files revealed there was no HIV or restraint training completed annually for the following staff: The Speech Therapist (hire date 08/23/21) and Occupational Therapist (hire date 09/01/21). During an interview on 09/13/23 at 2:58 PM, the POM (People Operations Manager)/ HR Director said RN F, RN G, CNA H, CNA K, CNA L, the Speech Therapist, and the Occupational Therapist did not have the required training completed. The POM said they had not been assigning the HIV training to the staff until April 2023. The POM said the DON and herself were responsible for ensuring the staff had the required trainings completed. The POM said by staff not having the required HIV and restraint trainings, they could infringe on the residents' rights, be unaware of any new changes or know how to properly deal with HIV and restraints. During an interview on 09/15/23 at 11:08 AM, the POM said the HIV and restraint trainings were assigned to the employee before hire. The POM said the employee had 30 days to complete the required HIV training. The POM said the restraint training was to be completed within the first three days of hire. The POM said the trainings were completed in the CEU 360 (which is an automated online training program). The POM said she monitored the online training by running a weekly report on the 1st and 15th of the month, and 1 week after the 15th to ensure the staff was completing their trainings. The POM said she did not keep a check list for each employee to ensure they had completed all the required trainings. The POM said the CEU 360 automatically assigned the required annual trainings. The POM said if an employee did not complete the required training, she would have a 1 on 1 conversation with them. The POM said if the employee continued to not complete the required training, she notified the DON. During an interview on 09/15/23 at 12:13 PM, the ADON said she expected the HIV and restraint training to be completed upon hire and annually. The ADON said the POM was responsible for ensuring the trainings were kept current. The ADON said by staff not completing the required HIV and restraint training they would be unaware of HIV precautions and the reason why restraints were not used. During an interview on 09/15/23 at 1:37 PM, the DON said HIV and restraint were done upon hire and annually and were part of the CEU 360 training. The DON said the staff was to be knowledgeable regarding blood borne pathogens and restraints, as restraints were tied to abuse and neglect. The DON said the HIV and restraint training were assigned upon hire and HR was to follow up they were completed. During an interview on 09/15/23 at 06:51 PM, the Administrator said he expected restraint and HIV training to be done upon hire and annually for compliance with the mandate. The Administrator said he was not clinical, so he was unsure of the risks of not completing the required training. The Administrator said the HR director assigned the trainings upon hire and the CEU 360 program automatically assigned them annually. The Administrator said the HR director ran a report monthly to check for compliance. Record review of the facility's policy titled, Staff Development Program, last revised May 2019, indicated, All personnel must participate in initial orientation and regularly scheduled in-service training classes . 