Does BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION have any serious inspection findings?

Yes, BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION has 8 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 48 total deficiencies from recent inspections.

What are the staffing levels at BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION?

BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION has a three-star staffing rating from CMS with 0.59 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION

Q: What is BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION's CMS rating?

BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Where is BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION located?

BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION is located in PARIS, TX. It is a Medicare and Medicaid certified skilled nursing facility.

Q: How many beds does BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION have?

BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION has 119 certified beds.

Q: Who owns BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION?

BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION is a for profit - limited liability company facility and is part of the CREATIVE SOLUTIONS IN HEALTHCARE chain.

Q: Do nurses at BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION stick around?

BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION has average staff turnover at 46%, which is typical for the nursing home industry.

Q: Was BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION ever fined?

Yes, BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION has been fined $237,792 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION on any federal watch list?

No, BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

2885 STILLHOUSE ROAD, PARIS, TX 75460 · (903) 784-4111

For profit - Limited Liability company 119 Beds CREATIVE SOLUTIONS IN HEALTHCARE Data: November 2025 8 Immediate Jeopardy citations

Trust Grade

0/100

#937 of 1168 in TX

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Last Inspection: June 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Brentwood Terrace Healthcare and Rehabilitation has received a Trust Grade of F, indicating significant concerns about its operations and care quality. In Texas, it ranks #937 out of 1168 facilities, placing it in the bottom half of the state, and it is the lowest-ranked facility in Lamar County. While the facility is showing improvement in its trend, with issues decreasing from 30 in 2024 to 15 in 2025, its staffing rating is average at 3 out of 5 stars, with a turnover rate of 46%, which is slightly better than the state average. However, the facility has incurred fines totaling $237,792, higher than 93% of Texas facilities, indicating serious compliance issues. There are also critical concerns highlighted in recent inspections, including failures to provide adequate staff, leading to incidents where residents were left unsupervised and suffered falls or were involved in assaults. For example, one resident was physically assaulted due to insufficient supervision, while another resident experienced multiple unwitnessed falls, resulting in serious injuries. Although the facility has good RN coverage, which is more than 88% of Texas facilities, these weaknesses raise significant red flags for families considering care options here.

Trust Score: F
In Texas: #937/1168
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $237,792 in fines. Higher than 66% of Texas facilities. Some compliance issues.
Skilled Nurses: Each resident gets 35 minutes of Registered Nurse (RN) attention daily — about average for Texas. RNs are the most trained staff who monitor for health changes.
Violations: 48 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 30 issues

2025: 15 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: 46%

Near Texas avg (46%)

Higher turnover may affect care consistency

Federal Fines: $237,792

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: CREATIVE SOLUTIONS IN HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 48 deficiencies on record

8 life-threatening

Jun 2025 8 deficiencies

CONCERN (D)

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

Deficiency F0553 (Tag F0553)

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 residents and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 20 residents (Resident #68) reviewed for resident rights. The facility failed to ensure Resident #68's representative was invited to participate in the development and review of Resident #68's care plan. This failure could place residents at risk of not having needs met by depriving them the opportunity to participate in the decision making regarding their care. Findings included: Record review of Resident #68's face sheet dated 06/04/25, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of dementia (memory loss), muscle weakness, and anxiety. Record review of Resident #68's quarterly MDS assessment dated [DATE], indicated she was usually understood and usually understood others. Resident #68 had short/long term memory problems and her cognition was severely impaired. Record review of Resident #68's comprehensive care plan dated 04/02/24, indicated Resident #68 had impaired cognitive function, impaired thought processes and communication related to dementia. The care plan interventions included to communicate with the resident/family regarding resident's capabilities and needs. Record review of Resident #68's EMR on 06/04/25, did not reveal a care plan conference had been completed or uploaded. During an interview on 06/02/25 at 10:50 AM, Resident #68's representative said she had not been invited to a care plan meeting since Resident #68 admitted to the facility February of last year (2024). She said she would like to be invited to the care plan meetings so she would be aware of what was going on with Resident #68's care. During an interview on 06/04/25 at 09:26 AM, the SW reviewed Resident #68's EMR and said she did not see where a care plan meeting had been completed. The SW said a care plan meeting was to be completed quarterly and as needed. The SW said a care plan meeting was conducted to update the resident's family and to see if they had any issues or concerns. The SW said the MDS Coordinator and herself were responsible for ensuring the care plan meetings were being completed. She said she was unsure of how Resident #68's care plan meetings were missed. She said from what she could tell, Resident #68 had not had a care plan meeting since she admitted to the facility. During an interview on 06/04/25 at 11:42 AM, the RNC said the care plan meetings should be held at least quarterly. She said the care plan meetings were held to ensure the families were being updated with the current plan of care. The RNC said the SW was responsible for ensuring the care plan meetings were being conducted as required. During an interview on 06/04/25 at 11:46 AM, the Administrator said he expected the care plan meetings to be to be held at least quarterly. He said the care plan meetings were held with the resident and family to ensure the plan of care was best suited for the resident. The Administrator said the SW was responsible for ensuring the care plan meetings were being conducted. During an interview on 06/04/25 at 12:08 PM, MDS Coordinator B said the SW was responsible for setting up the care plan meeting. Record review of the facility's undated policy Comprehensive Care Planning, indicated .The facility will provide the resident and resident representative, if applicable, with advance notice of care planning conferences to enable resident/resident representative participation. Resident and resident representative participation in care planning can be accomplished in many forms such as holding care planning conferences at a time the resident representative is available to participate, holding conference calls or video conferencing .

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 interviews, observations, and record review the facility failed to ensure residents were free from abuse for 1 of 20 residents (Resident #47) reviewed for resident abuse. The facility did not ensure Resident #47 was free from abuse when Resident #4 hit Resident #47 in the head. The noncompliance was identified as PNC. The past noncompliance began on 04/21/25 and ended on 04/24/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Resident #47 Record review of Resident #47's face sheet, dated 06/04/25, reflected Resident #47 was an [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (brain chemical imbalance in the blood), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of the quarterly MDS assessment, dated 03/05/24, reflected Resident #47 made himself understood and understood others. The MDS assessment did not address Resident #47's BIMS score. The staff assessment reflected Resident #47 had short- and long-term memory problem. The MDS reflected Resident #47 had no behaviors or refusal of care during the look-back period. Record review of Resident #47's comprehensive care plan revised 01/10/23 reflected Resident #47 had behavior problem including cursing, talking to self, physical aggression toward staff during care, and history of grabbing and/or verbal threats to others. The care plan interventions included anticipate/meet the resident's needs and monitor behavior episodes and attempts to determine underlying cause. Resident #4 Record review of Resident #4's face sheet, reflected Resident #4 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included bipolar disorder (mental health condition characterized by significant mood swings), schizophrenia (a condition that can make you feel detached from reality and can affect our mood), delusions (unshakable belief in something that is not true) disorder, and anxiety disorder. Record review of Resident #4's annual MDS, dated [DATE], reflected Resident #4 made herself understood and usually understood others. Resident #4's BIMS score was 14, which indicated his cognition was intact. The MDS reflected Resident #4 had no behaviors or refusal of care during the look-back period. Record review of Resident #4's comprehensive care plan initiated on 04/21/25 reflected Resident #4 had potential to demonstrate physical behaviors and poor impulse control. The care plan interventions included analyze of key times, places, circumstances, triggers, what de-escalates behavior and document. The interventions also included if the resident had physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. Record review of the facility's PIR dated 04/24/25 with an incident category of abuse was signed by the Administrator on 04/24/25. The PIR reflected CNA N reported that Resident #4 hit Resident #47 in the head while in the dining room. The PIR included a witnessed statement by CNA N that reflected she witnessed Resident #4 hitting Resident #47 in the head while taking a tray to the kitchen. The witnessed statement reflected CNA N immediately reported the incident to the charge nurse. The PIR included a witnessed statement by MDS Coordinator B as he was walking from Hall 1 to nursing station when Resident #4 yelled out Hey get off my foot, MDS Coordinator B stated he noted Resident #4 sitting in her wheelchair in day room and noted her pushing Resident #47's wheelchair away from her stating he ran over her foot. The witnessed statement written by Social Services reflected Resident #4 stated he (pointing at Resident #47) run over her foot, so she hit him. The PIR included a skin assessment for Residents #4 and #47 completed 04/21/25 reflected no new skin issues, psychiatric assessment for Resident #4 completed 04/21/25, social service notes for Residents #4 and #47 completed 04/21/25 reflected no s/s of distress and no new orders, trauma informed PRN assessment for Resident #47 completed 4/21/25 reflected negative for any new findings, Q15 minute monitoring log for Resident #4 with (start date 04/21/25, end date 04/22/25) reflected no new behaviors noted, resident safe surveys with no areas of concerns dated for 04/21/25, staff/resident and resident to resident monitoring completed 05/23/25 reflected no new behaviors noted. The PIR reflected staff was in-serviced promptly on abuse and neglect including resident to resident completed 04/21/25 reflected who the abuse coordinator was, how to contact the abuse coordinator and when to notify the abuse coordinator. During an observation and attempted interview on 06/02/25 at 12:01 p.m., Resident #47 was sitting in his wheelchair next to the bed. Resident #47 was non-interview able. During an observation and interview on 06/02/25 at 2:38 p.m., Resident #4 was lying in bed. Resident #4 stated, I haven't hit nobody when asked if she remembered the incident between her and Resident #47. Resident #4 stated, I don't remember him running over my foot. During an interview on 06/02/25 at 2:45 p.m., CNA N stated Resident #4 and Resident #47 was sitting in the day room when Resident #47 run over Resident #4 foot with his wheelchair. CNA N stated she was taking a tray into the dining room from lunch when she heard Resident #4 and Resident #47 arguing and by the time she laid the tray down to intervene that was when Resident #4 hit Resident #47 on his head which was loud enough that everyone heard it. CNA N stated she did not see the part when Resident #47 run over Resident #4 foot. CNA N stated she intervened immediately by separating the residents and notifying LVN O. An attempted telephone interview on 06/04/25 at 1:48 p.m. with LVN O, was unsuccessful. During interviews on 06/02/25 beginning at 10:00 a.m., - with 10 residents (#4, #47, #68, #54, #132, #17, #129, #130, #76, #131) regarding abuse and neglect with a focus presented on resident-to-resident physical abuse reflected they all denied abuse. During staff interviews beginning on 06/02/25 at 10:00 a.m. and ending 06/04/25 at 3:13 p.m.,- with LVN (A, D, E, O), RN (C, K), CNA (L, M, N, P, R, T), MA G, MDS Coordinator (B, F), Laundry Aide S, Human Resources, Dietary Manager, ADON revealed they were in serviced 04/21/25 on abuse/neglect including resident to resident and were able to define abuse, when to report, and whom to report it to. During an interview on 06/04/25 at 2:27 p.m., the Regional Compliance Nurse stated she was aware of the abuse allegation between Residents #4 and #47 and was told by the DON that the residents were separated immediately, skin assessments were completed to make sure there were no harm, safe surveys were completed to make sure everyone was ok, and trauma assessments were completed to ensure that no one had a negative psychosocial outcome from it. During an interview on 06/04/25 at 2:39 p.m., the Administrator stated he was the abuse coordinator for the facility. The Administrator stated he was aware of the incident between Residents #4 and #47. The Administrator stated the victims did not have any changes in behavior since the incident. The Administrator stated abuse was monitored daily during rounds by visiting with residents and directly observing the residents and facility. The Administrator stated once he was learned of any allegations he reported accordingly, investigate, and ensure all residents were protected. Record review of the facility's policy titled Abuse/Neglect revised 03/29/18 reflected . the resident has the right to be free from abuse . Residents should not be subjected to abuse by anyone, including, but not limited to . other residents .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

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 assessments accurately reflected the resident status for 1 of 20 residents (Resident #4) reviewed for MDS assessment accuracy. The facility did not ensure Resident #4's MDS assessment was accurately coded for PASRR (a preliminary assessment completed for all individuals before admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability). This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #4's face sheet, reflected Resident #4 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included bipolar disorder (mental health condition characterized by significant mood swings), schizophrenia (a condition that can make you feel detached from reality and can affect our mood), delusions (unshakable belief in something that is not true) disorder, and anxiety disorder. Record review of Resident #4's annual MDS assessment, dated 05/02/25, reflected in Section A1500 (PASRR) asked Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? This section was marked 0 which meant No. Section A.1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions did not have A. Serious mental illness, B. Intellectual Disability, or C. Other related conditions checked. Resident #4 made herself understood and usually understood others. Resident #4's BIMS score was 14, which indicated his cognition was intact. Record review of Resident #4's comprehensive care plan revised on 10/03/24 reflected Resident #4 had a diagnosis of ID and was PASRR positive. The care plan interventions included Resident #4 was receiving habilitation coordination and independent living skills trainings. During an interview on 06/04/25 at 1:14 p.m., MDS Coordinator B stated MDS Coordinator F was responsible for Resident #4's MDS annual MDS. MDS Coordinator B stated if the resident was PASRR positive yes should have been marked that the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition and mental illness/ID should have been checked. MDS Coordinator B stated MDS Coordinator F was out today due to personal reasons. MDS Coordinator B stated it was important to ensure the MDS was accurate so services will be evaluated and given. During an interview on 06/04/25 at 1:37 p.m., the Regional Reimbursement Specialist stated he expected yes to be marked that the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition and mental illness/ID should have been checked. The Regional Reimbursement Specialist stated he expected the Administrator to be responsible for monitoring and overseeing MDS accuracy. The Regional Reimbursement Specialist stated it was important for MDS accuracy to reflect the resident's status. During an interview on 06/04/25 at 1:55 p.m., the Regional Compliance Nurse stated there was not a policy and procedure regarding MDS assessment accuracy. The Regional Compliance Nurse stated the facility followed the RAI manual. During an interview on 06/04/25 at 2:39 p.m., the Administrator stated he expected the MDS to be marked correctly because Resident #4 was PASRR positive. The Administrator stated he monitored accuracy by random as needed audits/spot checks. The Administrator was unable to recall his last audit. The Administrator stated it was important to ensure MDS accuracy to ensure the residents received the necessary 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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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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 observation, interview, and record review the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 of 12 residents (Resident #132) reviewed for oxygen therapy. The facility failed to ensure Resident #132 had a physician's order in her chart for oxygen. This failure could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. Findings Included: Record review of Resident #132's face sheet, dated 06/04/25, reflected Resident #132 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the MDS assessment, accessed on 06/04/25, reflected Resident #132's admission MDS had not been completed yet. Record review of Resident #132's comprehensive care plan initiated on 05/24/25 reflected Resident #132 received oxygen therapy. The care plan interventions give medications as ordered by physician, monitor for s/sx of respiratory distress and report to MD PRN. The care plan did not address how many liters Resident #132 should be at. Record review of Resident #132's physician order summary report, dated 06/03/25, reflected there was not an order for oxygen in the summary. During an observation and interview on 06/02/25 at 11:08 a.m., Resident #132 was lying in bed wearing oxygen via nasal cannula. Resident #132's five-liter oxygen concentrator was set on 2 lpm. Resident #132 stated she wore oxygen all the time due to COPD. During an observation on 06/03/25 at 4:22 p.m., Resident #132 was wearing oxygen via nasal cannula while sitting on a bedside commode. Resident #132's five-liter oxygen concentrator was set on 2 lpm. During an interview beginning on 06/04/25 at 12:37 p.m., LVN A stated she was Resident #132's 6am-6pm charge nurse. LVN A stated Resident #132 had been wearing oxygen since admission. After reviewing Resident #132's electronic medical records, LVN A stated Resident #132 did not have an order for oxygen. LVN A stated she was unaware Resident #132 did not have an order for oxygen until the state surveyor intervention. LVN A stated all nurses were responsible for checking the orders in PCC to ensure there was an order for oxygen. LVN A stated it was important to ensure oxygen orders were placed in Resident #132's electronic medical records because if the resident did not need oxygen, she could come dependent on the oxygen or if the oxygen was taken away because there was no order, Resident #132 could become hypoxic (an absence of enough oxygen in the tissues to sustain bodily functions). An attempted telephone interview on 06/04/25 at 1:28 p.m. with RN C, the nurse that admitted Resident #132, was unsuccessful. During an interview on 06/04/25 at 2:27 p.m., the Regional Compliance Nurse stated she expected Resident #132 to have an order for oxygen upon admission. The Regional Compliance Nurse stated the charge nurse that admitted Resident #132 should have entered the order upon admission. The Regional Compliance Nurse stated the nursing administration, which included the DON/ADONs, were responsible for monitoring and overseeing by checking orders upon admission to ensure accuracy. The Regional Compliance Nurse stated it was important to ensure oxygen orders were place in PCC to communicate with all nurses that resident needs oxygen. During an interview on 06/04/25 at 2:39 p.m., the Administrator stated if the resident was receiving oxygen she should have had an order. The Administrator stated the admission was responsible for ensuring an order was placed in PCC. The Administrator stated the DON and ADONs were responsible for monitoring and overseeing by reviewing the admission order after a new admission. The Administrator stated it was important to ensure an oxygen order was place in PCC for resident safety. Record review of an undated facility policy titled, Oxygen Administration, indicated, the amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician .

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 2 of 3 residents (Resident #17 and Resident #54) reviewed for medication administration accuracy. 1. The facility failed to ensure Resident #17 received his blood sugar checks or insulin for 21 out of 31 days during May 2025. 2.The facility failed to ensure Resident #54 received his Metoprolol (used to treat heart condition, lowers blood pressure, reducing the risk of strokes and heart attacks) on 05/30/2025 at 4:00 p.m. These failures could place residents at risk of not receiving the therapeutic effect of the medication. The findings included: 1.Record review of Resident #17's face sheet dated 06/04/25, indicated a [AGE] year-old male who admitted [DATE] and re-admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2 (also known as diabetes, a chronic disease that occurs when the body has high blood sugar levels), schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors), and high blood pressure. Record review of Resident #17's quarterly MDS assessment dated [DATE] indicated Resident #17 was usually able to make himself understood and understood others. The MDS assessment indicated Resident #17 had a BIMS score of 12, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #17 had received insulin 7 days out of the 7-day look-back period. The MDS assessment indicated Resident #17 had received a hypoglycemic medication within the last 7 days of the look-back period. Record review of Resident #17's comprehensive care plan, revised on 05/23/25, indicated Resident #17 had Diabetes Mellitus. The care plan interventions were for staff to give medication as ordered by the doctor. Record review of Resident #17's order summary report dated 03/15/25 indicated Resident #17 had an order for the following: Humalog Kwik Pen Subcutaneous Solution Pen-injector 100 units per milliliter (Insulin Lispro), Inject as per the sliding scale: if 0 - 150 = 0; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units. Call the physician if above 400, subcutaneously, before meals and at bedtime, related to type 2 diabetes mellitus. Record review of Resident #17's order summary report dated 06/03/25, after surveyor intervention, indicated Resident #17 had an order for the following: Humalog Kwik Pen Subcutaneous Solution Pen-injector 100 units per milliliter (Insulin Lispro), Inject as per the sliding scale: if 0 - 150 = 0; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units. Call the physician if above 400, subcutaneously, two times a day (7:00 am and 4:00 pm), related to type 2 diabetes mellitus. Record review of the MAR dated 05/01/25 through 05/31/25 revealed Resident #17's blood sugar was not checked at 11:00 am on the following days: 05/01/25, 05/02/25, 05/04/25, 05/05/25, 05/06/25, 05/07/25, 05/08/25, 05/09/25, 05/11/25, 05/12/25, 05/13/25, 05/15/25, 05/16/25, 05/19/25, 05/20/25, 05/21/25, 05/23/25, 05/25/25, 05/27/25, 05/28/25, 05/29/25. Record review of the MAR revealed the nurses had placed a number 3 under their initial, which indicated Resident #17 was away from the facility. During a phone interview on 06/02/25 at 2:21 p.m., the case manager said she worked at the adult habilitation center, where they specialize in mental health or developmental disability diagnosis. She said Resident #17 came to their facility Monday through Friday from 9 am until 2 pm. She said they were unable to give any medication to any resident while at their facility. She said the facility the resident (s) resided in was responsible for administering their residents' medication if required. During an interview on 06/03/25 at 9:20 a.m., LVN D said she was the nurse for Resident #17. She said on the days she worked, and Resident #17 was not in the facility because he was at the adult habilitation center, she would put a 3 on his medication administration records for his 11:00 am blood sugar check/insulin. She said the 3, indicating he was not in the facility for his 11:00 am blood sugar check or insulin if required. She said she did not notify the physician because she thought the physician was aware he missed the 11:00 am blood sugar check or insulin. During a phone interview on 06/03/25 at 10:22 a.m., the Medical Director said he was unaware Resident #17 was not receiving his blood sugar checks or medication while at the adult habilitation center. He said the facility notified him today (06/03/25), and he made some medication changes. He said Resident #17 was non-compliant with following his diabetes management, but missing his medication could cause his blood sugar levels to be higher and require more insulin. During an interview on 06/03/25 at 4:09 p.m., Resident #17 said he went to the adult habilitation center Monday through Friday. He said that while he was at the center, he did not receive his 11:00 am blood sugar check or insulin. He said he did receive his blood sugar checks and insulin on the weekend while he was at the facility. During an interview on 06/04/24 at 12:53 p.m., LVN A said she was one of Resident #17's primary nurses. She said Resident #17 was at the adult habilitation center Monday through Friday. She said she would put a 3, which meant not given, on his medication administration record because he was not in the facility. She said she was unaware that the adult habilitation center did not check to monitor his blood sugars or give him medication as ordered. She said without his medication, it could cause him to go into diabetic ketoacidosis (a serious complication of diabetes). During an interview on 06/04/25 at 2:00 p.m., the Regional Nurse Consultant said she expected medication to be given as ordered. She said she was aware the adult habilitation center did not give medication, but did not realize Resident #17 was not receiving his 11:00 am blood sugar checks or insulin medication. She said the facility was responsible for giving the medication as ordered. She said Resident #17 could have had a negative outcome with his blood sugars being either too high or too low. During an interview on 06/04/25 at 2:27 p.m., the Administrator said he expected staff to follow the physician's orders. He said the nurses should have ensured Resident #17 received his blood sugars or insulin as ordered. He said the DON was responsible for ensuring medication was being given. The Administrator said failure to check blood sugars could impact their blood sugar levels by being too low or too high. 2.Record review of Resident #54's face sheet dated 06/03/2025, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included dysphagia (difficulty swallowing), gastrostomy hemorrhage (bleeding associated with a gastrostomy, which was a surgical procedure creating an opening in the abdomen to insert a feeding tube into the stomach), muscle wasting and atrophy (loss of muscle mass). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #54's speech was unclear, but he was able to make himself understood, and understood others. The MDS assessment indicated Resident #54's had a BIMS score of 10 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #54 had a feeding tube. Record review of Resident #54's comprehensive care plan revised dated 04/15/2025, indicated he had hypertension with interventions to give anti-hypertensive medication as ordered. Record review of Resident #54's order summary report dated 05/06/25, indicated he had the following orders, Metoprolol 25 mg give 1 tablet via gastrostomy tube twice a day 8:00 a.m. and 4:00 p.m. with start date 02/14/2024. During an interview on 06/02/2025 at 3:16 p.m., Resident #54 stated he did not receive his 4:00 p.m. medication on 05/30/2025. Resident #54 stated he felt like the nurse did not give him because he had spoken with the state surveyor earlier that day. During an interview on 06/04/2025 at 12:00 p.m., RN K stated it was her responsibility to administer Resident #54's medications on time. RN K stated Resident # 54's medications were important to ensure he received the treatment he needed. RN K stated the risk to Resident #54 could leave his condition untreated. During an interview on 06/04/2025 at 1:15 p.m., the Corporate Nurse stated she expected the medications to be administered as ordered by the physician. The Corporate Nurse stated the nurse was responsible for ensuring this was done. The Corporate Nurse stated the failure to provide the medications as ordered could result in a change of condition. The Corporate Nurse stated she would monitor by watching a medication pass. During an interview on 06/04/2025 at 1:30 p.m., the Administrator stated his expectations were for nursing staff to follow physician orders The Administrator stated the nurse was responsible for ensuring the medications were being administered as ordered. The Administrator stated it was important for compliance and resident safety. The Administrator stated he was not clinical, so he was unsure of the risk. The Administrator stated he would monitor by direct observation and in-service. Record review of the facility's policy titled, Medication Orders, from Pharmacare USA V3-2025, indicated, Policy: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Record review of the facility's policy titled, Medication Administration and General Guidelines, from Pharmacare USA V3-2025, indicated, Policy: Medications are administered as prescribed, by State Regulations, using good nursing principles and practices and only by persons legally authorized to do so. #17. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g., resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. The physician must be notified when a dose of medication has not been given. If an electronic medical record is being utilized than the caregiver administering the medication will enter the correct documentation that will then be electronically date/time stamped with their initials.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #129's face sheet, dated 06/04/25, reflected Resident #129 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and asthma (chronic condition that affects the airways in the lungs). Record review of the MDS assessment, accessed on 06/04/25, reflected Resident #129's admission MDS had not been completed yet. Record review of Resident #129's comprehensive care plan initiated on 05/23/25 reflected Resident #129 had emphysema (long term lung condition that causes shortness of breath) and COPD. The care plan interventions included give aerosol (spray) or bronchodilators (inhaler) as ordered and monitor/document side effects and effectiveness. Record review of the order summary report dated 06/02/25 reflected an active physician order for Albuterol Sulfate HFA Inhalation Aerosol Solution (medication used to treat or prevent bronchospasm (muscles that line bronchi (airway in your lungs) tighten or narrowing of the airway in the lungs) 90 mcg/act: 2 puff inhales orally one time a day for COPD with a start date 05/24/25. During an interview and observation on 06/02/25 at 11:12 a.m., Resident #129 was lying in bed. An inhaler that was labeled Albuterol Sulfate HFA Inhalation Aerosol was on her dresser. Resident #129 stated she did 2-3 puffs as needed and it really depended on how bad she felt. Resident #129 stated she brought it from home. During an interview and observation on 06/02/25 at 11:48 a.m., with MA G revealed Resident #129's inhaler was located on the nurse's medication cart. MA G stated the medication was administered by a nurse one time a day, every day. During an observation on 06/03/25 at 8:02 a.m., Resident #129 was eating her breakfast. An inhaler that was labeled Albuterol Sulfate HFA Inhalation Aerosol was on her dresser. During an observation and interview on 06/04/25 at 12:33 p.m., Resident #129 was sitting on her bed. An inhaler that was labeled Albuterol Sulfate HFA Inhalation Aerosol was on her dresser. Resident #129 stated she told someone that it was her inhaler, and she did not use the one that was in the nurse's medication cart, when asked if she had let the facility know that she had one her dresser. Resident #129 was unable to give the staff name that she told. 3. Record review of Resident #130's face sheet, dated 06/04/25, reflected Resident #130 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included gastroenteritis (stomach virus) and colitis (inflammation of the colon). Record review of the MDS assessment, accessed on 06/04/25, reflected Resident #130's admission MDS had not been completed yet. Record review of Resident #130's comprehensive care plan did not address nystatin cream. Record review of Resident #130's order summary report dated 06/02/25 reflected there was not an order for nystatin cream in the summary. During an observation and interview on 06/02/25 at 11:01 a.m., Resident #130 was lying in bed. A tube that was labeled nystatin cream was on her bedside table. Resident #130 stated she used it because her private area itched. Resident #130 stated her husband brought the medication to her. During an observation and interview on 06/03/25 at 8:15 a.m., Resident #130 was lying in bed. Resident #130 stated her husband took the medication home on [DATE]. During an interview beginning on 06/04/25 at 12:37 p.m., LVN A stated Residents #129 and #130 had not been evaluated for self-administration of medications. LVN A stated if a resident was able to self-administer, he/she must be assessed for competence. LVN A stated she saw Resident #130's nystatin cream over the weekend and told her she was not allowed to keep the cream in her room. LVN A stated Resident #130 told her that her husband would take the medication home. LVN A stated she was unaware Resident #129 had an inhaler on her dresser. LVN A stated medications should be stored on the medication cart. LVN A stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 06/04/25 at 2:27 p.m., the Regional Compliance Nurse stated her expectations were that medications were locked in the medication cart and administered by the nurse or MA. The Regional Compliance Nurse stated to self-administrate, an assessment for self-administration must be completed and an order obtained from the MD. The Regional Compliance Nurse stated the nursing administration, which included the DON and ADONs, were responsible for monitoring and overseeing medications at bedside by daily facility rounds. The Regional Compliance Nurse stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 06/04/25 at 2:39 p.m., the Administrator stated medications should not be left at bedside. The Administrator stated medications should be locked and secured and administered by the nurse or MA. The Administrator stated the charge nurse should be ensuring medications were not left at bedside. The Administrator stated the DON and ADONs were responsible for monitoring and overseeing medication storage by daily rounds. The Administrator stated it was important to ensure medications were not left at bedside for resident safety. Record review of the facility's policy undated policy titled Storage of Medication indicated . Medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .2 . Medications rooms, carts and medication supplies are locked and attended by persons with authorized access . Record review of an undated facility policy titled Self-Administration of Medications by Residents Policy, indicated . 2. If the resident desires to self-administer medications as assessment is conduced by the IDT of the resident's cognitive, physician, and visual ability to carry out the responsibility . 6. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage, and then give unauthorized medications to the charge nurse for return to the family or responsible party . Based on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 20 residents (Resident #129 and Resident #130) and 1 of 7 medication carts (400 hall Nurse Medication Cart) reviewed for drugs and biologicals. 1. The facility failed to ensure RN C secured the 400 hall Nurse Medication Cart, when she went in Resident #47's room to obtain his blood sugar on 06/02/25. 2. The facility did not ensure Resident #129's inhaler (a device that delivers medication directly into the lungs by inhaling it) was not left on her dresser. 3. The facility did not ensure Resident #130's nystatin cream (antifungal medication) was not left on her bedside table. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: 1. During an observation and interview on 06/02/25 at 11:41 AM, RN C entered Resident #47's room to obtain his blood sugar. RN C left the nurse's medication cart unlocked. RN C proceeded to obtain Resident #47's blood sugar. RN C said she forgot to lock the cart because was nervous. RN C said the nurse cart should always be locked when leaving it unattended. RN C said she was responsible for ensuring the cart was locked. RN C said failure to lock the cart was a safety concern and a resident could have walked by and gotten into the cart. During an interview on 06/04/25 at 11:42 AM, the RNC said she expected medication carts to be to be locked when leaving unattended. She said failure to properly lock the medication cart could leave other residents at risk for getting into the cart. The RNC said the nurse or medication aide was responsible for ensuring medication carts were kept locked when leaving unattended. During an interview on 06/04/25 at 11:46 PM, the Administrator said he expected medications carts to be to be locked when leaving unattended. He said by not properly locking the medications carts, residents could access the cart. The Administrator said the nurse or medication aide were responsible for ensuring medication carts were kept locked with leaving unattended.

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 review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Resident #76, Resident #54, and Resident #131) reviewed for infection control. 1.The facility failed to ensure CNA L performed hand hygiene while providing incontinent care for Resident #76 on 06/02/25. 2. The facility failed to ensure LVN D applied a gown when she administered an IV medication to Resident #131 on 06/03/25. 3. The facility failed to ensure LVN E applied a gown when she administered medications via a gastrostomy tube (feeding tube) to Resident #54 on 06/03/25. 4.The facility failed to ensure CNA L and CNA M applied a gown when they administered care to Resident #54 on 05/30/2025. These failures could place any resident at the facility at risk for cross-contamination and the spread of infection. Finding included: 1.Record review of Resident #76's face sheet, dated 06/04/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses to include dementia (progressive loss of intellectual functioning), muscle weakness, and Congestive heart failure, or heart failure, is a long-term condition in which your heart can't pump blood well enough to meet your body's needs. Record review of Resident #76's quarterly MDS assessment, dated 04/11/25, indicated Resident #76 understood and was understood by others. Resident #76's BIMS score was 08, which indicated her cognition was moderately impaired. The MDS indicated Resident #76 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS indicated she was frequently incontinent of bladder. Record review of Resident #76's comprehensive care plan revised on 11/07/24, indicated Resident #76 was incontinent of bladder. The care plan interventions were for staff to provide incontinent care at least every 2 hours and apply a moisture barrier after each episode. During an observation on 06/02/25 at 11:40 a.m., CNA L provided incontinent care for Resident #76. She wiped her front area and then her backside without changing her gloves or performing hand hygiene. She then grabbed a clean brief, applied it, pulled down her gown, and assisted Resident #76 to her wheelchair with the same dirty gloves still on. CNA L then removed her gloves, gathered her equipment, washed her hands, and left the room. During an interview on 06/02/25 12:03 p.m., CNA L said she did not realize she did not perform hand hygiene or change her gloves after wiping Resident #76's front, then wiping her back and touching the clean brief and her gown with dirty gloves. S. The Regional Nurse Consultant said they went over incontinence care and hand washing upon hire, annually, and as needed. She said nurse management oversaw infection control and cross-contamination. She said staff should change gloves and practice hand hygiene to prevent infection and cross-contamination. During an interview on 06/04/25 at 12:17 p.m., the Administrator said he expected all staff to use proper hand hygiene techniques between dirty and clean areas with all care. The Administrator said the DON was responsible for ensuring staff were trained on incontinent care and infection control. He said improper hand hygiene could place residents at risk for cross-contamination.he said she knew, that without hand hygiene or removing dirty gloves, she could cause cross-contamination. During an interview on 06/04/25 at 11:44 a.m., LVN A said she was Resident #76's nurse. She said she expected the CNAs to perform incontinent care the correct way. She said she expected them to change their gloves between clean and dirty to prevent cross-contamination. During an interview on 06/04/25 at 2:00 p.m., the Regional Nurse Consultant said she expected the CNAs to perform incontinent care correctly. She said she expected staff to change their gloves between dirty to clean and use hand hygiene between glove changes Record review of CNA L's proficiency on incontinent care and handwashing was dated 05/26/25. 2. Record review of Resident #131's face sheet dated 06/03/25, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included sepsis (a serious condition in which the body responds improperly to an infection, causing organ damage and sometimes death) and cellulitis (bacterial infection involving the inner layers of the skin) of the right lower limb. Record review of Resident #131's admission MDS assessment dated [DATE], indicated he had a BIMS score of 10, which indicated his cognition was moderately impaired. Resident #131 had received IV antibiotics within the last 14 days of the look back period. Record review of Resident #131's comprehensive care plan dated 05/21/25, indicated Resident #131 was on enhanced barrier precautions with the interventions for gloves and gown should be donned if any of the following activities were to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, bathing, or high-contact activity. Record review of Resident #131's order summary report dated 06/03/25, indicated he had the following orders: o Flush IV line with 10 mls of normal saline before and after medication with an order start date of 05/21/25. o Flush IV with 10 ml normal saline q shift with an order start date of 05/21/25. o Vancomycin 1 GM give 1 GM intravenously two times a day for wound with a start date of 05/29/25. During an observation and interview on 06/03/25 at 8:09 AM, LVN C entered Resident #131's room to administer vancomycin 1 GM IV via his PICC (a thin flexible tube that is inserted into a vein in the upper arm for IV antibiotics or IV medications) line. LVN C performed hand hygiene, applied gloves, flushed Resident #131's PICC line with 10 ml of normal saline and set the IV at 200 mls/hour to administer the vancomycin medication. LVN C did not apply a gown before she administered Resident #131's medication. LVN C removed her gloves and performed hand hygiene. Resident #131 had a 3-drawer plastic bin, with PPE, inside his room to the left side of the door and EBP signage on his door. LVN C said she missed applying the gown because she was very nervous. LVN C said she should have applied the gown to protect Resident #131 from bacteria. LVN C said she was responsible for ensuring proper PPE was worn. During an interview on 06/04/25 at 11:42 AM, the RNC said she expected proper PPE to be worn when caring for a device or if the staff was providing close personal care to residents on EBP. The RNC said PPE should have been worn when providing IV and peg-tube medications. The RNC said failure to apply proper PPE placed the residents at risk for infection. The RNC said the person caring for the device was responsible for ensuring EBP precautions were followed. During an interview on 06/04/25 at 11:46 AM, the Administrator said he expected EBP precautions to be followed as per the facility's policy and when it was required. The Administrator said PPE should be worn when providing IV medications or when providing medications through a peg-tube to protect the resident from any infections. The Administrator said the staff taking care of the resident was responsible for ensuring proper PPE was worn. During an interview on 06/04/25 at 3:13 PM, the ADON H, said she was the Infection Preventionist. ADON H said she expected the staff to follow the EBP protocol. She said if a nurse was providing medications through an IV or peg tube, PPE should be worn. She said failure to apply proper PPE placed the residents at risk for exposure to bacteria. ADON H said the nurse was responsible for ensuring proper PPE was worn. Resident #54 Record review of Resident #54's face sheet dated 06/04/25, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of quadriplegia (paralysis that affects all limbs and body from the neck down) and dysphagia (difficulty swallowing). Record review of Resident #54's annual MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. Resident #54 had a BIMS score of 10 which indicated his cognition was moderately impaired. Resident #54 was dependent on staff with all ADLs. The MDS assessment indicated Resident #54 had a feeding tube. Record review of Resident #54's comprehensive care plan dated 04/03/24, indicated Resident #54 was on enhanced barrier precautions with the interventions for gloves and gown to be donned if any of the following activities were to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, bathing, or high-contact activity. 3. Record review of Resident #54's order summary report date 06/03/25, indicated Resident #54 had the following orders: o Enteral Feed Order flush tube with 60 ML water before and after medication and feedings with an order start date of 02/13/24. o Hydroxyzine 50 mg give one tablet via peg tube (tube inserted in the stomach for nutrition or medications) three times a day for itching with an order start date of 03/03/25. o Clonazepam 0.5 mg give one tablet via peg tube three times a day related to anxiety with an order start date of 09/26/24. o Lyrica 100 mg give one capsule via peg tube four times a day for pain with a start date of 03/25/25. o Zofran 4 mg give one tablet via g-tube 3 times a day for nausea/vomiting with a start date of 11/18/24. o Tylenol 325 mg give 2 tablets via g-tube every 6 hours as needed for pain with a start date of 02/13/24. During an observation and interview on 06/03/25 at 11:00 AM, LVN E prepared Resident #54's medications. LVN E obtained the following medications: 1 capsule of Lyrica 100mg, 1 tablet of clonazepam 0.5mg, 1 tablet of ondansetron 4 mg, 1 tablet of hydroxyzine 50 mg, and 2 tablets of Tylenol 325 mg. LVN E entered Resident #54's room to administer his routine medications via his peg tube. LVN E performed hand hygiene, applied gloves, administered all medications via his peg tube, removed her gloves and washed her hands. LVN E failed to apply a gown. Resident #54 had a 3-drawer plastic bin, with PPE, inside his room to the left side of the door and an EBP signage on his door. LVN E said Resident #54 was on EBP precautions which indicated gown and gloves were required when providing direct patient care. LVN E said she forgot to apply her PPE because the state surveyor made her nervous. LVN E said failure to apply proper PPE placed the resident at risk for bacteria. LVN E said she was responsible for ensuring EBP precautions were followed. 4. During a video observation dated 05/30/2025, on 06/03/2025 at 11:00 a.m., CNA L and CNA M were observed coming into Resident#54's room to provide care, applied their gloves, bathed resident's face, chest, and abdomen without applying a gown. During an interview attempt on 06/03/2025 at 11:42 a.m., surveyor attempted to contact CNA M by phone and left voicemail to return call. During an interview on 06/03/2025 at 2:44 p.m. CNA L stated she had worked for the facility for 3 days prior to giving Resident #54 care on 05/30/2025. CNA L stated she had been trained on when to apply PPE. CNA L stated it was important to wear PPE because you did not want to contaminate Resident #54's catheter and a feeding tube. CNA L stated the risk to Resident #54 was infection. During an interview on 06/04/2025 at 1:15 p.m., the Corporate Nurse stated she expected proper PPE to be worn when providing close personal care to residents on EBP. The Corporate Nurse stated it was the nursing staff's responsibility to wear PPE when providing personal care. The Corporate Nurse stated it was important to wear PPE for infection control. The Corporate Nurse stated she would monitor by in-service and entering Resident rooms to make sure staff was properly donning PPE. During an interview on 06/04/2025 at 1:30 p.m., the Administrator stated his expectations were for the staff to don and doff PPE correctly. The Administrator stated it was important to wear PPE to ensure no cross contamination. The Administrator stated it was the individual staff members responsibility to wear PPE correctly. The Administrator stated he was not clinical, so he was unsure of the risk. The Administrator stated he would monitor by direct observation and in-service. Record review of the facility's policy titled, Fundamentals of Infection Control Precautions, section AD 03-08, indicated, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. 1. Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection. Record review of the facility's undated policy Enhanced Barrier Precautions, indicated .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomy .

Jan 2025 7 deficiencies

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** Based on interview, and record review, the facility failed to ensure the right to formulate an advanced directive for 1 of 20 residents (Residents #9) reviewed for advanced directives. The facility did not ensure Resident #9's OOH-DNR included the physician's printed name. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #9's face sheet, dated 01/08/25, indicated Resident #9 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #9's physician order summary report, dated 01/08/25, indicted an active physician's order for code status: DNR with an order date 05/28/19. Record review of Resident #9's quarterly MDS, dated [DATE], indicated Resident #9 sometimes made herself understood, understood others. Resident #9's BIMS score was a 3, which indicated her cognition was severely impaired. Record review of the comprehensive care plan, initiated 12/09/24, indicated Resident #9 had an order for DNR. The care plan interventions included all aspects of DNR will be explained to resident or responsible party, resident will be maintained at a level of comfort as ordered by the physician and social services to consult with resident and RP regarding their decision to continue DNR. Record review of Resident #9's OOH-DNR form dated 05/23/18 reflected the physician's printed name was missing. During an interview on 01/07/25 at 3:47 p.m., the Social Worker stated she was responsible for completing DNRs. The Social Worker stated she started working at the facility around May 2020. After reviewing Resident #9's electronic medical record, she stated Resident #9 OOH-DNR was missing the physician printed name. The Social Worker stated she monitored by random audits. The Social Worker stated she could not give a specific date on her last audit. The Social Worker stated she happened to miss the actual printed name was missing. The Social Worker stated it was important to ensure DNRs were completed to respect the resident wishes. During an interview on 01/08/25 at 12:43 p.m., the Administrator stated he expected DNRs to be filled out completely, including signatures. The Administrator stated the social worker was responsible for overseeing and monitoring the DNR. The Administrator stated it was important to ensure residents code status was up to date and DNRs completed to respect the resident preference. Record review of the facility's policy titled Do Not Resuscitate Order revised 10/12/13 indicated . the facility will honor two types of Do Not Resuscitate orders: a physician's order for Do Not Resuscitate and the Texas Out-of-Hospital DNR Order

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 observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 24 (Resident #43) residents reviewed for care plans. The facility failed to update Resident #43's care plan after she no longer required a fall mat on last revision date 11/26/2024. This failure could place Resident # 43 at risk of not having their individualized needs met and a decreased quality of life. Findings Included: Record review of Resident # 43's face sheet dated 1/07/2025, revealed Resident # 43 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness (decreased ability of muscles to generate force or power), reduced mobility ( person has difficulty moving around or walking as they normally would), anxiety disorder (a mental health condition that causes excessive and uncontrollable feelings of fear or worry that can interfere with daily life). Record review of a comprehensive MDS dated [DATE] indicated Resident #43 was sometimes understood and usually understands others. The MDS indicated Resident #43 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #43 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #43 had no behavioral symptoms but wandering. The MDS indicated Resident #43 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. Record review of the comprehensive care plan dated 11/26/24 indicated Resident #43 was at a high risk for falls, related to confusion and poor safety awareness. The care plan interventions indicated Resident #43 fall mat to be placed at bed side. Record review of Resident # 43's order summary dated 01/07/2025, did not indicate she required a fall mat at bedside. During an observation on 01/06/2025 at 9:35 a.m., Resident #43 was sitting up in bed with no fall mat at the bedside. Resident # 43 was non-interview able. During an observation on 01/07/2025 at 8:30 a.m., Resident #43 was in bed with no fall mat at the bedside. Resident # 43 was non-interview able, surveyor attempted to contact family member. During an interview on 01/07/2025 at 9:35 a.m., RN K stated MDS was responsible for updating the care plan. RN K stated if an incident occurred over the weekend, she would try to update the care plan. RN K stated Resident # 43 no longer needed a fall mat at bedside because she could not transfer or ambulate on her own. RN K stated Resident # 43 did not attempt to get out of the bed by herself. RN K stated it was important for the care plan to be updated so the nursing staff would be able to provide the appropriate care. During an interview on 01/08/2025 at 9:30 a.m., RN L stated the nursing staff usually updated the care plan with any change of condition and the MDS updated the care plan quarterly and performed annual assessments. RN L stated it was a group effort with the nursing staff to make sure the care plans were correct. RN L stated if Resident #43 had a change in condition and no longer required a fall mat the care plan should have been updated at that time. RN L stated residents are discussed in morning meeting and adjustments were made as needed to the care plan. RN L stated she did not know why Resident # 43's care plan was not updated. During an interview on 01/08/2025 at 9:45 p.m., the Administrator stated nursing staff was responsible for updating the care plan. The Administrator stated it was nursing responsibility to make sure residents care plan reflected Resident #43 no longer needed a fall mat at bedside. The Administrator stated any change in condition a resident had was discussed in the morning meeting and the change to the care plan should be done at that time. The Administrator stated he would monitor in morning meeting. Record review of the undated Comprehensive Care Planning policy The facility will establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #59's face sheet, dated 01/08/25, reflected he was admitted to the facility on [DATE] with diagnoses which included Parkinson's (brain disorder that causes unintended or uncontrollable movements). Record review of the order summary report dated 01/08/25 did not address the use of Lamisil, Cortizone-10, or Flonase. Record review of the quarterly MDS assessment, dated 12/06/24, indicated Resident #59 made himself understood and understood others. Resident BIMS score was 11, which indicated his cognition was moderately impaired. Record review of the comprehensive care plan, revised on 04/26/23, indicated Resident #59 has an ADL self-care performance deficit related to Parkinson's disease. The interventions included: personal hygiene as required: hair, shaving, oral care as needed, and required staff x1 for assistance with bathing and toileting. During an observation and interview on 01/05/25 at 10:48 a.m., Resident #59 was lying in bed when the state surveyor observed a tube labeled Lamisil and Cortizone-10 on his nightstand in a basket. The state surveyor also noted a nasal spray labeled Flonase in the basket. When asked what the medications were used for Resident #59 stated he had not used the Lamisil in a long time, and the Flonase was used for deodorant and could not remember what the Cortizone-10 was used for. Resident #59 stated a family member probably brought the medications to the facility. During an observation on 01/06/25 at 8:59 a.m., Resident #59 was sitting in his wheelchair when the state surveyor observed a tube labeled Lamisil and Cortizone-10 on his nightstand in a basket. During an observation and interview on 01/08/25 at 8:45 a.m., RN C stated Resident #59 had not been checked off for self-administration. RN C stated if a resident was able to self-administer an assessment must be completed and an order obtained prior to administration. RN C observed the Lamisil, Cortzione-10, and Flonase in the basket on Resident #59's nightstand. RN C removed the medications from Resident #59's room. RN C stated it was important medications were not at bedside for resident safety. During an interview on 01/08/25 at 12:05 p.m., the DON stated nurses were responsible for ensuring medications were stored appropriately. The DON stated before a resident could keep medications at bedside a self-administer assessment must be completed. The DON stated the MD must be notified and orders would be obtained. The DON stated she monitored by daily champion rounds to ensure compliance. The DON stated there had not been any issues in the past. The DON stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 01/08/25 at 12:34 p.m., the Dietary Manager stated she was responsible for champion rounds for Resident #59. The Dietary Manager stated during her rounds this week she did not notice any medications in the basket. The Dietary Manager stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 01/08/25 at 12:43 p.m., the Administrator stated he expected medications to be stored on the medication cart. The Administrator stated the nursing department was responsible for monitoring and overseeing that medications were not left out. The Administrator stated it was important to ensure medications were not left at bedside to prevent a medication error or misadministration. Record review of the facility's undated policy titled Storage of Medication indicated . Medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . 6. Except for those requiring refrigeration, medications intended for internal use are stored in medication cart or other designated area . Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 2 of 20 residents (Resident #34 and Resident #59) reviewed for medications at their bedside. 1. The facility failed to ensure the nebulizer medication for Resident #34 was not left at the bedside on 01/05/2025 and 01/06/2025. 2. The facility did not ensure Resident #59's Lamisil (medication used to treat fungal infections of the skin), Cortizone-10 (medication used to treat swelling, itching and redness of the skin), and Flonase (medication used to relieve seasonal and year-round allergic and non-allergic nasal symptoms) were properly safe and secured. These failures could place residents at risk for misuse of medication and overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. The findings included: 1. Record review of the face sheet, dated 01/07/2025, reflected Resident #34 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of COPD (type of progressive lung disease characterized by chronic respiratory symptoms and airflow limitation). Record review of the quarterly MDS assessment, dated 11/21/2024, reflected Resident #34 had clear speech and was understood by others. The MDS reflected Resident #34 was able to understand others. The MDS reflected Resident #34 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS reflected Resident #34 had an active diagnosis of COPD. Record review of the comprehensive care plan, revised 09/18/2023, reflected Resident #34 had a diagnosis of COPD. The interventions included: give aerosol or bronchodilators as ordered and monitor/document any side effects and effectiveness. Record review of the order summary report, dated 01/07/2025, reflected Resident #34 had an order, which started on 03/05/2024, for Ipratropium-Albuterol Inhalation Solution (nebulizer breathing treatment) 0.5-2.5mg/3mL - 1 application inhale orally two times a day for wheeze/shortness of breath related to COPD. Record review of the MAR, dated January 2025, reflected Resident #34 received Ipratropium-Albuterol Inhalation Solution (nebulizer breathing treatment) twice daily. During an observation and interview on 01/05/2025 at 10:37 AM, the chamber of Resident #34's nebulizer mask was filled approximately half full of a clear liquid. Resident #34 stated the nurse had placed his breathing treatment medication into the chamber earlier in the morning, but he had not taken it yet. Resident #34 stated the nursing staff usually placed the medication into his nebulizer and left the medication at bedside for him to take when he was ready. During an observation and interview on 01/06/2025 at 8:16 AM, the chamber of Resident #34's nebulizer mask was filled approximately half full of a clear liquid. Resident #34 stated the nurse brought the medication to him this morning, but he had not taken it yet. During an interview on 01/08/2025 beginning at 10:05 AM, LVN F stated she normally administered Resident #34's breathing treatment. LVN F said the procedure for administering breathing treatments was to check the oxygen level and vital signs, set up the breathing treatment, and turn on the machine. LVN F stated she did not stay with Resident #34 because he took the treatment himself. LVN F stated Resident #34 could have turned the machine off if he was not ready to take it. LVN F stated on most days she checked to ensure Resident #34 completed the breathing treatment. LVN F stated she was unsure if she went back to check if Resident #34 had finished his treatment on 01/06/2025. LVN F stated the breathing treatment was considered medication. LVN F stated Resident #34 had not been assessed for self-administration of medication. LVN F stated it was important to ensure medication was administered and not left at the bedside to ensure no other residents took the medication and so the residents would have received the prescribed dosage of medication. During an interview on 01/08/2025 beginning at 10:20 AM, LVN G said she was responsible for administering Resident #34's breathing treatment. LVN G said the procedure for administering breathing treatments was to set up the breathing treatment, turn on the machine, and leave the room. LVN G said after she left the room, she set a timer on her watch to go back and check on Resident #34. LVN G said Resident #34 turned off the breathing machine at times after she left the room. LVN G said Resident #34 had not been assessed for self-administration of medication and was unable to self-administer his medications. LVN G said Resident #34 was unable to have medications left at the bedside. LVN G stated on 01/05/2025 she went back to check on Resident #34, but she did not check his breathing machine to ensure the medication had been taken. LVN G said it was important to ensure medication was administered and not left at the bedside to ensure resident safety and prevent exacerbation of COPD. During an interview on 01/08/2025 beginning at 12:29 PM, the DON stated nurses were responsible to ensure breathing treatments were administered, completed, and placed back into the bag. The DON stated Resident #34 turned his machine off at times, but the nurses should have made sure the breathing treatment was completed. The DON stated Resident #34 had not been assessed for self-administration of medication and his breathing treatment should not have been left at bedside. The DON stated she started in-service education with the nurses. The DON said it was important to ensure breathing treatments were completed and not left at the bedside to prevent COPD exacerbation or respiratory symptoms.

CONCERN (D)

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

Deficiency F0807 (Tag F0807)

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 liquids consistent with the resident's needs, for 1 of 23 (Resident #9) residents reviewed for liquid inconsistency. The facility did not ensure staff served Resident #9 her iced tea during her lunch meal on 01/05/25. This failure could place residents at risk for dehydration and loss of interest in eating. Findings included: Record review of Resident #9's face sheet, dated 01/08/25, indicated Resident #9 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and unspecified protein-calorie malnutrition (protein calorie deficiency). Record review of the order summary report dated 01/08/25 indicated Resident #9 had the following orders: *Regular diet ground meat texture, thin/regular consistency with an order start date of 03/31/23. Record review of Resident #9's quarterly MDS, dated [DATE], indicated Resident #9 sometimes made herself understood, understood others. Resident #9's BIMS score was a 3, which indicated her cognition was severely impaired. Resident #9 required setup or clean-up assistance with eating. Record review of the comprehensive care plan, revised 01/06/25, indicated Resident #9 was at risk for nutritional problem including weight loss and dehydration related to missing some teeth. The care plan interventions included maintain preferences, offer alternatives, provide between meal snacks, and provide, serve diet as ordered. Record review of Resident #9's meal ticket dated 01/05/25 indicated Resident #9 would receive iced tea for her beverage during her lunch meal. During an observation on 01/05/25 at 12:39 p.m., Resident #9 was served her lunch tray consisting of baked ham, turnip greens, lima beans, cornbread, and blackberry cobbler. Resident #9 did not receive here iced tea. During an observation and interview on 01/05/25 at 12:47 p.m., the state surveyor asked RN C to review Resident #9's meal ticket for any missing items. After reviewing the meal ticket RN C stated Resident #9 had not received her iced tea. RN C stated Resident #9 should have received a glass of iced tea when her tray was provided. RN C stated it was important for Resident #9 to receive her drink to prevent dehydration. During an interview on 01/08/25 at 12:05 p.m., the DON stated she expected Resident #9's drink to be served with her meal. The DON stated nursing staff should ensure a drink was given to the resident when the resident sat down. The DON stated prior to state surveyor intervention there was not a system in place to monitor because this issue had never happened. The DON stated it was important to ensure residents received their drinks with their meal for hydration purposes. During an interview on 01/08/25 at 12:43 p.m., the Administrator stated he expected drinks to be served with meals. The Administrator stated whoever was assisting in the dining room was responsible for ensuring residents received their drinks. The Administrator stated it was important to ensure drinks were given when the residents received their tray to prevent dehydration. Record review of the facility's policy titled Hydration revised 10/05/16 indicated . The facility provides each resident with sufficient fluid intake to maintain proper hydration and health. The resident will receive sufficient amounts of fluid based on assessed need to prevent dehydration and promote optimum physiological functions Staff should offer hydration, unless contraindicated at the following intervals: prior to, during, and following meals .

CONCERN (E) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 4 of 5 residents (Resident #5, Resident #7, Resident #10, and Resident #58) reviewed for resident rights. The facility failed to ensure CNA A treated Resident #5, Resident #7, Resident #10, and Resident #58 respectfully when she failed to speak to them while providing care. This failure could place residents at risk of embarrassment, feelings of worthlessness, decreased self-worth, loss of dignity, and a diminished quality of life. Findings included: 1. Record review of Resident #5's face sheet dated 01/08/2025 indicated Resident #5 was an [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #5 was able to make herself understood and understood others. The MDS assessment indicated Resident #5 had a BIMS score of 13, which indicated her cognition was intact. The MDS assessment indicated Resident #5 required supervision or touching assistance with personal and toileting hygiene and lower body dressing, and partial to moderate assistance with showering/bathing self and putting on taking off footwear. Record review of Resident #5's care plan last reviewed 01/05/2025 indicated she had an impaired cognitive function that varies. Resident #5's care plan indicated interventions to use the resident's preferred name, identify yourself at each interaction, face the resident when speaking and make eye contact, reduce any distractions, the resident understands consistent, simple, directive sentences, provide the resident with necessary cues stop and return if agitated, and cue, reorient and supervise as needed. 2. Record review of Resident #7's face sheet dated 01/08/2025 indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included dementia with other behavioral disturbance (deterioration of memory, language, and other thinking abilities). Record review of Resident #7's Quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #7 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #7 was independent with eating, oral hygiene, toileting hygiene, required set-up or clean-up assistance with dressing, and supervision or touching assistance with showering/bathing, putting on/taking off footwear, and personal hygiene. Record review of Resident #7's care plan last reviewed 12/17/2024 indicated she had a limited physical mobility related to poor balance to provide supportive care, and assistance with mobility as needed. 3. Record review of Resident #10's face sheet dated 01/08/2025 indicated she was an [AGE] year-old-female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). Record review of Resident #10's Quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #10's BIMS was a 14, which indicated her cognition was intact. The MDS assessment indicated Resident #10 required partial/moderate assistance for toileting hygiene, showering/bathing self, dressing, and personal hygiene. Record review of Resident #10's care plan last reviewed 10/31/2024 indicated she had a behavior problem of excessive use of call light unknowingly at times without need due to numbness to left hand and tremors in right hand. Interventions included explain all procedures to her before starting and allow her to adjust to changes, assist her to develop more appropriate methods of coping and interacting, and anticipate and meet resident's needs. 4. Record review of Resident #58's face sheet dated 01/08/2025 indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow without chest pain). Record review of Resident #58's Comprehensive MDS assessment dated [DATE] indicated he was able to make himself understood and understood others. Resident #58's BIMS score was 13, which indicated his cognition was intact. The MDS assessment indicated Resident #58 required substantial to maximal assistance with toileting, dressing, showering/bathing self, and personal hygiene. Record review of Resident #58's care plan last reviewed 10/31/2024 indicated he had impaired cognitive function or impaired thought processes. Interventions included to use the resident's preferred name, identify yourself at each interaction, face the resident when speaking and make eye contact, reduce any distractions-turn off TV, radio, close door, the resident understands consistent, simple, directive sentences, provide the resident with necessary cues, stop and return if agitated. During a resident group meeting starting on 01/06/2025 at 11:04 AM, Resident #5, Resident #7, Resident #10, and Resident #58 said CNA A did not treat them with dignity and respect, and she was rude to them. Resident #58 said CNA A had been working every day without a day off and she was not a people person. Resident #58 said CNA A did not treat anyone with respect. Resident #58 said CNA A was usually the only one on his hall and I think she takes it out on us because she is the only one working that hall. Resident #58 said CNA A did not speak when she was providing care. Resident #58 said he had reported CNA A to the nurses 2-3 times before and they never do anything. Resident #7 said CNA A did not treat her respectfully and ignored her because CNA A did not speak to Resident #7 when Resident #7 spoke to CNA A. Resident #7 said one day CNA A was sitting at the nurses' station on the computer and Resident #7 asked her something and she did not respond. Resident #10 said CNA A was rude to her because she overheard CNA A refer to her as the white person, and CNA A did not speak to her while providing care. Resident #10 said she had not reported it because they won't do anything. Resident #5 said CNA A was rude to her because she did not speak to her while providing care. Resident #5, Resident #7, Resident #10, and Resident #58 said they were not afraid of CNA A, but they felt disrespected by CNA A. During an interview on 01/07/2025 at 1:16 PM, CNA A said she was coming up on one year for her employment at the facility. CNA A said she had not had any issues with Resident #5, Resident #7, Resident #10, or Resident #58. CNA A said when she provided care to the residents she went in their room and asked them what they needed and did it for them. CNA A said she explained to the residents what she was doing while providing care to them. CNA A said she had not ignored any residents, and when they spoke to her, she spoke back to them. CNA A said she had never refused to provide care to any residents. CNA A said she had not been working every day and worked per her rotation. CNA A said it was important to treat the residents with dignity and respect for good customer service, to do as they needed because it was her job to make sure they were okay. CNA A said if the residents were not treated with dignity and respect, they could feel neglected and abused, and it would affect them if they did not get their needs met. During an interview on 01/07/2025 at 9:26 PM, CNA B said she worked the night shift with CNA A. CNA B said Resident # 10 had told her CNA A would not speak back to Resident #10 when spoken to. CNA B said she had not reported Resident #10 telling her CNA A would not speak to her to anyone. CNA B said she told CNA A she might want to speak to Resident #10. CNA B said she had not heard CNA A refer to Resident #10 as the white lady. CNA B said no other residents reported any issues with CNA A. During an interview on 01/08/2025 at 12:14 PM, the DON said in the past, there was an incident between Resident #7 and CNA A. Resident #7 reported CNA A was rude to her because she would not talk while providing care. The DON said a customer service in-service was completed with CNA A. The DON said there were not other complaints about CNA A. The DON said she had not observed any issue with CNA A's care towards the residents. The DON said she expected the staff to treat the residents respectfully, talk to the residents while they were providing care, and let them know what they were doing. During an interview on 01/08/2025 at 12:48 PM, the Administrator said to his knowledge CNA A did not have any inappropriate behaviors towards residents. The Administrator said he expected for every resident to be treated with respect and customer service was a big deal. The Administrator said if residents were not treated with dignity and respect it could impact their emotional well-being. Record review of a Resident Grievance received 08/06/2024 indicated Resident #7 reported in resident council that the night aide (CNA A) was rude because she would not talk to her when she was providing care. Resolved date 08/06/2024. The DON was assigned to take action, and the corrective action taken to prevent recurrence was employee to receive counseling. Signed by the Administrator 08/06/2024. Record review of CNA A's employee file indicated an In-Service Training Topic Customer Service dated 08/06/2024 provided by the DON signed by multiple staff, including CNA A. Record review of the facility's policy titled, Resident Rights, revised 11/28/2016, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident .The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care .The resident has a right to be treated with respect and dignity, including .The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents .

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility and failed to demonstrate their response and rationale for such response for 6 of 6 confidential residents reviewed for resident council. The facility failed to ensure there was documentation of the facility's efforts to resolve concerns about call light response times collected at the resident council meetings on 07/15/2024, 08/22/2024, and 09/20/2024. This failure could place residents at risk of not having their concerns and grievances followed through and a diminished quality of life. Findings included: Record review of the Resident Advisory Council Minutes for 07/15/2024 indicated the call lights were not being answered timely. Record review of the Resident Advisory Council Minutes for 08/22/2024 indicated the call lights were not being answered timely. Record review of the Resident Advisory Council Minutes for 09/20/2024 indicated the call lights were not being answered timely. Record review of the grievances from July 2024-January 2025 did not indicate grievances to address the efforts to resolve the resident councils' concerns. During a confidential group interview with 6 residents on 01/06/2025 starting at 11:04 AM, the resident group said call lights were not answered timely. The resident group said they had mentioned it in the resident council meetings and to staff members and nobody had gotten back to them with any resolution. During an interview on 01/07/2025 at 7:17 PM, RN D said occasionally the residents complained about the call lights not being answered timely. RN D said he reported it to the ADONs and was not provided a resolution. RN D said he tried to help the CNAs the best he could. RN D said it was important for the call lights to be answered timely because it was the residents' home, and they should have their needs met in a timely manner. During an interview on 01/08/2025 at 10:22 AM, ADON E said none of the residents had reported to her the call lights not being answered timely. ADON E said none of the staff had reported to her the call lights were not being answered timely. During an interview on 01/08/2025 at 12:14 PM, the DON said the staff had not reported issues with answering the call lights timely. The DON said none of the residents had reported to her that the call lights were not answered timely. During an interview on 01/08/2025 at 12:48 PM, the Administrator said when there were grievances in resident council, they started off with staff education, and then they followed up at the next resident council meeting. The Administrator said after the resident council he completed grievances if there were multiple concerns. The Administrator said he would look for grievances completed for the resident council and provide them (none were provided upon exit of the facility). The Administrator said he was aware of the call lights not being answered timely and it was an ongoing issue. The Administrator said it was important to address the issues that the resident council voices to do the best to meet the residents' needs. Record review of the facility's policy titled, Grievances, revised 11/02/2016, indicated, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. 1. The facility will notify residents on how to file a grievance orally, in writing, or anonymously with postings in prominent locations. 2. The grievance official of this facility is the administrator or their designee. 3. The grievance official will: o Oversee the grievance process o Receive and track grievances to their conclusion o Lead any necessary investigations by the facility o Maintain the confidentiality of all information associated with grievances o Issue written grievance decisions to the resident .

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. The facility failed to ensure: 1. The microwave was clean and free of food debris. 2. The deep fryer was clean and free of food debris. 3. Three sheet pans were free from encrusted black colored grease buildup coating on the outside and the inside surface. These failures could place residents at risk for foodborne illness. Findings include: During an initial tour observation in the kitchen on 01/05/2025 at 10:20 a.m., there was brown flakey debris in the microwave, dark brown grease with brown flakey debris floating in the deep fryer, and three sheet pans with encrusted black colored grease buildup coating on the outside and the inside surface. During an interview on 01/05/2025 at 11:00 a.m., [NAME] H stated the microwave was used during breakfast and had not been cleaned out. [NAME] H stated the deep fryer was cleaned weekly on Thursdays. [NAME] H stated they had fried fish last Friday and had not had time to clean the deep fryer. [NAME] H stated the sheet pans had carbon build on them and needed to be replaced. [NAME] H stated it was important to keep appliances clean to prevent food born illness. During an interview on 01/06/2025 at 8:25 a.m., the Dietary Manager stated the microwave was to be wiped out after every use, the deeper fryer was cleaned weekly unless they had fried fish, then it was cleaned after frying fish. The Dietary Manager stated she knew the sheet pans had carbon buildup on them and she was trying to order new ones as she could to keep from going over budget. The Dietary Manager stated she would do an in-service on kitchen sanitation. The Dietary Manager stated it was important for the equipment in the kitchen to be clean to prevent the residents from getting sick. During an interview on 01/08/2025 at 9:45 a.m., the Administrator stated he expected equipment in the kitchen to be clean to prevent food borne illness. The Administrated stated the deep fryer should be cleaned weekly and the microwave cleaned after each use. The Administrated stated he would do daily observance to monitor the kitchen. Record review of the facility's undated policy Dietary Service Personnel Policy and Procedures, revealed work surfaces must be kept as neat and clean as possible during preparation and service. All work areas must be thoroughly cleaned and sanitized after use

Mar 2024 27 deficiencies 8 IJ (2 facility-wide)

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

Investigate Abuse (Tag F0610)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview, and record review the facility failed to have evidence alleged violations were thoroughly investigated to prevent further abuse for 1 of 11 residents (Resident #44) reviewed for abuse. The facility failed to thoroughly investigate when Resident #44 was found to have a large bruise to her right inner thigh measuring 17 centimeters x approximately 11 centimeters that was painful on 6/21/2023. The facility failed to thoroughly investigate when Resident #44 was transferred to the local emergency room and found to have a new fracture and dislocation of the right trochanter (hip joint) on 6/21/2023. An IJ was identified on 3/01/2024. The IJ template was provided to the facility on 3/01/2024 at 11:05 a.m. While the IJ was removed on 3/01/2024, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not having allegations of abuse, neglect or exploitation investigated properly to prevent re-occurrence. Findings Included: Record review of a face sheet dated 2/27/2024 indicated Resident #44 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness, reduced mobility, anxiety disorder. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was sometimes understood and usually understands others. The MDS indicated Resident #44 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #44 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #44 had no behavioral symptoms but wandered 1-3 days during the assessment period. The MDS indicated Resident #44 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. The MDS indicated Resident #44 had a history of falls with fractures within the last 6 months. Record review of the comprehensive care plan dated 12/13/2023 and updated on 1/07/2024 indicated Resident #44 was at risk to fall related to unsteady gait/balance, generalized weakness, and poor safety awareness. The care plan indicated Resident #44 was at risk to wander related to a history of attempts to leave the facility related to poor safety awareness and resides on the secured unit. Record review of a Weekly Skin assessment dated [DATE] and documented by LVN CCC, indicated Resident #44's skin was normal with no bruising. The note indicated Resident #44's had a surgical incision to the right hip with staples and steri-strips in place with no drainage and no signs of infection. Record review of a Fall Nurses Note dated 6/12/2023 and documented by LVN YY indicated Resident #44 had a fall with a bump on the right side of her head. Record review of a Weekly Skin assessment dated [DATE] documented by LVN DDD, indicated Resident #44's skin was normal with no bruising. Record review of a SBAR note dated 6/18/2024 documented by LVN YY indicated Resident #44 had swelling and pain to the right hip replacement. The note indicated Resident #44 was ordered a mild pain reliever and an x-ray to the right hip. Record review of a right hip x-ray dated 6/19/2023 indicated Resident #44's prosthetic right femoral head (hip joint) was in proper alignment. Resident #44's x-ray revealed there were no fractures or acute dislocation. The x-ray indicated Resident #44's prothesis was properly situated without any loosing. The x-ray conclusion indicated the right hip arthroplasty (hip restoration) was intact. Record review of a progress note dated 6/21/2023 at 6:15 a.m., LVN YY documented Resident #44 had a bruise to the inner thigh on the right leg measuring 17 centimeters x approximately 11 centimeters with pain. LVN YY noted she administered a mild pain reliever to Resident #44. Record review of an Event Nurses' note dated 6/21/2023 at 6:15 a.m., LVN YY documented a bruise was found to Resident #44's right inner thigh measuring 17 centimeters x approximately 11 centimeters. The note indicated Resident #44's bruise was blue/purple and painful. LVN YY documented Resident #44 could not provide a statement related to her cognitive impairment. LVN YY said previous factors included previous falls. Record review of an incident note dated 6/21/2023 documented by LVN YY indicated Resident #44 had a large purple bruise on her inner right thigh (front) measuring 17 centimeters x approximately 11 centimeters. LVN YY said Resident #44 was unable to state what had happened. LVN YY documented there were no predisposing environmental factors, and the predisposing physiological factor was Resident #44 had memory impairment. Record review of a Weekly Skin assessment dated [DATE] indicated Resident #44 skin color was normal, temperature was normal, with a large purple bruise to the right inner thigh with a firm center with bruising to her knee. Record review of a Consultation note dated 6/21/2023 indicated the orthopedic physician documented he knew Resident #44. The physician said he had treated her femoral neck fracture(connection between the ball of the hip and the femur bone) a month previous. The physician wrote he had seen Resident #44 a week ago and the x-rays showed a well-fitted well-fixed bipolar hip. The physician wrote he had plans to surgically repair Resident #44's right hip by removing the prothesis, wire her with cables then reimplant the prothesis and then put a plate and screws with wires and screws around the periprosthetic fracture. During an interview on 2/29/2024 at 11:42 a.m., LVN YY said she was notified of Resident #44's by CNA K. LVN YY said she assessed and measured the bruising and notified the physician, family, DON, and Administrator (previous). LVN YY said she was unsure how Resident #44 sustained the bruise and unsure why no one else had seen the bruise. During an interview on 2/29/2024 at 3:22 p.m., CNA K said she had found the bruising to Resident #44's right leg and reported to LVN YY. CNA K said while she was providing incontinent care for Resident #44, she moved the pillow between Resident #44's legs when she found a large purple bruise. During an interview on 2/29/2023 at 3:40 p.m., the DON said she was not the DON during the incident on 6/21/2023 with Resident #44 but she indicated she would have investigated and report the bruising. During an interview on 03/01/2024 at 8:52 AM, previous Administrator ZZ said she always did an investigation when something was reported to her but depending on her investigation if she reported. Administrator ZZ said if she had not reported the incident with Resident #44's bruising/hip fracture it had to be for a reason. Administrator ZZ said she did not remember the specifics off the top of her head, and she kept a soft file in the administrator's office with her investigations . The soft file was not could not be located. Administrator ZZ said a bruise that was not correlated with an incident was considered an injury of unknown injury and should be reported within 2 hours of finding it or being notified. Record review of an Abuse/Neglect policy dated 3/29/2018 indicated the resident had a right to be free from abuse, neglect, misappropriation of property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the residents' medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals 3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and /or Abuse Preventionist within 24 hours of complaint. Appropriate notification to the state and home office will be the responsibility of the administrator and per policy. 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect, the facility has in place a method to identify events such as suspicious bruising of resident, occurrences, patterns, and trends that may constitute abuse. This was determined to be an Immediate Jeopardy (IJ) on 3/01/2024 at 11:05 a.m. The facility Administrator and assistant Administrator were notified. The Administrator was provided with the IJ templates on 3/01/2024 at 11:05 a.m. The facility's plan of removal was accepted on 03/01/2024 at 11:01 AM and included the following: Facility: Date: 3/1/24 Problem: Failure to thoroughly Investigate Abuse Interventions: 1. A head-to-toe skin assessment was completed on resident #44 on 3/1/24 by the Charge Nurse. No additional issues were noted. 2. A pain assessment was completed on resident #44 on 3/1/24 by the Charge Nurse. No pain was voiced. 3. All residents in the facility have had a head-to-toe assessment completed as of 3/1/24 by the DON, ADON, and Charge Nurses. No signs or symptoms of injuries of unknow origin noted. 4. The Administrator and DON were in-serviced 1:1 on the Provider Letter and the Abuse/Neglect Policy by the Area Director of Operation on 3/1/24. The in-service included reporting injuries of unknown origin and conducting a thorough investigation. 5. A review of the Abuse and Neglect policy was reviewed by Corporate Management on 3/1/24. The policy included reporting and investigating events of abuse and neglect. No changes have been made to the policy. 6. The Medical Director was notified of the immediate jeopardy situation on 3/1/24 by the Administrator. 7. An ADHOC QAPI meeting was completed with QA committee to include the Medical Director on 3/1/24. 8. The following in-services were initiated by the Administrator, DON, and Regional Compliance Nurse as of 3/1/24 for all staff. All staff not present on 3/1/24 will be in-serviced prior to the start of next shift. All new hires will be in-serviced during orientation. All agency staff will be in-serviced prior to the start of their shift. Abuse and Neglect Policy to include reporting any signs of injury such as bruising, redness, swelling and pain. All allegations of abuse must be reported to the Administrator who is the abuse coordinator. In the absence of the administrator, allegations of abuse must be reported to the DON. On 03/01/2024 the surveyor conformed the facility implement their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of Weekly Skin Assessment, dated 02/27/2024, revealed Resident #44 had a bruise to the right side of her forehead, which measured 2 cm x 3.3 cm. The assessment further revealed a bruise to her right forearm, which measured 3.5 cm x 2.1 cm. Record review of the pain assessment was completed for Resident #44, and she received a mild pain reliever acetaminophen 325 milligrams give two tablets every 4 hours as needed for pain. Record review of the skin assessments, completed on 02/27/2024, revealed no injuries of unknown origin. Record review of the In Service Training Attendance Roster, dated 03/01/2024 , revealed the Administrator and DON were provided education on the abuse and neglect policy, procedure, and the long-term care regulatory provider letter on abuse, neglect, exploitation, misappropriation of resident property, and other incidents that a nursing facility must report to the Health and Human Services Commission. During an interview on 3/01/2024 at 1:23 p.m., the Administrator said he expected all allegations of abuse, neglect to be reported to him promptly to ensure he had enough time to initiate an investigation to include when he called the allegation to the state agency. The Administrator said the alleged perpetrator would be suspended during the investigation. The Administrator said he in the past had used reviewing bath sheets, incident and accidents as a way to evaluate areas concerning abuse and neglect. During an interview on 3/01/2024 at 2:00 p.m., the DON said she expected the nurses to notify her and the Administrator with any injuries including bruises and fractures immediately. The DON said reporting immediately allows for a starting of an investigation to include when reporting to the state agency in the required time frame. Record review of the Off Cycle (ad hoc) QA Meeting Document, dated 02/01/2024, revealed an action plan was initiated and discussed. Record review of the In Service Training Attendance Roster, dated 03/01/2024, revealed LVN L, [NAME] M, the Administrator, MDS Coordinator N, SNA O, SNA P, DA UU, LVN Q, MDS Coordinator R, ADON S, the Marketing Coordinator, the Maintenance Supervisor, Housekeeper T, DA W, RN U, CNA V, the Medical Records, LVN W, the HR Coordinator, CNA K, CNA X, CNA Y, CNA Z, the BOM, CNA BB, CNA CC, the DON, LVN F, the DOR, LVN AA, RN DD, CNA EE, the Social Worker, CNA H, LVN C, LVN FF, COTA GG, the DM, LA HH, Housekeeper KK, and MA LL had been in-serviced on the abuse and neglect policy, to include reporting resident injuries immediately. The in-service further revealed education was provided on reporting allegations of abuse immediately to the Administrator, who was the abuse coordinator. The in-service stated, In the absence of the administrator, allegations of abuse must be reported to the DON. During interviews on 03/01/2024 between 12:33 PM and 4:38 PM, LVN L, [NAME] M, the Administrator, MDS Coordinator N, SNA O, SNA P, DA UU, LVN Q, MDS Coordinator R, ADON S, the Marketing Coordinator, the Maintenance Supervisor, Housekeeper T, DA W, RN U, CNA V, the Medical Records, LVN W, the HR Coordinator, CNA K, CNA X, CNA Y, CNA Z, the BOM, CNA BB, CNA CC, the DON, LVN F, the DOR, LVN AA, RN DD, CNA EE, the Social Worker, CNA H, LVN C, LVN FF, COTA GG, the DM, LA HH, Housekeeper KK, and MA LL had been provided education on abuse and neglect policy, to include reporting injuries immediately. The staff further indicated allegations of abuse must be reported immediately to the Administrator, who was the abuse coordinator. The staff indicated in the absence of an administrator the DON was the abuse coordinator. On 03/01/2024 at 5:10 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