2. The primary objective of our facility's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchens reviewed for food safety requirements. The facility failed to ensure 3 skillets were free from encrusted carbon buildup on the outside and half of the inside of the cooking surface. The facility failed to prepare over easy fried eggs with pasteurized eggs. The facility failed to ensure [NAME] P wore her hairnet when entering the kitchen during meal service. These failures could place residents at risk for foodborne illness. Findings included: During an observation on 9/11/2023 at 9:40 a.m., the dishrack had three skillets of varying sizes with encrusted carbon buildup on the outside surface and half of the inside cooking surface. During an observation on 9/11/2023 at 9:43 a.m., the refrigerator had 3 (30 count) flats and ½ of a (30 count) flat of brown eggs. The brown eggs did not have the P stamped on the eggs indicating pasteurized eggs. During an interview on 9/11/2023 at 9:50 a.m., the cook said she prepared the resident's over easy eggs with the brown eggs in the refrigerator. During a record review and interview on 9/11/2023 at 11:27 a.m., there was a egg listing hanging on the steam table. The listing indicated there were 8 residents who received fried eggs. The cook said each resident received their eggs cooked over easy. Record review of an undated grocery delivery listing provided by the DM on 9/11/2023 indicated the facility received one box with 15 dozen eggs (fresh shell large free range). During an observation on 9/12/2023 at 12:07 p.m., [NAME] P walked through the side door of the kitchen with no hair net on during the preparation of the resident's meal trays. During an interview on 9/15/2023 at 6:05 p.m., the DM said the unpasteurized should not be used for over easy fried eggs. The DM said the skillets were unable to be cleaned and she had to order more skillets. The DM said using the unclean skillets and the undercooked unpasteurized eggs could make the residents sick. The DM said all staff should wear a hair net when entering the kitchen to prevent hair from getting in foods. During an interview on 9/15/2023 at 12:15 p.m., the ADON said she expected the kitchen cooking pans to be cleaned to the best of their ability. The ADON said all staff entering the kitchen should wear hair nets to keep their hair from flying in the foods. The ADON said she was unsure on the use of unpasteurized eggs served over easy style. During an interview on 9/15/2023 at 1:40 p.m., the DON said she expected the skillets to be clean, she expected all staff in the kitchen to wear hair nets, and she was unsure about the pasteurized egg use. The DON said the DM was responsible for ensuring DM had knowledge of pasteurized egg use, skillets in the kitchen were clean, and ensuring all staff wore hairnets in the kitchen. During an interview on 9/15/2023 at 7:18 p.m., the Administrator said he had never seen an over easy egg cooked in the facility. The Administrator said he was unaware what could happen when a resident ate an undercooked unpasteurized egg. The Administrator said he expected the dietary staff to wear hair nets when entering the kitchen to keep foods free of hair. The Administrator said he had no idea about carbon build up on the skillets, but he said it could be cross contamination. Record review of the facility's Shell Egg Use policy dated October 1, 2018, indicated the consultant dietician will monitor the use of eggs in each facility to ensure that eggs are treated and handled as a potentially hazardous food. The following guidelines should be followed 6. For resident that request soft-cooked or sunny side up eggs (meaning eggs cooked less than 3 minutes at 140 degrees F or at less than 15 seconds at 145 degrees F), on pasteurized eggs may be used. 9. The Dietary Manager in-services the dietary staff on the safe handling of eggs. https://www.fda.gov/media/110822/download accessed on 10/05/2023 indicated 2-402.11 Effectiveness. (A) Except as provided in ¶ (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLE