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

Free from Abuse/Neglect (Tag F0600)

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 to ensure the right of the residents to be free from abuse and neglect 7 of 11 residents reviewed for abuse and neglect. (Resident #'s 44, 55, 41, 47, 52, 179 and 36) The facility failed to ensure Resident #44 was protected from Resident #41 after an alleged resident to resident assault resulting in Resident 44 being sent to a local emergency. Resident #44 was assessed with a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel) when she was left alone with her alleged assailant Resident #41. The facility failed to ensure Resident #55 was not left alone with Resident #41 after he allegedly assaulted Resident #44. The facility failed to ensure Resident #179 was not verbally and physically abused by CNA B. The facility failed to ensure Resident #179 was not suffering on-going neglect by CNA B of not performing incontinent care and not responding to his call light. The facility failed to ensure Resident #36 was not verbally abused when cursed by CNA B. The facility failed to prevent verbal abuse when Resident #47 cursed at Resident #52 and did not allow him to enter his room. The facility failed to prevent abuse and neglect when LVN C reported abuse to the DON and the DON did not report it to HHSC. An IJ was identified on 2/27/2024. The IJ template was provided to the facility on 2/27/2024 at 3:39 p.m. While the IJ was removed on 3/01/2024,the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1)Record review of a face sheet dated 2/27/2024 indicated Resident #44 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness, reduced mobility, anxiety disorder. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was sometimes understood and usually understands others. The MDS indicated Resident #44 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #44 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #44 had no behavioral symptoms but wandered 1-3 days during the assessment period. The MDS indicated Resident #44 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. The MDS indicated Resident #44 had a history of falls with fractures within the last 6 months. Record review of the comprehensive care plan dated 12/13/2023 and updated on 1/07/2024 indicated Resident #44 was at risk to fall related to unsteady gait/balance, generalized weakness, and poor safety awareness. The care plan indicated Resident #44 was at risk to wander related to a history of attempts to leave the facility related to poor safety awareness and resides on the secured unit. Record review of the of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #44 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #41 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital. The note indicated interventions in place prior to this fall was none. Record review of a progress note dated 2/25/2024 at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 was found on the floor bedside the closet door on her back with Resident #41 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented after the Resident #44's incident with Resident #41 by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency room on 2/25/2024 with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination documented indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated 2/25/2024 indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in the area of space and tissue between the skull and skin). During an observation and interview on 2/27/2024 at 9:00 a.m., Resident #44 was sitting at the dining table with a large size raised area with bruising noted to her right side of her head in the temporal/parietal region. Resident #44 said she felt well but she denied having her head hurt. 2) Record review of a face sheet dated 3/2/2024 indicated Resident #41 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, the need for continuous supervision, and high blood pressure. Record review of a Significant Change MDS dated [DATE] indicated Resident #41 was usually understood and sometimes understands. The MDS indicated Resident #41's cognition was severely impaired. The MDS indicated Resident #41 had no physical, or verbal behaviors exhibited. The MDS indicated Resident #41 wandered daily. Record review of the comprehensive care plan dated 8/08/2023 and revised on 9/08/2023 indicated Resident #41 was at risk for mood problems and received medications. The goal of the care plan indicated Resident #41 would have an improved mood state. The care plan interventions included administer medications, behavioral health consults as needed, monitor and record mood to determine if problems seem to be related to external causes. Record review of a progress note dated 2/25/2024 at 6:00 p.m., LVN D documented she was called to a resident room by CNA A. LVN D documented Resident #41 was in Resident #55's room where she found Resident #44 on the floor beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented she asked Resident #41 and Resident #44 what had occurred, and neither could explain. LVN D documented Resident #55 said Resident #41 pushed Resident #44 against the closet door and she fell. LVN D documented Resident #41 was very uncooperative and had tried to hit CNA A and Resident #55. Record review of Behavior Nurses Note dated 2/25/2023 at 6:30 p., LVN D documented she was called to the secured unit by the nurse aide. LVN D documented Resident #41 was in Resident #55's room. LVN D documented she found Resident #44 on the floor lying beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented Resident #55 said he pushed her up against the closet door and she fell. LVN D said Resident #41 and #44 was unable to indicate what had happened. LVN D said Resident #41 was very uncooperative and had tried to the hit the CNA on duty and Resident #55. Record review of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented Resident #41 was found in another resident room. LVN D documented Resident #41 had displayed physical, and resident to resident behaviors with another resident injured. The Event Nurses' note indicated LVN D moved Resident #41's room and initiated every 15-minute checks. Record review of a Every 15 Minute Check sheet indicated Resident #41 was placed on every 15-minute checks starting on 02/25/2024 at 6:30 p.m. The Every 15- minute checks at 0015 indicated LVN D documented at 12:15 a.m., Resident #44 was asleep. LVN D had only her initials beside the other every 15-minute checks starting at 12:30 a.m. - 5:45 a.m. on 02/26/2024 there was no remarks indicating anything in regarding Resident #41. During an observation on 2/25/2024 at 9:31 a.m., Resident #41 was lying in his bed asleep. During an interview on 2/26/2024 at 10:54 a.m., LVN F said Resident #44 was discharged to the hospital and Resident #41 was on every 15-minute checks for aggressive behaviors. LVN F said after she reviewed Resident #44's electronic medical record and said there was not a progress note, a SBAR (situation, background, assessment, recommendation) note, a transfer note, or an incident report. LVN F said the electronic medical record should have had those assessments completed . LVN F said the nurse was responsible for documenting all the events occurring with the incident with Resident #'s 41,44, and 55. During an interview on 2/26/2024 at 11:46 a.m., the DON said on 2/25/2024 CNA A heard a noise and responded to the noise. The DON said LVN D called and said Resident #41 was upset and wandering in other rooms. The DON said CNA A had said Resident #44 was on the floor. The DON said she was unsure of Resident #44 hitting her head although she had an abrasion to her head. The DON said Resident #44 was sent to the emergency room closer to midnight due to complaining her head was hurting. During an interview on 2/26/2024 at 11:51 a.m., LVN D said she was called to the unit by CNA A. LVN D said Resident #44 was lying in the floor of Resident #55's room, with Resident #41 standing over Resident #44 around 6:30 p.m. on 2/25/2024. LVN D said Resident #55 said Resident #41 pushed Resident #44 against the closet and Resident #41 fell. LVN D said at the time of the incident Resident #44 had an abrasion to her right temple area and a bruise to her inner right arm. LVN D said Resident #41 was very uncooperative and attempted to hit others. LVN D said she was advised to place Resident #41 on every 15-minute checks by the DON. LVN D said although her documentation was not completed yet Resident #41 remained asleep. LVN D said CNA A had to leave Resident #44 to come for help. LVN D said she was not on the secured unit but was on hall 400 when the incident occurred. During an interview on 2/26/2024 at 12:22 p.m., CNA H said CNA A had always worked the secured unit alone. CNA H said when CNA A was in the room with other residents who would be watching the other residents, or who would go for help. CNA H said there was no one on the unit to get help when CNA A needed help. During an interview on 2/26/2024 at 4:17 p.m., the SW said she was notified by the DON regarding the incident with Resident #44 and Resident #41. The SW said upon her arrival Resident #44 was already at the local emergency room, and Resident #41 was wandering on the unit. The SW said Resident #41 and Resident #55 both were unable to recollect the recent incident. During an interview on 2/26/2024 at 9:32 p.m., CNA A said she was alone on the secured unit gathering her supplies in the spa/communal shower room when she heard a loud scream. CNA A said she ran out of the spa room and ran toward the end of the hall where she believed the sound was heard from. CNA A said upon entering the room, Resident #44 was lying in the floor, Resident #55 said Resident #41 had thrown Resident #44 into the door. CNA A said Resident #41 was aggressive with her at the time and tried to swing at her. CNA A said she left Resident #55's room and ran the length of the secured unit, opened the door, and yelled for help. CNA A said she was alone on the secured unit and had no other recourse than to go for help. CNA A said LVN D was passing medications and another nurse responded to her call for help. 3) Record review of a face sheet dated 3/02/2024 indicated Resident #55 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of stroke, high blood pressure, and dementia (memory loss). Record review of the Annual MDS dated [DATE] indicated Resident #55 was usually understood, and usually understands. The MDS indicated Resident #55 had severe cognitive impairment. The MDS indicated Resident #55 had not displayed any verbal or physical behaviors. During an observation and interview on 2/26/2024 at 12:42 p.m., Resident #55 was sitting at the dining table and was unable to recall the incident in his room last night. This was determined to be an Immediate Jeopardy (IJ) on 2/27/2024 at 3:39 p.m. The facility Administrator and assistant Administrator were notified. The Administrator was provided with the IJ templates on 2/27/2024 at 3:39 p.m and a Plan of Removal was requested. 4)Record review of the face sheet, dated 02/29/2024, revealed Resident #47 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and altered mental status (broad term used to indicate an abnormal state of alertness or awareness). Record review of the significant change MDS assessment, dated 12/20/2023, revealed Resident #47 had clear speech and was usually understood by others. The MDS revealed Resident #47 was sometimes able to understand others. The MDS revealed Resident #47 had short-term and long-term memory problems. The MDS revealed Resident #47 was not able to recall the current season, the location of his room, staff names or faces, and that he was in a nursing facility. The MDS revealed Resident #47 had severely impaired decision-making skills. The MDS revealed Resident #47 had continuous inattention and disorganized thinking. The MDS revealed Resident #47 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 02/21/2024, revealed Resident #47 had potential to demonstrate verbally abuse behaviors. The interventions included: analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document .assess resident's coping skills and support system .evaluate for side effects of medications .notify the charge nurse of any abusive behaviors .provide positive feedback for good behavior, emphasize the positive aspects of compliance .psychiatric/psychogeriatric consult as indicated. Record review of the nursing progress note on 02/19/2024 at 12:20 AM, revealed Resident #47 was repeatedly yelling at his roommate [Resident #52] You son-of-a-bitch get out of my room! The nursing progress note further revealed the DON was notified immediately and told LVN C to notify the Medical Director because there was no abuse coordinator at the facility. The progress note revealed the Medical Director was notified and Resident #47 was placed in a different room. 5) Record review of a face sheet dated 03/02/2024 indicated Resident #52 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, with other behavioral disturbance (deterioration of memory, language, and other thinking abilities with behaviors) , anxiety disorder, and depression. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #52 was usually able to understand others and was usually understood by others. The MDS assessment indicated Resident #52 had a BIMS score of 5, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #52 had no physical, verbal, or other behaviors directed toward others. The MDS assessment indicated Resident #52 required setup or cleanup assistance with eating, supervision for oral, toileting, and personal hygiene, and partial to moderate assistance with showering and dressing. Record review of Resident #52's care plan last revised 02/02/2024 indicated Resident #52 had impaired cognitive function/dementia or impaired thought processes. Record review of Resident #52's progress notes indicated: o 02/19/2024 12:20 AM Resident #52 was very forgetful and usually confused. He was pacing, wandering, and coming in and out of his room. This resident was redirected numerous times back to his room and to bed. The last time resident was redirected back to his room, his roommate was cursing, repeatedly telling this resident, You son-of-a-bitch get out of my room! Which explained why Resident #52 would not stay in his room. CNA remained in the room with both residents until the DON and doctor were notified. DON notified immediately and stated to call the Medical Director. 12:35 AM both residents were separated with the roommate moved to another room. o Strike out note dated 2/23/2024, effective date for the note prior to strike out 02/19/2024 created by LVN C indicated, 12:20 AM the DON stated they did not have an abuse coordinator at the time, that their new administrator was supposed to start work that day (02/19/24). The DON stated to call the Medical Director and report it to him. During an observation and attempted interview on 02/23/2024 at 3:48 PM Resident #52 was observed walking down the hall with his rollator (walker with wheels). Resident #52 did not want to be interviewed at the time. During an interview on 02/26/2024 at 9:07 PM, LVN C said Resident #52 kept getting up and coming out of his room, and she kept telling him to go back to his room because it was in the middle of the night. LVN C said she finally decided to take him back to his room, and that was when she realized Resident #52's roommate, Resident #47, was yelling and cursing at Resident #52 to get out of the room and calling him a son of a bitch'. LVN C said this was really confusing Resident #52. LVN C said she called the DON, who was the abuse coordinator at the time, and she told her to keep them separated. LVN C said she called the Medical Director, and he told her to separate them and place them in 2 different rooms. Regarding the struck out note about the incident, LVN C said when she called the DON, she did not know the DON was the abuse coordinator. LVN C said the DON told her they currently did not have an abuse coordinator, but the new administrator was starting that day to notify the Medical Director. LVN C said she learned the DON was the abuse coordinator after talking to the DON on the phone. LVN C said one of her co-workers informed her if there was no administrator it automatically fell on the DON to be the abuse coordinator. LVN C said ADON E instructed her to correct her note to show that she did call the DON immediately. LVN C said after notifying the DON of the incident the night it occurred, the DON never talk to her about the incident again. LVN C said there had been a lot of changes in administrators and administration and they were not providing education on who was the abuse coordinator. LVN C said in the past she had called to report other incidents of abuse to who she thought was the abuse coordinator for them to tell her they were no longer employed at the facility. During an interview on 02/27/2024 at 8:46 AM, the DON said she was not able to recall any incident with Resident #47 and Resident #52. The DON said she did not remember an incident where Resident #47 cursed out Resident #52. The DON said the staff were supposed to report abuse to the Administrator and herself. The DON said the staff were notified when there were changes in administration one-on-one. The DON denied LVN C calling her to report when Resident #47 cursed at Resident #52. The DON said if the Administrator was not in the facility, she was the abuse coordinator. During an interview on 02/28/2024 at 3:33 PM, the Area Director of Operations said she was a consultant for the facility. The Area Director of Operations said she was there as a resource for the facility administration to reach out to her with assistance regarding the policies and procedures. The Area Director of Operations said the administrators were responsible for the facility and that is why when one administrator left an interim was put in place. The Area Director of Operations said she did not provide oversight for the facility that was the administrators responsibility because she had 10 other facilities, she was over. The Area Director of Operations said she made sure the facilities were in the green and monitored their spending to help them reach their financial goals. During an interview on 02/28/2024 at 9:24 PM, the Medical Director said there had been at least 5 administrators and half a dozen DONs and several ADONs in the past year. The Medical Director said there was no consistency, and the staff were unfamiliar with the residents and left often, which resulted in difficulty maintaining staff stability. The Medical Director said resident to resident altercations were a regular situation on the secured unit and was directly related to lack of supervision. The Medical Director said the residents should never have been left unsupervised. The Medical Director said the issue with the resident-to-resident altercations was staffing, and the facility being understaffed. The Medical Director said he had expressed his concerns regarding staffing to upper management. The Medical Director said amongst all the changes in administrators and DONs he did not know who was supposed to be keeping the facility together to prevent system failures, but he knew the Area Director of Operations was one of the major decision makers. The Medical Director said one evening he had been in to assess Resident #57, and he had noticed Resident #57 had 2 spots on her skin as if somebody had grabbed her strong and a very large skin tear on her body. The Medical Director said he told the staff those were traction marks as if somebody had been holding her too tight. The Medical Director said he had told the staff they might have to use the Hoyer lift to transfer her. The Medical Director said the incident happened earlier in February 2024 . During an interview on 03/01/2024 at 1:22 PM, the Administrator said he expected bruises to be automatically reported to him, and if not to him directly to the DON or nursing supervisor and they would report it to him. The Administrator said when he was notified of an injury of unknown injury, he would investigate it and report it within the 2 hours. The Administrator said he had not had a chance to look for Resident #44's soft file in his office (the soft file was never provided exit date 03/02/2024). The Administrator said they reviewed incidents and accidents every morning in the morning meetings and care plan the issues. The Administrator said if there was an injury of unknown origin, they should look at the last skin assessment to try to piece together a timeline, staff would be interviewed, the resident would be interviewed, if able to be interviewed. The Administrator said he expected the staff to call him and report to him any abuse concerns no matter the time of day. The Administrator said in his absence the staff should report to the DON, and the DON should report it per the requirements to HHSC and to him . During an interview on 03/01/2024 at 1:50 PM, the DON said she had started at the facility on January 13, 2024. The DON said if the nurses found a new bruise, she expected them to notify the Administrator or herself, so it could be reported to HHSC within 2 hours and investigated. The DON said the staff should report abuse to the abuse coordinator, the Administrator, and in his absence to her. During an interview on 03/02/2024 at 10:04 AM, Resident #52 said he did not remember his roommate (Resident #47) yelling and cursing at him. During an interview on 03/02/2024 at 5:36 PM, ADON E said she had been employed at the facility for 3 years, but she had been out for several months for medical reasons. ADON E said she had told LVN C to edit her note regarding notifying the DON about Resident #47 cursing at Resident #52 because the DON had denied LVN C notifying her about the incident. ADON E proceeded to say they called her and told her to tell LVN C to change her documentation. ADON E said she often gets called and instructed to tell the nurses to edit their documentation. ADON E said she could not remember who called her to instruct her to tell the nurses to edit their documentation. 6) Record review of a face sheet dated 03/02/2024 indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body), congenital insufficiency of aortic valve (heart defect that prevents blood from flowing backward through the heart), neuromuscular dysfunction of the bladder (condition where a person lacks bladder control due to brain, spinal cord, or nerve problems), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and anxiety disorder. Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #179's speech was unclear, was sometimes able to make himself understood, and understood others. The MDS assessment indicated Resident #179 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #179 was dependent on staff for all ADLs. Record review of the care plan last revised 02/23/2024 indicated Resident #179 had quadriplegia to assist with ADLs and locomotion as required. During an observation and interview on 02/26/2024 at 10:46 AM, Resident #179 said he did not like it at night. Resident #179 said CNA B was mean to him, and she throws me around with the sheet. He said CNA B ignored his call light and did not provide incontinent care. Resident #179 became very emotional and started crying because he said CNA B said she was not going to take care of him, and he had to wait to be changed until 6 AM the next morning. Resident #179 said he was not able to remember the exact day of the incident, but he had told the DON one night she had worked on the floor. Resident #179 said the DON told him she would handle it, but she never returned to tell him how she handled it. Resident #179 said CNA B was still supposed to provide care for him, but she refused to provide care to him. Resident #179 remained tearful throughout the rest of the interview. During an interview on 02/26/2024 at 12:22 PM, the DON said she had worked on the floor on the night shift to help the CNAs provide ADL care (the DON did not specify the date). The DON said no residents had reported to her any abuse allegations. The DON said if a resident reported an abuse allegation to her, she would start and investigation, fill out a grievance, and notify the abuse coordinator, the AIT, immediately, and call the Social Worker. The DON said she had talked to Resident #179, and he was a bit hard to understand, but he had not notified her of any abuse or neglect allegations. The DON said no residents had complained about CNA B to her. The DON said Resident #179 could have reported the abuse to another staff member. During an interview on 02/27/2024 at 10:35 AM, CNA B said she had been employed at the facility since October 2022, and she worked the night shift. CNA B said she provided care to Resident #179. CNA B said she answered Resident #179's call light and denied any abuse towards Resident #179 . CNA B said there were times when she was not able to provide the care required to the residents because the facility was shorthanded. CNA B said sometimes from 6 PM-10PM the facility only had 2 CNAs. CNA B said Resident #179 was needy. CNA B said Resident #179 was very needy, and he required 2 staff assist with his ADLs. CNA B said she could do what he asked her to do and ask him if he was satisfied, and when she walked out, he would turn his call light on. CNA B repeated that Resident #179 was very needy, and she would have to tell him that she had other people to take care of and he would say ok. During an observation and interview on 02/27/2024 at 4:40 PM, CNA EE and SNA O were in Resident #179's room. Upon entering room, surveyor noticed Resident #179 was crying uncontrollably and emotionally distraught. CNA EE and SNA O were attempting to reassure and comfort Resident #179. CNA EE said Resident #179 was crying because he did not want them to leave for the day (referring to the 6 AM- 6PM shift) because the night shift would not turn him or answer his call light. Resident #179 started crying even more and said CNA OO had called him a rat for telling on CNA B, took his call light away, and told him nobody wanted to answer his call light the previous night (02/26/24). Resident #179 had not reported the incident to any other facility staff . During an interview on 03/02/2024 at 10:43 AM, CNA OO said Resident #179 was a high-risk care because he was a 2-person total assist with mobility and his ADLs. CNA OO said she had never had any issues with him, and she had not taken his call light away. CNA OO said generally when she went into Resident #179's room there was another staff member with her. CNA OO said she had not called Resident #179 a rat . 7)Record review of Resident #36's face sheet dated 02/27/2024, indicate Resident # 36 was a [AGE] year-old female admitted to the facility on [DATE], with a diagnosis which include Metabolic Encephalopathy (a problem in the brain), morbid severe obesity due to excess calories (BMI greater than 40, a BMI of greater than 35 with at least one serious obesity-related condition, or being more than 100 pounds over your recommended weight), abnormal posture (rigid body movements and chronic abnormal positions of the body), muscle weakness (commonly due to lack of exercise, aging, muscle injury) chronic obstructive pulmonary disease (disease that causes airflow blockage and breathing-related problems). Bipolar disorder, current episode depressed, severe, without psychotic features (depressed, as in severe depressive episode without psychotic symptoms, and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past). Record review of Resident # 36's Quarterly MDS assessment dated [DATE], indicated Resident #36 was understood and was able to understand others. The MDS assessment indicated Resident #36 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #36 had no delusions or hallucinations. The MDS assessment indicated Resident #36 had no physical, verbal, or other behavioral symptoms directed toward others. Record review of Resident #36's a care plan dated 02/26/2024, indicated Resident #36 has a behavior problem: will request certain services and tasks then refuse or state it was not offered. (Showers, therapy, meal preferences). Record review of Resident #36's progress notes dated 02/27/2024, revealed no documented incidents regarding Resident #36's allegations with CNA B. During an interview on 02/26/2024 at 10:23 AM, Resident # 36 stated CNA came into her room with an attitude. Resident #36 stated she asked the CNA if she was having a bad day and the CNA said do not worry about me. R[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

Abuse Prevention Policies (Tag F0607)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations for 8 of 11 residents (Resident #'s 44, 55, 41, 47, 52, 179, 57 and 36) reviewed for abuse and neglect. The facility failed to report and investigate when Resident #44 was found to have a large purple bruise to her inner thigh and a fractured hip. The facility failed to ensure Resident #44 was protected from Resident #41 after a resident to resident assault allegation resulting in Resident # 44 being sent to a local emergency room. Resident #44 was assessed with a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). when she was left alone with her alleged assailant Resident #41. The facility failed to ensure Resident #55 was protected by not leaving him alone with Resident #41 after Resident #41 allegedly assaulted Resident #44. The facility failed to ensure Resident #179 was not verbally and physically abused by CNA B. The facility failed to ensure Resident #179 was not suffering on-going neglect abuse by CNA B of not performing incontinent care and not responding to his call light. The facility failed to ensure Resident #36 was not verbally abused when cursed by CNA B. The facility failed to ensure the DON reported physical and verbal abuse and neglect to the abuse coordinator after Resident #179 reported it to her in February 2024. The facility failed to ensure the DON reported abuse to HHSC, after LVN C reported abuse to her on 02/19/2024. The facility failed to ensure Resident #52 was not cursed at and not allowed in his room by Resident #47 who had a history of verbal abuse. The facility failed to report to the state agency when Resident #57 had shearing, hematoma, bruising, and a skin tear. An IJ was identified on 3/01/2024. The IJ template was provided to the facility on 3/01/2024 at 11:05 a.m. While the IJ was removed on 3/01/2024, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of the facility's policy dated 03/29/2018, titled, Abuse/Neglect, indicated, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members, or legal guardians, friends, or other individuals . Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability . Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again, etc . 5. Physical Abuse: Includes, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Abuse as defined in 40 TAC 19.101 (1). 6. Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Abuse as defined in 40 TAC 19.101(1). 7. Neglect: is the failure of the facility. its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . 12. Injury of Unknown Source any injury to a resident where: o The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and o The injury is suspicious because of the extent of the injury or the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time . The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property investigation . Resident to Resident the above policy will apply to potential resident-to-resident abuse . 1) Record review of a face sheet dated 2/27/2024 indicated Resident #44 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness, reduced mobility, anxiety disorder. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was sometimes understood and usually understands others. The MDS indicated Resident #44 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #44 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #44 had no behavioral symptoms but wandered 1-3 days during the assessment period. The MDS indicated Resident #44 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. The MDS indicated Resident #44 had a history of falls with fractures within the last 6 months. Record review of the comprehensive care plan dated 12/13/2023 and updated on 1/07/2024 indicated Resident #44 was at risk to fall related to unsteady gait/balance, generalized weakness, and poor safety awareness. The care plan indicated Resident #44 was at risk to wander related to a history of attempts to leave the facility related to poor safety awareness and resides on the secured unit. Record review of a Weekly Skin assessment dated [DATE] and documented by LVN CCC, indicated Resident #44's skin was normal with no bruising. The note indicated Resident #44's had a surgical incision to the right hip with staples and Steri-strips (tape like strips) in place with no drainage and no signs of infection. Record review of a Fall Nurses Note dated 6/12/2023 and documented by LVN YY indicated Resident #44 had a fall with a bump on the right side of her head. Record review of a Weekly Skin assessment dated [DATE] documented by LVN DDD, indicated Resident #44's skin was normal with no bruising. Record review of a SBAR note dated 6/18/2024 documented by LVN YY indicated Resident #44 had swelling and pain to the right hip replacement. The note indicated Resident #44 was ordered a mild pain reliever and an x-ray to the right hip. Record review of a right hip x-ray dated 6/19/2023 indicated Resident #44's prosthetic right femoral head (hip joint) was in proper alignment. Resident #44's x-ray revealed there were no fractures or acute dislocation. The x-ray indicated Resident #44's prothesis was properly situated without any loosing. The x-ray conclusion indicated the right hip arthroplasty (joint restoration) was intact. Record review of a progress note dated 6/21/2023 at 6:15 a.m., LVN YY documented Resident #44 had a bruise to the inner thigh on the right leg measuring 17 centimeters x approximately 11 centimeters with pain but no pain level was documented. LVN YY noted she administered a mild pain reliever to Resident #44 . Record review of an Event Nurses' note dated 6/21/2023 at 6:15 a.m., LVN YY documented a bruise was found to Resident #44's right inner thigh measuring 17 centimeters x approximately 11 centimeters. The note indicated Resident #44's bruise was blue/purple and painful. LVN YY documented Resident #44 could not provide a statement related to her cognitive impairment. LVN YY said previous factors included previous falls. Record review of an incident note dated 6/21/2023 documented by LVN YY indicated Resident #44 had a large purple bruise on her inner right thigh (front) measuring 17 centimeters x approximately 11 centimeters. LVNYY said Resident #44 was unable to state what had happened. LVN YY documented there were no predisposing environmental factors, and the predisposing physiological factor was Resident #44 had memory impairment. Record review of a Weekly Skin assessment dated [DATE] indicated Resident #44 skin color was normal, temperature was normal, with a large purple bruise to the right inner thigh with a firm center with bruising to her knee. Record review of a Consultation note dated 6/21/2023 indicated the orthopedic physician documented he knew Resident #44. The physician said he had treated her femoral neck fracture (connects the hip ball to the femur bone) a month previous. The physician wrote he had seen Resident #44 a week ago and the x-rays showed a well-fitted well-fixed bipolar hip. The physician wrote he had plans to surgically repair Resident #44's right hip by removing the prothesis, wire her with cables then reimplant the prothesis and then put a plate and screws with wires and screws around the periprosthetic fracture. During an interview on 2/29/2024 at 11:42 a.m., LVN YY said she was notified of Resident #44's by CNA K. LVN YY said she assessed and measured the bruising and notified the physician, family, DON, and Administrator (previous). LVN YY said she was unsure how Resident #44 sustained the bruise and unsure why no one else had seen the bruise. LVN YY said reporting to the DON and Administrator was the policy of the facility. During an interview on 2/29/2024 at 3:22 p.m., CNA K said she had found the bruising to Resident #44's right leg and reported to LVN YY. CNA K said while she was providing incontinent care for Resident #44, she moved the pillow between Resident #44's legs when she found a large purple bruise. During an interview on 2/29/2023 at 3:40 p.m., the DON said she was not the DON during the incident on 6/21/2023 with Resident #44 but she indicated she would have investigated and report the bruising. During an interview on 03/01/2024 at 8:52 AM, previous Administrator ZZ said she always did an investigation when something was reported to her but depending on her investigation if she reported. Administrator ZZ said if she had not reported the incident with Resident #44's bruising/hip fracture it had to be for a reason. Administrator ZZ said she did not remember the specifics off the top of her head, and she kept a soft file in the administrator's office with her investigations. Administrator ZZ said a bruise that was not correlated with an incident was considered an injury of unknown injury and should be reported within 2 hours of finding it or being notified. During an interview on 03/01/2024 at 1:22 PM, the Administrator said he expected bruises to be automatically reported to him, and if not to him directly to the DON or nursing supervisor and they would report it to him. The Administrator said when he was notified of an injury of unknown injury, he would investigate it and report it within the 2 hours. The Administrator said he had not had a chance to look for Resident #44's soft file in his office (the soft file was never provided prior to the exit date of 03/02/2024). The Administrator said they reviewed incidents and accidents every morning in the morning meetings and care plan the issues. The Administrator said if there was an injury of unknown origin, they should look at the last skin assessment to try to piece together a timeline, staff would be interviewed, the resident would be interviewed, if able to be interviewed. The Administrator said he expected the staff to call him and report to him any abuse concerns no matter the time of day. The Administrator said in his absence the staff should report to the DON, and the DON should report it per the requirements to HHSC and to him. 2)Record review of the of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #55 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #41 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital. Record review of a progress note dated 2/25/2024 at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 on the floor bedside the closet door on her back with Resident #41 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency room on 2/25/2024 with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination documented indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated 2/25/2024 indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in the area of space and tissue between the skull and skin). Record review of the of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #55 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #41 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital Record review of a progress note dated 2/25/2024 at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 was found on the floor bedside the closet door on her back with Resident #44 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency room on 2/25/2024 with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination document indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated 2/25/2024 indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in space and tissue between the skull and skin). 3)Record review of a face sheet dated 3/2/2024 indicated Resident #41 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, the need for continuous supervision, and high blood pressure. Record review of a Significant Change MDS dated [DATE] indicated Resident #41 was usually understood and sometimes understands. The MDS indicated Resident #41's cognition was severely impaired. The MDS indicated Resident #41 had no physical, or verbal behaviors exhibited. The MDS indicated Resident #41 wandered daily. Record review of the comprehensive care plan dated 8/08/2023 and revised on 9/08/2023 indicated Resident #41 was at risk for mood problems and received medications. The goal of the care plan indicated Resident #41 would have an improved mood state. The care plan interventions included administer medications, behavioral health consults as needed, monitor and record mood to determine if problems seem to be related to external causes. Record review of a progress note dated 2/25/2024 at 6:00 p.m., LVN D documented she was called to a resident room by CNA A. LVN D documented Resident #41 was in Resident #55's room where she found Resident #44 on the floor beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented she asked Resident #41 and Resident #44 what had occurred, and neither could explain. LVN D documented Resident #55 said Resident #41 pushed Resident #44 against the closet door and she fell. LVN D documented Resident #41 was very uncooperative and had tried to hit CNA A and Resident #55. Record review of Behavior Nurses Note dated 2/25/2023 at 6:30 p., LVN D documented she was called to the secured unit by the nurse aide. LVN D documented Resident #41 was in Resident #55's room. LVN D documented she found Resident #44 on the floor lying beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented Resident #55 said he pushed her up against the closet door and she fell. LVN D said Resident #41 and #44 was unable to indicate what had happened. LVN D said Resident #44 was very uncooperative and had tried to the hit the CNA on duty and Resident #55. Record review of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented Resident #41 was found in another resident room. LVN D documented Resident #41 had displayed physical, and resident to resident behaviors with another resident injured. The Event Nurses' note indicated LVN D moved Resident #41's room and initiated every 15-minute checks. Record review of a Every 15 Minute Check sheet indicated Resident #41 was placed on every 15-minute checks starting on 2/25/2024 at 6:30 p.m. The Every 15- minute checks at 0015 indicated LVN D documented at 12:15 a.m., Resident #44 was asleep. LVN D had only her initials beside the other every 15-minute checks starting at 12:30 a.m. -5:45 a.m. on 2/26/2024 there was no remarks indicating anything in regarding Resident #44. During an interview on 2/26/2024 at 9:32 p.m., CNA A said she was alone on the secured unit gathering her supplies in the spa/communal shower room when she heard a loud scream. CNA A said she ran out of the spa room and ran toward the end of the hall where she believed the sound was heard from. CNA A said upon entering the room, Resident #44 was lying in the floor, Resident #55 said Resident #41 had thrown Resident #44 into the door. CNA A said Resident #41 was aggressive with her at the time and tried to swing at her. CNA A said she left Resident #55's room and ran the length of the secured unit, opened the door, and yelled for help. CNA A said she was alone on the secured unit and had no other recourse than to go for help. CNA A said LVN D was passing medications and another nurse responded to her call for help. During an interview on 2/26/2024 at 11:46 a.m., the DON said on 2/25/2024 CNA A heard a noise and responded to the noise. The DON said LVN D called and said Resident #41 was upset and wandering in other rooms. The DON said CNA A had said Resident #44 was on the floor. The DON said she was unsure of Resident #44 hitting her head although she had an abrasion to her head. The DON said Resident #44 was sent to the emergency room closer to midnight due to complaining her head was hurting. During an interview on 2/26/2024 at 11:51 a.m., LVN D said she was called to the unit by CNA A. LVN D said Resident #44 was lying in the floor of Resident #55's room, with Resident #41 standing over Resident #44 around 6:30 p.m. on 2/25/2024. LVN D said Resident #55 said Resident #41 pushed Resident #44 against the closet and Resident #41 fell. LVN D said at the time of the incident Resident #44 had an abrasion to her right temple area and a bruise to her inner right arm. LVN D said Resident #41 was very uncooperative and attempted to hit others. LVN D said she was advised to place Resident #41 on every 15-minute checks by the DON. LVN D said although her documentation was not completed yet Resident #41 remained asleep. LVN D said CNA A had to leave Resident #44 to come for help. LVN D said she was not on the secured unit but was on hall 400 when the incident occurred. During an observation and interview on 2/27/2024 at 9:00 a.m., Resident #44 was sitting at the dining table with a large size raised area with bruising noted to her right side of her head in the temporal/parietal region. Resident #44 said she felt well but she denied having her head hurt. 4) Record review of a face sheet dated 3/02/2024 indicated Resident #55 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of stroke, high blood pressure, and dementia (memory loss). Record review of the Annual MDS dated [DATE] indicated Resident #55 was usually understood, and usually understands. The MDS indicated Resident #55 had severe cognitive impairment. The MDS indicated Resident #55 had not displayed any verbal or physical behaviors. During an observation on 2/25/2024 at 9:31 a.m., Resident #41 was lying in his bed asleep. During an interview on 2/26/2024 at 10:54 a.m., LVN F said Resident #44 was discharged to the hospital and Resident #41 was on every 15-minute checks for aggressive behaviors. LVN F said after she reviewed Resident #44's electronic medical record and said there was not a progress note, a SBAR (situation, background, assessment, recommendation) note, a transfer note, or an incident report. LVN F said the electronic medical record should have had those assessments completed. During an observation and interview on 2/26/2024 at 12:42 p.m., Resident #55 was sitting at the dining table and was unable to recall the incident in his room last night. 5)Record review of the face sheet, dated 02/29/2024, revealed Resident #47 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and altered mental status (broad term used to indicate an abnormal state of alertness or awareness). Record review of the significant change MDS assessment, dated 12/20/2023, revealed Resident #47 had clear speech and was usually understood by others. The MDS revealed Resident #47 was sometimes able to understand others. The MDS revealed Resident #47 had short-term and long-term memory problems. The MDS revealed Resident #47 was not able to recall the current season, the location of his room, staff names or faces, and that he was in a nursing facility. The MDS revealed Resident #47 had severely impaired decision-making skills. The MDS revealed Resident #47 had continuous inattention and disorganized thinking. The MDS revealed Resident #47 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 02/21/2024, revealed Resident #47 had potential to demonstrate verbally abuse behaviors. The interventions included: analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document .assess resident's coping skills and support system .evaluate for side effects of medications .notify the charge nurse of any abusive behaviors .provide positive feedback for good behavior, emphasize the positive aspects of compliance .psychiatric/psychogeriatric consult as indicated. Record review of the nursing progress note on 02/19/2024 at 12:20 AM, revealed Resident #47 was repeated yelling at his roommate [Resident #52] You son-of-a-bitch get out of my room! The nursing progress note further revealed the DON was notified immediately and told LVN C to notify the Medical Director because there was no abuse coordinator at the facility. The progress note revealed the Medical Director was notified and Resident #47 was placed in a different room. 6) Record review of a face sheet dated 03/02/2024 indicated Resident #52 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, with other behavioral disturbance (deterioration of memory, language, and other thinking abilities with behaviors) , anxiety disorder, and depression. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #52 was usually able to understand others and was usually understood by others. The MDS assessment indicated Resident #52 had a BIMS score of 5, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #52 had no physical, verbal, or other behaviors directed toward others. The MDS assessment indicated Resident #52 required setup or cleanup assistance with eating, supervision for oral, toileting, and personal hygiene, and partial to moderate assistance with showering and dressing. Record review of Resident #52's care plan last revised 02/02/2024 indicated Resident #52 had impaired cognitive function/dementia or impaired thought processes. Record review of Resident #52's progress notes indicated: o 02/19/2024 12:20 AM Resident #52 was very forgetful and usually confused. He was pacing, wandering, and coming in and out of his room. This resident was redirected numerous times back to his room and to bed. The last time resident was redirected back to his room, his roommate was cursing, repeatedly telling this resident, You son-of-a-bitch get out of my room! Which explained why Resident #52 would not stay in his room. CNA remained in the room with both residents until the DON and doctor were notified. DON notified immediately and stated to call the Medical Director. 12:35 AM both residents were separated with the roommate moved to another room. o Strike out note dated 2/23/2024, effective date for the note prior to strike out 02/19/2024 created by LVN C indicated, 12:20 AM the DON stated they did not have an abuse coordinator at the time, that their new administrator was supposed to start work that day (02/19/24). The DON stated to call the Medical Director and report it to him. During an observation and attempted interview on 02/23/2024 at 3:48 PM Resident #52 was observed walking down the hall with his rollator (walker with wheels). Resident #52 did not want to be interviewed at the time. During an interview on 02/26/2024 at 9:07 PM, LVN C said Resident #52 kept getting up and coming out of his room, and she kept telling him to go back to his room because it was in the middle of the night. LVN C said she finally decided to take him back to his room, and that was when she realized Resident #52's roommate, Resident #47, was yelling and cursing at Resident #52 to get out of the room and calling him a son of a bitch'. LVN C said this was really confusing Resident #52. LVN C said she called the DON, who was the abuse coordinator at the time, and she told her to keep them separated. LVN C said she called the Medical Director, and he told her to separate them and place them in 2 different rooms. Regarding the struck out note about the incident, LVN C said when she called the DON, she did not know the DON was the abuse coordinator. LVN C said the DON told her they currently did not have an abuse coordinator, but the new administrator was starting that day to notify the Medical Director. LVN C said she learned the DON was the abuse coordinator after talking to the DON on the phone. LVN C said one of her co-workers informed her if there was no administrator it automatically fell on the DON to be the abuse coordinator. LVN C said ADON E instructed her to correct her note to show that she did call the DON immediately. LVN C said after notifying the DON of the incident the night it occurred, the DON never talk to her about the incident again. LVN C said there had been a lot of changes in administrators and administration and they were not providing education on who was the abuse coordinator. LVN C said in the past she had called to report other incidents of abuse to who she thought was the abuse coordinator for them to tell her they were no longer employed at the facility. During an interview on 02/27/2024 at 8:46 AM, the DON said she was not able to recall any incident with Resident #47 and Resident #52. The DON said she did not remember an incident where Resident #47 cursed out Resident #52. The DON said the staff were supposed to report abuse to the Administrator and herself. The DON said the staff were notified when there were changes in administration one-on-one. The DON denied LVN C calling her to report when Resident #47 cursed at Resident #52. The DON said if the Administrator was not in the facility, she was the abuse coordinator. During an interview on 02/28/2024 at 3:33 PM, the Area Director of Operations said she was a consultant for the facility. The Area Director of Operations said she was there as a resource for the facility administration to reach out to her with assistance regarding the policies and procedures. The Area Director of Operations said the administrators were responsible for the facility and that is why when one administrator left an interim was put in place. The Area Director of Operations said she did not provide oversight for the facility that was the administrators responsibility because she had 10 other facilities, she was over. The Area Director of Operations said she made sure the facilities were in the green and monitored their spending to help them reach their financial goals. During an interview on 02/28/2024 at 9:24 PM, the Medical Director said there had been at least 5 administrators and half a dozen DONs and several ADONs in the past year. The Medical Director said there was no consistency, and the staff were unfamiliar with the residents and left often, which resulted in difficulty maintaining staff stability. The Medical Director said resident to resident altercations were a regular situation on the secured unit and was directly related to lack of supervision. The Medical Director said the residents should never have been left unsupervised. The Medical Director said the issue with the resident-to-resident altercations was staffing, and the facility being understaffed. The Medical Director said he had expressed his concerns regarding staffing to upper management. The Medical Director said amongst all the changes [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

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 failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 4 of 11 residents (Resident #'s 4, 44, 130, and 180) reviewed for accidents. The facility failed to ensure Resident #44 was provided with adequate supervision when she was physically assaulted by Resident #41 on [DATE]. The facility failed to ensure Resident #4 who required 1 person assistance with toileting was provided adequate supervision to prevent an unwitnessed fall on [DATE] at 10:30 p.m. The facility failed to ensure Resident #4 was not left unsupervised on the toilet on [DATE] and was able to self-transfer between the toilet and the wheelchair. The facility failed to ensure Resident #130 was not provided adequate supervision to prevent an unwitnessed fall on [DATE] and [DATE]. The facility failed to prevent incidents and accidents when Resident #180 sustained an unwitnessed fall with injury (moderate sized frontal scalp soft tissue hematoma (blood collected outside of the blood vessels due to injury or trauma to the right side of the forehead)) and expired on [DATE]. An IJ was identified on [DATE] at 3:39 PM. The IJ template was provided to the facility on [DATE] at 3:39 PM. While the IJ was removed on [DATE], the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm, severe injury, and possible death to residents who require supervision. The findings included: 1)Record review of a face sheet dated [DATE] indicated Resident #44 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness, reduced mobility, anxiety disorder. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was sometimes understood and usually understands others. The MDS indicated Resident #44 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #44 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #44 had no behavioral symptoms but wandered 1-3 days during the assessment period. The MDS indicated Resident #44 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. The MDS indicated Resident #44 had a history of falls with fractures within the last 6 months. Record review of the comprehensive care plan dated [DATE] and updated on [DATE] indicated Resident #44 was at risk to fall related to unsteady gait/balance, generalized weakness, and poor safety awareness. The care plan indicated Resident #44 was at risk to wander related to a history of attempts to leave the facility related to poor safety awareness and as the intervention resides on the secured unit. Record review of the of an Event Nurses' note dated [DATE] at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #55 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #414 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital. The note in #17 interventions in place prior to this fall was none of the above. Record review of a progress note dated [DATE] at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 was found on the floor bedside the closet door on her back with Resident #414 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency room on [DATE] with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination documented indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated [DATE] indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in the area of space and tissue between the skull and skin). Record review of the of an Event Nurses' note dated [DATE] at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #55 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #44 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital. The note in #17 interventions in place prior to this fall was none of the above. Record review of a progress note dated [DATE] at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 was found on the floor bedside the closet door on her back with Resident #44 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency room on [DATE] with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination documented indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated [DATE] indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in space and tissue between the skull and skin). During an observation and interview on [DATE] at 9:00 a.m., Resident #44 was sitting at the dining table with a large size raised area with bruising noted to her right side of her head in the temporal/parietal region. Resident #44 said she felt well but she denied having her head hurt. 2) Record review of a face sheet dated [DATE] indicated Resident #41 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, the need for continuous supervision, and high blood pressure. Record review of a Significant Change MDS dated [DATE] indicated Resident #41 was usually understood and sometimes understands. The MDS indicated Resident #41's cognition was severely impaired. The MDS indicated Resident #41 had no physical, or verbal behaviors exhibited. The MDS indicated Resident #41 wandered daily. Record review of the comprehensive care plan dated [DATE] and revised on [DATE] indicated Resident #41 was at risk for mood problems and received medications. The goal of the care plan indicated Resident #41 would have an improved mood state. The care plan interventions included administer medications, behavioral health consults as needed, monitor and record mood to determine if problems seem to be related to external causes. Record review of a progress note dated [DATE] at 6:00 p.m., LVN D documented she was called to a resident room by CNA A. LVN D documented Resident #41 was in Resident #55's room where she found Resident #44 on the floor beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented she asked Resident #41 and Resident #44 what had occurred, and neither could explain. LVN D documented Resident #55 said Resident #41 pushed Resident #55 against the closet door and she fell. LVN D documented Resident #41 was very uncooperative and had tried to hit CNA A and Resident #55. Record review of Behavior Nurses Note dated [DATE] at 6:30 p., LVN D documented she was called to the secured unit by the nurse aide. LVN D documented Resident #41 was in Resident #55's room. LVN D documented she found Resident #44 on the floor lying beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented Resident #55 said he pushed her up against the closet door and she fell. LVN D said Resident #41 and #44 was unable to indicate what had happened. LVN D said Resident #44 was very uncooperative and had tried to the hit the CNA on duty and Resident #55. Record review of an Event Nurses' note dated [DATE] at 6:30 p.m., indicated LVN D documented Resident #41 was found in another resident room. LVN D documented Resident #41 had displayed physical, and resident to resident behaviors with another resident injured. The Event Nurses' note indicated LVN D moved Resident #41's room and initiated every 15-minute checks. Record review of a Every 15 Minute Check sheet indicated Resident #41 was placed on every 15-minute checks starting on [DATE] at 6:30 p.m. The Every 15- minute checks at 0015 indicated LVN D documented at 12:15 a.m., Resident #44 was asleep. LVN D had only her initials beside the other every 15-minute checks starting at 12:30 a.m. - 5:45 a.m. on [DATE] there was no remarks indicating anything in regarding Resident #41. During an observation on [DATE] at 9:31 a.m., Resident #41 was lying in his bed asleep. During an interview on [DATE] at 4:17 p.m., the SW said she was notified by the DON regarding the incident with Resident #44 and Resident #41. The SW said upon her arrival Resident #44 was already at the local emergency room, and Resident #41 was wandering on the unit. The SW said Resident #41 and Resident #55 both were unable to recollect the recent incident. During an interview on [DATE] at 9:32 p.m., CNA A said she was alone on the secured unit gathering her supplies in the spa/communal shower room when she heard a loud scream. CNA A said she ran out of the spa room and ran toward the end of the hall where she believed the sound was heard from. CNA A said upon entering the room, Resident #44 was lying in the floor, Resident #55 said Resident #41 had thrown Resident #44 into the door. CNA A said Resident #41 was aggressive with her at the time and tried to swing at her. CNA A said she left Resident #55's room and ran the length of the secured unit, opened the door, and yelled for help. CNA A said she was alone on the secured unit and had no other recourse than to go for help. CNA A said LVN D was passing medications and another nurse responded to her call for help. During an interview on [DATE] at 11:46 a.m., the DON said on [DATE] CNA A heard a noise and responded to the noise. The DON said LVN D called and said Resident #41 was upset and wandering in other rooms. The DON said CNA A had said Resident #44 was on the floor. The DON said she was unsure of Resident #44 hitting her head although she had an abrasion to her head. The DON said Resident #44 was sent to the emergency room closer to midnight due to complaining her head was hurting. During an interview on [DATE] at 11:51 a.m., LVN D said she was called to the unit by CNA A. LVN D said Resident #44 was lying in the floor of Resident #55's room, with Resident #41 standing over Resident #44 around 6:30 p.m. on [DATE]. LVN D said Resident #55 said Resident #41 pushed Resident #44 against the closet and Resident #41 fell. LVN D said at the time of the incident Resident #44 had an abrasion to her right temple area and a bruise to her inner right arm. LVN D said Resident #41 was very uncooperative and attempted to hit others. LVN D said she was advised to place Resident #41 on every 15-minute checks by the DON. LVN D said although her documentation was not completed yet Resident #41 remained asleep. LVN D said CNA A had to leave Resident #44 to come for help. LVN D said she was not on the secured unit but was on hall 400 when the incident occurred. During an interview on [DATE] at 12:22 p.m., CNA H said CNA A had always worked the secured unit alone. CNA H said when CNA A was in the room with other residents who would be watching the other residents, or who would go for help. CNA H said there was no one was on the unit to get help when CNA A needed help. 3) Record review of a face sheet dated [DATE] indicated Resident #130 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, lack of coordination, and a need for assistance with personal care. Record review of the Comprehensive Care Plan dated [DATE] and revised on [DATE] indicated Resident #130 was a high risk for falls related to wandering. The goal of the care plan was Resident #130 would be free of falls. The care plan interventions included to anticipate and met Resident #130's needs, ensure his call light was within reach, encourage the use of the call light, and have prompt response to the request for assistance, and ensure Resident #130 wore appropriate footwear. The comprehensive care plan failed to have interventions after the falls on [DATE] and [DATE]. Record review of an incident report dated [DATE] at 10:00 p.m., LVN C indicated Resident #130 was found by the CNA on the floor, with no signs of pain. The note indicated Resident #130 was limping on the left leg and was sent to the local emergency room at 10:35 p.m. via the ambulance. Record review of an Event Nurses-Note dated [DATE] at 10:00 p.m., indicated Resident #130 had an unwitnessed fall in his room. LVN C documented Resident #130 was assisted up and was noted to be limping on the left leg. LVN C documented the physician was notified and Resident #130 was sent to the local hospital. The note indicated the interventions included interval monitoring (specify below) there was no documentation below. The note indicated in additional interventions there were interventions of a low bed and interval monitoring (again not specified). The note indicated Resident #130 was independent with bed mobility, toileting, and transferring. The note indicated Resident #130 had an unsteady gait, balance problem, and lack of mobility strength. The note indicated Resident #130 was wearing shoes or anti-slip socks. The note indicated Resident #130 had Ativan 0.5 milligrams twice daily started on [DATE]. Record review of a fall risk assessment completed by LVN C on [DATE] indicated Resident #130 was disoriented at all times to person, place, and time. The assessment indicated Resident #130 had no previous falls, was ambulatory, continent, had balance problems, decreased muscular coordination, and gait pattern changes. Record review of a Medication Administration Record dated [DATE] - [DATE] indicated on [DATE] Resident #130 was administered Ativan 0.5 milligrams for anxiety or agitation. The record also indicated Resident #130 received the Ativan 0.5 milligrams twice daily on [DATE] and on the morning of [DATE]. Record review of an Event Nurses-Note dated [DATE] at 10:00 p.m., indicated Resident #130 had an unwitnessed fall in his room. LVN C documented Resident #130 was assisted up and was noted to be limping on the left leg. LVN C documented the physician was notified and Resident #130 was sent to the local hospital. The note indicated the interventions included interval monitoring (specify below) there was no documentation below. The note indicated in additional interventions there were interventions of a low bed and interval monitoring (again not specified). The note indicated Resident #130 was independent with bed mobility, toileting, and transferring. The note indicated Resident #130 had an unsteady gait, balance problem, and lack of mobility strength. The note indicated Resident #130 was wearing shoes or anti-slip socks. The note indicated Resident #130 had Ativan 0.5 milligrams twice daily started on [DATE]. Record review of an incident report dated [DATE] at 5:30 p.m., indicated Resident #130 was found with his head lying against the closet door by LVN HHH. The note indicated Resident #130 had a bruise to his right shoulder and a skin tear to his left hand. The note indicated the conclusion was Resident #130 had an unwitnessed fall with injuries. The note indicated his bed was changed to a low bed. Record review of an Event Nurses-Note dated [DATE] at 6:39 p.m., indicated Resident #130 was found by LVN HHH when she was passing dining trays. The note indicated Resident #130 was lying with his head against the closet door. The note indicated Resident #130 had a skin tear. The note indicated Resident #130 had a purple bruise to his right shoulder. The note indicated Resident #130 was in pain noted by his occasional moans or groans, and facial grimacing. The note indicated Resident #130's physical factors included previous fall, urinary tract infection, pain, and incontinence. The note indicated Resident #130 required 1 staff with bed mobility, toileting, transferring, and walking. The note indicated Resident #130 leaned forward. Record review of an e-Transfer Form dated [DATE] at 6:00 p.m., indicated Resident #130 was transferred to the local hospital due to a fall by LVN HHH. Record review of a Fall-Risk assessment dated [DATE] at 6:47 p.m. indicated Resident #130 was disoriented, has fallen 3 or more falls in the past 3 months, ambulatory, and incontinent. The assessment indicated Resident #130 had balance problems while standing and walking. Record review of the History of Present Illness from the local hospital on [DATE] indicated Resident #130 fell and was sent to the local emergency room. The note indicated Resident #130 had a right hip fracture. The note indicated Resident #130 was seen 24 hours prior to this visit related to multiple falls at the facilitydur . Record review from the hospital orthopedist report dated [DATE] indicated Resident #130 had fallen over the last couple of weeks at least 8-9 times. The orthopedist documented Resident #130 was in the emergency room the day before post a fall with negative x-rays at the time. The note indicated the CT results indicated a minimally impacted right femoral neck fracture. The note indicated the physician spoke to the family and the family wanted a non-operative treatment and return to the facility with palliative care. Record review of hospital records dated [DATE] indicated Resident #130 was admitted at 6:59 p.m. with the diagnosis of closed fracture of the right hip. The discharge records indicated Resident #130 was returned to the facility on hospice services. Resident #130's discharge orders included bedrest, non-weight bearing to the right leg, and pain management. Record review of the cat scan of the chest, abdomen, and pelvis dated [DATE] indicated right femoral neck fracture. Record review of a progress note dated [DATE] at 4:25 p.m., indicated the social worker documented Resident #130 returned from the hospital, admitted on a hospice service, and was made a do not resuscitate status. Record review of a physician's progress note dated [DATE] indicated Resident #130 had a fall with a fracture to the right hip and he was being treated conservatively. Record review of an Incident Report dated [DATE] at 3:30 p.m., completed by LVN YY indicated Resident #130 was observed sitting on the floor beside his bed with his back leaning on the mattress. The note indicated Resident #130's bed was in low position. The note indicated the predisposing physiological factors were confusion, incontinent, recent medication changes, and impaired memory. Record review of a progress note dated [DATE] at 8:00 p.m., LVN D documented Resident #130 had a fall slipped off of the bed. LVN D documented there were no injuries. LVN D documented she administered Tramadol 50 milligrams due to Resident #130 appeared in pain, and then he was assisted up to the recliner because he refused to rest in his bed. During an interview on [DATE] at 11:43 a.m., CNA H said she has had to work the secured unit alone. CNA H said she had voiced the inability to provide supervision to Resident #130 during the time his leg was fractured and to prevent him from trying to ambulate on his broken leg. During an observation and interview on [DATE] at 10:55 p.m., CNA K said she had to work the secured unit many times alone. CNA K said she could remember Resident #130 had a fall and fractured his hip. CNA K said she could not remember providing care to Resident #130. CNA K said she had told the DON, and ADONs previously the secured unit was not staffed enough to provide adequate supervision to the residents. During this interview there were 5 residents of the secured unit up and ambulating about the unit in and out of rooms. CNA K said she was having a difficulty time keeping the residents centrally located to ensure their safety. During an interview on [DATE] at 11:30 p.m., LVN C said she had cared for Resident #130. LVN C said she had voiced concern numerous times and threatened to call safe harbor due to the inability to provide adequate supervision and care to her assigned residents. LVN C said due to the lack of staff on the secured unit she was unable to ensure the residents remained safe. LVN C said it was not unusual to have only one staff member on the secured unit from 10:00 p.m. - 6:00 p.m. LVN C said she still had medication to administer to Resident #4, therefore she was on her way to the secured unit. 4) Record review of a face sheet dated [DATE] indicated Resident #4 admitted on [DATE] and readmitted [DATE] with the diagnosis of diabetes, muscle weakness, lack of coordination, reduced mobility, repeated falls, dementia, and assistance with personal care. Record review of the comprehensive care plan dated [DATE] and revised on [DATE] indicated Resident #4 had an ADL self-care performance deficit. The goal of the care plan indicated Resident #4 would remain at her current level of function in transfers, and toileting. The care plan interventions included Resident #4 required one staff assistance with toileting. The comprehensive care plan indicated Resident #4 was at risk for falls related to weakness and impaired cognition. The goal of the care plan was Resident #4 would not sustain a serious injury. The care plan interventions included ensure Resident #4's call light was within reach, ensure don't call fall sign (fall prevention sign) at the foot of the bed visible by Resident #4, and frequent visual checks while in bed. Record review of an admission MDS dated [DATE] indicated Resident #4 was usually understood and understands others. The MDS indicated Resident #4's cognition was moderately impaired. The MDS in section GG indicated Resident #4 required partial to moderate assistance with toileting, bed to chair transfers, toileting transfers and to sit and stand. Record review of a Fall-Risk assessment dated [DATE] at midnight LVN D indicated Resident #4 had 1-2 falls in the past, required assistance with elimination, and took 3-4 medications which could increase the risk of falls. The fall risk assessment indicated Resident #4 was at high risk to fall. Record review of a fall incident report dated [DATE] at midnight, LVN D indicated Resident #4 ambulated without assistance and was not wearing any shoes or socks. Record review of a progress note dated [DATE] at midnight, LVN D documented Resident #4 was sitting in the hallway on her bottom with her legs straight in front of her. LVN D said Resident #4 said she had slipped down. LVN D documented Resident #4 was not wearing shoes or socks. LVN D documented Resident #4 complained of right foot pain. Record review of a fall incident report dated [DATE] at 10:30 p.m., LVN C indicated no injuries were observed. The incident report was left blank. Record review of a Fall-Risk assessment dated [DATE] at 10:30 p.m., LVN C documented Resident #4 was at high risk to fall. LVN C documented Resident #4 was disoriented, had 3 or more falls in the past 3 months, required assistance with elimination, had problems with balance, and took 3-4 medications which could cause falls. Record review of a Fall Nurses Note dated [DATE] at 10:46 a.m., LVN F documented Resident #4 had a fall without injury. LVN F documented fall interventions were the bed low, interval monitoring, neurological checks, frequent visual checks, encourage and educate use of the call light. Record review of a progress note dated [DATE] at 11:30 p.m., LVN C indicated Resident #4 said she had fallen on the floor, and she had been pulling up her pants. During an interview on [DATE] at 8:48 a.m., LVN C said CNA K was in another resident's room providing care when she heard Resident #4 calling for help. LVN C said CNA K was alone, so she had to hurriedly finish in the room to be able to assist Resident #4. LVN C said Resident #4 was lying on the bathroom floor when CNA C was able to get to her. LVN C said the secured unit was understaffed to provide adequate supervision for Resident #4 and other residents. During an observation and interview on [DATE] at 11:48 a.m., CNA H responded to the surveyor assisting Resident #4 with activating her call light for assistance to the bathroom. CNA H responded and assisted Resident #4 from her bed to the wheelchair, then from the wheelchair to the toilet. CNA H left Resident #4 alone on the toilet and went to get Resident #4's lunch tray. Upon returning to the room, Resident #4 was exiting the bathroom already in her wheelchair. CNA H said Resident #4 had a history of falls and was a fall risk. CNA H said she should have not left Resident #4 alone because of her risk to fall. Record review of an incident report dated [DATE] at 11:45 p.m., LVN C documented Resident #4 had a fall with no injuries noted. The incident report had no further documentation within. Record review of an Event Nurses' Note-Fall dated [DATE] at 11:45 p.m., LVN C documented Resident #4 had an unwitnessed fall. LVN C documented Resident #4 was found on the floor, indicated Resident #4 said legs gave out, and Resident #4 attempted to self-toilet. LVN C documented in the area of Nursing Description: Resident #4 indicated she got up to use the bathroom, failed to call for help, denied bumping her head, and was found sitting on the floor. 5) Record review of a face sheet dated [DATE] indicated Resident #180 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fracture of the left lower leg, chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (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 Quarterly MDS assessment dated [DATE] indicated Resident #180 was understood and understood others. The MDS assessment indicated Resident #180 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS assessment indicated Resident #180 was frequently incontinent of urine and occasionally incontinent of bowel. The MDS assessment indicated Resident #180 had not had any falls since admission/entry or reentry or the prior assessment. Record review of the care plan last revised [DATE] indicated Resident #180 was at risk for falls related to weakness and confusion with a goal of Resident #180 will be free of falls through the review date. Interventions included to anticipate and meet her needs, be sure her call light was within reach and encourage the resident to use it for assistance as needed, bed in low position when care is not being provided, Resident #180 needed a safe environment, mechanical lift with 2 staff assistance with transfers, and to review information on past falls and attempt to determine the cause of the falls record possible root causes. The care plan indicated Resident #180 had bladder incontinence to provide incontinent care at least every 2 hours. The care plan indicated Resident #180 had bowl incontinence to check her every two hours and assist with toileting as needed and to provide peri care after each incontinent episode. The care plan indicated Resident #180 had an ADL self-care performance deficit and required a lift for all transfers, one staff assistance with bed mobility, dressing and two staff assistance for toileting. Record review of Resident #180's Order Summary report dated active orders as of [DATE] indicated she was admitted to hospice on [DATE] and resident was weight bearing as tolerated with walking boot on her left lower leg with a start date of [DATE]. Record review of Resident #180's progress notes indicated: [DATE] at 5:17 PM, late entry, 6:15 AM this morning RN U went down to assess patient and she had a change in her mental and respiratory status. Blood pressure was 130/68, heart rate 80, respirations 26, oxygen saturation 86% RN U immediately contacted EMS, the Medical Director, and her family member at 6:30 AM. The note indicated Resident #180 had diagnoses of congestive heart failure, cellulitis to both lower extremities and mild dementia and had oxygen ordered at 2 liters via nasal canula but apparently, she would take it off. RN U reapplied the oxygen 2 liters via nasal canula and Resident #180's oxygen saturation improved to 90%. RN U noted that fire and EMS arrived and pt started speaking more clearly and told them she was not going to the hospital. Resident #180 stated she would not die at the hospital she wanted to die at the facility. Resident #180 refused to go to the ER. RN U contacted Resident #180's family member and he stated to honor her wishes and she did not have to go to the hospital. RN U notified the doctor and noted she would monitor the patient every 15 minutes for 3 hours then every 30 minutes for 5 hours and every hour thereafter. [DATE] at 10:30 PM, late entry, LVN D documented Resident #180 returned from the ER at this time. Resident #180 was awake and appeared a little lethargic, she responded with touch and when she c