Jul 2022 6 deficiencies

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 9 residents (Resident #2) reviewed for care plans. The facility failed to review and update Resident #2's care plan in that it include diarrhea as needed care for Resident #2. This failure could affect resident and result in injury or decline of physical well-being. Findings include: Review of the Face Sheet for Resident #2 reflected she was admitted on [DATE] with diagnoses of: Unspecified Dementia, Morbid Obesity, Abnormal Gait, Type 2 diabetes, Congestive Heart Failure, Hypothyroidism , Chronic pain, Muscle Wasting and Atrophy. Review of the MDS for Resident #2 dated 4/18/22 reflected a blank cognitive assessment. Her functional assessment reflected she required only supervision for all ADLs. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #2 reflected no interventions were in place for assisting resident to bathroom or toileting. Review of Progress notes for Resident #2 dated from 6/01/22 to 7/20/22 reflected no mention of uncontrolled bowels as stated by resident to surveyor. On 6/28/22 Resident #2 was assessed after a fall with pain to her right hip, an x-ray was ordered . In an interview on 7/19/22 at 9:56 am with Resident #2, she reported she had no control over her bowels and had a Foley catheter in place. Resident #2 stated she had so many loose stools, she did not want to attend activities. In an interview on 7/20/22 at 2:48 pm with LVN W, she stated Resident #2 had not reported any concerns with uncontrolled bowel movements. She stated Resident #2 did receive Loperamide 2 mg for Diarrhea twice a day, and on rare occasion she would refuse that medication. She stated Resident #2 also had a prescription for Lomotil 2.5/0.025 mg one tablet as needed/PRN every 4 hours for diarrhea. Review of the Lomotil sign out sheet reflected no doses had been given in July 2022. She stated Resident #2 could use her PRN medication to be sure she could attend activities. LVN W stated Resident #2 had not discussed this problem with her earlier and she stated she would educate the resident on her medications. LVN W stated uncontrolled bowel movements should be included in her care plan. In an interview on 7/20/22 at 2:54 pm with Resident #2 , she stated she continued to have a problem with loose bowels and she had no choice but to get up and sit in the bathroom every couple of hours. She stated she was taking the Loperamide in the morning and evening but not the Lomotil PRN medication. In an interview on 7/20/22 at 3:56 pm with the Nurse Practitioner, she stated Resident #2 had been seen by a Gastroenterologist in the hospital and had not reported any diarrhea or loose stools to him. He stated Resident #2 was prescribed Metformin and the medication could cause diarrhea. He stated he would cancel the Metformin prescription. He then stated she had mentioned diarrhea at times in the past but not recently. In an interview on 7/21/22 at 8:24 am with the Administrator , he/ she stated care plans should be updated according to policy and whenever a Resident had a change in condition. In an interview on 7/21/22 at 9:22 am with the DON , she stated she had not received any reports from Resident #2 or the nursing staff about diarrhea or loose stools. She stated Resident #2 was continent of bowels and had a urinary catheter. She stated any change in condition should be included in her care plan and, if serious, should trigger a change in status assessment.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure psychotropic medication was prescribed to treat a specific condition with appropriate diagnosis. for 1 of 5 (Resident #33) residents reviewed for unnecessary medication. The facility failed to document an appropriate diagnosis for Resident #33 who was prescribed a controlled medication (Seroquel). This failure could place residents on psychoactive medications at risk for possible adverse side effects, adverse consequences and decreased quality of life. Findings include: Review of the Face Sheet for Resident #33 reflected she was admitted to the facility on [DATE] with diagnoses of: Atrial Fibrillation, Acute Kidney failure, Acute Respiratory Failure, Encephalopathy and Pneumonia due to COVID-19 . Review of the MDS assessment for Resident #33 dated 6/26/22 reflected a BIMS score of 6 indicating severe cognitive status. Her functional assessment reflected she required extensive assistance to dress, toilet and bath. She required only supervision for other ADLs. She was assessed as Frequently Incontinent of bowels and bladder. Review of the Care Plan for Resident #33 reflected interventions were in place for: infection control, ADL performance deficit, resistance to Oxygen therapy, altered Cardiovascular status (Arrythmia, CHF, HTN), High fall risk r/t poor safety awareness, anti-anxiety medications, Nutritional problems r/t end of life comorbid conditions, Hospice for CHF terminal prognosis. Review of Physician's orders dated 7/09/22 reflected Resident #33 was prescribed Quetiapine (Seroquel) 100 mg at bedtime for metastic cancer. Resident #33 was also prescribed Trazodone 50 mg at bedtime for Insomnia. In an interview on 7/20/22 at 1:28 pm, LVN J stated the diagnosis of metastic cancer was not appropriate to a medication prescribed to Resident #33. Resident #33 was prescribed Seroquel 100 mg at bedtime. The medication was classified as Antipsychotic/Antimanic Agent. LVN J stated she had entered the diagnosis as written on the orders received from the Hospice Physician. In an interview on 7/20/22 at 2:00 pm, the Hospice RN Case Manager for Resident #33 stated the physician had written the prescription for Insomnia. She stated Resident #33 had behaviors and Insomnia related to metastasis to her brain from her breast cancer. The Hospice RN stated other medications were not effective at relieving the Insomnia . The Hospice RN Case Manager stated the diagnosis would be changed to an appropriate classification for Seroquel. She stated understanding the diagnosis was not appropriate to the medication and she would consult the doctor to change it as soon as possible. In an interview on 7/21/22 at 8:24 am, the Administrator stated medication reviews or monthly pharmacist reviews should be conducted according to facility policy . He stated the diagnosis entered for Resident #33's Seroquel was not within RAI guidelines. In an interview on 7/21/22 at 9:22 am the DON stated she did not feel the diagnosis of metastatic cancer was appropriate for the prescription of Seroquel. She stated she would contact the physician right away and have an appropriate diagnosis entered in Resident records