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

Pharmacy Services (Tag F0755)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 9 of 24 residents (Resident #9, Resident #36, Resident #41, Resident #44, Resident #45, Resident #57, Resident #71, Resident #127 and Resident #179) and 1 of 1 medication storage room reviewed for pharmacy services. 1. The facility failed to ensure Resident #45's hospital discharge orders were reconciled accurately to include his Lantus (long-acting insulin used to lower blood sugar) 10 units every hour of sleep, Humalog (short acting insulin used to lower blood sugar) per sliding scale before meals, Farxiga 10 mg (used to control high blood sugar) daily, and Augmentin 875 mg-125 mg (antibiotic) after his discharge on [DATE] which resulted in his hospitalization for metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body) and hyperglycemia (elevated blood sugar at 926) on [DATE]. 2. The facility failed to ensure Resident #127 received his Vesicare as ordered after being admitted on [DATE]. 3. The facility failed to ensure Resident #179 was administered his antidepressant, antianxiety and pain medications timely on [DATE] and [DATE]. 4. The facility failed to ensure Resident #36's Sertraline (anxiety), Keppra (seizures), Diltiazem (anti-hypertension), Hydralazine (anti-hypertension) were administered at the prescribed time. 5. The facility failed to ensure Resident #9's Lisinopril (ant- hypertension), Trazadone (insomnia), Atorvastatin (hyperlipidemia), Clonazepam (anxiety), and Valproate Sodium Solution (bipolar and depression) were administered at the prescribed time. 6. The facility failed to ensure Resident #57's antihypertensive, antidepressant, anticoagulant, antihyperlipidemic, diuretic, supplemental and pain medications during [DATE]-[DATE] were provided timely. 7. The facility failed to ensure Resident #71's blood pressure met the parameters for the administration of an anti-hypertensive medication. 8. The facility failed to ensure Resident #44 received the ordered Cephalexin an antibiotic medication to treat her urinary tract infection timely. 9. The facility failed to ensure Resident #41 received the ordered weight loss supplement to treat weight loss timely. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 3:50 PM. The IJ template was provided to the facility on [DATE] at 4:19 PM. While the IJ was removed on [DATE] at 5:10 PM, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 10. The facility failed to discard 9 bottles of We Care Enema Saline laxative expired on 8-2023 in the medication storage room on [DATE]. These failures could place residents at risk of serious harm, not receiving their medications as ordered, illnesses, hospitalizations, exacerbation of their disease processes, coma, and death. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #45 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and type 2 diabetes mellitus with ketoacidosis without coma (chronic condition that affects the way the body processes blood sugar resulting in high blood sugars). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #45 was rarely/never understood and sometimes understood others. Resident #45 required supervision for eating and substantial/maximal assistance with shower/bathe self, upper body dressing, and personal hygiene. The MDS assessment did not indicate Resident #45 received insulin. Record review of the care plan last revised [DATE] indicated Resident #45 had diabetes and would refuse his blood sugars and insulin at times. The goal was for Resident #45 to have no complications related to diabetes through the review date. Interventions included Diabetes medication as ordered by doctor, blood sugar checks as ordered by doctor, if infection is present, consult doctor regarding any changes in diabetic medications. Record review of the Order Summary Report dated [DATE]-[DATE] did not indicate orders for Resident #45's Lantus (long-acting insulin used to lower blood sugars), Humalog (short acting used to lower blood sugars) Farxiga 10 mg (used to control high blood sugar) daily, or Augmentin 875 mg-125 mg (antibiotic). Record review of Resident #45's [DATE] MAR indicated: Farxiga 10 mg one tablet by mouth in the morning discontinued on [DATE]. Farxiga was administered from [DATE]-[DATE]. Check blood sugar at bedtime for hyper/hypoglycemia (high or low blood sugars) discontinued on [DATE]. [DATE] blood sugar was 239, [DATE] blood sugar was 169, [DATE] blood sugar was 210, [DATE] blood sugar was 266, [DATE] blood sugar was 209, [DATE] blood sugar was 345, [DATE] blood sugar was 434, [DATE] blood sugar was 190, [DATE] blood sugar was 134, [DATE] blood sugar was 258, [DATE] blood sugar was 324, [DATE] blood sugar was 106, [DATE] blood sugar check refused, [DATE] blood sugar was 315, [DATE] blood sugar was 120, [DATE] hospitalized . Lantus SoloStar Pen-injector 100 unit/ml inject 40 units subcutaneously (under the skin) every morning discontinued [DATE] [DATE] medication not given due to low blood sugar, [DATE] administered, [DATE] administered, [DATE] not administered due to low blood sugar, [DATE]-[DATE] administered, [DATE] not administered due to low blood sugar, [DATE]-[DATE] administered, [DATE] not administered due to low blood sugar, [DATE] administered, [DATE] medication refused. Fasting Blood Sugar twice a day discontinued [DATE]. 6:30 AM [DATE] blood sugar was 66, [DATE] blood sugar was 175, [DATE] blood sugar was 163, [DATE] blood sugar was 72, [DATE] blood sugar was 72, [DATE] blood sugar was 220, [DATE] blood sugar was 201, [DATE] blood sugar was 180, [DATE] blood sugar was 88, [DATE] blood sugar was 118, [DATE] blood sugar was 107, [DATE] blood sugar was 134, [DATE] blood sugar was 79, [DATE] blood sugar was 58, [DATE] blood sugar was 88, [DATE] refused. 4:30 PM [DATE] blood sugar was 148, [DATE] blood sugar was 367, [DATE] blood sugar was 328, [DATE] blood sugar was 293, [DATE] resident sleeping , [DATE] blood sugar was 198, [DATE] blood sugar was 148, [DATE] blood sugar was 249, [DATE] blood sugar was 242, [DATE] blood sugar was 235, [DATE] blood sugar was 102, [DATE] refused, [DATE] blood sugar was 71, [DATE] blood sugar was 268, [DATE] blood sugar was 290, [DATE] resident sleeping. Humalog Injection Solution 100 unit/ml Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units 450 and greater give the 12 units and call MD, subcutaneously before meals may only use 3 times a day discontinue date [DATE]. Humalog was administered per sliding scale from [DATE]-[DATE]. Record review of Resident #45's February 2024 MAR did not indicate the administration of Farxiga, Lantus or Humalog. Resident #45's February 2024 MAR did not indicate his blood sugar was checked. Record review of Resident #45's progress notes from [DATE]-[DATE] indicated: [DATE] at 11:00 AM Resident #45 was transferred to the behavioral hospital. Documented by LVN HHH. The progress notes did not include documentation of Resident #45's readmission on [DATE] or that Resident #45's orders were reconciled with the Medical Director. The progress notes did not include documentation regarding Resident #45's discontinuation of his insulins or blood sugar checks. [DATE] at 1:05 PM, CNA reported Resident #45 was not acting like his normal self. Upon entering residents room resident was found lethargic lying horizontally across the bed, eyes looked glossy, resident's speech was incoherent, he was clammy upon touch. Blood pressure was 128/76, heart rate 86, oxygen saturation 96%, respirations 18, temperature 98.7 F, fingerstick blood sugar too high to read. NP was notified and order was given to send to the ER for evaluation. 1:20 PM 911 contacted for transport 1:25 PM report given to the RN in the ER. EMS arrived on the seen fingerstick blood sugar per EMS was 568. 1:43 PM residents responsible party was notified 2:20 PM the DON and the AIT were notified. Documented by LVN RRR. Record review of the readmission Nurses' Note effective date [DATE] completed by LVN W on [DATE] indicated Resident #45 was readmitted to the facility on [DATE] the area for blood glucose indicated if not diabetic enter N/A (not applicable), N/A was documented. There was no documentation to indicate Resident #45's orders were reconciled with the Medical Director. Record review of Resident #45's Discharge Medication Summary for Patient (in bold) dated [DATE] indicated do not continue these medications at home (noted in big letters across the page) Lantus (also known as insulin glargine) 100 units/ml 40 units under skin once daily, Namenda (also known as memantine used to treat confusion related to Alzheimer's) 10 mg twice a day, Farxiga (also known as dapagliflozin used to treat high blood glucose) 10 mg once daily. The Discharge Medication Summary for Patient continued Medications to take after discharge (in bold letters at the top of the page) buspirone (also known as buspar dividose medication for anxiety) 30 mg twice a day, Trileptal (also known as oxcarbazepine used to treat mood disorders) 150 mg twice a day, Zoloft (also known as sertraline used to treat depression) 100 mg once daily, Desyrel (also known as trazadone used to treat insomnia) 25 mg at bedtime as needed. The behavioral hospitals discharge papers for Resident #45 continued Discharge/Aftercare Instructions-Nursing (bold print at the top of the page): amoxicillin-clavulanate (antibiotic) 875 mg-125 mg 1 tablet by mouth every 12 hours buspirone (anxiety medication) 30 mg by mouth twice daily donepezil (used to treat confusion related to Alzheimer's disease) 10 mg by mouth every hour of sleep Farxiga 10 mg by mouth daily Ferrous sulfate (iron supplement) 325 mg by mouth daily Glucagon injectable (raises blood sugar when it is low) 1 mg intramuscular (in the muscle) injection every 1 hour for blood glucose less than 70 and not able to drink orange juice Humalog per sliding scale subcutaneously before meals Lantus 10 units subcutaneously every hour of sleep Namenda 10 mg by mouth daily Multivitamin 1 tablet by mouth daily Zoloft 100 mg by mouth daily Desyrel 25 mg by mouth every hour of sleep as needed Trilepta 300 mg by mouth twice daily Vitamin B-12 500 mcg by mouth daily Tylenol 650 mg by mouth every 8 hours for pain or fever Mylanta (used to treat upset stomach, heartburn and indigestion) 30 ml by mouth every 6 hours as needed. During an observation and interview on [DATE] at 8:45 PM, Resident #45 was in the hospital in the ICU resting in his hospital bed. Resident #45 was unable to answer questions appropriately. Resident #45's nurse at the hospital said he was awaiting transfer to the medical surgical floor but there were no beds available. Resident #45's nurse said when he arrived to the ER they had to obtain his blood glucose level by a blood specimen due to it not reading on the hospital glucometer. Resident #45's blood glucose level was 929. Resident #45's nurse said when he arrived at the ER he was not alert, he was lethargic and it had taken him 24-48 hours to return to his baseline (normal). Resident #45 was being administered Humalog and Lantus during his hospitalization. Record review of Resident #45's undated hospital medical records indicated he admitted on [DATE] arrived to the ER via EMS from the local nursing home due to altered mental status and elevated glucose. In the emergency room his blood glucose was in excess of 900. Resident #45 had other metabolic abnormalities and was worrisome for UTI. The nursing home staff reported that Resident #45 had been out of his insulin for 1 month because the medication was on backorder. The nursing home staff said there was no replacement for his insulin since that time. Resident #45's problem list included acute metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), hyperosmolar hyperglycemic state (life threatening complication of diabetes characterized by severe high blood glucose, extreme dehydration and altered consciousness), sepsis (condition as a result of an infection that can lead to organ failure and death if not treated quickly), urinary tract infection, volume depletion (blood plasma is too low and causes rapid heartbeat, weak pulse, confusion and loss of consciousness), lactic acidemia (too much lactic acid buildup in the body), acute kidney injury on chronic kidney disease, hypernatremia (high sodium levels), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), atrial fibrillation with rapid ventricular response (rapid, irregular heartbeat). During an interview on [DATE] at 11:14 AM, ADON S said when residents came back from a hospitalization, they were readmitted into the computer system. ADON S said the admitting nurse was responsible for reconciliating the admitting medication orders with the medical director, and the ADONS looked over them to ensure accuracy. ADON S said she was responsible for monitoring the orders for Halls 1 and 2, ADON WW was responsible for Halls 3 and 4, and the secured unit was split between the 2 of them. ADON S said it was important to accurately reconcile the admitting orders to ensure the medications were correct, allergies were discussed, and to discuss with the doctor new medication orders and dosages and ensure the administration times were appropriate. ADON S said if medications were not accurately reconciled upon admission residents could miss a scheduled medication. During an interview on [DATE] at 11:25 AM, the DON said when a resident readmitted to the facility the nurses should call the doctor to reconcile medications with him. The DON said the orders were then reviewed the next day in the morning meetings to double check the residents received the right medications. The DON said the ADONs and herself were responsible for reviewing the orders the day after a resident admitted . The DON said generally ADON S was responsible for checking the orders the day after a resident's admission. The DON said it was important for the medications to be reconciled on admission to ensure the residents received the proper medications and were getting what was necessary and to keep the residents safe. The DON said if medications were not reconciled appropriately this could lead to the residents not receiving the necessary medications. The DON said she was not familiar with Resident #45. During an interview on [DATE] at 11:42 AM, the NP said Resident #45 had been a resident at the facility for quite some time. The NP said she was aware he was diabetic, and she thought he had readmitted to the facility in [DATE], but she could not recall for sure. The NP said she had not spoken to the nurses upon his readmission to the facility. The Medical Director was the one notified of his readmission. The NP said the facility notified her of the issue with Resident #45's insulin this week. The NP said when a resident readmitted to the facility the nurses were supposed to call the Medical Director or herself with the changes and ask if they wanted to reconcile and continue previous orders and what changes should be made. The NP said a lot of times the hospital or the behavioral health units will stop residents' insulin because they do not want to take the risk of hypoglycemia (low blood sugars). The NP said if medications were not reconciled appropriately on admission residents could not get medications that they would need, and this could lead to hyperglycemia (high blood sugars), hypertension (high blood pressure) depending on the disease process. The NP said not receiving necessary medications could lead to exacerbation of the residents' disease processes. During an attempted interview on [DATE] at 11:49 AM, ADON WW did not answer the phone. During an interview on [DATE] at 12:21 PM, the Administrator said he expected for the nurses to follow the discharge orders. The Administrator said he had only been at the facility for about a week, and typically the IDT in the morning meetings reviewed the admissions orders together the day after a resident admitted to ensure the orders were correct and so multiple eyes could verify the orders were correct. The Administrator said in other places the DON and ADON were responsible for reviewing orders after a resident's admission, but he was not sure at the facility what the process was. The Administrator said it was important for the medication orders to be reconciled upon a resident's admission to ensure they were getting the correct medications to treat the diagnoses that the residents had. During an interview on [DATE] at 12:26 PM, Pharmacist XX said when a resident was out of the facility past midnight, the residents' medication orders were discontinued. Pharmacist XX said when the resident returned to the facility there was a renew button in the computer system that the nurses clicked and then they could reconciliate the residents' previous orders with the new orders. Pharmacist XX said once the orders were reconciliated they were transmitted, and medications sent out to the facility. During an interview on [DATE] at 12:33 PM, LVN W said she was aware Resident #45 was diabetic. LVN W said she had done part of the readmission orders for Resident #45. LVN W said there were no orders for Resident #45's insulin, and she had questioned the orders and notified the Medical Director, but he provided instructions to not restart Resident #45's insulin at that time because his blood sugars were running low, and he was not eating much. LVN W said the Medical Director had not given orders to monitor blood sugars, and she had asked him, but he said no. LVN W said to be honest Resident #45 was not acting like he was having problems with his blood sugars. LVN W said he was active and did not think he required blood sugar checks. LVN W said she had called the behavioral unit to ask them about the insulin orders and the nurse that had given her report said they had been holding Resident #45's insulin because he was not eating. LVN W said she had not seen Resident #45's insulin orders on his discharge paperwork. LVN W said it was important for medications to be reviewed and reconciled upon a resident's admission because if a mistake was made the residents would not get medications they required. LVN W said more than one person should have reviewed Resident #45's orders upon his admission because she was human and could miss things. LVN W said Resident #45 not receiving his insulin could hurt his kidneys and liver. LVN W said she had placed Resident #45's orders in the file box for the ADON to review the orders and to audit them. LVN W said she assumed the ADON was the one responsible for reviewing the medications orders, but there had been a lot of changes and there were other people also reviewing the orders. During an interview on [DATE] at 3:33 PM, the Area Director of Operations said her expectations when a resident admitted to the facility were for the nurses to follow the physician orders, review the hospital records and put in the medications order and review the medication orders with the physician. The Area Director of Operations said she was a consultant for the facility. The Area Director of Operations said she was there as a resource for the facility administration to reach out to her with assistance regarding the policies and procedures. The Area Director of Operations said the administrators were responsible for the facility that is why when one administrator left an interim was put in place. The Area Director of Operations said she did not provide oversight for the facility that was the administrators responsibility because she had 10 other facilities she was over. The Area Director of Operations said she made sure the facilities were in the green and monitored their spending to help them reach their financial goals. During an interview on [DATE] at 9:24 PM, the Medical Director said there had been at least 5 administrators and half a dozen DONs and several ADONs in the past year. The Medical Director said there was no constancy, and the staff were unfamiliar with the residents and left often, which resulted in difficulty maintaining staff stability. The Medical Director said then there was the human factor, and if they had 1-2 loose links it destroyed everything. The Medical Director said he was at the facility almost every night spending hours trying to figure out mistakes with medication management issues. The Medical Director said staffing had become a big challenge for the facility that they had major staffing issues. The Medical Director said the staffing shortage was contributing to the falls, worsening wounds, nutrition issues, medication administration issues. The Medical Director said he reconciled the orders with the nurses on admission by phone call because he was not always in the facility when a resident admitted . The Medical Director said with Resident #45 nursing had miscommunicated the information regarding his insulin orders to him. The Medical Director said he was not aware that both of Resident #45's insulins (the short acting and long acting) had been stopped. The Medical Director said stopping both insulins resulted in Resident #45 having high blood sugars, which could lead to severe dehydration and a coma. The Medical Director said he was not able to physically look at the discharge orders from the behavioral health unit. The Medical Director said Resident #45's blood sugars should have been checked three times a day because he was diabetic. The Medical Director said amongst all the changes in administrators and DONs he did not know who was supposed to be keeping the facility together to prevent system failures, but he knew the Area Director of Operations was one of the major decision makers. During an interview on [DATE] at 3:26 PM, the Pharmacy Consultant said she preferred not to answer general questions regarding the risks of administering medications late or the effects of not administering insulin, and she was not currently in her office, so she had no access to resident information. During an attempted interview on [DATE] at 5:02 PM, LVN RRR did not answer the phone. During an interview on [DATE] at 5:32 PM, the DON said the reconciliation for Resident #45 was not done properly. The DON said there was confusion with the discharge orders, and the nurse should have made sure the reconciliation of meds was done properly when Resident #45 readmitted . The DON said she was not employed at the facility when Resident #45 readmitted . The DON said when residents were readmitted /admitted the nurse reconciled the orders with the physician and then the orders would be reviewed in the morning meeting by nurse management. The DON said medications not being reconciled properly could lead to exacerbation of conditions and injury to the residents. Record review of the EvenCare G2 blood glucose monitoring system's user guide indicated on page 50 a HI(high) reading on the glucometer was seen it means your blood glucose if above 600. 2. Record review of a face sheet dated [DATE] indicated Resident #127 was an [AGE] year-old male who admitted on [DATE] with the diagnoses of dementia, and overactive bladder. Record review of the admission papers dated [DATE] provided by the Resident #127's primary physician indicated Resident #127 had an overactive bladder requiring medication management. Resident #127's active medication regimen provided included Vesicare (Solifenacin) 5 milligrams daily with a start date of [DATE] (active medication). Record review of the February 2024 Medication Administration Record indicated Solifenacin Succinate (Vesicare) oral tablet 5 milligrams daily was ordered on [DATE] and discontinued on [DATE] with no administrations provided to Resident #127. Record review of the admission MDS dated [DATE] indicated Resident #127 was understood and understands others. The admission MDS indicated Resident #127 had moderate cognitive impairment. The MDS indicated Resident #127 was occasionally incontinent of urine. Record review of the Order Summary Report dated [DATE] failed to include the medication Vesicare on the facility orders. Record review of the Comprehensive Care Plan dated [DATE] failed to indicate Resident #127 had an overactive bladder requiring medication management or his occasional incontinence. During an observation and interview on [DATE] at 3:56 p.m., Resident #127 was sitting in the dining room/ day room with his peers. Resident #127 was unsure if he was taking any medications for his overactive bladder. 3. Record review of a face sheet dated [DATE] indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body), congenital insufficiency of aortic valve (heart defect that prevents blood from flowing backward through the heart), neuromuscular dysfunction of the bladder (condition where a person lacks bladder control due to brain, spinal cord, or nerve problems), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and anxiety disorder. Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #179's speech was unclear, was sometimes able to make himself understood, and understood others. The MDS assessment indicated Resident #179 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #179 was dependent on staff for all ADLs. The MDS assessment indicated Resident #179 had pain almost constantly and it frequently interfered with his ability to sleep. The MDS assessment indicated Resident #179 received antianxiety, antidepressant, and opioids in the last 7 days. Record review of the care plan last revised on [DATE] indicated Resident #179 required antidepressant medication to give medications as ordered. The care plan indicated Resident #179 had a potential for uncontrolled pain to evaluate pain interventions. The care plan indicated Resident #179 was on pain medication therapy to administer medications as ordered. Record review of the Order Summary Report dated [DATE] indicated Resident #179 had the following medication orders: Buspirone (medication for anxiety) 15 mg give 1 tablet via g-tube two times a day with a start date of [DATE]. Trazodone 50 mg (medication for depression) give 1 tablet via g-tube two times a day with a start date of [DATE]. Pregabalin (medication for nerve pain) 75 mg give 1 capsule via g-tube three times a day with a start date of [DATE]. Hydrocodone (pain medication) 10-325 mg give 1 tablet via g-tube four times a day with a start date of [DATE]. Gabapentin (medication for nerve pain) 100 mg give 1 capsule via g-tube three times a day with a start date of [DATE]. Record review of Resident #179's medication administration audit report dated [DATE]-[DATE] indicated the following: On [DATE] the following medications were scheduled to be received at 8:00 PM were administered over 6 hours late, after the 1-hour grace period: Pregabalin 75 mg give 1 capsule via g-tube three times a day administered at 3:58 AM Gabapentin 100 mg give 1 capsule via g-tube three times a day administered at 5:33 AM Trazodone 50 mg give 1 tablet via g-tube two times a day administered at 5:33 AM Hydrocodone 10-325 mg give 1 tablet via g-tube four times a day for pain administered at 5:33 AM On [DATE] the following medications were scheduled to be received at 8:00 PM were administered over 1 hour late, after the 1-hour grace period: Hydrocodone 10-325 mg give 1 tablet via g-tube four times a day for pain administered at 10:28 PM Buspirone 15 mg give 1 tablet via g-tube two times a day administered at 10:28 PM Trazadone 50 mg give 1 tablet via g-tube two times a day administered at 10:29 PM Pregabalin 75 mg give 1 capsule via g-tube three times a day administered at 1:26 AM During an interview on [DATE] at 10:46 AM, Resident #179 said his night medications were due at 8 PM and sometimes he was not receiving them until midnight. Resident #179 said he had asked the nurses about his medications being administered late, and they had said it was because they were short staffed on the night shift. 4. Record review of Resident #36's face sheet dated [DATE], indicate Resident # 36 was a [AGE] year-old female admitted to the facility on [DATE], with a diagnosis which include Metabolic Encephalopathy (a problem in the brain), morbid severe ob[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 F0760 (Tag F0760)

Someone could have died · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free of any significant medication errors for 9 of 24 residents (Resident #9, Resident #36, Resident #41, Resident #44, Resident #45, Resident #57, Resident #71, Resident #127 and Resident #179) residents reviewed for medication errors. 1. The facility failed to ensure Resident #45's hospital discharge orders were implemented to include his Lantus (long-acting insulin used to lower blood sugar) 10 units every hour of sleep, Humalog (short acting insulin used to lower blood sugar) per sliding scale before meals, Farxiga 10 mg (used to control high blood sugar) daily, and Augmentin 875 mg-125 mg (antibiotic) every 12 hours after his discharge on [DATE] which resulted in his hospitalization for metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body) and hyperglycemia (elevated blood sugar at 926) on 02/25/2024. 2. The facility failed to ensure Resident #127 received his Vesicare as ordered after being admitted on [DATE]. 3. The facility failed to ensure Resident #179 was administered his antidepressant, antianxiety and pain medications timely. 4. The facility failed to ensure Resident #36's Sertraline (anxiety), Keppra (seizures), Diltiazem (anti-hypertension), Hydralazine (anti-hypertension) were administered at the prescribed time. 5. The facility failed to ensure Resident #9's Lisinopril (ant- hypertension), Trazadone (insomnia), Atorvastatin (hyperlipidemia), Clonazepam (anxiety), and Valproate Sodium Solution (bipolar and depression) were administered at the prescribed time. 6. The facility failed to ensure Resident #57's antihypertensive, antidepressant, anticoagulant, antihyperlipidemic, diuretic, supplemental and pain medications during 02/01/2024-02/27/2024 were provided timely. 7. The facility failed to ensure Resident #71's blood pressure met the parameters for the administration of an anti-hypertensive medication. 8. The facility failed to ensure Resident #44 received the ordered Cephalexin an antibiotic medication to treat her urinary tract infection timely. 9. The facility failed to ensure Resident #41 received the ordered weight loss supplement to treat weight loss timely. An Immediate Jeopardy (IJ) situation was identified on 02/28/2024 at 3:50 PM. The IJ template was provided to the facility on [DATE] at 4:19 PM. While the IJ was removed on 03/01/2024 at 5:10 PM, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents who require medications administered by the facility at risk of not receiving their medications as ordered, illness, hospitalizations, exacerbation of their disease processes, and death. Findings included: 1. Record review of a face sheet dated 02/28/2024 indicated Resident #45 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and type 2 diabetes mellitus with ketoacidosis without coma (chronic condition that affects the way the body processes blood sugar resulting in high blood sugars). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #45 was rarely/never understood and sometimes understood others. Resident #45 required supervision for eating and substantial/maximal assistance with shower/bathe self, upper body dressing, and personal hygiene. The MDS assessment did not indicate Resident #45 received insulin. Record review of the care plan last revised 10/20/2023 indicated Resident #45 had diabetes and would refuse his blood sugars and insulin at times. The goal was for Resident #45 to have no complications related to diabetes through the review date. Interventions included Diabetes medication as ordered by doctor, blood sugar checks as ordered by doctor, if infection is present, consult doctor regarding any changes in diabetic medications. Record review of the Order Summary Report dated 01/01/2024-02/29/2024 did not indicate orders for Resident #45's Lantus (long-acting insulin used to lower blood sugars), Humalog (short acting used to lower blood sugars) Farxiga 10 mg (used to control high blood sugar) daily, or Augmentin 875 mg-125 mg (antibiotic). Record review of Resident #45's January 2024 MAR indicated: o Farxiga 10 mg one tablet by mouth in the morning discontinued on 01/27/2024. Farxiga was administered from 01/01/2024-01/16/2024. o Check blood sugar at bedtime for hyper/hypoglycemia (high or low blood sugars) discontinued on 01/27/2024. 01/1/2024 blood sugar was 239, 01/02/2024 blood sugar was 169, 01/03/2024 blood sugar was 210, 01/04/2024 blood sugar was 266, 01/05/2024 blood sugar was 209, 01/06/2024 blood sugar was 345, 01/07/2024 blood sugar was 434, 01/08/2024 blood sugar was 190, 01/09/2024 blood sugar was 134, 01/10/2024 blood sugar was 258, 01/11/2024 blood sugar was 324, 01/12/2024 blood sugar was 106, 01/13/2024 blood sugar check refused, 01/14/2024 blood sugar was 315, 01/15/2024 blood sugar was 120, 01/16/2024 hospitalized . o Lantus SoloStar Pen-injector 100 unit/ml inject 40 units subcutaneously (under the skin) every morning discontinued 01/27/2024 01/01/2024 medication not given due to low blood sugar, 01/02/2024 administered, 01/03/2024 administered, 01/04/2024 not administered due to low blood sugar, 01/05/2024-01/08/2024 administered, 01/09/2024 not administered due to low blood sugar, 01/10/2024-01/13/2024 administered, 01/14/2024 not administered due to low blood sugar, 01/15/2024 administered, 01/16/2024 medication refused. o Fasting Blood Sugar twice a day discontinued 01/27/2024. 6:30 AM 01/1/2024 blood sugar was 66, 01/02/2024 blood sugar was 175, 01/03/2024 blood sugar was 163, 01/04/2024 blood sugar was 72, 01/05/2024 blood sugar was 72, 01/06/2024 blood sugar was 220, 01/07/2024 blood sugar was 201, 01/08/2024 blood sugar was 180, 01/09/2024 blood sugar was 88, 01/10/2024 blood sugar was 118, 01/11/2024 blood sugar was 107, 01/12/2024 blood sugar was 134, 01/13/2024 blood sugar was 79, 01/14/2024 blood sugar was 58, 01/15/2024 blood sugar was 88, 01/16/2024 refused. 4:30 PM 01/1/2024 blood sugar was 148, 01/02/2024 blood sugar was 367, 01/03/2024 blood sugar was 328, 01/04/2024 blood sugar was 293, 01/05/2024 resident sleeping , 01/06/2024 blood sugar was 198, 01/07/2024 blood sugar was 148, 01/08/2024 blood sugar was 249, 01/09/2024 blood sugar was 242, 01/10/2024 blood sugar was 235, 01/11/2024 blood sugar was 102, 01/12/2024 refused, 01/13/2024 blood sugar was 71, 01/14/2024 blood sugar was 268, 01/15/2024 blood sugar was 290, 01/16/2024 resident sleeping. o Humalog Injection Solution 100 unit/ml Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units 450 and greater give the 12 units and call MD, subcutaneously before meals may only use 3 times a day discontinue date 01/27/2024. Humalog was administered per sliding scale from 01/01/2024-01/16/2024. Record review of Resident #45's February 2024 MAR did not indicate the administration of Farxiga, Lantus or Humalog. Resident #45's February 2024 MAR did not indicate his blood sugar was checked. Record review of Resident #45's progress notes from 12/29/2023-02/29/2024 indicated: o 01/16/2024 at 11:00 AM Resident #45 was transferred to the behavioral hospital. Documented by LVN HHH. o The progress notes did not include documentation of Resident #45's readmission on [DATE] or that Resident #45's orders were reconciled with the Medical Director. The progress notes did not include documentation regarding Resident #45's discontinuation of his insulins or blood sugar checks. o 02/25/2024 at 1:05 PM, CNA reported Resident #45 was not acting like his normal self. Upon entering residents room resident was found lethargic lying horizontally across the bed, eyes looked glossy, resident's speech was incoherent, he was clammy upon touch. Blood pressure was 128/76, heart rate 86, oxygen saturation 96%, respirations 18, temperature 98.7 F, fingerstick blood sugar too high to read. NP was notified and order was given to send to the ER for evaluation. 1:20 PM 911 contacted for transport 1:25 PM report given to the RN in the ER. EMS arrived on the seen fingerstick blood sugar per EMS was 568. 1:43 PM residents responsible party was notified 2:20 PM the DON and the AIT were notified. Documented by LVN RRR. Record review of the readmission Nurses' Note effective date 01/29/2024 completed by LVN W on 01/30/2024 indicated Resident #45 was readmitted to the facility on [DATE] the area for blood glucose indicated if not diabetic enter N/A (not applicable), N/A was documented. There was no documentation to indicate Resident #45's orders were reconciled with the Medical Director. Record review of Resident #45's Discharge Medication Summary for Patient (in bold) dated 01/29/2024 indicated do not continue these medications at home (noted in big letters across the page) o Lantus (also known as insulin glargine) 100 units/ml 40 units under skin once daily, o Namenda (also known as memantine used to treat confusion related to Alzheimer's) 10 mg twice a day, o Farxiga (also known as dapagliflozin used to treat high blood glucose) 10 mg once daily. The Discharge Medication Summary for Patient continued Medications to take after discharge (in bold letters at the top of the page) o buspirone (also known as buspar dividose medication for anxiety) 30 mg twice a day, o Trileptal (also known as oxcarbazepine used to treat mood disorders) 150 mg twice a day, o Zoloft (also known as sertraline used to treat depression) 100 mg once daily, o Desyrel (also known as trazadone used to treat insomnia) 25 mg at bedtime as needed. The behavioral hospitals discharge papers for Resident #45 continued Discharge/Aftercare Instructions-Nursing (bold print at the top of the page): o amoxicillin-clavulanate (antibiotic) 875 mg-125 mg 1 tablet by mouth every 12 hours o buspirone (anxiety medication) 30 mg by mouth twice daily o donepezil (used to treat confusion related to Alzheimer's disease) 10 mg by mouth every hour of sleep o Farxiga 10 mg by mouth daily o Ferrous sulfate (iron supplement) 325 mg by mouth daily o Glucagon injectable (raises blood sugar when it is low) 1 mg intramuscular (in the muscle) injection every 1 hour for blood glucose less than 70 and not able to drink orange juice o Humalog per sliding scale subcutaneously before meals o Lantus 10 units subcutaneously every hour of sleep o Namenda 10 mg by mouth daily o Multivitamin 1 tablet by mouth daily o Zoloft 100 mg by mouth daily o Desyrel 25 mg by mouth every hour of sleep as needed o Trilepta 300 mg by mouth twice daily o Vitamin B-12 500 mcg by mouth daily o Tylenol 650 mg by mouth every 8 hours for pain or fever o Mylanta (used to treat upset stomach, heartburn and indigestion) 30 ml by mouth every 6 hours as needed. During an observation and interview on 02/28/2024 at 8:45 PM, Resident #45 was in the hospital in the ICU resting in his hospital bed. Resident #45 was unable to answer questions appropriately. Resident #45's nurse at the hospital said he was awaiting transfer to the medical surgical floor but there were no beds available. Resident #45's nurse said when he arrived to the ER they had to obtain his blood glucose level by a blood specimen due to it not reading on the hospital glucometer. Resident #45's blood glucose level was 929. Resident #45's nurse said when he arrived at the ER he was not alert, he was lethargic and it had taken him 24-48 hours to return to his baseline (normal). Resident #45 was being administered Humalog and Lantus during his hospitalization. Record review of Resident #45's undated hospital medical records indicated he admitted on [DATE] arrived to the ER via EMS from the local nursing home due to altered mental status and elevated glucose. In the emergency room his blood glucose was in excess of 900. Resident #45 had other metabolic abnormalities and was worrisome for UTI. The nursing home staff reported that Resident #45 had been out of his insulin for 1 month because the medication was on backorder. The nursing home staff said there was no replacement for his insulin since that time. Resident #45's problem list included acute metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), hyperosmolar hyperglycemic state (life threatening complication of diabetes characterized by severe high blood glucose, extreme dehydration and altered consciousness), sepsis (condition as a result of an infection that can lead to organ failure and death if not treated quickly), urinary tract infection, volume depletion (blood plasma is too low and causes rapid heartbeat, weak pulse, confusion and loss of consciousness), lactic acidemia (too much lactic acid buildup in the body), acute kidney injury on chronic kidney disease, hypernatremia (high sodium levels), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), atrial fibrillation with rapid ventricular response (rapid, irregular heartbeat). During an interview on 02/28/2024 at 11:14 AM, ADON S said when residents came back from a hospitalization, they were readmitted into the computer system. ADON S said the admitting nurse was responsible for reconciliating the admitting medication orders with the medical director, and the ADONS looked over them to ensure accuracy. ADON S said she was responsible for monitoring the orders for Halls 1 and 2, ADON WW was responsible for Halls 3 and 4, and the secured unit was split between the 2 of them. ADON S said it was important to accurately reconcile the admitting orders to ensure the medications were correct, allergies were discussed, and to discuss with the doctor new medication orders and dosages and ensure the administration times were appropriate. ADON S said if medications were not accurately reconciled upon admission residents could miss a scheduled medication. During an interview on 02/28/2024 at 11:25 AM, the DON said when a resident readmitted to the facility the nurses should call the doctor to reconcile medications with him. The DON said the orders were then reviewed the next day in the morning meetings to double check the residents received the right medications. The DON said the ADONs and herself were responsible for reviewing the orders the day after a resident admitted . The DON said generally ADON S was responsible for checking the orders the day after a resident's admission. The DON said it was important for the medications to be reconciled on admission to ensure the residents received the proper medications and were getting what was necessary and to keep the residents safe. The DON said if medications were not reconciled appropriately this could lead to the residents not receiving the necessary medications. The DON said she was not familiar with Resident #45. During an interview on 02/28/2024 at 11:42 AM, the NP said Resident #45 had been a resident at the facility for quite some time. The NP said she was aware he was diabetic, and she thought he had readmitted to the facility in October 2023, but she could not recall for sure. The NP said she had not spoken to the nurses upon his readmission to the facility. The Medical Director was the one notified of his readmission. The NP said the facility notified her of the issue with Resident #45's insulin this week. The NP said when a resident readmitted to the facility the nurses were supposed to call the Medical Director or herself with the changes and ask if they wanted to reconcile and continue previous orders and what changes should be made. The NP said a lot of times the hospital or the behavioral health units will stop residents' insulin because they do not want to take the risk of hypoglycemia (low blood sugars). The NP said if medications were not reconciled appropriately on admission residents could not get medications that they would need, and this could lead to hyperglycemia (high blood sugars), hypertension (high blood pressure) depending on the disease process. The NP said not receiving necessary medications could lead to exacerbation of the residents' disease processes. During an attempted interview on 02/28/2024 at 11:49 AM, ADON WW did not answer the phone. During an interview on 02/28/2024 at 12:21 PM, the Administrator said he expected for the nurses to follow the discharge orders. The Administrator said he had only been at the facility for about a week, and typically the IDT in the morning meetings reviewed the admissions orders together the day after a resident admitted to ensure the orders were correct and so multiple eyes could verify the orders were correct. The Administrator said in other places the DON and ADON were responsible for reviewing orders after a resident's admission, but he was not sure at the facility what the process was. The Administrator said it was important for the medication orders to be reconciled upon a resident's admission to ensure they were getting the correct medications to treat the diagnoses that the residents had. During an interview on 02/28/2024 at 12:26 PM, Pharmacist XX said when a resident was out of the facility past midnight, the residents' medication orders were discontinued. Pharmacist XX said when the resident returned to the facility there was a renew button in the computer system that the nurses clicked and then they could reconciliate the residents' previous orders with the new orders. Pharmacist XX said once the orders were reconciliated they were transmitted, and medications sent out to the facility. During an interview on 02/28/2024 at 12:33 PM, LVN W said she was aware Resident #45 was diabetic. LVN W said she had done part of the readmission orders for Resident #45. LVN W said there were no orders for Resident #45's insulin, and she had questioned the orders and notified the Medical Director, but he provided instructions to not restart Resident #45's insulin at that time because his blood sugars were running low, and he was not eating much. LVN W said the Medical Director had not given orders to monitor blood sugars, and she had asked him, but he said no. LVN W said to be honest Resident #45 was not acting like he was having problems with his blood sugars. LVN W said he was active and did not think he required blood sugar checks. LVN W said she had called the behavioral unit to ask them about the insulin orders and the nurse that had given her report said they had been holding Resident #45's insulin because he was not eating. LVN W said she had not seen Resident #45's insulin orders on his discharge paperwork. LVN W said it was important for medications to be reviewed and reconciled upon a resident's admission because if a mistake was made the residents would not get medications they required. LVN W said more than one person should have reviewed Resident #45's orders upon his admission because she was human and could miss things. LVN W said Resident #45 not receiving his insulin could hurt his kidneys and liver. LVN W said she had placed Resident #45's orders in the file box for the ADON to review the orders and to audit them. LVN W said she assumed the ADON was the one responsible for reviewing the medications orders, but there had been a lot of changes and there were other people also reviewing the orders. During an interview on 02/28/2024 at 3:33 PM, the Area Director of Operations said her expectations when a resident admitted to the facility were for the nurses to follow the physician orders, review the hospital records and put in the medications order and review the medication orders with the physician. The Area Director of Operations said she was a consultant for the facility. The Area Director of Operations said she was there as a resource for the facility administration to reach out to her with assistance regarding the policies and procedures. The Area Director of Operations said the administrators were responsible for the facility that is why when one administrator left an interim was put in place. The Area Director of Operations said she did not provide oversight for the facility that was the administrators responsibility because she had 10 other facilities she was over. The Area Director of Operations said she made sure the facilities were in the green and monitored their spending to help them reach their financial goals. During an interview on 02/28/2024 at 9:24 PM, the Medical Director said there had been at least 5 administrators and half a dozen DONs and several ADONs in the past year. The Medical Director said there was no constancy, and the staff were unfamiliar with the residents and left often, which resulted in difficulty maintaining staff stability. The Medical Director said then there was the human factor, and if they had 1-2 loose links it destroyed everything. The Medical Director said he was at the facility almost every night spending hours trying to figure out mistakes with medication management issues. The Medical Director said staffing had become a big challenge for the facility that they had major staffing issues. The Medical Director said the staffing shortage was contributing to the falls, worsening wounds, nutrition issues, medication administration issues. The Medical Director said he reconciled the orders with the nurses on admission by phone call because he was not always in the facility when a resident admitted . The Medical Director said with Resident #45 nursing had miscommunicated the information regarding his insulin orders to him. The Medical Director said he was not aware that both of Resident #45's insulins (the short acting and long acting) had been stopped. The Medical Director said stopping both insulins resulted in Resident #45 having high blood sugars, which could lead to severe dehydration and a coma. The Medical Director said he was not able to physically look at the discharge orders from the behavioral health unit. The Medical Director said Resident #45's blood sugars should have been checked three times a day because he was diabetic. The Medical Director said amongst all the changes in administrators and DONs he did not know who was supposed to be keeping the facility together to prevent system failures, but he knew the Area Director of Operations was one of the major decision makers. During an interview on 03/02/2024 at 3:26 PM, the Pharmacy Consultant said she preferred not to answer general questions regarding the risks of administering medications late or the effects of not administering insulin, and she was not currently in her office, so she had no access to resident information. During an attempted interview on 03/02/2024 at 5:02 PM, LVN RRR did not answer the phone. During an interview on 03/02/2024 at 5:32 PM, the DON said the reconciliation for Resident #45 was not done properly. The DON said there was confusion with the discharge orders, and the nurse should have made sure the reconciliation of meds was done properly when Resident #45 readmitted . The DON said she was not employed at the facility when Resident #45 readmitted . The DON said when residents were readmitted /admitted the nurse reconciled the orders with the physician and then the orders would be reviewed in the morning meeting by nurse management. The DON said medications not being reconciled properly could lead to exacerbation of conditions and injury to the residents. Record review of the EvenCare G2 blood glucose monitoring system's user guide indicated on page 50 a HI(high) reading on the glucometer was seen it means your blood glucose if above 600. 2. Record review of a face sheet dated 3/02/2024 indicated Resident #127 was an [AGE] year-old male who admitted on [DATE] with the diagnoses of dementia, and overactive bladder. Record review of the admission papers dated 2/09/2024 provided by the Resident #127's primary physician indicated Resident #127 had an overactive bladder requiring medication management. Resident #127's active medication regimen provided included Vesicare (Solifenacin) 5 milligrams daily with a start date of 1/05/2024 (active medication). Record review of the February 2024 Medication Administration Record indicated Solifenacin Succinate (Vesicare) oral tablet 5 milligrams daily was ordered on 2/12/2024 and discontinued on 2/27/2024 with no administrations provided to Resident #127. Record review of the admission MDS dated [DATE] indicated Resident #127 was understood and understands others. The admission MDS indicated Resident #127 had moderate cognitive impairment. The MDS indicated Resident #127 was occasionally incontinent of urine. Record review of the Order Summary Report dated 3/02/2024 failed to include the medication Vesicare on the facility orders. Record review of the Comprehensive Care Plan dated 2/13/2024 failed to indicate Resident #127 had an overactive bladder requiring medication management or his occasional incontinence. During an observation and interview on 2/26/2024 at 3:56 p.m., Resident #127 was sitting in the dining room/ day room with his peers. Resident #127 was unsure if he was taking any medications for his overactive bladder. 3. Record review of a face sheet dated 03/02/2024 indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body), congenital insufficiency of aortic valve (heart defect that prevents blood from flowing backward through the heart), neuromuscular dysfunction of the bladder (condition where a person lacks bladder control due to brain, spinal cord, or nerve problems), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and anxiety disorder. Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #179's speech was unclear, was sometimes able to make himself understood, and understood others. The MDS assessment indicated Resident #179 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #179 was dependent on staff for all ADLs. The MDS assessment indicated Resident #179 had pain almost constantly and it frequently interfered with his ability to sleep. The MDS assessment indicated Resident #179 received antianxiety, antidepressant, and opioids in the last 7 days. Record review of the care plan last revised on 02/23/2024 indicated Resident #179 required antidepressant medication to give medications as ordered. The care plan indicated Resident #179 had a potential for uncontrolled pain to evaluate pain interventions. The care plan indicated Resident #179 was on pain medication therapy to administer medications as ordered. Record review of the Order Summary Report dated 02/26/2024 indicated Resident #179 had the following medication orders: Buspirone (medication for anxiety) 15 mg give 1 tablet via g-tube two times a day with a start date of 02/23/2024. Trazodone 50 mg (medication for depression) give 1 tablet via g-tube two times a day with a start date of 02/14/2024. Pregabalin (medication for nerve pain) 75 mg give 1 capsule via g-tube three times a day with a start date of 02/25/2024. Hydrocodone (pain medication) 10-325 mg give 1 tablet via g-tube four times a day with a start date of 02/13/2024. Gabapentin (medication for nerve pain) 100 mg give 1 capsule via g-tube three times a day with a start date of 02/13/2024. Record review of Resident #179's medication administration audit report dated 02/01/2024-02/27/2024 indicated the following: On 02/25/2024 the following medications were scheduled to be received at 8:00 PM were administered over 6 hours late, after the 1-hour grace period: Pregabalin 75 mg give 1 capsule via g-tube three times a day administered at 3:58 AM Gabapentin 100 mg give 1 capsule via g-tube three times a day administered at 5:33 AM Trazodone 50 mg give 1 tablet via g-tube two times a day administered at 5:33 AM Hydrocodone 10-325 mg give 1 tablet via g-tube four times a day for pain administered at 5:33 AM On 02/26/2024 the following medications were scheduled to be received at 8:00 PM were administered over 1 hour late, after the 1-hour grace period: Hydrocodone 10-325 mg give 1 tablet via g-tube four times a day for pain administered at 10:28 PM Buspirone 15 mg give 1 tablet via g-tube two times a day administered at 10:28 PM Trazadone 50 mg give 1 tablet via g-tube two times a day administered at 10:29 PM Pregabalin 75 mg give 1 capsule via g-tube three times a day administered at 1:26 AM During an interview on 02/26/2024 at 10:46 AM, Resident #179 said his night medications were due at 8 PM and sometimes he was not receiving them until midnight. Resident #179 said he had asked the nurses about his medications being administered late, and they had said it was because they were short staffed on the night shift. 4. Record review of Resident #36's face sheet dated 02/27/2024, indicate Resident # 36 was a [AGE] year-old female admitted to the facility on [DATE], with a diagnosis which include Metabolic Encephalopathy (a problem in the brain), morbid severe obesity due to excess calories (BMI greater than 40, a BMI of greater than 35 with at least one serious obesity-related condition, or being more than 100 pounds over your recommended weight), abnormal posture (rigid body movements and chronic abnormal positions of the body), muscle weakness (commonly due to lack of exercise, aging, muscle injury) chronic obstructive pulmonary disease (disease that causes airflow blockage and breathing-related problems). Bipolar [TRUNCATED]

CRITICAL (L) 📢 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 F0725 (Tag F0725)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 9 of 24 residents (Residents #9, #4, #41, #36, #44, #57, #130, #180, and #179 and 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient nursing staff to ensure adequate supervision and to prevent accidents involving Resident #44, who was physically assaulted on [DATE], Resident #4, had an unwitnessed fall on [DATE], Resident #4 was left unsupervised in the bathroom on [DATE] and self-transferred from the toilet to the wheelchair, Resident 180, sustained an unwitnessed fall with injury on [DATE] and expired on [DATE], and Resident #130 suffered unwitnessed falls on [DATE] and [DATE] in his room while only one CNA was available on the secured unit. The facility failed to provide sufficient nursing staff to ensure Resident #44, Resident #41, Resident #57, Resident #179, Resident #36, and Resident #9 did not receive their medications 1 to 6 hours late. The facility failed to ensure LVN D was able to complete her required nursing tasks timely allowing LVN D to work 24 hours on [DATE] - [DATE]. The facility failed to ensure LVN C was able to complete her required nursing tasks timely allowing LVN C to work 4 hours and 55 minutes over her scheduled shift. The facility failed to provide sufficient nursing staff to ensure ADON E did not remain on shift for over 24 hours on [DATE]-[DATE] due to excessive call offs. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:50 PM. The IJ template was provided to the facility Administrator on [DATE] at 3:39 PM. While the IJ was removed on [DATE] at 3:44 PM, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures place residents at risk of inadequate supervision, an unsafe environment, falls, serious harm and injury, exacerbations of disease processes, abuse, and death. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #44 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness, reduced mobility, anxiety disorder. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was sometimes understood and usually understands others. The MDS indicated Resident #44 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #44 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #44 had no behavioral symptoms but wandered 1-3 days during the assessment period. The MDS indicated Resident #44 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. The MDS indicated Resident #44 had a history of falls with fractures within the last 6 months. Record review of the comprehensive care plan dated [DATE] and updated on [DATE] indicated Resident #44 was at risk to fall related to unsteady gait/balance, generalized weakness, and poor safety awareness. The care plan indicated Resident #44 was at risk to wander related to a history of attempts to leave the facility related to poor safety awareness and resides on the secured unit. Record review of the Consolidated Physician's orders dated February 2024 indicated Resident #44 was ordered Cephalexin 500 milligrams three times daily for a urinary tract infection. Record review of a Medication Administration Record dated February 2024 indicated Resident #44's Cephalexin was ordered for administration on [DATE] at 8:00 p.m., the medication administration record indicated Resident #44 received her antibiotic therapy Cephalexin at 2:51 a.m. on [DATE]. Record review of the of an Event Nurses' note dated [DATE] at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #55 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #41 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital. Record review of a progress note dated [DATE] at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 was found on the floor bedside the closet door on her back with Resident #44 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency room on [DATE] with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination documented indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated [DATE] indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in space and tissue between the skull and skin). During an observation and interview on [DATE] at 9:00 a.m., Resident #44 was sitting at the dining table with a large size raised area with bruising noted to her right side of her head in the temporal/parietal region. Resident #44 said she felt well but she denied having her head hurt. 2. Record review of a face sheet dated [DATE] indicated Resident #41 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, the need for continuous supervision, and high blood pressure. Record review of a Significant Change MDS dated [DATE] indicated Resident #41 was usually understood and sometimes understands. The MDS indicated Resident #41's cognition was severely impaired. The MDS indicated Resident #41 had no physical, or verbal behaviors exhibited. The MDS indicated Resident #41 wandered daily. Record review of the comprehensive care plan dated [DATE] and revised on [DATE] indicated Resident #41 was at risk for mood problems and received medications. The goal of the care plan indicated Resident #41 would have an improved mood state. The care plan interventions included administer medications, behavioral health consults as needed, monitor and record mood to determine if problems seem to be related to external causes. Record review of the Consolidated Physician's orders dated February 2024 Resident #41 was ordered Medpass 2.0 (supplement for weight loss) four times daily for protein-calorie malnutrition. Record review of the Medication Administration Audit Report Resident #41 was scheduled to receive the Medpass 2.0 supplement at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. Resident #41 received the ordered Medpass 2.0 on [DATE] at 12:56 a.m. and on [DATE] at 10:15 p.m. Record review of a progress note dated [DATE] at 6:00 p.m., LVN D documented she was called to a resident room by CNA A. LVN D documented Resident #41 was in Resident #55's room where she found Resident #44 on the floor beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented she asked Resident #41 and Resident #44 what had occurred, and neither could explain. LVN D documented Resident #55 said Resident #41 pushed Resident #55 against the closet door and she fell. LVN D documented Resident #41 was very uncooperative and had tried to hit CNA A and Resident #55. Record review of Behavior Nurses Note dated [DATE] at 6:30 p., LVN D documented she was called to the secured unit by the nurse aide. LVN D documented Resident #41 was in Resident #55's room. LVN D documented she found Resident #44 on the floor lying beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented Resident #55 said he pushed her up against the closet door and she fell. LVN D said Resident #41 and #44 was unable to indicate what had happened. LVN D said Resident #41was very uncooperative and had tried to the hit the CNA on duty and Resident #55. Record review of an Event Nurses' note dated [DATE] at 6:30 p.m., indicated LVN D documented Resident #41 was found in another resident room. LVN D documented Resident #41 had displayed physical, and resident to resident behaviors with another resident injured. The Event Nurses' note indicated LVN D moved Resident #41's room and initiated every 15-minute checks. Record review of a Every 15 Minute Check sheet indicated Resident #41 was placed on every 15-minute checks starting on [DATE] at 6:30 p.m. The Every 15- minute checks at 0015 indicated LVN D documented at 12:15 a.m., Resident #44 was asleep. LVN D had only her initials beside the other every 15-minute checks starting at 12:30 a.m. - 5:45 a.m. on [DATE] there was no remarks indicating anything in regarding Resident #41. During an observation on [DATE] at 9:31 a.m., Resident #41 was lying in his bed asleep. During an interview on [DATE] at 4:17 p.m., the SW said she was notified by the DON regarding the incident with Resident #44 and Resident #41. The SW said upon her arrival Resident #44 was already at the local emergency room, and Resident #41 was wandering on the unit. The SW said Resident #41 and Resident #55 both were unable to recollect the recent incident. During an interview on [DATE] at 9:32 p.m., CNA A said she was alone on the secured unit gathering her supplies in the spa/communal shower room when she heard a loud scream. CNA A said she ran out of the spa room and ran toward the end of the hall where she believed the sound was heard from. CNA A said upon entering the room, Resident #44 was lying in the floor, Resident #55 said Resident #41 had thrown Resident #44 into the door. CNA A said Resident #41 was aggressive with her at the time and tried to swing at her. CNA A said she left Resident #55's room and ran the length of the secured unit, opened the door, and yelled for help. CNA A said she was alone on the secured unit and had no other recourse than to go for help. CNA A said LVN D was passing medications and another nurse responded to her call for help. During an interview on [DATE] at 11:46 a.m., the DON said on [DATE] CNA A heard a noise and responded to the noise. The DON said LVN D called and said Resident #41 was upset and wandering in other rooms. The DON said CNA A had said Resident #44 was on the floor. The DON said she was unsure of Resident #44 hitting her head although she had an abrasion to her head. The DON said Resident #44 was sent to the emergency room closer to midnight due to complaining her head was hurting. During an interview on [DATE] at 11:51 a.m., LVN D said she was called to the unit on [DATE] at 6:30 p.m. by CNA A. LVN D said Resident #44 was lying in the floor of Resident #55's room, with Resident #41 standing over Resident #44 around 6:30 p.m. on [DATE]. LVN D said Resident #55 said Resident #41 pushed Resident #44 against the closet and Resident #41 fell. LVN D said at the time of the incident Resident #44 had an abrasion to her right temple area and a bruise to her inner right arm. LVN D said Resident #41 was very uncooperative and attempted to hit others. LVN D said she was advised to place Resident #41 on every 15-minute checks by the DON. LVN D said although her documentation was not completed yet Resident #41 remained asleep. LVN D said CNA A had to leave Resident #44 and Resident #55 to come for help. LVN D said she was not on the secured unit but was on hall 400 when the incident occurred. LVN D said she was late with administering the medications due to being called to the secured unit during the medication administering time. During an interview on [DATE] at 12:22 p.m., CNA H said CNA A had always worked the secured unit alone. CNA H said when CNA A was in the room with other residents who would be watching the other residents, or who would go for help. CNA H said there was no one was on the unit to get help when CNA A needed help. During an interview on [DATE] at 10:54 a.m., LVN F said Resident #44 was discharged to the hospital and Resident #41 was on every 15-minute checks for aggressive behaviors. LVN F said after she reviewed Resident #44's electronic medical record and said there was not a progress note, a SBAR (situation, background, assessment, recommendation) note, a transfer note, or an incident report. LVN F said the electronic medical record should have had those assessments completed by the nurse on duty at the time of the incident. 3. Record review of a face sheet dated [DATE] indicated Resident #4 admitted on [DATE] and readmitted [DATE] with the diagnosis of diabetes, muscle weakness, lack of coordination, reduced mobility, repeated falls, dementia, and assistance with personal care. Record review of the comprehensive care plan dated [DATE] and revised on [DATE] indicated Resident #4 had an ADL self-care performance deficit. The goal of the care plan indicated Resident #4 would remain at her current level of function in transfers, and toileting. The care plan interventions included Resident #4 required one staff assistance with toileting. The comprehensive care plan indicated Resident #4 was at risk for falls related to weakness and impaired cognition. The goal of the care plan was Resident #4 would not sustain a serious injury. The care plan interventions included ensure Resident #4's call light was within reach, ensure don't call fall sign at the foot of the bed visible by Resident #4, and frequent visual checks while in bed. Record review of an admission MDS dated [DATE] indicated Resident #4 was usually understood and understands others. The MDS indicated Resident #4's cognition was moderately impaired. The MDS in section GG indicated Resident #4 required partial to moderate assistance with toileting, bed to chair transfers, toileting transfers and to sit and stand. Record review of a Fall-Risk assessment dated [DATE] at midnight LVN D indicated Resident #4 had 1-2 falls in the past, required assistance with elimination, and took 3-4 medications which could increase the risk of falls. The fall risk assessment indicated Resident #4 was at high risk to fall. Record review of a fall incident report dated [DATE] at midnight, LVN D indicated Resident #4 ambulated without assistance and was not wearing any shoes or socks. Record review of a progress note dated [DATE] at midnight, LVN D documented Resident #4 was sitting in the hallway on her bottom with her legs straight in front of her. LVN D said Resident #4 said she had slipped down. LVN D documented Resident #4 was not wearing shoes or socks. LVN D documented Resident #4 complained of right foot pain. Record review of a fall incident report dated [DATE] at 10:30 p.m., LVN C indicated no injuries were observed. The incident report was left blank. Record review of a Fall-Risk assessment dated [DATE] at 10:30 p.m., LVN C documented Resident #4 was at high risk to fall. LVN C documented Resident #4 was disoriented, had 3 or more falls in the past 3 months, required assistance with elimination, had problems with balance, and took 3-4 medications which could cause falls. Record review of a Fall Nurses Note dated [DATE] at 10:46 a.m., LVN F documented Resident #4 had a fall without injury. LVN F documented fall interventions were the bed low, interval monitoring, neurological checks, frequent visual checks, encourage and educate use of the call light. Record review of a progress note dated [DATE] at 11:30 p.m., LVN C indicated Resident #4 said she had fallen on the floor, and she had been pulling up her pants. During an interview on [DATE] at 8:48 a.m., LVN C said CNA K was in another resident's room providing care when she heard Resident #4 calling for help. LVN C said CNA K was alone, so she had to hurriedly finish in the room to be able to assist Resident #4. LVN C said Resident #4 was lying on the bathroom floor when CNA C was able to get to her. LVN C said the secured unit was understaffed to provide adequate supervision for Resident #4 and other residents. During an observation and interview on [DATE] at 11:48 a.m., CNA H responded to the surveyor assisting Resident #4 with activating her call light for assistance to the bathroom. CNA H responded and assisted Resident #4 from her bed to the wheelchair, then from the wheelchair to the toilet. CNA H left Resident #4 alone on the toilet and went to get Resident #4's lunch tray. Upon returning to the room, Resident #4 was exiting the bathroom already in her wheelchair. CNA H said Resident #4 had a history of falls and was a fall risk. Record review of an incident report dated [DATE] at 11:45 p.m., LVN C documented Resident #4 had a fall with no injuries noted. The incident report had no further documentation within. Record review of an Event Nurses' Note-Fall dated [DATE] at 11:45 p.m., LVN C documented Resident #4 had an unwitnessed fall. LVN C documented Resident #4 was found on the floor, indicated Resident #4 said legs gave out, and Resident #4 attempted to self-toilet. LVN C documented in Nursing Description: Resident #4 indicated she got up to use the bathroom, failed to call for help, denied bumping her head, and was found sitting on the floor. 4. Record review of a face sheet dated [DATE] indicated Resident #130 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, lack of coordination, and a need for assistance with personal care. Record review of the Comprehensive Care Plan dated [DATE] and revised on [DATE] indicated Resident #130 was a high risk for falls related to wandering. The goal of the care plan was Resident #130 would be free of falls. The care plan interventions included to anticipate and met Resident #130's needs, ensure his call light was within reach, encourage the use of the call light, and have prompt response to the request for assistance, and ensure Resident #130 wore appropriate footwear. The comprehensive care plan failed to have interventions after the falls on [DATE] and [DATE]. Record review of an incident report dated [DATE] at 10:00 p.m., LVN C indicated Resident #130 was found by the CNA on the floor, with no signs of pain. The note indicated Resident #130 was limping on the left leg and was sent to the local emergency room at 10:35 p.m. via the ambulance. Record review of a fall risk assessment completed by LVN C on [DATE] indicated Resident #130 was always disoriented. The assessment indicated Resident #130 had no previous falls, was ambulatory, continent, had balance problems, decreased muscular coordination, and gait pattern changes. Record review of a Medication Administration Record dated [DATE] - [DATE] indicated on [DATE] Resident #130 was administered Ativan 0.5 milligrams for anxiety or agitation. The record also indicated Resident #130 received the Ativan 0.5 milligrams twice daily on [DATE] and on the morning of [DATE]. Record review of an Event Nurses-Note dated [DATE] at 10:00 p.m., indicated Resident #130 had an unwitnessed fall in his room. LVN C documented Resident #130 was assisted up and was noted to be limping on the left leg. LVN C documented the physician was notified and Resident #130 was sent to the local hospital. The note indicated the interventions included interval monitoring (specify below) there was no documentation below. The note indicated in additional interventions there were interventions of a low bed and interval monitoring (again not specified). The note indicated Resident #130 was independent with bed mobility, toileting, and transferring. The note indicated Resident #130 had an unsteady gait, balance problem, and lack of mobility strength. The note indicated Resident #130 was wearing shoes or anti-slip socks. The note indicated Resident #130 had Ativan 0.5 milligrams twice daily started on [DATE]. Record review of an incident report dated [DATE] at 5:30 p.m., indicated Resident #130 was found with his head lying against the closet door by LVN HHH. The note indicated Resident #130 had a bruise to his right shoulder and a skin tear to his left hand. The note indicated the conclusion was Resident #130 had an unwitnessed fall with injuries. The note indicated his bed was changed to a low bed. Record review of an Event Nurses-Note dated [DATE] at 6:39 p.m., indicated Resident #130 was found by LVN HHH when she was passing dining trays. The note indicated Resident #130 was lying with his head against the closet door. The note indicated Resident #130 had a skin tear. The note indicated Resident #130 had a purple bruise to his right shoulder. The note indicated Resident #130 was in pain noted by his occasional moans or groans, and facial grimacing. The note indicated Resident #130's physical factors included previous fall, urinary tract infection, pain, and incontinence. The note indicated Resident #130 required 1 staff with bed mobility, toileting, transferring, and walking. The note indicated Resident #130 leaned forward. Record review of an e-Transfer Form dated [DATE] at 6:00 p.m., indicated Resident #130 was transferred to the local hospital due to a fall by LVN HHH. Record review of a Fall-Risk assessment dated [DATE] at 6:47 p.m. indicated Resident #130 was disoriented, has fallen 3 or more falls in the past 3 months, ambulatory, and incontinent. The assessment indicated Resident #130 had balance problems while standing and walking. Record review of the History of Present Illness from the local hospital on [DATE] indicated Resident #130 fell and was sent to the local emergency room. The note indicated Resident #130 had a right hip fracture. The note indicated Resident #130 was seen 24 hours prior to this visit related to multiple falls at the facility. Record review from the hospital orthopedist report dated [DATE] indicated Resident #130 had fallen over the last couple of weeks at least 8-9 times. The orthopedist documented Resident #130 was in the emergency room the day before post a fall with negative x-rays at the time. The note indicated the CT results indicated a minimally impacted right femoral neck fracture. The note indicated the physician spoke to the family and the family wanted a non-operative treatment and return to the facility with palliative care. Record review of hospital records dated [DATE] indicated Resident #130 was admitted at 6:59 p.m. with the diagnosis of closed fracture of the right hip. The discharge records indicated Resident #130 was returned to the facility on hospice services. Resident #130's discharge orders included bedrest, non-weight bearing to the right leg, and pain management. Record review of the cat scan of the chest, abdomen, and pelvis dated [DATE] indicated right femoral neck fracture. Record review of a progress note dated [DATE] at 4:25 p.m., indicated the social worker documented Resident #130 returned from the hospital, admitted on a hospice service, and was made a do not resuscitate status. Record review of a physician's progress note dated [DATE] indicated Resident #130 had a fall with a fracture to the right hip and he was being treated conservatively. Record review of an Incident Report dated [DATE] at 3:30 p.m., completed by LVN YY indicated Resident #130 was observed sitting on the floor beside his bed with his back leaning on the mattress. The note indicated Resident #130's bed was in low position. The note indicated the predisposing physiological factors were confusion, incontinent, recent medication changes, and impaired memory. Record review of a progress note dated [DATE] at 8:00 p.m., LVN D documented Resident #130 had a fall slipped off the bed. LVN D documented there were no injuries. LVN D documented she administered Tramadol 50 milligrams due to Resident #130 appeared in pain, and then he was assisted up to the recliner because he refused to rest in his bed. Record review of a Daily Census form dated [DATE] indicated on Hall 400 resided 24 residents and on the secured unit there were 15 residents. During an interview on [DATE] at 11:51 p.m., LVN D said she worked the 6:00 p.m. - 6:00 a.m. shift as the nurse for the secured unit and Hall 400. LVN D said her job duties on this shift was to pass the assigned residents their medications, provide nursing care, and assist with nurse aide care as needed. LVN D said on this night she had Resident #44 was assaulted by Resident #41 in the room of Resident #55. LVN D said she had to stop the tasks she was completing to assess the situation, send Resident #44 to the local emergency room, place Resident #41 on 1:1 oversight, and then complete all the tasks this associated with this incident. LVN D said CNA A was alone in the unit when Resident #41 assaulted Resident #44 according to Resident #55's statement. LVN D said CNA A tried to separate Resident #41 and Resident #55 but Resident #41 was too aggressive. During an observation and interview on [DATE] at 6:15 p.m., LVN D was at the nursing desk when she said she had a bit more to complete on the tasks from her shift before leaving. LVN D said she had been at the facility now 24 hours. During an interview on [DATE] at 8:48 a.m., LVN C said she was not able to physically able to visualize Resident #41 but relied on the CNA to do 1:1 with Resident #41. LVN C said due to having only 2-3 CNAs on the 6:00 p.m. to 6:00 a.m. shift she was unable to complete her resident care tasks including administration of medications timely according to the orders. LVN C said she had many times informed the nursing management she would have to invoke Safe Harbor to ensure resident safety. LVN C said only when she would tell management she would invoke Safe Harbor would she get extra help to pass medications at least to the assigned Hall 400. LVN C said she had also notified the Medical Director of the nursing duties she was unable to complete timely. LVN C said in the secured unit the CNA was most often working alone and she would assist as she could. LVN C said CNA K was in a room with another resident when Resident #44 fell. During an interview on [DATE] at 10:55 a.m., LVN C said she had not completed all the tasks from her shift regarding resident care but was told by nursing management she had to leave because she was scheduled for her next shift at 6:00 p.m. Record review of the Schedule Sheet dated [DATE] indicated the census was 81 and the facility had scheduled: 6:00 a.m. - 6:00 p.m.: 2 student nurse aides, and 3 CNAs with one a no call no show status; 2 RNs and 1 LVN 6:00 p.m. - 6:00 a.m.: 2 CNAs and 1 student nurse aide who called off; and 1 RN and 1 LVN 6:00 a.m. - 2:00 p.m. 1 MA was scheduled 2:00 p.m. - 10:00 p.m. 1 CNA who called off. 10:00 p.m. - 6:00 a.m. 1 CNA Record review of the Employee Punch Report dated [DATE] - [DATE] indicated: LVN YY, RN U, LVN EEE, and LVN RRR worked 6:00 a.m. - 6:00 p.m. shift on [DATE]. LVN D and RN DD worked 6:00 p.m. -6:00 a.m. shift, on [DATE]. ADON E worked 7:47 p.m. - 11:11 p.m. on [DATE]. ADON WW worked 7:19 p.m. - 11:17 p.m. on [DATE]. CNA Y, CNA GGG, SNAs RR and PPP worked 6:00 a.m. - 6:00 p.m. shift on [DATE]. CNA SSS worked 6:00 p.m. - 6:00 a.m. shift on [DATE]. CNA H worked 5:00 a.m. - 5:00 p.m. shift on [DATE]. CNA K worked 10:00 p.m. - 6:00 p.m. shift on [DATE]. CNA A worked 6:00 p.m. - 9:00 p.m. shift on [DATE]. Record review of the Budgeted PPD on the facility assessment indicated, (based on a census of 77) 0.41 was required, which is equivalent to 31.57 hours (for CNAs) of budgeted time was unused. This indicated there was a shortage of approximately 3 CNAs on [DATE] when the incident with Resident #41 and Resident #44 occurred. During an interview on [DATE] at 8:28 AM, ADON WW stated she was at the facility working on [DATE]. ADON WW said she went to work at 5:23 AM and stayed until 1 PM then returned to the facility and worked from 7 PM to 11 PM. ADON WW stated she was administering medications on the 300/400 Hall in the morning and that evening returned due to the incident that occurred on the secured unit. During an interview on [DATE] at 8:39 AM, ADON E said she had 5 call-ins on the morning of [DATE] when she got to work and ADON WW was at the facility working. ADON E stated she had worked all day on [DATE] and into the early morning on [DATE] (24 hours). She stated they had 2 nurses on the floor and 2 aides (DON included). ADON E stated she had contacted the Area Director of Operations and stated to offer bonuses, but she had already called everyone, and they refused to come in. She stated she volunteered to stay over for 24 hours because it was easier than to come back in the morning. She stated she had gotten complaints about being short staffed and she had to work it. She stated she had worked night shifts and having 2 nurses was doable, but it was rough. She stated it was easier when everyone pitched in and all the CNAs that were scheduled were there because they were the backbone, and they were the first to notice any changes. She stated there should be a minimum of 3 CNAs up front and 1 in the back (secured unit). ADON E said it was important to ensure sufficient staff was in the facility for resident safety. During an interview on [DATE] at 10:59 AM, the Regional Compliance Nurse said there was no policy on sufficient staffing. The Regional Compliance Nurse stated there was not a true staffing issue. The Regional Compliance Nurses stated when a nurse was at the nursing station for over an hour then this becomes a time management problem. During an interview on [DATE] at 11:43 a.m., CNA H said she has had to work the secured unit alone. CNA H said she had voiced the inability to provide supervision to Resident #130 and prevent him from trying to ambulate on his broken leg. During an observation and interview on [DATE] at 10:55 p.m., CNA K said she had to work the secured unit many times alone. CNA K said she could remember Resident #130 had a fall and fractured his hip. CNA K said she could not remember providing care to Resident #130. CNA K said she had told the DON, and ADONs previously the secured unit was not staffed enough to provide adequate supervision to the residents. During this interview there were 5 residents of the secured unit up and ambulating about the unit in and out of rooms. CNA K said she was having a difficult time keeping the residents centrally located to ensure their safety. During an interview on [DATE] at 11:30 p.m., LVN C said she had cared for Resident #130. LVN C said she had voiced concern numerous times and threatened to call safe harbor due to the inability to provide[TRUNCATED]

CRITICAL (L) 📢 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

Administration (Tag F0835)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, 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 of each resident for 1 of 1 facility reviewed for administration. The facility administration failed to ensure adequate staff were available and aware of job functions to provide for residents needs when the facility's Administrator position experienced 4 changes within 6 months. The facility failed to ensure the DON was aware that she was the abuse coordinator in absence of the Administrator, and she did not report, investigate or prevent further incidents of abuse per the facility's policy. The facility administration failed to ensure adequate nursing staff were available to provide for residents needs which resulted in Resident #44's physical assault by Resident #41, Resident #130's, Resident #4's, and Resident #180's unwitnessed falls. The facility administration failed to ensure pharmaceutical services were provided as needed, which resulted in Resident #45's hospitalization on 02/25/2024, Resident #127's Vesicare not being administered, and medications being administered 1-6 hours late to Resident #71, Resident #179, Resident #44, Resident #45, and Resident #57. The facility administration failed to ensure the secured unit was not staffed with only 1 direct care staff (CNA) at night, which resulted in staff not being able to prevent accidents or request emergent assistance and having to leave the secured unit unsupervised to seek assistance. The facility administration failed to ensure ADON E did not remain on a shift for over 24 hours on 02/23/2024-02/24/2024 due to excessive call ins. An Immediate Jeopardy (IJ) situation was identified on 02/28/2024 at 3:50 PM. The IJ template was provided to the facility on [DATE] at 4:19 PM. While the IJ was removed on 03/01/2024 at 5:10 PM, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for abuse, serious injury, serious harm, serious impairment, and death. Findings included: 1. Record review of a face sheet dated 2/27/2024 indicated Resident #44 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness, reduced mobility, anxiety disorder. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was sometimes understood and usually understands others. The MDS indicated Resident #44 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #44 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #44 had no behavioral symptoms but wandered 1-3 days during the assessment period. The MDS indicated Resident #44 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. The MDS indicated Resident #44 had a history of falls with fractures within the last 6 months. Record review of the comprehensive care plan dated 12/13/2023 and updated on 1/07/2024 indicated Resident #44 was at risk to fall related to unsteady gait/balance, generalized weakness, and poor safety awareness. The care plan indicated Resident #44 was at risk to wander related to a history of attempts to leave the facility related to poor safety awareness and resides on the secured unit. Record review of a Weekly Skin assessment dated [DATE] and documented by LVN CCC, indicated Resident #44's skin was normal with no bruising. The note indicated Resident #44's had a surgical incision to the right hip with staples and steri-strips in place with no drainage and no signs of infection. Record review of a Fall Nurses Note dated 6/12/2023 and documented by LVN YY indicated Resident #44 had a fall with a bump on the right side of her head. Record review of a Weekly Skin assessment dated [DATE] documented by LVN DDD, indicated Resident #44's skin was normal with no bruising. Record review of a SBAR note dated 6/18/2024 documented by LVN YY indicated Resident #44 had swelling and pain to the right hip replacement. The note indicated Resident #44 was ordered a mild pain reliever and an x-ray to the right hip. Record review of a right hip x-ray dated 6/19/2023 indicated Resident #44's prosthetic right femoral head was in proper alignment. Resident #44's x-ray revealed there were no fractures or acute dislocation. The x-ray indicated Resident #44's prothesis was properly situated without any loosing. The x-ray conclusion indicated the right hip arthroplasty was intact. Record review of a progress note dated 6/21/2023 at 6:15 a.m., LVN YY documented Resident #44 had a bruise to the inner thigh on the right leg measuring 17 centimeters x approximately 11 centimeters with pain. LVN YY noted she administered a mild pain reliever to Resident #44. Record review of an Event Nurses' note dated 6/21/2023 at 6:15 a.m., LVN YY documented a bruise was found to Resident #44's right inner thigh measuring 17 centimeters x approximately 11 centimeters. The note indicated Resident #44's bruise was blue/purple and painful. LVN YY documented Resident #44 could not provide a statement related to her cognitive impairment. LVN YY said previous factors included previous falls. Record review of an incident note dated 6/21/2023 documented by LVN YY indicated Resident #44 had a large purple bruise on her inner right thigh (front) measuring 17 centimeters x approximately 11 centimeters. LVNYY said Resident #44 was unable to state what had happened. LVN YY documented there were no predisposing environmental factors, and the predisposing physiological factor was Resident #44 had memory impairment. Record review of a Weekly Skin assessment dated [DATE] indicated Resident #44 skin color was normal, temperature was normal, with a large purple bruise to the right inner thigh with a firm center with bruising to her knee. During an interview on 2/29/2024 at 11:42 a.m., LVN YY said she was notified of Resident #44's bruise by CNA K. LVN YY said she assessed and measured the bruising and notified the physician, family, DON, and Administrator (previous). LVN YY said she was unsure how Resident #44 sustained the bruise and unsure why no one else had seen the bruise. During an interview on 2/29/2024 at 3:22 p.m., CNA K said she had found the bruising to Resident #44's right leg and reported to LVN YY. CNA K said while she was providing incontinent care for Resident #44, she moved the pillow between Resident #44's legs when she found a large purple bruise. Record review of a Consultation note dated 6/21/2023 indicated the orthopedic physician documented he knew Resident #44. The physician said he had treated her femoral neck fracture a month previous. The physician wrote he had seen Resident #44 a week ago and the x-rays showed a well-fitted well-fixed bipolar hip. The physician wrote he had plans to surgically repair Resident #44's right hip by removing the prothesis, wire her with cables then reimplant the prothesis and then put a plate and screws with wires and screws around the periprosthetic fracture. Record review of the Consolidated Physician's orders dated February 2024 indicated Resident #44 was ordered Cephalexin 500 milligrams three times daily for a urinary tract infection. Record review of a Medication Administration Record dated February 2024 indicated Resident #44's Cephalexin was ordered for administration on 2/26/2024 at 8:00 p.m., the medication administration record indicated Resident #44 received her antibiotic therapy Cephalexin at 2:51 a.m. on 2/27/2024. Record review of the of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #55 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #44 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital. The note in #17 interventions in place prior to this fall was none of the above. Record review of a progress note dated 2/25/2024 at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 was found on the floor bedside the closet door on her back with Resident #44 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency room on 2/25/2024 with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination documented indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated 2/25/2024 indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in space and tissue between the skull and skin). During an interview on 2/29/2023 at 3:40 p.m., the DON said she was not the DON during the incident on 6/21/2023 with Resident #44 but she indicated she would have investigated and reported the bruising. During an interview on 03/01/2024 at 8:52 AM, Administrator ZZ (previous administrator) said she always did an investigation when something was reported to her but depending on her investigation if she reported. Administrator ZZ said if she had not reported the incident with Resident #44's bruising/hip fracture it had to be for a reason. Administrator ZZ said she did not remember the specifics off the top of her head, and she kept a soft file in the administrator's office with her investigations. Administrator ZZ said a bruise that was not correlated with an incident was considered an injury of unknown injury and should be reported within 2 hours of finding it or being notified. 2. Record review of a face sheet dated 3/2/2024 indicated Resident #41 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, the need for continuous supervision, and high blood pressure. Record review of a Significant Change MDS dated [DATE] indicated Resident #41 was usually understood and sometimes understands. The MDS indicated Resident #41's cognition was severely impaired. The MDS indicated Resident #41 had no physical, or verbal behaviors exhibited. The MDS indicated Resident #41 wandered daily. Record review of the comprehensive care plan dated 8/08/2023 and revised on 9/08/2023 indicated Resident #41 was at risk for mood problems and received medications. The goal of the care plan indicated Resident #41 would have an improved mood state. The care plan interventions included administer medications and monitor and record mood to determine if problems seem to be related to external causes. Record review of a progress note dated 2/25/2024 at 6:00 p.m., LVN D documented she was called to a resident room by CNA A. LVN D documented Resident #41 was in Resident #55's room where she found Resident #44 on the floor beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented she asked Resident #41 and Resident #44 what had occurred, and neither could explain. LVN D documented Resident #55 said Resident #41 pushed Resident #55 against the closet door and she fell. LVN D documented Resident #41 was very uncooperative and had tried to hit CNA A and Resident #55. Record review of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented Resident #41 was found in another resident room. LVN D documented Resident #41 had displayed physical, and resident to resident behaviors with another resident injured. The Event Nurses' note indicated LVN D moved Resident #41's room and initiated every 15-minute checks. Record review of a Every 15 Minute Check sheet indicated Resident #41 was placed on every 15-minute checks starting on 2/25/2024 at 6:30 p.m. The Every 15- minute checks at 0015 indicated LVN D documented at 12:15 a.m., Resident #44 was asleep. LVN D had only her initials beside the other every 15-minute checks starting at 12:30 a.m. - 5:45 a.m. on 12/26/2024 there was no remarks indicating anything in regarding Resident #41. During an interview on 2/26/2024 at 9:32 p.m., CNA A said she was alone on the secured unit gathering her supplies in the spa/communal shower room when she heard a loud scream. CNA A said she ran out of the spa room and ran toward the end of the hall where she believed the sound was heard from. CNA A said upon entering the room, Resident #44 was lying in the floor, Resident #55 said Resident #41 had thrown Resident #44 into the door. CNA A said Resident #41 was aggressive with her at the time and tried to swing at her. CNA A said she left Resident #55's room and ran the length of the secured unit, opened the door, and yelled for help. CNA A said she was alone on the secured unit and had no other recourse than to go for help. CNA A said LVN D was passing medications and another nurse responded to her call for help. During an interview on 2/26/2024 at 11:46 a.m., the DON said on 2/25/2024 CNA A heard a noise and responded to the noise. The DON said LVN D called and said Resident #41 was upset and wandering in other rooms. The DON said CNA A had said Resident #44 was on the floor. The DON said she was unsure of Resident #44 hitting her head although she had an abrasion to her head. The DON said Resident #44 was sent to the emergency room closer to midnight due to complaining her head was hurting. During an interview on 2/26/2024 at 11:51 a.m., LVN D said she was called to the unit on 2/25/2024 at 6:30 p.m. by CNA A. LVN D said Resident #44 was lying in the floor of Resident #55's room, with Resident #41 standing over Resident #44 around 6:30 p.m. on 2/25/2024. LVN D said Resident #55 said Resident #41 pushed Resident #44 against the closet and Resident #41 fell. LVN D said at the time of the incident Resident #44 had an abrasion to her right temple area and a bruise to her inner right arm. LVN D said Resident #41 was very uncooperative and attempted to hit others. LVN D said she was advised to place Resident #41 on every 15-minute checks by the DON. LVN D said although her documentation was not completed yet Resident #41 remained asleep. LVN D said CNA A had to leave Resident #44 to come for help. LVN D said she was not on the secured unit but was on hall 400 when the incident occurred. During an interview on 2/26/2024 at 12:22 p.m., CNA H said CNA A had always worked the secured unit alone. CNA H said when CNA A was in the room with other residents who would be watching the other residents, or who would go for help. CNA H said there was no one was on the unit to get help when CNA A needed help. During an interview on 2/26/2024 at 10:54 a.m., LVN F said Resident #44 was discharged to the hospital and Resident #41 was on every 15-minute checks for aggressive behaviors. LVN F said after she reviewed Resident #44's electronic medical record and said there was not a progress note, a SBAR (situation, background, assessment, recommendation) note, a transfer note, or an incident report. LVN F said the electronic medical record should have had those assessments completed. During an observation and interview on 2/26/2024 at 12:42 p.m., Resident #55 was sitting at the dining table and was unable to recall the incident in his room last night with Resident #'s 41 and 44. 3. Record review of a face sheet dated 2/27/2024 indicated Resident #4 admitted on [DATE] and readmitted [DATE] with the diagnosis of diabetes, muscle weakness, lack of coordination, reduced mobility, repeated falls, dementia, and assistance with personal care. Record review of the comprehensive care plan dated 1/22/2024 and revised on 2/05/2024 indicated Resident #4 had an ADL self-care performance deficit. The goal of the care plan indicated Resident #4 would remain at her current level of function in transfers, and toileting. The care plan interventions included Resident #4 required one staff assistance with toileting. The comprehensive care plan indicated Resident #4 was at risk for falls related to weakness and impaired cognition. The goal of the care plan was Resident #4 would not sustain a serious injury. The care plan interventions included ensure Resident #4's call light was within reach, ensure don't fall call sign at the foot of the bed visible by Resident #4, and frequent visual checks while in bed. Record review of an admission MDS dated [DATE] indicated Resident #4 was usually understood and understands others. The MDS indicated Resident #4's cognition was moderately impaired. The MDS in section GG indicated Resident #4 required partial to moderate assistance with toileting, bed to chair transfers, toileting transfers and to sit and stand. Record review of a Fall-Risk assessment dated [DATE] at midnight LVN D indicated Resident #4 had 1-2 falls in the past, required assistance with elimination, and took 3-4 medications which could increase the risk of falls. The fall risk assessment indicated Resident #4 was at high risk to fall. Record review of a fall incident report dated 2/24/2024 at midnight, LVN D indicated Resident #4 ambulated without assistance and was not wearing any shoes or socks. Record review of a progress note dated 2/24/2023 at midnight, LVN D documented Resident #4 was sitting in the hallway on her bottom with her legs straight in front of her. LVN D said Resident #4 said she had slipped down. LVN D documented Resident #4 was not wearing shoes or socks. LVN D documented Resident #4 complained of right foot pain. Record review of a fall incident report dated 2/26/2024 at 10:30 p.m., LVN C indicated no injuries were observed. The incident report was left blank. Record review of a Fall-Risk assessment dated [DATE] at 10:30 p.m., LVN C documented Resident #4 was at high risk to fall. LVN C documented Resident #4 was disoriented, had 3 or more falls in the past 3 months, required assistance with elimination, had problems with balance, and took 3-4 medications which could cause falls. Record review of a Fall Nurses Note dated 2/26/2024 at 10:46 a.m., LVN F documented Resident #4 had a fall without injury. LVN F documented fall interventions were the bed low, interval monitoring, neurological checks, frequent visual checks, encourage and educate use of the call light. Record review of a progress note dated 2/26/2024 at 11:30 p.m., LVN C indicated Resident #4 said she had fallen on the floor, and she had been pulling up her pants. During an interview on 2/27/2024 at 8:48 a.m., LVN C said CNA K was in another resident's room providing care when she heard Resident #4 calling for help. LVN C said CNA K was alone, so she had to hurriedly finish in the room to be able to assist Resident #4. LVN C said Resident #4 was lying on the bathroom floor when CNA K was able to get to her. LVN C said the secured unit was understaffed to provide adequate supervision for Resident #4 and other residents. During an observation and interview on 2/27/2024 at 11:48 a.m., CNA H responded to the surveyor assisting Resident #4 with activating her call light for assistance to the bathroom. CNA H responded and assisted Resident #4 from her bed to the wheelchair, then from the wheelchair to the toilet. CNA H left Resident #4 alone on the toilet and went to get Resident #4's lunch tray. Upon returning to the room, Resident #4 was exiting the bathroom already in her wheelchair. CNA H said Resident #4 had a history of falls and was a fall risk. Record review of an incident report dated 2/27/2023 at 11:45 p.m., LVN C documented Resident #4 had a fall with no injuries noted. The incident report had no further documentation within. Record review of an Event Nurses' Note-Fall dated 2/27/2024 at 11:45 p.m., LVN C documented Resident #4 had an unwitnessed fall. LVN C documented Resident #4 was found on the floor, indicated Resident #4 said legs gave out, and Resident #4 attempted to self-toilet. LVN C documented in Nursing Description: Resident #4 indicated she got up to use the bathroom, failed to call for help, denied bumping her head, and was found sitting on the floor. 4. Record review of a face sheet dated 2/29/2024 indicated Resident #130 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, lack of coordination, and a need for assistance with personal care. Resident #130 resided on the secured unit. Record review of the Comprehensive Care Plan dated 9/07/2023 and revised on 12/09/2023 indicated Resident #130 was a high risk for falls related to wandering. The goal of the care plan was Resident #130 would be free of falls. The care plan interventions included to anticipate and met Resident #130's needs, ensure his call light was within reach, encourage the use of the call light, and have prompt response to the request for assistance, and ensure Resident #130 wore appropriate footwear. The comprehensive care plan failed to have interventions after the falls on 11/26/2023 and 11/27/2023. Record review of an incident report dated 11/26/2023 at 10:00 p.m., LVN C indicated Resident #130 was found by the CNA on the floor, with no signs of pain. The note indicated Resident #130 was limping on the left leg and was sent to the local emergency room at 10:35 p.m. via the ambulance. Record review of a fall risk assessment completed by LVN C on 11/26/2023 indicated Resident #130 was always disoriented. The assessment indicated Resident #130 had no previous falls, was ambulatory, continent, had balance problems, decreased muscular coordination, and gait pattern changes. Record review of a Medication Administration Record dated 11/01/2023 - 11/30/2023 indicated on 11/25/2023 Resident #130 was administered Ativan 0.5 milligrams for anxiety or agitation. The record also indicated Resident #130 received the Ativan 0.5 milligrams twice daily on 11/26/2023 and on the morning of 11/27/2023. Record review of an Event Nurses-Note dated 11/26/2023 at 10:00 p.m., indicated Resident #130 had an unwitnessed fall in his room. LVN C documented Resident #130 was assisted up and was noted to be limping on the left leg. LVN C documented the physician was notified and Resident #130 was sent to the local hospital. The note indicated the interventions included interval monitoring (specify below) there was no documentation below. The note indicated in additional interventions there were interventions of a low bed and interval monitoring (again not specified). The note indicated Resident #130 was independent with bed mobility, toileting, and transferring. The note indicated Resident #130 had an unsteady gait, balance problem, and lack of mobility strength. The note indicated Resident #130 was wearing shoes or anti-slip socks. The note indicated Resident #130 had Ativan 0.5 milligrams twice daily started on 11/25/2024. Record review of an incident report dated 11/27/2023 at 5:30 p.m., indicated Resident #130 was found with his head lying against the closet door by LVN HHH. The note indicated Resident #130 had a bruise to his right shoulder and a skin tear to his left hand. The note indicated the conclusion was Resident #130 had an unwitnessed fall with injuries. The note indicated his bed was changed to a low bed. Record review of an Event Nurses-Note dated 11/27/2023 at 6:39 p.m., indicated Resident #130 was found by LVN HHH when she was passing dining trays. The note indicated Resident #130 was lying with his head against the closet door. The note indicated Resident #130 had a skin tear. The note indicated Resident #130 had a purple bruise to his right shoulder. The note indicated Resident #130 was in pain noted by his occasional moans or groans, and facial grimacing. The note indicated Resident #130's physical factors included previous fall, urinary tract infection, pain, and incontinence. The note indicated Resident #130 required 1 staff with bed mobility, toileting, transferring, and walking. The note indicated Resident #130 leaned forward. Record review of an e-Transfer Form dated 11/27/2023 at 6:00 p.m., indicated Resident #130 was transferred to the local hospital due to a fall by LVN HHH. Record review of a Fall-Risk assessment dated [DATE] at 6:47 p.m. indicated Resident #130 was disoriented, has fallen 3 or more falls in the past 3 months, ambulatory, and incontinent. The assessment indicated Resident #130 had balance problems while standing and walking. Record review of the History of Present Illness from the local hospital on [DATE] indicated Resident #130 fell and was sent to the local emergency room. The note indicated Resident #130 had a right hip fracture. The note indicated Resident #130 was seen 24 hours prior to this visit related to multiple falls at the facility. Record review from the hospital orthopedist report dated 11/27/2023 indicated Resident #130 had fallen over the last couple of weeks at least 8-9 times. The orthopedist documented Resident #130 was in the emergency room the day before post a fall with negative x-rays at the time. The note indicated the CT results indicated a minimally impacted right femoral neck fracture. The note indicated the physician spoke to the family and the family wanted a non-operative treatment and return to the facility with palliative care. Record review of hospital records dated 11/27/2023 indicated Resident #130 was admitted at 6:59 p.m. with the diagnosis of closed fracture of the right hip. The discharge records indicated Resident #130 was returned to the facility on hospice services. Resident #130's discharge orders included bedrest, non-weight bearing to the right leg, and pain management. Record review of the cat scan of the chest, abdomen, and pelvis dated 11/27/2023 indicated right femoral neck fracture. Record review of a progress note dated 11/29/2023 at 4:25 p.m., indicated the social worker documented Resident #130 returned from the hospital, admitted on a hospice service, and was made a do not resuscitate status. Record review of a physician's progress note dated 11/29/2023 indicated Resident #130 had a fall with a fracture to the right hip and he was being treated conservatively. Record review of an Incident Report dated 12/01/2023 at 3:30 p.m., completed by LVN YY indicated Resident #130 was observed sitting on the floor beside his bed with his back leaning on the mattress. The note indicated Resident #130's bed was in low position. The note indicated the predisposing physiological factors were confusion, incontinent, recent medication changes, and impaired memory. Record review of a progress note dated 12/02/2023 at 8:00 p.m., LVN D documented Resident #130 had a fall slipped off the bed. LVN D documented there were no injuries. LVN D documented she administered Tramadol 50 milligrams due to Resident #130 appeared in pain, and then he was assisted up to the recliner because he refused to rest in his bed. During an interview on 2/26/2024 at 11:51 p.m., LVN D said she worked the 6:00 p.m. - 6:00 a.m. shift as the nurse for the secured unit and Hall 400. LVN D said her job duties on this shift was to pass the assigned residents their medications, provide nursing care, and assist with nurse aide care as needed. LVN D said on this night she had Resident #44 was assaulted by Resident #41 in the room of Resident #55. LVN D said she had to stop the tasks she was completing to assess the situation, send Resident #44 to the local emergency room, place Resident #41 on 1:1 oversight, and then complete all the tasks this associated with this incident. LVN D said CNA A was alone in the unit when Resident #41 assaulted Resident #44 according to Resident #55's statement. LVN D said CNA A tried to separate Resident #41 and Resident #55 but Resident #41 was too aggressive. During an observation and interview on 2/26/2024 at 6:15 p.m., LVN D was at the nursing desk when she said she had a bit more to complete on the tasks from her shift before leaving. LVN D said she had been at the facility now 24 hours. During an interview on 2/27/2024 at 8:48 a.m., LVN C said she was not able to physically able to visualize Resident #41 but relied on the CNA to do 1:1 with Resident #41. LVN C said due to having only 2-3 CNAs on the 6:00 p.m. to 6:00 a.m. shift she was unable to complete her resident care tasks including administration of medications timely according to the orders. LVN C said she had many times informed the nursing management she would have to invoke Safe Harbor to ensure resident safety. LVN C said only when she would tell management she would invoke Safe Harbor would she get extra help to pass medications at least to the assigned Hall 400. LVN C said she had also notified the Medical Director of the nursing duties she was unable to complete timely. LVN C said in the secured unit the CNA was most often working alone and she would assist as she could. LVN C said CNA K was in a room with another resident when Resident #44 fell. During an interview on 2/27/2024 at 10:55 a.m., LVN C said she had not completed all the tasks from her shift regarding resident care but was told by nursing management she had to leave because she was scheduled for her next shift at 6:00 p.m. Record review of the Schedule Sheet dated 2/25/2024 indicated the census was 81 and the facility had scheduled: 6:00 a.m. - 6:00 p.m.: 2 student nurse aides, and 3 CNAs with one a no call no show status; 2 RNs and 1 LVN 6:00 p.m. - 6:00 a.m.: 2 CNAs and 1 student nurse aide who called off; and 1 RN and 1 LVN 6:00 a.m. - 2:00 p.m. 1 MA was scheduled 2:00 p.m. - 10:00 p.m. 1 CNA who called off. 10:00 p.m. - 6:00 a.m. 1 CNA Record review of the Employee Punch Report dated 2/25/2024 - 2/26/2024 indicated: LVN YY, RN U, LVN EEE, and LVN RRR worked 6:00 a.m. - 6:00 p.m. shift on 2/25/2024. LVN D and RN DD worked 6:00 p.m. -6:00 a.m. shift, on 2/25/2024. ADON E worked 7:47 p.m. - 11:11 p.m. on 2/25/2024. ADON WW worked 7:19 p.m. - 11:17 p.m. on 2/25/2024. CNA Y, CNA GGG, SNAs RR and PPP worked 6:00 a.m. - 6:00 p.m. shift on 2/25/2024. CNA SSS worked 6:00 p.m. - 6:00 a.m. shift on 2/25/2024. CNA H worked 5:00 a.m. - 5:00 p.m. shift on 2/25/2024. CNA K worked 10:00 p.m. - 6:00 p.m. shift on 2/25/2024. CNA A worked 6:00 p.m. - 9:00 p.m. shift on 2/25/2024. Record review of a Daily Census form dated 2/26/2024 indicated on Hall 400 resided 24 residents and on the secured unit there were 15 residents. During an interview on 02/27/2024 at 8:28 AM, ADON WW stated she was at the facility working on 02/25/2024. ADON WW said she went to work at 5:23 AM and stayed until 1 PM then returned to the facility and worked from 7 PM to 11 PM. ADON WW stated she was administering medications on the 300/400 Hall in the morning and that evening returned due to