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 observations, record review, and interviews, the facility failed to ensure the MDS assessments of Residents were completed in compliance with RAI (Resident Assessment Instrument) guidelines for 4 of 9 (Resident #16, #2, #3 and #9) reviewed for appropriate MDS assessments. The facility failed to perform a BIMS or cognitive assessment Resident #16, Resident #2, Resident #3 and Resident #9. This deficient practice placed residents at risk of an undiagnosed decline in mental status and postpone needed medical treatment. Findings include: Review of the Face Sheet for Resident #16 reflected she was admitted on [DATE] with diagnosis of: Orthopedic Aftercare, Pneumonia, Fracture around left Hip Joint Prosthetic, Alzheimer's disease, Depressive Episodes and Osteoporosis. Review of the MDS Assessment for Resident #16 dated 5/08/22 reflected a blank cognitive assessment, no indication of the status of her cognitive impairment. The previous assessment dated [DATE] reflected a BIMS score of 6 indicating severe cognitive impairment. On 5/08/22 her functional assessment reflected she required extensive assistance for all ADLs. She was assessed as frequently incontinent of bowel and bladder. Review of Resident #16's Care plan reflected interventions were in place for: DNR status, ADL performance deficit r/t Alzheimer's-Fractured Hip and Impaired balance, Impaired cognitive function, high risk for falls, antidepressant medication, Hx of stroke, Weight loss over 30 days, potential for further fractures r/t Osteoporosis. Review of Progress Notes for Resident #16 reflected she went out of facility to hospital on 4/21/22 for Orthopedic repair of prosthetic hip fracture. Review of the Face Sheet for Resident #2 reflected she was admitted on [DATE] with diagnoses of: Unspecified Dementia, Morbid Obesity, Abnormal Gait, Type 2 diabetes, Congestive Heat Failure, Hypothyroidism, Chronic pain, Muscle Wasting and Atrophy. Review of the MDS for Resident #2 dated 4/18/22 reflected a blank cognitive assessment. Her functional assessment reflected she required only supervision for all ADLs. She was assessed as always continent of bowel and bladder. Review of the Care Plan for Resident #2 reflected interventions were in place for: Infection Control, DNR status, ADL performance deficit r/t Dementia and limited mobility, Potential Abnormal blood sugar levels r/t Diabetes, fall risk and Foley Catheter r/t Neurogenic bladder. Review of Progress notes for Resident #2 dated from 6/01/22 to 7/20/22 reflected no mention of uncontrolled bowels as stated by resident to surveyor. On 6/28/22 Resident #2 was assessed after a fall with pain to her right hip, an x-ray was ordered. Review of the Face Sheet for Resident #9 reflected she was admitted to the facility on [DATE] with diagnosis of: Chronic Kidney Disease, Anxiety disorder, Bradycardia, Diabetes, Muscle Weakness, Schizoaffective disorder, Parkinson's disease, Restless leg syndrome, CHF, and generalized edema. Review of the MDS Assessment for Resident #9 dated 5/05/22 reflected the cognitive assessment was blank. Her functional assessment reflected she required extensive assistance for all ADLs. She was assessed as frequently to always incontinent of bowel and bladder. Review of the Care Plan for Resident #9 reflected interventions were in place for: DNR status, Infection Control, ADL performance Deficit, Limited mobility, Cardiac health issues, Joint Pain, Diabetes, Morbid Obesity, Antipsychotic Medications, Parkinson's disease, Renal insufficiency. Review of the Face sheet for Resident #3 reflected she was admitted on [DATE] with diagnosis of: Unspecified Dementia, Alzheimer's disease, Pain to both knees, unsteady gait, Unspecified Behavioral syndromes associated with Physiological disturbances, Anxiety Disorder, Visual Hallucinations. Review of the MDS assessment for Resident #3 dated 4/18/22 reflected no cognitive assessment was completed and no staff assessment was completed. Her behavioral assessment reflected she did have verbal and physical behavioral symptoms directed towards others every 1 to 3 days. Her functional assessment reflected she required she required extensive assistance for transfers, but only limited or one person assistance for other ADLs. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #3 reflected interventions were in place for : Infection control, DNR status, ADL self performance Deficit, behaviors of yelling out with no cause or need, wandering with poor safety awareness, impaired cognitive process with history of stroke, History of falls (will attempt to self transfer), mobilize in wheelchair, monitor for psychoactive medication side affects. Observation of Resident #3 on 7/19/22 revealed she was resting in her bed with her eyes closed. Later observation revealed Resident #3 was ambulatory in her wheelchair and would respond to staff when asked questions. Resident #3 had right sided weakness In an interview on 7/21/22 at 8:24 am the Administrator stated the MDS assessment should be updated according to policy and whenever a resident had a change in condition. In an interview on 7/21/22 at 9:22 am the DON stated any change in condition should be included in the Resident Care Plan and if serious should trigger a change in status MDS assessment. In an interview on 7/21/22 at 8:55 am the Clinical VP/RN stated the MDS assessments of sampled Residents were not completed. She stated the MDS assessments should have either the BIMS assessment or the staff assessment of cognitive skills. She stated she did not know why the assessments were accepted by the system. She stated the assessments were not completed according to RAI guidelines. The Clinical VP stated the facility would audit MDS for all residents and correct as needed. She stated going forward the corporate office would audit the MDS assessments submitted. In an interview on 7/21/22 at 9:02 am the LVN/MDS coordinator stated she was not aware the cognitive assessments for residents was not completed. She stated the Social Worker conducted BIMS assessments at the facility. She stated the staff assessment should have been filled in if a resident could not answer BIMS questions. She stated the RN/Corporate reviewer was responsible for signing and reviewing all MDS assessments, because she was an LVN. She stated RN/Corporate Reviewer was not available for interview as she was at another facility. In an interview on 7/21/22 at 9:40 am the Social Worker (SW) stated the Corporate Nurse/RN performed the BIMS assessments whenever a Resident had impaired cognitive abilities.