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's representative immediately when there was a significant change in the resident's physical, mental, or psychosocial status that is, a deterioration of health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 24 residents ( Resident #57) reviewed for notification of changes. The facility failed to notify Resident #57's representative when the new areas of shearing, hematoma, bruising, and redness were found on Resident #57. This failure placed residents' caregivers at risk of not being aware of any changes in their conditions and could result in a delay in treatment and decline in residents' health and well-being. Findings included: Record review of Resident #57's face sheet dated 02/29/24, indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included heart failure (progressive heart disease that affects pumping action of the heart muscles), atrial fibrillation (abnormal heart rhythm), weakness, protein-calorie malnutrition (not consuming enough protein or calories), and anxiety. Record review of Resident #57's comprehensive care plan dated 12/28/2023 and revised on 02/22/2024, indicated Resident #57 had a bruise with interventions to attempt to determine the cause of bruising, if known attempt to alleviate that factor. The care plan indicated Resident #57 had a skin tear, laceration, or abrasion with interventions to assess reason for skin injury occurrence, notify staff of cause and determine measures to prevent further skin injuries. The care plan indicated Resident #57 had a pressure ulcer or potential for pressure ulcer development due to limited mobility and occasional bowel and bladder incontinence. The care plan interventions included to inform Resident #57's family of any new areas of skin breakdown. Record review of Resident #57's weekly skin assessment dated [DATE] at 09:40 PM , indicated Resident #57 had no bruising. The skin assessment indicated Resident #57 had a skin tear to left arm measuring 11.4 cm x 8.0 cm. The skin assessment did not indicate the new shearing with hematoma measuring 22 cm x 19 cm, 1 cm x 6 cm skin tear to right upper arm, reddened areas to inner thighs, or discolorations to upper back and center chest found on Resident #57 at 09:58 PM that night. The skin assessment indicated there were no new areas that have not been communicated to the physician/nurse practitioner or family. Record review of Resident #57's progress note dated 02/05/24 at 9:58 PM and signed by ADON E indicated MD (medical director) visit to resident room and assessment of resident, with MD requesting myself and DON to resident's room for skin assessment findings. Resident noted to have area to right upper arm appearing to be shearing with hematoma (blood filled swelling) pooling at posterior upper arm measuring 22 cm x 19 cm and a 1 cm x 6 cm skin tear to right, anterior upper arm. Telfa (clear wound dressing) nonadherent dressing with wrap in place noted. Multiple areas of discoloration to the upper back and one noted to the upper, center chest. Blanchable reddened areas to inner thighs bilateral from the brief. New orders for zinc oxide to bilateral arms, upper back, peri area, and any reddened areas for skin integrity. Ace bandage wraps to bilateral legs beginning above toes and extending above knees for compression to lessen edema. CNA documentation notes skin discoloration areas. A new order from MD was received for a left arm x-ray and change ABT to begin in a.m. The progress note did not indicate Resident #57's family member had been notified of the new areas or orders. Record review of Resident #57's quarterly MDS assessment dated [DATE], indicated Resident #57 was usually understood and usually understood others. The MDS assessment indicated Resident #57 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS indicated Resident #57 required partial/moderate assistance with toileting, bathing, dressing, and personal hygiene. Resident #57 required substantial/maximal assistance with chair/bed to chair transfer. The MDS assessment indicated Resident #57 had one venous or arterial ulcers present and skin tears. Record review of Resident #57's order summary report dated 02/29/24, indicated Resident #57 had the following orders: * Wrap bilateral legs with ACE bandage from just above the toes to above knees for compression in the morning for compression to reduce edema. May remove for daily skin observation with an order date of 02/05/2024. During an interview on 02/29/2024 at 11:32 AM, Resident 57's family members said they were not notified by facility staff of the new skin concerns on Resident #57 on 02/05/2024. Resident 57's family members said they noticed the areas themselves, when they were assisting Resident #57 to bed (unsure of date). During an interview on 02/29/2024 at 01:08 PM, ADON E said Resident #57's skin was so fragile. ADON E said on February 5, 2024, the MD came and got her because he wanted the DON and herself to look at Resident #57's skin since Resident #57 had different scattered bruising. She said Resident #57's legs were swollen and as a group he wanted them to see what they could do to care for Resident #57. ADON E said she saw the MD step outside the room and call Resident's #57's family member that day but she must have not charted that he had called them . ADON E said if it was not documented then it was not done. ADON E said it was important for Resident #57's family to be notified of the new skin concerns and orders because they should be involved in her care. ADON E said failure to notify resident's representative indicated they were not notified of any changes in care for the resident. During an interview on 03/01/2024 at 01:53 PM, the DON said Resident #57 constantly had bruising and said she was unable to recall if the injuries found on 02/05/2024 were a new discovery. The DON said she was unsure of how Resident #57 had sustained them but believed Resident #57 had constant multiple discolored areas due to her condition. The DON said the progress note did not indicate Resident #57's family was notified of the new skin areas or orders. The DON said Resident #57's family should have been notified of the news areas and orders because it was a change in condition, and they should have been made aware of new areas and orders. The DON said it was the responsibility of the nurse to notify the family of any changes. During an interview on 03/01/2024 at 10:45 AM, Resident #57's family member said they were not notified by the MD regarding any new skin concerns found on Resident #57 on 02/05/2024. During an interview on 03/02/2024 at 02:22 PM, the Interim Administrator said he expected the resident's representatives to be notified of any changes in the resident's care. The Interim Administrator said he expected the staff to document of the notification to the family. The Interim Administrator said Resident #57's family should have been notified of the new areas and orders because Resident #57's family could come in, see, and suspect Resident #57 was being abused. The Interim Administrator said the nurse was responsible for notifying the resident's representative. The Interim Administrator said he was unsure if there was a system in place to monitor if resident's representatives where being notified of any changes in condition or new orders. Record review of the facility's policy Notifying the Physician of Change in Status revised March 11, 2013 indicated . 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise . 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative.

CONCERN (D)

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

Deficiency F0582 (Tag F0582)

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 each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 2 residents (Resident #57) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #57 was given a SNFABN (SNFABN document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: Record review of Resident #57's face sheet dated 02/29/24, indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included heart failure (progressive heart disease that affects pumping action of the heart muscles), and weakness. Record review of Resident #57's quarterly MDS assessment dated [DATE], indicated Resident #57 was usually understood and usually understood others. The MDS assessment indicated Resident #57 had a BIMS score of 12, which indicated her cognition was moderately impaired. Record review of the SNF Beneficiary Protection Notification Review indicated Resident #57 was receiving Medicare Part A services starting on 12/27/2023 and the last covered day of Part A services was 02/15/2024, however it was revealed that a SNF ABN was not completed which would have informed Resident #57 of the option to continue services at the risk of out-of-pocket cost. During an interview on 03/02/2024 at 1:57 PM, MDS Coordinator R said Resident #57 should have been given a SNF ABN form. MDS Coordinator R said she had forgotten about it because she does not usually provide the SNF ABN forms. MDS Coordinator R said MDS Coordinator N was typically responsible for completing the SNF ABN forms, but he had been out of the facility, and she had to fill in for him. MDS Coordinator R said it was important for the SNF ABN form to be completed so the residents knew their options and they could decide if they wanted to stay, and for them to know how much it would cost without Medicare paying and decide if they wanted to continue with therapy services. During an interview on 03/02/2024 at 4:30 PM, the Administrator said MDS Coordinator N and the BOM were responsible for completing the Skilled Nursing Facility Advance Beneficiary Notice. The Administrator said he expected for them to complete the form per the requirements. The Administrator said it was important to complete this form to let the resident know or the family know that they were being discharged from skilled services and they do have the ability to appeal. Record review of an undated document titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 (2018), indicated, Medicare requires SNFs to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or considered custodial . The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility .

CONCERN (D)

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

Grievances (Tag F0585)

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 prompt efforts were made to resolve grievances for 1 of 6 residents (Resident #57) reviewed for grievances . The facility failed to appropriately resolve Resident #57's grievance when issues with receiving baths continued. This failure could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of Resident #57's face sheet dated 02/29/24, indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included heart failure (progressive heart disease that affects pumping action of the heart muscles), atrial fibrillation (abnormal heart rhythm), weakness, protein-calorie malnutrition (not consuming enough protein or calories), and anxiety. Record review of Resident #57's comprehensive care plan dated 12/28/2023 and revised on 02/22/2024 indicated Resident #57 had an ADL self-care performance deficit with interventions she required one staff member for assistance with bathing. Record of review of Resident #57's grievance dated 01/05/2024 indicated Resident #57's family member had a grievance regarding, room condition, showering/bathing/hygiene, medications, therapy, food and other. The grievance report indicated Resident #57 had been having issues with receiving baths. The grievance report indicated under pertinent findings and conclusion that Resident #57 was given a bed bath immediately. The grievance report under corrective action to be taken to prevent further recurrence did not address Resident #57's baths from being missed. The grievance report indicated the grievance was confirmed and was resolved on 01/05/2024 . Record review of Resident #57's quarterly MDS assessment dated [DATE], indicated Resident #57 was usually understood and usually understood others. The MDS assessment indicated Resident #57 had a BIMS score of 12 which indicated her cognition was moderately impaired. The MDS indicated Resident #57 required partial/moderate assistance with toileting, bathing, dressing, and personal hygiene. Resident #57 required substantial/maximal assistance with chair/bed to chair transfer. The MDS assessment indicated Resident #57 had one venous or arterial ulcers present and skin tears. The MDS assessment did not indicate Resident #57 had any behaviors or refused care. During an interview on 02/28/2024 at 09:00 AM, Resident #57's family member said Resident #57 was not on a bath schedule. Resident #57's family member said Resident #57 has had to ask for a bath in the past. Resident #57's family member said they would prefer for Resident #57's showers/baths to be somewhat consistent and it was not happening. Resident #57's family member said all they had asked for, from the facility staff, was for Resident #57 to be provided a reasonable level of care and for them to have the confidence that Resident #57 was being provided the care she deserved. During an interview on 02/28/24 at 11:45 AM, Resident #57's family member said they were very involved in Resident #57's care. Resident #57's family member said they had thought of putting a sign in Resident #57's room as a reminder for staff of Resident #57's scheduled bath days. Resident #57's family member said they felt they needed to remind staff of when Resident #57's baths/showers were scheduled so her baths would not be missed. Resident #57's family member said they had voiced their concerns to the corporate staff and never received a follow up phone call. Resident #57's family member said they had also reported their concerns regarding Resident #57's care to the previous administrator and her response was we can help you find another facility. Record review of Resident #57's progress notes dated 01/30/2024-03/01/2024 did not indicate Resident #57 had refused any showers/baths. Record review of Resident #57's follow-up question report dated 02/01/2024-02/28/2024 indicated Resident #57 received a bath/shower on 02/02/24, 02/05/2024, 02/07/2024, 02/12/2024, 02/14/2024, 02/16/2024, 02/19/2024, 02/23/2024, and 02/28/2024. Resident #57's scheduled bath days were on Monday, Wednesday, Friday on the 6:00 AM- 2:00 PM shift. The facility failed to provide a bath/shower to Resident #57 on 02/09/2024, 02/21/2024, and 02/26/2024. During an interview on 03/02/2024 at 02:04 PM, the DON said she expected the baths/showers to be completed according to their bath schedule unless there was an extraneous circumstance the bath/shower could not be provided. The DON said she expected the resident to have a file if they refused their bath/shower. The DON said the charge nurses and aides were responsible for ensuring the baths/showers were being provided as scheduled. The DON said there was a report she could print to indicate if the showers were being completed but she did not review it. The DON said she believed the ADONs were responsible for reviewing the report. The DON said if a resident was not receiving their bath/showers as desired, they could become upset, and it could lead to skin issues. During an interview on 03/02/2024 at 02:22 PM, the Interim Administrator said he expected the residents to receive their showers/baths on their scheduled bath day. The Interim Administrator said if a resident was to refuse their bath/shower, he expected staff to ask again or get a staff member that had a better rapport with the resident to ask. The Interim Administrator said if the resident continued to refuse then he expected the staff to document the refusal. The Interim Administrator said he was unsure, if a resident was to receive their baths as scheduled, helped with skin breakdown, or preventing skin issues since he was not clinical. The Interim Administrator said residents not receiving their baths/showers as scheduled was an infection control issue. During an observation and interview on 03/02/2024 at 05:23 PM, Resident #57's family member was seen coming out of her room and was extremely upset. Resident #57's family member voiced that Resident #57 was not provided a bath the day before, on 03/01/2024. Resident #57's family member said her last bath had been given on 02/28/2024. Resident #57's family member said they had voiced concerns of Resident #57's baths not being provided consistently multiple times to the facility staff. Resident #57's family member was observed voicing his concerns to the Interim Administrator. During an interview on 03/02/2024 at 05:33 PM, the SW said when a grievance was filed, it was placed in the resident's medical record. The SW said the management staff (nursing) was responsible for handling this grievance. During an interview on 03/02/2024 at 05:50 PM. The Interim Administrator said Resident #57's family member had not voiced any concerns to him regarding Resident #57's care. The Interim Administrator said he expected once a grievance was resolved, he did not expect the same issues to continue. The Interim Administrator said Resident #57's grievance had not been resolved as she continued having issues receiving her baths. Record review of the facility's policy titled Grievance revised on 11/02/2016, indicated . The Resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal . The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances s the resident may have All written grievances decisions will include: . Any corrective action taken or to be taken by the facility as a result of the grievance .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

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 ensure assessments accurately reflected the resident status for 1 of 24 residents (Resident #33) reviewed for MDS assessment accuracy. The facility inaccurately coded Resident #33's having received an antidepressant medication on his significant change in status MDS assessment dated [DATE]. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #33's face sheet dated 02/29/24, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #33's diagnoses included dementia (memory loss), unspecified protein calorie malnutrition (not consuming enough protein and calories), major depression, and bipolar disorder (serious mental illness characterized by extreme mood swings). Record review of Resident #33's comprehensive care plan dated 05/17/2019 and revised on 08/22/2019, indicated Resident #33 was taking antidepressant medication (Celexa) related to depression daily. The care plan interventions indicated to administer antidepressant medications as ordered by the physician. Record review of Resident #33's significant change in status MDS assessment dated [DATE], indicated Resident #33 was able to make himself understood and understood others. The MDS assessment indicated Resident #33's had a BIMS score of 13, which indicated his cognition was intact. The MDS assessment indicated Resident #33 had taken an antidepressant medication within the last 7 day look back period. Record review of Resident #33's order summary report dated 02/29/24, did not indicate Resident #33 had an order for an antidepressant medication. Record review of Resident #33's medication administration record for the month of January 2024, indicated Resident #33 received citalopram (Celexa) one time a day from 01/1/2024 until 01/16/2024 for diagnosis of major depressive disorder. The medication administration record indicated citalopram was discontinued on 01/27/2024. Record review of Resident #33's medication administration record for the month of February 2024, indicated Resident #33 did not receive any antidepressant medications for the month. During an observation and interview on 03/01/2024 at 03:44 PM, MDS Coordinator N reviewed Resident #33's medical record and said Resident #33 MDS indicated he had received antidepressant medication within the 7-day look back period. MDS Coordinator N was observed reviewing Resident #33's orders and said Resident #33's Celexa was discontinued on 01/27/2024 and should not have been coded on his MDS assessment. MDS Coordinator N said he made an error and was unsure of how it happened. MDS Coordinator N said the Corporate MDS Coordinator audited the MDS assessments frequently. MDS Coordinator N said he was responsible for ensuring the MDS assessments were accurate. MDS Coordinator N said Resident #33 was at risk for having an inaccurate assessment. During an interview on 03/01/2024 at 03:54 PM, the DON said he expected the MDS assessments to be accurate. The DON said the MDS Coordinator was responsible for ensuring the MDS assessments were accurate. The DON said Resident #33 MDS assessment did not accurately reflect Resident #33's care. During an interview on 03/01/2024 at 03:58 PM, the RNC said the facility did not have a policy on MDS accuracy and that they followed the RAI (Resident Assessment Instrument) manual. During an attempted interview on 03/03/2024 at 09:44 AM, the Corporate MDS Coordinator did not answer the phone. During an interview on 03/02/2024 at 02:22 PM, the Interim Administrator said he expected the MDS assessments to be accurate. The Interim Administrator said the MDS Coordinator was responsible for ensuring the MDS assessments were accurate. The Interim Administrator said Resident #33 inaccurate MDS assessment could be looked as Resident #33 still received an antidepressant medication. During an interview on 03/02/2024 at 03:35 PM, the RNC said she expected the MDS assessments be accurate. The RNC said the MDS Coordinator was responsible for ensuring the MDS assessments were accurate. The RNC said inaccurate MDS assessments would not reflect an accurate picture of the resident's care. Record review of the Resident Assessment Instrument 3.0 User's Manual, last revised October 2023, indicated .Coding Instructions .N0145C1. Antidepressant: Check if any antidepressant medications was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

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 observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 24 (Resident #70) residents reviewed for care plans. The facility failed to provide fall mat at bedside for Resident #70, as indicated on the care plan. These failures could place the residents at increased risk of not having their individual needs met, injury, not receiving necessary services, and a decreased quality of life. Findings Included: Record review of Resident #70's face sheet dated 03/02/2024, indicate Resident # 70 was a [AGE] year-old male admitted to the facility on [DATE], with a diagnosis which include unspecified Dementia (mild cognitive impairment has yet to be diagnosed as a specific type of dementia), muscle weakness (a lack of muscle strength). Record review of Resident # 70's Quarterly MDS assessment dated [DATE], indicated Resident #70 had a BIMS score of 6, which indicated severe cognitive impairment. Resident # 70 was able to understand and make himself understood to others. The MDS Resident #70 uses a wheelchair and needs partial to moderate assistance with transfers. Record review of Resident #70's care plan dated 01/19/2024, indicated Resident #70 was at risk for falls, may use fall mat at bedside. Record review of Resident # 70's order summary dated 03/02/2024, indicated Resident #70 was to have a fall mat at bedside. During an observation on 02/26/2024 at 11:31 A.M., Resident #70 was sleeping with no fall mat at the bedside. During an observation on 02/26/2024 at 3:32 P.M., Resident #70 was in bed with no fall mat at the bedside. During an interview on 03/02/2024 at 2:01 P.M, CNA Z stated she was not aware Resident #70 needed a fall mat because the kiosk did not alert her. CNA Z stated all nursing staff was responsible for making sure Resident # 70 had a fall mat. CNA Z stated it was important for Resident#70 to have a fall mat so if he falls it would be on the mat and that was more cushion than the floor. CNA Z stated the harm was he could hurt himself if he fell. During an interview on 03/02/2024 at 2:24 P.M, LVN L stated it was nursing responsibility to ensure Resident #70 had a fall mat at the bedside. LVN L stated someone must have moved the fall mat and not put it back. LVN L stated it was important for the fall mat to be in place to prevent injury. LVN L stated the harm could be an injury. During an interview on 03/02/2024 at 3:00 P.M, ADON E stated she expected resident who need a fall mat to have one. ADON E stated she was afraid the fall mat was moved and did not get put back. ADON E stated it was important for Resident # 70 to have a fall mat to prevent injury. ADON E stated the harm could be personal injury. During an interview on 03/02/2024 at 3:33 P.M, the ADM stated it was he expected Resident #70 to have a fall mat if he has an order. The ADM stated it was it was nursing responsibility to make sure residents has a fall mat at bedside. The ADM stated it was important for Resident #70 to have a fall mat so if he fails out of bed, he was not hitting the floor, he would hit padding and not a direct hit to the floor. The ADM stated the harm could be possible injury. The ADM stated he would monitor by making a list who has an order for fall mats and doing rounds. During an interview on 03/02/2024 at 4:15 P.M, the DON stated she expected the Resident #70 to have a fall mat at bedside. The DON stated it was important for Resident # 70 to have a fall mat to prevent injury. The DON stated Resident #70 could injure himself without a fall mat. If they refused or just did not remember. The DON state to ensure fall mat were in place she would pull up a list and do daily rounds. Record review of the undated Comprehensive Care Planning policy The facility will establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 24 residents (Resident #179) reviewed for activities. The facility failed to provide consistent and scheduled in-room activities for Resident #179 to meet his needs. These failures could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial wellbeing. Findings included: Record review of a face sheet dated 03/02/2024 indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and anxiety disorder. Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #179's speech was unclear, was sometimes able to make himself understood, and understood others. The MDS assessment indicated Resident #179 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #179 was dependent on staff for all ADLs. The staff assessment of daily and activity preferences indicated Resident #179 preferred choosing clothes to wear receiving shower, bed bath, sponge bath, staying up past 8:00 PM, family or significant other involvement in care discussions, use of phone in private, place to lock personal belongings, listening to music, keeping up with the news, doing things with groups of people, participating in favorite activities, and participating in religious activities or practices. Record review of the care plan with date initiated 02/23/2024 did not indicated Resident #179's had activities care planned. Record review of Resident #179's Activity assessment dated [DATE] indicated it was somewhat important to him to listen to music, be around animals such as pets, keep up with the news, do things with groups of people, do your favorite activities, to participate in religious services or practices, and it was very important to him to take care of his personal belongings or things, and to choose between a tub bath, shower, bed bath, or sponge bath, to have his family or a close friend involved in discussion about his care, to be able to use the phone in private, and to have a place to lock his things to keep them safe. Record review of the Activity Participation task in Resident #179's electronic health record for the past 30 days did not indicate any activities had been done. During an interview on 03/02/2024 at 10:11 AM, the AD said her last day at the facility was Monday (02/26/2024), and prior to her last day she had been employed at the facility for 2 years. The AD said Resident #179 had recently admitted to the facility a couple of weeks ago, and she had visited with Resident #179 in his room a couple times. The AD said Resident #179 was supposed receive in-room activities. The AD said in-room activities should be performed 2-3 times a week with the residents. The AD said she did not have a schedule for in-room activities. The AD said she had not been able to provide in-room activities for Resident #179 2-3 times a week. The AD said she had gotten to the point where she just popped into the residents' rooms for the in-room activities because there was only one AD, and she was having to do 5-10 activities a day between the front of the building and the secured unit. The AD said when she performed in-room activities she documented it in the resident's electronic health record. The AD said it was important for the residents to receive in-room activities for social interaction and because activities gave the residents purpose. The AD said not doing the in-room activities could make the residents decline and depressed. The AD said she had mentioned to the previous administrators multiple times that she required assistance, and they told her the CNAs could help her when they were available. During an interview on 03/02/2024 at 4:21 PM, the Administrator said he would assume it was the AD responsibility to do in-room activities. The Administrator said he expected for activities to be provided so the residents were not just sitting there to give them something to do. During an interview on 03/02/2024 at 5:10 PM, Resident #179 said they were supposed to do in-room activities for him this week, but nobody had done them. Resident #179 said not having in-room activities made him sad and lonely. Resident #179 said in-room activities would give him the opportunity to have someone to talk to. Record review of the facility's Activity Policy & Procedure Manual 2011, titled Individualized Activity Programs, indicated, Standard: The Activity Director and staff will provide individual programming to meet individual needs and interests. Practice Guidelines: 1. The Activity Director determines the need for individual programming through the resident assessment process .one on one activities are provided regularly for those residents unable or unwilling to attend groups unless otherwise indicated by assessment. 4. Individual programs are coordinated by the Activity Director, or designee, maintained, and documented in the plan of care .