CONCERN (E)

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

Deficiency F0655 (Tag F0655)

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 develop a baseline care plan within 48 hours of a resident's admission for 8 (Resident #100, Resident #38, Resident #125, Resident #24, Resident #115, Resident #120, Resident #7 and Resident #25) of 12 residents reviewed for baseline care plan completion. The facility failed to develop a baseline care plan for Resident #100, Resident #38, Resident #125, Resident #24, Resident #115, Resident #120, Resident #7 and Resident 25 within the required 48-hour timeframe. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included: Review of Resident #24's face sheet on 07/21/22 revealed an [AGE] year-old male admitted on [DATE] with diagnoses including COPD, Muscle weakness, Cognitive communication deficit and Type 2 Diabetes. Review of Resident #25's face sheet on 07/21/22 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including Displaced fracture of base of neck of right femur, Dementia, Bipolar Disorder and Major Depressive Disorder. Review of Resident #125's face sheet on 07/21/22 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including Cerebral Infarction (stroke) , Bipolar Disorder and Type 2 Diabetes. Review of Resident #38's face sheet on 07/21/22 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) , Hyperlipidemia (high concentration of fats in the blood.) and Dementia. Review of Resident #7's face sheet on 07/21/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including Peripheral Vascular Disease (poor blood circulation due to narrowing, blockage, or spasms in a blood vessel), Non-Pressure Chronic Ulcer on foot and Depression. Review of Resident #115's face sheet on 07/21/22 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including unspecified Dementia, Arthralgia (pain in a joint), Hypertension and Type 2 Diabetes. Review of Resident #120's face sheet on 07/21/22 revealed a [AGE] year-old female admitted on [DATE] with a diagnosis of the Presence of Right artificial Knee Joint. Review of Resident #100's face sheet on 07/21/22 revealed a [AGE] year-old male admitted on [DATE] with a diagnosis of Diarrhea unspecified. Record review of Residents' electronic health records for Resident #100, Resident #38, Resident #125, Resident #24, Resident #115, Resident #120, Resident #7 and Resident #25 on 07/21/22 at 10:00 AM revealed no evidence that a baseline care plan was developed for any of them as of 07/21/22. In an interview with the MDSC on 07/21/22 at 9:00 AM, she stated it was a mistake that no baseline care plan developed for any of these residents. She said developing a baseline care plan within the first 48 hours of admission was essential to provide necessary care effectively. This was the responsibility of the respective nurses on duty. In an interview with the Administrator on 07/21/22 at 10:00 AM, he stated a baseline care plan was a very important tool for providing nursing care to a newly admitted resident and it had to be developed within 48 hours. He identified there was a pattern and did not know how this mistake happened. He said he was committed to investigate for the cause and would take corrective measures immediately. Review of facility's policy Care Plans-Baseline dated December 2016 reflected, . to assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission .

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled drugs for one (400-hall) of two medication carts reviewed in that: The facility failed to perform counts of controlled medications each shift for the month of July 2022 for the 400 hall medication cart This deficient practice left the facility vulnerable to medication diversion, theft and missed doses of medication for residents. Findings include: In an interview and observation on 7/20/22 at 11:14 am of the medication cart on Hall 400 with the DON revealed the facility had 2 medication carts and two nursing medication carts . Record review of the Cart for Hall 400 revealed the narcotic count sheet for shift to shift counts was not completed . A total of 22 blank spots were observed on the sheet for July 2022. The DON stated nurses were aware shift to shift counts were to be performed, but as she was new to the facility, she had not completed an in-service about that topic yet. The DON stated she had no idea why blank signature spots appeared on the count sheet. The DON and surveyor performed an audit of the nurses cart. No medications were found to be missing from the controlled medications. In an interview on 7/21/22 at 8:24 am with the Administrator, he stated he expected staff to perform medication counts for controlled medications or narcotics every shift. He stated he had no explanation for the blanks on the July 2022 count sheet for Hall 400. The Administrator stated medication reviews or monthly pharmacist reviews should be conducted according to facility policy. Review of the facility's Controlled Substances policy dated April, 2019 reflected controlled substances are reconciled upon receipt, administration, disposition and at the end of each shift.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items in the refrigerator were dated and labeled appropriately. 2. The facility failed to ensure expired items were discarded. This failure could place residents in the facility at risk for food-borne illness, and food contamination. Findings included: Observations of the Refrigerator 1 of 2 in the kitchen on 07/19/22 at 9:40 A.M. revealed that the following items were expired: One plastic bag of Ham prepared on 7/13/ 22. The used by date was 7/16 /22. One plastic bag of Turkey meat prepared on 6/18/22. The used by date was 6/20/22. One plastic bag of pimento prepared on 7/11/22 had no used by date Observations of the Refrigerator 1 of 2 in the kitchen on 07/19/22 at 9:40 A.M. revealed that the following items were not dated and/or labeled appropriately: One 6lbs.5 Oz bottle of Cranberry sauce with '6/13/22' written on the cap. There was no used by date. One steel tray with a white pasty substance that had no name, prepared, and used by dates. One 1-gallon bottle soy sauce had no opened and used by dates. One plastic container of fruit cocktail had no prepared and used by dates. One plastic container of pork chops prepared on 7/17/22 had no used by date, Observations of the Refrigerator 2 of 2 in the kitchen on 07/19/22 at 9:40 A.M. revealed that the following items were expired: One plastic container with a pink creamy substance had no name, prepared, and used by dates on it. The Dietary Manager identified it as Pureed Ham. It emitted strong rotten smell when opened. The foul smell was substantiated by the DM as well while inspecting it. One plastic container of Pureed brisket prepared on 7/13/22 had no used by date. One plastic container of [NAME] Gravy prepared on 7/13/22 had no used by date One plastic container of Chili Mac prepared on 7/13/22 had no used by date Observations of the Refrigerator 2 of 2 in the kitchen on 07/19/22 at 9:40 A.M. revealed that the following items were not dated and/or labeled appropriately: One zip lock plastic bag with a loaf of meat in it had no name of the meat, prepared date and used by date. One 12lbs cardboard case of sliced muffin that had no prepared and used by date. The instruction on the box says 'keep frozen zero or below' Two packets of hickory smoked turkey breast had no dates on it One 1-gallon bottle of golden Italian dressing with '4/19' written on the cap. There was no used by date. One plastic container of pureed eggs prepared on 7/17/22 had no used by date. One plastic container of Chicken prepared on 7/17/22 had no used by date One plastic bag of ham with 7/13/22 written on it. There was no used by date. Interview with the DM on 7/19/22 at 10:30 am revealed that she was aware food that were opened or prepared were required to be named, dated, labeled, and sealed. She also stated that prepared food items older than 72 should be discarded. Interview on 7/19/22 at 3:30 pm, the Administrator stated that the employees should have followed the facility's food service policies and procedures. Review of the facility policy titled Nutrition and Food Service Policies and Procedures Manual for Long- term Care, dated 05/02/2022 stated: .Refrigerators: d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.

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?"
"What safeguards are in place to prevent abuse and neglect?"
"Why is there high staff turnover? How do you retain staff?"
"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: Federal abuse finding, 6 life-threatening violation(s), 1 harm violation(s), $83,033 in fines. Review inspection reports carefully.
• 41 deficiencies on record, including 6 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $83,033 in fines. Extremely high, among the most fined facilities in Texas. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Lakeside Health And Wellness's CMS Rating?

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

How is Lakeside Health And Wellness Staffed?

CMS rates LAKESIDE HEALTH AND WELLNESS's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 58%, which is 12 percentage points above the Texas average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Lakeside Health And Wellness?

State health inspectors documented 41 deficiencies at LAKESIDE HEALTH AND WELLNESS during 2022 to 2024. These included: 6 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 34 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 Lakeside Health And Wellness?

LAKESIDE HEALTH AND WELLNESS 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 ML HEALTHCARE, a chain that manages multiple nursing homes. With 124 certified beds and approximately 84 residents (about 68% occupancy), it is a mid-sized facility located in KEMP, Texas.

How Does Lakeside Health And Wellness Compare to Other Texas Nursing Homes?

Compared to the 100 nursing homes in Texas, LAKESIDE HEALTH AND WELLNESS's overall rating (1 stars) is below the state average of 2.8, staff turnover (58%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Lakeside Health And Wellness?

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?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.

Is Lakeside Health And Wellness Safe?

Based on CMS inspection data, LAKESIDE HEALTH AND WELLNESS has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 6 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Lakeside Health And Wellness Stick Around?

Staff turnover at LAKESIDE HEALTH AND WELLNESS is high. At 58%, the facility is 12 percentage points above the Texas average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Lakeside Health And Wellness Ever Fined?

LAKESIDE HEALTH AND WELLNESS has been fined $83,033 across 4 penalty actions. This is above the Texas average of $33,909. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Lakeside Health And Wellness on Any Federal Watch List?

LAKESIDE HEALTH AND WELLNESS 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: 124
Avg. Residents: 84
Occupancy: 68.1%
Ownership: For profit - Corporation
Chain: ML HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
6 Immediate Jeopardy citations: -72
1 Actual Harm citation: -5
41 Deficiencies: -10
Fines ($83,033): -10
Abuse Finding: -15
Final Score: 0/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 676497