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents (Resident #53 and Resident #179) reviewed for indwelling urinary catheters and incontinent care. 1. The facility failed to ensure Resident #179's urinary (foley) catheter was properly secured to his leg. 2. The facility failed to ensure Resident #53 was provided proper incontinent care. This failure could place residents with urinary catheters at risk for damage to the bladder, penis, or urethra (a hollow tube that lets urine leave your body), dislodging of the catheter, and urinary tract infections. Findings included: 1. Record review of a face sheet dated 03/02/2024 indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body) and neuromuscular dysfunction of the bladder (condition where a person lacks bladder control due to brain, spinal cord, or nerve problems. Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #179's speech was unclear, was sometimes able to make himself understood, and understood others. The MDS assessment indicated Resident #179 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #179 was dependent on staff for all ADLs. The MDS assessment indicated Resident #179 had an indwelling catheter. Record review of the care plan last revised on 02/23/2024 indicated Resident #179 had a foley related to neurogenic bladder with a goal that he would show no signs and symptoms of urinary infection through the review date. Interventions included to place catheter bag and tubing below the level of the bladder in a privacy bag, check tubing for [NAME] and maintain the drainage bag off the floor during room rounds as needed, and to monitor/document pain/discomfort due to catheter, and monitor for signs and symptoms of infection. Record review of the Order Summary Report dated 02/26/2024 indicated Resident #179 had an order to ensure his catheter strap was in place and holding every shift change as needed with a start date of 02/13/2024. During an observation on 02/26/2024 at 10:46 AM, Resident #179's foley catheter was not secured to his leg. Resident #179 said he had asked one of the nurses about it and they had told him they did not have the supplies to secure it to his leg. During an interview on 03/02/2024 at 4:29 PM, the Administrator said the nurses were responsible for ensuring foley catheters were properly secured, and he expected them to do this. The Administrator said it was important for foley catheters to be properly secured, so they did not get caught on anything and get pulled. During an interview on 03/02/2024 at 4:44 PM, LVN W said the nurses were responsible for ensuring foley catheters were secured properly, and if the CNAs noticed they were not secured properly they should notify the nurse. LVN W said she did not know why Resident #179's foley catheter was not secured. She said she tried to ensure it was always secured to Resident #179's leg, but she could not answer for the other nurses. LVN W said it was important for the foley catheters to be secured properly because they did not want it to get pulled out and cause trauma. During an interview on 03/02/2024 at 5:14 PM, the DON said everyone that was responsible for taking care of Resident #179 should have ensured his foley catheter was secured properly. The DON said she provided oversight by making rounds on the residents frequently to ensure their catheters were properly secured. The DON said it was important for the foley catheters to be secured properly so it did not get pulled out or cause injury. 2. Record review of a face sheet dated 3/06/2024 indicated Resident #53 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of dementia, need for assistance with personal care, and kidney disease. Record review of the Quarterly MDS dated [DATE] indicated Resident #53 was usually understood and usually understood others. The MDS indicated Resident #53's BIMS score was 2 indicating she had severe cognitive impairment. The MDS in section GG indicated Resident #53 required substantial/maximal assistance with toileting hygiene, and partial/moderate assistance for personal hygiene. The MDS indicated Resident #53 was always incontinent of bowel and bladder. Record review of the Comprehensive Care Plan dated 1/05/2023 indicated Resident #53 had a pressure ulcer to her sacrum and indicated the intervention of incontinent care after each episode and apply a moisture barrier. The comprehensive care plan provided failed to mention an ADL care deficit. Record review of a Wound Evaluation and Management Summary dated 2/26/2024 indicated Resident #53 had a Stage 3 pressure wound (full thickness skin loss, involves damage or death of subcutaneous tissue that may extend down to, but not through, underlying tissues and muscles, and presents clinically as a deep crater, with or without undermining of adjacent tissues) to her sacrum (large triangular bone at the base of the spine). During an observation and interview on 2/28/2024 at 11:37 a.m., ADON S and CNA G was prepared to administer wound care to Resident #53's sacral pressure injury when Resident #53 was rolled on to her left side and was found to have had a bowel movement. CNA G removed her gloves, exited the room, entered the spa room, obtained incontinent care items (wipes, gloves, and a brief) and returned to Resident #53's room. CNA G returned to the room, applied another pair of gloves, then taking some wipes she cleansed Resident #53's anal area with wiping twice, then CNA G raised to dressing covering Resident #53's wound and used the wipes and cleansed again front to back, folded the wipe and cleansed from front to back again. CNA G then rolled the brief up towards Resident #53 as she was pulling the brief out from underneath Resident #53. With the same gloves on CNA G then pulled the clean brief from the plastic bag and held the brief until ADON S was ready to place brief on Resident #53. After ADON S placed brief underneath Resident #53, CNA G assisted Resident #53 to roll to apply the brief. Using the same gloves CNA G repositioned Resident #53, applied her sheet and blanket, and even held Resident #53's hand for a few moments. CNA G then removed her soiled gloves and placed them in the plastic bag. CNA G then walked over to Resident #53's roommate to answer a question and placed her hand on her shoulder without performing hand hygiene. CNA G exited Resident #53's room without hand hygiene. CNA G stated she did pretty good when asked how she believed she performed incontinent care. CNA G said she was not aware even though her gloves were not visibly soiled she had to change gloves and perform hand hygiene between clean and dirty. CNA G said she failed to perform incontinent care on Resident #53's peri area. During an interview on 2/28/2024 at 11:55 a.m., ADON S said CNA G should have not brought in a whole package of wipes into Resident #53's room to perform incontinent care. ADON S said CNA G failed to cleanse Resident #53's peri area, failed to change gloves, and complete hand hygiene. ADON S said the provision of incontinent care incorrectly could lead to urinary tract infections, skin conditions, and affects infection control practices. ADON S said the CNAs have been checked off and she expected the CNAs to provide incontinent care correctly. During an interview on 3/02/2024 at 3:02 p.m., the DON said she expected incontinent care to be performed correctly. The DON said the ADONs perform skills check offs with the CNAs to ensure incontinent care and hand hygiene were performed correctly. The DON said incontinent care was monitored by rounds, and thru proficiency check offs. The DON said proper hand hygiene and incontinent care should be provided to prevent infections. During an interview on 3/02/2024 at 4:00 p.m., the Administrator said he expected staff to follow the facility's infection control policy. The Administrator said he expected glove changes to occur between dirty and clean to prevent urinary tract infections. The Administrator said the nursing management was responsible for monitoring the competency check offs for hand hygiene and incontinent care. During an interview on 3/02/2024 at 4:39 p.m., the Regional Compliance Nurse said CNA G was nervous performing incontinent care and hand hygiene because she was able to perform skills check offs within the hour and pass the skills. The Regional Compliance Nurse said when hand hygiene and incontinent care was not provided accurately there was a risk for infection. The Regional Compliance Nurse said the nursing management was responsible for ensure these skills monitored. During an interview with the Administrator on 03/02/2024 at 8:50 AM, the policy for foley catheters was requested and not received upon exit. Record review of a CNA Proficiency Audit dated 2/20/2024 indicated NA G was checked off in the skills area of perineal care by ADON E: female and passed satisfactory skill level. Record review of a Nursing: personal Care-Perineal Care policy dated 5/11/2022 indicated: Purpose This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. 16) Wipe across the pubis area 17) Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area - CLEAN to DIRTY! ? Female resident: Working from front to back, wipe one side of the labia majora, the outside folds of perineal skin that protect the urinary meatus and the vaginal opening. Continue perineal care to the inner thigh. 18) If visibly moist, pat the areas dry with a clean, dry towel or washcloth 19) Note skin changes and apply moisture barrier cream as directed Back 20) Reposition the resident to their side 21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area 22) If visibly moist, pat the areas dry with a clean, dry towel or washcloth 23) Note skin changes and apply moisture barrier cream as directed 24) Doff gloves and PPE 25) Perform hand hygiene . 31) Perform hand hygiene

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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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 observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 4 residents (Resident's #6 and #227) reviewed for respiratory care. 1. The facility failed to ensure Resident #6's nebulizer mask was stored in a bag when it was not in use. 2. The facility failed to administer Resident #227's oxygen as ordered by the physician. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. The findings included: 1. Record review of the face sheet, dated 03/02/2024, revealed Resident #6 was an [AGE] year-old female who re-admitted to the facility on [DATE] with a diagnosis of COPD (common, preventable, and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough). Record review of the quarterly MDS assessment, dated 02/21/2024, revealed Resident #6 had clear speech and was understood by others. The MDS revealed Resident #6 was able to understand others. The MDS revealed Resident #6 had a BIMS score of 14, which indicated no cognitive impairment. The MDS revealed Resident #6 had no behaviors or refusal of care. The MDS revealed Resident #6 had impairment on both upper extremities that interfered with daily functions. Record review of the comprehensive care plan, revised on 05/17/2023, revealed Resident #6 had COPD. The goal was Resident #6 will be free of signs or symptoms of respiratory infections through review date. The interventions included: give aerosol or bronchodilators as ordered .monitor, document, and report any signs of respiratory infection . Record review of the order summary report, dated 03/02/2024, revealed Resident #6 had an order, which started on 12/03/2023, to change nebulizer, date, and place in new bag every Sunday night . The orders further revealed an order, which started on 10/02/2023, for ipratropium-albuterol solution 0.5 - 2.5 mg / 3 mL (used to treat and prevent wheezing or shortness of breath caused by COPD) vial inhalation three times a day. Record review of the MAR, dated February 2024, revealed Resident #6 received nebulizer medication three times a day. During an observation on 02/28/2024 at 3:16 PM, Resident #6's nebulizer mask was laying on top of the nebulizer machine, uncovered and not in a bag. During an interview on 02/28/2024 beginning at 3:30 PM, LVN RRR stated nebulizer masks should have been in a bag when they were not being used. LVN RRR stated the last person to administer her breathing treatment did not put it back in the bag. LVN RRR stated nurses should have gone back and checked after Resident #6 was finished with her breathing treatment. LVN RRR stated she was going to replace the nebulizer mask, but it was normally changed every Sunday. LVN RRR stated it was important to ensure nebulizer masks were kept in bags so it would have been clean, and no bacteria got into Resident #6's lungs from inhaling, which could have caused bacterial pneumonia, or aspiration depending on what they inhaled. LVN RRR stated it was also important to ensure nebulizer masks were kept in bags when not in use to prevent infection. During an interview on 03/02/2024, beginning at 4:51 PM, the DON stated the charge nurses were responsible to ensure nebulizer masks were kept in a bag while not in use. The DON stated everyone was responsible for monitoring to ensure the nebulizer masks were kept in bags, when not in use. The DON stated it was important to ensure nebulizer masks were kept in bags when not in use to prevent infections, injury to the lungs, and exacerbation of disease process. During an interview on 03/02/2024 beginning at 5:04 PM, the Interim Administrator stated he expected all equipment to have been stored properly. The Interim Administrator stated he did not have a clinical background, so he was unsure why it was important to ensure nebulizer masks were stored in a bag when not in use. 2. Record review of Resident #227's face sheet dated 02/29/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (brain dysfunction), chronic obstructive pulmonary disease (a group of lung conditions that make it hard to breathe and limit airflow), anxiety, and shortness of breath. Record review of Resident #227's comprehensive care plan dated 02/23/2024 indicated Resident #227 had emphysema (enlargement of air sacs in the lungs)/COPD with interventions to give oxygen therapy as ordered by the physician. Record review of Resident #227's EMR on 02/29/2024 indicated the admission MDS assessment had not been completed due to his recent admission to the facility. Record review of Resident #227's order summary report dated 02/29/24, indicated Resident #227 had an order for oxygen at 2 liters per minute via nasal cannula every shift with a start date of 02/22/2024. Record review of Resident #227's treatment administration record for the month of February 2024, indicated he had been receiving oxygen at 2 liters per minute via nasal cannula every shift since 02/22/2024. During an observation on 02/26/2024 at 09:40 AM, Resident #227 was lying in bed and received oxygen at 3 l/min via nasal cannula. During an observation on 02/26/2024 at 05:07 PM, Resident #227 was lying in bed and received oxygen at 3 l/min via nasal cannula. During an observation on 02/29/2024 at 09:22 AM, Resident #227 was sitting up in his wheelchair and received oxygen at 3 l/min via nasal cannula. During an observation and interview on 02/29/2024 at 11:47 AM, Resident #227 was sitting up in his wheelchair and received oxygen at 3l/min via nasal cannula. Resident #227 said the nurse set the oxygen rate. Resident #227's family member was in the room and said Resident #227 was not able to adjust the rate himself. During an observation on 02/29/2024 at 02:51 PM, Resident #227 was lying in bed and received oxygen at 3 l/min via nasal cannula. During an observation and interview on 02/29/2024 at 02:38 PM, RN U said Resident #227's oxygen should be set at 3 l/min. RN U went to Resident #227 and confirmed Resident #227's oxygen was set at 3 l/min via nasal cannula. RN U reviewed Resident #227's orders and said his order read to administer oxygen at 2 l/min via NC. RN U said the MD had changed Resident #227's oxygen order to 3l/min via nasal cannula and she obviously did not correct it. RN U said it was her fault for not transcribing the order when it was received. RN U said it was her responsibility to update Resident #227's orders when new orders were received. RN U said Resident #227 was at risk for his respiratory rate to shut down because it was set at a higher rate than the ordered amount of 2 l/min. RN U said she ensured the oxygen was set at the prescribed rate during her morning rounds. During an interview on 03/02/2024 at 02:04 PM, the DON said she expected the residents to receive oxygen at the ordered rate. The DON said the charge nurse was responsible for ensuring residents received their oxygen as prescribed by the physician when they did their rounds or when they obtained vital signs. The DON said by not setting the oxygen at the ordered rate, the resident was at risk for not receiving enough oxygen or receiving too much. During an interview on 03/02/2024 at 02:22 PM, the Interim Administrator said he expected the oxygen to be set at the prescribed rate. The Interim Administrator said nursing was responsible for ensuring residents were receiving oxygen as prescribed during their rounds. The Interim Administrator said he was unsure of the risks of not having the oxygen set at the prescribed rate. Record review of the facility's policy titled Oxygen Administration revised on February 13, 2007, indicated . Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions cause by pulmonary or cardiac diseases. The amount of oxygen by percent of concentration or l/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. The policy did not address storage of oxygen equipment.

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 interview and record review the facility failed to ensure the resident's drug regimen was free from unnecessary psychotropic drugs for 2 of 5 residents (Resident #52, and Resident #179) reviewed for unnecessary psychotropic drugs. 1. The facility failed to ensure Resident #179 was monitored for side effects and behaviors related to the use of Buspirone (anxiety medication), Clonazepam (anxiety medication), Lexapro (antidepressant), and Trazodone (used to treat depression) since his admission on [DATE]. 2. The facility failed to ensure Resident #52's PRN Clonazepam was administered with an adequate indication for its use on 02/23/24 and 02/24/24. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: 1. Record review of a face sheet dated 03/02/2024 indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body), congenital insufficiency of aortic valve (heart defect that prevents blood from flowing backward through the heart), neuromuscular dysfunction of the bladder (condition where a person lacks bladder control due to brain, spinal cord, or nerve problems), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and anxiety disorder. Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #179's speech was unclear, was sometimes able to make himself understood, and understood others. The MDS assessment indicated Resident #179 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #179 was dependent on staff for all ADLs. The MDS assessment indicated Resident #179 received antianxiety and antidepressants in the last 7 days. Record review of the care plan last revised on 02/23/2024 indicated Resident #179 required antidepressant medication to give medications as ordered. The care plan indicated Resident #179 used anti-anxiety medications, Buspirone and Clonazepam, to monitor/document side effects and effectiveness. The care plan indicated Resident #179 required antidepressant medications, Trazodone and Lexapro, to monitor side effects and effectiveness. Record review of the Order Summary Report dated 02/26/2024 indicated Resident #179 had the following medication orders: Buspirone 15 mg give 1 tablet via g-tube two times a day with a start date of 02/23/2024. Trazodone 50 mg give 1 tablet via g-tube two times a day with a start date of 02/14/2024. Lexapro 10 mg give 1 tablet via g-tube one time a day with a start date of 02/14/2024. Clonazepam 1 mg give 1 tablet via g-tube every 8 hours with a start date of 02/14/2024. Record review of Resident #179's MAR for February 2024 indicated Resident #179 received his Buspirone, Trazodone, Lexapro, and Clonazepam as ordered since 02/14/2023. Record review of Resident #179's TAR for February 2024, did not indicate Resident #179 was being monitored for behaviors or side effects for the use of his Buspirone, Clonazepam, Lexapro, and Trazodone. 2. Record review of a face sheet dated 03/02/2024 indicated Resident #52 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, with other behavioral disturbance(deterioration of memory, language, and other thinking abilities with behaviors) , anxiety disorder, and depression. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #52 was usually able to understand others and was usually understood by others. The MDS assessment indicated Resident #52 had a BIMS score of 5, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #52 had no physical, verbal, or other behaviors directed toward others. The MDS assessment indicated Resident #52 required setup or cleanup assistance with eating, supervision for oral, toileting, and personal hygiene, and partial to moderate assistance with showering and dressing. The MDS assessment indicated Resident #52 received antianxiety in the last 7 days. Record review of Resident #52's care plan indicated he used anti-anxiety medications with a goal of Resident #52 will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions included Resident #52 was taking anti-anxiety meds which were associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs to monitor him frequently for safety, give anti-anxiety medications ordered by physician, monitor for side effects and effectiveness anti-anxiety side effects included drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision, mania, hostility and rage, aggressive or impulsive behaviors, hallucinations. Record review of Resident #52's Order Summary Report dated 03/02/2024 indicated orders for: Behavior Monitoring Enter the code - 0.None 1.Panic 2.Agitated 3.Angry 4.Anxiety 5.Biting 6.Compulsive 7. Crying 8.Pacing 9.Screaming/yelling 10.Pull IV line/tubes 11.Poor eye contact 12.Depressed withdrawn 13.Extreme fear 14.False beliefs 15.Fighting 16.Finger painting feces 17. Hallucinations/paranoia/delusion 18.Head banging 19. Insomnia 20.Jittery 21.Kicking 22.Noisy 23.Pinching 24.Restless 25.Scratching 26.Slapping 27. Suspiciousness 28.Throwing objects 29.Wandering 30.Other see progress notes every shift if any behaviors are noted, document details in a progress note with a start date of 06/13/2023. Clonazepam 0.5 MG give 1 tablet by mouth every 24 hours as needed for anxiety related only give from 6 AM to 12 noon do not give after 12 noon per his family member with a start date of 02/20/2024. Record review of Resident #52's February 2024 TAR indicated Clonazepam 0.5 mg was administered on 02/23/2024 and 02/24/2024 by LVN RRR. The TAR indicated no behaviors for 02/23/2024 and 02/24/2024 when the Clonazepam was administered. Record review of Resident #52's progress notes indicated: 02/23/2024 at 6:15 PM, PRN administration of Clonazepam was ineffective resident continued to wander facility anxiously and appeared frustrated and did not seem to understand where he was or why he repeatedly asked to call his family member, after just having spoken with her a few minutes prior, resident was extremely forgetful and had short term memory problems encouraged resident to relax and reminded him of his recent conversations with his daughters however he did not show understanding no distress noted and no signs and symptoms of pain or discomfort will continue to monitor completed by LVN RRR. There were no other notes to indicate what interventions were attempted prior to the administration of the Clonazepam or the indication for administering the Clonazepam. 02/24/2024 at 4:14 PM, PRN administration of Clonazepam was effective resident appeared less anxious throughout the shift completed by LVN RRR. There were no other notes to indicate what was the indication for administering the Clonazepam or what interventions were attempted prior to the administration of the Clonazepam. During an interview on 03/02/2024 at 4:24 PM, the Administrator said the nurses were responsible for monitoring for behaviors and side effects and administering the appropriate medications. The Administrator said appropriate monitoring of behaviors and side effects was important to ensure medications were administered appropriately and no side effects were experienced. During an attempted phone interview on 03/02/2024 at 5:02 PM, LVN RRR did not answer the phone. During an interview on 03/02/2024 at 5:19 PM, the DON said the nurses were responsible for doing the behavior monitoring and side effect monitoring. The DON said the ADONs and herself provided oversight by running weekly reports. The DON said the person inputting the medication order should put the behavior and side effect monitoring on the resident's MAR. The DON said she was not aware Resident #179 did not have behavior or side effect monitoring in place for his medications. The DON said it was important to complete the behavior monitoring to monitor for changes in behavior and to ensure the medications were adequate for them. The DON said it was important to monitor for side effects from medications to ensure the residents did not experience oversedation or negative side effects. The DON said if Resident #52 was having no behaviors the nurse should speak with the doctor for readjusting the medication and a PRN medication should not be administered. The DON said prior to administering an anxiety medication the nurse should attempt other interventions. The DON said administering PRN anxiety medications without the appropriate behaviors placed the residents at risk for injury. During an interview on 03/02/2024 at 05:22 PM, LVN W said all psychotropic medications should have behavior monitoring and side effect monitoring in place. LVN W said the nurse that received the order for antianxiety or antidepressant medications was responsible for ensuring that the behavior and side effect monitoring was in place. LVN W said before a PRN psychotropic medication, for example an antianxiety medication, was given the nurse should have had provided the resident with interventions such redirecting, offering them food or fluids, assessing for pain, and toileting. Those interventions should have been documented as completed prior to administration of an anti-anxiety medication. LVN W said if the nurse did not document all interventions provided then she would assume the medication was given for their convenience. LVN W said the nurse was responsible for administering all PRN medications. LVN W said if a resident was to receive a psychotropic medication with no documented interventions the resident was at risk for being knocked out for no reason and could get themselves hurt or injured if they became groggy and tried to get up. Record review of the facility's Pharmacy Policy & Procedure Manual 2003 policy titled, Medication Administration Procedures, indicated, .All PRN medication orders must specify the reason and frequency for use. PRN medications are to be charted on the medication administration record. An explanation as to symptoms prior to administration and results are to be documented. Complete documentation of PRN administration is to be noted in nurses notes, or in the area provided for PRN documentation on the medication administration record . Record review of the facility's Pharmacy Policy & Procedure Manual revised 10/25/2017, titled, Psychotropic Drugs, indicated, The intent of this policy is that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing, the facility implements gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety . Nurses will continually monitor for behaviors, adverse consequences and/or side effects and utilizing the Psychotropic Medication Behavior/Side Effect Monitoring forms generated by PCC, the nurse will document the behavior and/or side effect using charting by exception (only charting when the occurrence is observed or assessed) . Based on interview and record review the facility failed to ensure the resident's drug regimen was free from unnecessary psychotropic drugs for 2 of 5 residents (Resident #52, and Resident #179) reviewed for unnecessary psychotropic drugs. 1. The facility failed to ensure Resident #179 was monitored for side effects and behaviors related to the use of Buspirone (anxiety medication), Clonazepam (anxiety medication), Lexapro (antidepressant), and Trazodone (used to treat depression) since his admission on [DATE]. 2. The facility failed to ensure Resident #52's PRN Clonazepam was administered with an adequate indication for its use on 02/23/24 and 02/24/24. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: 1. Record review of a face sheet dated 03/02/2024 indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body), congenital insufficiency of aortic valve (heart defect that prevents blood from flowing backward through the heart), neuromuscular dysfunction of the bladder (condition where a person lacks bladder control due to brain, spinal cord, or nerve problems), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and anxiety disorder. Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #179's speech was unclear, was sometimes able to make himself understood, and understood others. The MDS assessment indicated Resident #179 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #179 was dependent on staff for all ADLs. The MDS assessment indicated Resident #179 received antianxiety and antidepressants in the last 7 days. Record review of the care plan last revised on 02/23/2024 indicated Resident #179 required antidepressant medication to give medications as ordered. The care plan indicated Resident #179 used anti-anxiety medications, Buspirone and Clonazepam, to monitor/document side effects and effectiveness. The care plan indicated Resident #179 required antidepressant medications, Trazodone and Lexapro, to monitor side effects and effectiveness. Record review of the Order Summary Report dated 02/26/2024 indicated Resident #179 had the following medication orders: Buspirone 15 mg give 1 tablet via g-tube two times a day with a start date of 02/23/2024. Trazodone 50 mg give 1 tablet via g-tube two times a day with a start date of 02/14/2024. Lexapro 10 mg give 1 tablet via g-tube one time a day with a start date of 02/14/2024. Clonazepam 1 mg give 1 tablet via g-tube every 8 hours with a start date of 02/14/2024. Record review of Resident #179's MAR for February 2024 indicated Resident #179 received his Buspirone, Trazodone, Lexapro, and Clonazepam as ordered since 02/14/2023. Record review of Resident #179's TAR for February 2024, did not indicate Resident #179 was being monitored for behaviors or side effects for the use of his Buspirone, Clonazepam, Lexapro, and Trazodone. 2. Record review of a face sheet dated 03/02/2024 indicated Resident #52 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, with other behavioral disturbance(deterioration of memory, language, and other thinking abilities with behaviors) , anxiety disorder, and depression. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #52 was usually able to understand others and was usually understood by others. The MDS assessment indicated Resident #52 had a BIMS score of 5, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #52 had no physical, verbal, or other behaviors directed toward others. The MDS assessment indicated Resident #52 required setup or cleanup assistance with eating, supervision for oral, toileting, and personal hygiene, and partial to moderate assistance with showering and dressing. The MDS assessment indicated Resident #52 received antianxiety in the last 7 days. Record review of Resident #52's care plan indicated he used anti-anxiety medications with a goal of Resident #52 will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions included Resident #52 was taking anti-anxiety meds which were associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs to monitor him frequently for safety, give anti-anxiety medications ordered by physician, monitor for side effects and effectiveness anti-anxiety side effects included drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision, mania, hostility and rage, aggressive or impulsive behaviors, hallucinations. Record review of Resident #52's Order Summary Report dated 03/02/2024 indicated orders for: Behavior Monitoring Enter the code - 0.None 1.Panic 2.Agitated 3.Angry 4.Anxiety 5.Biting 6.Compulsive 7. Crying 8.Pacing 9.Screaming/yelling 10.Pull IV line/tubes 11.Poor eye contact 12.Depressed withdrawn 13.Extreme fear 14.False beliefs 15.Fighting 16.Finger painting feces 17. Hallucinations/paranoia/delusion 18.Head banging 19. Insomnia 20.Jittery 21.Kicking 22.Noisy 23.Pinching 24.Restless 25.Scratching 26.Slapping 27. Suspiciousness 28.Throwing objects 29.Wandering 30.Other see progress notes every shift if any behaviors are noted, document details in a progress note with a start date of 06/13/2023. Clonazepam 0.5 MG give 1 tablet by mouth every 24 hours as needed for anxiety related only give from 6 AM to 12 noon do not give after 12 noon per his family member with a start date of 02/20/2024. Record review of Resident #52's February 2024 TAR indicated Clonazepam 0.5 mg was administered on 02/23/2024 and 02/24/2024 by LVN RRR. The TAR indicated no behaviors for 02/23/2024 and 02/24/2024 when the Clonazepam was administered. Record review of Resident #52's progress notes indicated: 02/23/2024 at 6:15 PM, PRN administration of Clonazepam was ineffective resident continued to wander facility anxiously and appeared frustrated and did not seem to understand where he was or why he repeatedly asked to call his family member, after just having spoken with her a few minutes prior, resident was extremely forgetful and had short term memory problems encouraged resident to relax and reminded him of his recent conversations with his daughters however he did not show understanding no distress noted and no signs and symptoms of pain or discomfort will continue to monitor completed by LVN RRR. There were no other notes to indicate what interventions were attempted prior to the administration of the Clonazepam or the indication for administering the Clonazepam. 02/24/2024 at 4:14 PM, PRN administration of Clonazepam was effective resident appeared less anxious throughout the shift completed by LVN RRR. There were no other notes to indicate what was the indication for administering the Clonazepam or what interventions were attempted prior to the administration of the Clonazepam. During an interview on 03/02/2024 at 4:24 PM, the Administrator said the nurses were responsible for monitoring for behaviors and side effects and administering the appropriate medications. The Administrator said appropriate monitoring of behaviors and side effects was important to ensure medications were administered appropriately and no side effects were experienced. During an attempted phone interview on 03/02/2024 at 5:02 PM, LVN RRR did not answer the phone. During an interview on 03/02/2024 at 5:19 PM, the DON said the nurses were responsible for doing the behavior monitoring and side effect monitoring. The DON said the ADONs and herself provided oversight by running weekly reports. The DON said the person inputting the medication order should put the behavior and side effect monitoring on the resident's MAR. The DON said she was not aware Resident #179 did not have behavior or side effect monitoring in place for his medications. The DON said it was important to complete the behavior monitoring to monitor for changes in behavior and to ensure the medications were adequate for them. The DON said it was important to monitor for side effects from medications to ensure the residents did not experience oversedation or negative side effects. The DON said if Resident #52 was having no behaviors the nurse should speak with the doctor for readjusting the medication and a PRN medication should not be administered. The DON said prior to administering an anxiety medication the nurse should attempt other interventions. The DON said administering PRN anxiety medications without the appropriate behaviors placed the residents at risk for injury. During an interview on 03/02/2024 at 05:22 PM, LVN W said all psychotropic medications should have behavior monitoring and side effect monitoring in place. LVN W said the nurse that received the order for antianxiety or antidepressant medications was responsible for ensuring that the behavior and side effect monitoring was in place. LVN W said before a PRN psychotropic medication, for example an antianxiety medication, was given the nurse should have had provided the resident with interventions such redirecting, offering them food or fluids, assessing for pain, and toileting. Those interventions should have been documented as completed prior to administration of an anti-anxiety medication. LVN W said if the nurse did not document all interventions provided then she would assume the medication was given for their convenience. LVN W said the nurse was responsible for administering all PRN medications. LVN W said if a resident was to receive a psychotropic medication with no documented interventions the resident was at risk for being knocked out for no reason and could get themselves hurt or injured if they became groggy and tried to get up. Record review of the facility's Pharmacy Policy & Procedure Manual 2003 policy titled, Medication Administration Procedures, indicated, .All PRN medication orders must specify the reason and frequency for use. PRN medications are to be charted on the medication administration record. An explanation as to symptoms prior to administration and results are to be documented. Complete documentation of PRN administration is to be noted in nurses notes, or in the area provided for PRN documentation on the medication administration record . Record review of the facility's Pharmacy Policy & Procedure Manual revised 10/25/2017, titled, Psychotropic Drugs, indicated, The intent of this policy is that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing, the facility implements gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety . Nurses will continually monitor for behaviors, adverse consequences and/or side effects and utilizing the Psychotropic Medication Behavior/Side Effect Monitoring forms generated by PCC, the nurse will document the behavior and/or side effect using charting by exception (only charting when the occurrence is observed or assessed) .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 1 nurse treatment carts reviewed for drugs and biologicals and storage of medications. The facility failed to ensure Nurse treatment cart were secured and unable to be accessed by unauthorized personnel on 2/27/2024. This failure could place residents at risk of misuse of medications, drug diversions, and not receiving the therapeutic benefit of medications. Findings Included: During an observation and interview on 02/27/2024 at 11:45 P.M., LVN Q was observed walking down hall 100 away from the nurse's station leaving the nurse treatment cart unlocked. LVN Q stated the cart should be locked and the nurse should keep the key with them. LVN Q stated she did not know who the last person in the nurse treatment cart was. LVN Q stated it was important to keep the nurse treatment cart locked so residents do not get into it and get stuff out that was unsafe. LVN Q stated residents could take something and have an adverse reaction. During an observation and interview on 02/27/2024 at 12:00 A.M., observed keys laying to the side on top the nurse treatment cart. LVN Q stated the cart should be locked and the nurse should keep the key with them. LVN Q stated she did not know who the last person in the nurse treatment cart was. LVN Q stated it was important to keep the nurse treatment cart locked so residents do not get into it and get stuff out that was unsafe. LVN Q stated residents could take something and have an adverse reaction. During an interview on 03/02/2024 at 3:00 P.M, ADON E stated she expected all the medication carts and the nurse treatment cart to be locked. ADON E stated it was the nursing staff responsibility to ensure the nurse treatment cart was locked. ADON E stated it was important to keep the nurse treatment cart locked because of harmful wound care supplies. ADON E stated the harm was a resident could get into the nurse treatment cart and drink or eat something that could cause major or minor issues. During an interview on 03/02/2024 at 3:33 P.M., the ADM stated he expected the nurses to lock the nurse treatment carts. The ADM stated the reason for the cart not being locked must had been a lapse of judgement or forgetfulness. The ADM state it was important to lock the nurse treatment cart to ensure no one has access that was not supposed to have access. The ADM stated the harm would depend on what someone got out of the nurse treatment cart. During an interview on 03/02/2024 at 4:15 P.M, the DON stated she expected the nurse treatment cart to be locked and the keys should be with the nurse. The DON stated it was the nursing staff responsibility to ensure the nurse treatment cart was locked. The DON stated it was important to keep the nurse treatment cart locked so no one could get into it. The DON stated the harm would depend on what they got out of the cart. The DON stated she would monitor by doing rounds and in-service. Record review of the Medication Administration policy, undated, revealed .After the medication administration process was completed, the medication cart must be completely locked, or otherwise secure .

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable disease and infections for 1 of 3 residents (Resident #53) reviewed for infection control practices. The facility failed to ensure CNA G performed hand hygiene and glove changes while providing incontinent care to Resident #53. These failures could place residents at risk for urinary tract infections, cross contamination, and the spread of infections. Findings included: Record review of a face sheet dated 3/06/2024 indicated Resident #53 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of dementia, need for assistance with personal care, and kidney disease. Record review of the Quarterly MDS dated [DATE] indicated Resident #53 was usually understood and usually understood others. The MDS indicated Resident #53's BIMS score was 2 indicating she had severe cognitive impairment. The MDS in section GG indicated Resident #53 required substantial/maximal assistance with toileting hygiene, and partial/moderate assistance for personal hygiene. The MDS indicated Resident #53 was always incontinent of bowel and bladder. Record review of the Comprehensive Care Plan dated 1/05/2023 indicated Resident #53 had a pressure ulcer to her sacrum and indicated the intervention of incontinent care after each episode and apply a moisture barrier. The comprehensive care plan provided failed to mention an ADL care deficit. Record review of a CNA Proficiency Audit dated 2/20/2024 indicated NA G was checked off in the skills area of perineal care by ADON E: female and passed satisfactory skill level. Record review of a Wound Evaluation and Management Summary dated 2/26/2024 indicated Resident #53 had a Stage 3 pressure wound (full thickness skin loss, involves damage or death of subcutaneous tissue that may extend down to, but not through, underlying tissues and muscles, and presents clinically as a deep crater, with or without undermining of adjacent tissues) to her sacrum (large triangular bone at the base of the spine). During an observation and interview on 2/28/2024 at 11:37 a.m., ADON S and CNA G was prepared to administer wound care to Resident #53's sacral pressure injury when Resident #53 was rolled on to her left side and was found to have had a bowel movement. CNA G removed her gloves, exited the room, entered the spa room, obtained incontinent care items (wipes, gloves, and a brief) and returned to Resident #53's room. CNA G returned to the room, applied another pair of gloves, then taking some wipes she cleansed Resident #53's anal area with wiping twice, then CNA G raised to the dressing covering Resident #53's wound and used the wipes and cleansed again front to back, folded the wipe and cleansed from front to back again. CNA G then rolled the brief up towards Resident #53 as she was pulling the brief out from underneath Resident #53. With the same gloves on CNA G then pulled the clean brief from the plastic bag and held the brief until ADON S was ready to place brief on Resident #53. After ADON S placed brief underneath Resident #53, CNA G assisted Resident #53 to roll to apply the brief. Using the same gloves CNA G repositioned Resident #53, applied her sheet and blanket, and even held Resident #53's hand for a few moments. CNA G then removed her soiled gloves and placed them in the plastic bag. CNA G then walked over to Resident #53's roommate to answer a question and placed her hand on her shoulder without performing hand hygiene. CNA G exited Resident #53's room without hand hygiene. CNA G stated thought she did pretty good when asked how she believed she performed incontinent care. CNA G said she was not aware even though her gloves were not visibly soiled she had to change gloves and perform hand hygiene between clean and dirty. CNA G said she failed to perform incontinent care on Resident #53's peri area. During an interview on 2/28/2024 at 11:55 a.m., ADON S said CNA G should have not brought in a whole package of wipes into Resident #53's room to perform incontinent care. ADON S said CNA G failed to cleanse Resident #53's peri area, failed to change gloves, and complete hand hygiene. ADON S said the provision of incontinent care incorrectly could lead to urinary tract infections, skin conditions, and affects infection control practices. ADON S said the CNAs have been checked off and she expected the CNAs to provide incontinent care correctly. During an interview on 3/02/2024 at 2:15 p.m., LVN F said she expected the CNAs to perform hand hygiene and glove changes between each resident's care, between clean and dirty exposures, and between resident rooms. LVN F said good hand hygiene practices prevent infections. LVN F said nursing was responsible for ensuring staff were performing hand hygiene correctly. During an interview on 3/02/2024 at 3:02 p.m., the DON said she expected incontinent care to be performed correctly. The DON said the ADONs perform skills check offs with the CNAs to ensure incontinent care and hand hygiene were performed correctly. The DON said incontinent care was monitored by rounds, and thru proficiency check offs. The DON said proper hand hygiene and incontinent care should be provided to prevent infections. During an interview on 3/02/2024 at 4:00 p.m., the Administrator said he expected staff to follow the facility's infection control policy. The Administrator said he expected glove changes to occur between dirty and clean to prevent urinary tract infections. The Administrator said the nursing management was responsible for monitoring the competency check offs for hand hygiene and incontinent care. During an interview on 3/02/2024 at 4:39 p.m., the Regional Compliance Nurse said CNA G was nervous performing incontinent care and hand hygiene because she was able to perform skills check offs within the hour and pass the skills. The Regional Compliance Nurse said when hand hygiene and incontinent care was not provided accurately there was a risk for infection. The Regional Compliance Nurse said the nursing management was responsible for ensure these skills monitored. Record review of a CNA Proficiency Audit dated 2/20/2024 indicated NA G was checked off in the skills area of perineal care by ADON E: female and passed satisfactory skill level. Record review of an Infection Control Plan: Overview policy dated 3/2023 indicated: Infection Control: the facility will establish and maintain and Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection .Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination.

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 1 of 2 residents and reviewed antibiotic use. (Resident #5) 1. The facility did not ensure Resident #5 was assessed using the established and accepted criteria to determine if her UTI met the criteria for antibiotic use. 2. The facility did not ensure an SBAR was performed to indicate a change of condition when Resident #5 was exhibiting signs and symptoms of a UTI. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. The findings included: Record review of the order summary report, dated 02/28/2024, revealed Resident #5 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Record review of the quarterly MDS assessment, dated 01/11/2024, revealed Resident #5 had clear speech and was usually understood by others. The MDS revealed Resident #5 was usually able to understand others. The MDS revealed Resident #5 had a BIMS score of 8, which indicated moderately impaired cognition. The MDS revealed Resident #5 had no behaviors or refusal of care. The MDS revealed Resident #5 was always incontinent of bowel and bladder. The MDS revealed Resident #5 had a diagnosis of UTI during the last 30 days. The MDS revealed Resident #5 received antibiotics during the 7-day look-back period. Record review of Resident #5's comprehensive care plan, dated 03/02/2024, did not address her history of UTIs. Record review of the urinalysis with culture and sensitivity, received 02/08/2024, revealed Resident #5 had a high range of Escherichia coli (bacteria) in her urine. Record review of the assessments tab in the electronic charting system, accessed 03/02/2024 at 2:21 PM, revealed Resident #5 had a urinary tract infection note for 02/09/2024, 02/10/2024, 02/12/2024, and 02/13/2024. There were no notes for 02/08/2024, 02/11/2024, 02/14/2024, or 02/15/2024. Record review of the assessments tab in the electronic charting system, accessed 03/02/2024 at 2:26 PM, revealed Resident #5 had no SBAR assessment completed during the month of February 2024. Record review of the orders tab in the electronic charting system, accessed 03/02/2024 at 2:26 PM, revealed Resident #5 had an order, which started on 02/02/2024 and was completed on 02/15/2024, for nitrofurantoin 100 mg (antibiotic) twice daily for a UTI. Record review of the MAR, dated February 2024, revealed Resident #5 received antibiotics for a UTI on and between 02/08/2024 to 02/15/2024. Record review of the antibiotic log between September 2024 and February 2024, revealed Resident #5 had no antibiotic use logged in February 2024. During an interview on 03/02/2024 beginning at 1:54 PM, LVN W stated when a resident exhibited signs or symptoms of a UTI, she would have contacted the doctor for an order for a urinalysis with a culture and sensitivity as appropriate. LVN W stated some assessments and progress notes were completed if the results of the labs indicated the resident had a UTI. LVN W stated an SBAR, and urinary tract infection note would have been completed under the assessments tab. LVN W stated there was no assessment that she filled out to indicate whether residents met the criteria for antibiotic use. LVN W was unsure why Resident #5 did not have an SBAR completed when the doctor was contacted. LVN W stated the doctor would have been notified and new orders would have been implemented per the doctor's orders. LVN W stated the doctors would usually start the antibiotics prophylactically while waiting for the culture and sensitivity results, and then change the antibiotics if it was required. LVN W stated when the culture and sensitivity results were received, they would have been collaborated with the doctor, who would have decided to either continue the current antibiotic or to change the antibiotic mediation. During an interview on 03/02/2024 beginning at 2:03 PM, ADON E stated she recently received her Infection Control Preventionist certification. ADON E stated the protocol for residents who exhibited signs and symptoms of a UTI was to contact the doctor and obtain an order for a urinalysis with culture and sensitivity as indicated. ADON E stated the doctors would usually start the antibiotics prophylactically while waiting for the culture and sensitivity results, and then change the antibiotics if it was required. ADON E stated when the results for the labs were received the facility should have collaborated with the doctor to determine if continued antibiotic use was indicated or if the antibiotic needed to have been changed. ADON E stated an SBAR, change of condition report, and urinary infection assessment should have been completed. ADON E stated the urinary infection assessment should have been completed daily if the resident was on an antibiotic. ADON E stated the nurses on the floor were responsible for completing the assessments. ADON E stated antibiotics were monitored in the morning stand up meeting. ADON E stated the nursing management made sure all forms were filled out correctly in the electronic charting system and if any forms were missing the nurses would have been called to complete the documentation. ADON E stated the antibiotics were logged into a report and it was determined if the antibiotic met criteria. ADON E was unsure why Resident #5 did not have the required forms completed or why her antibiotic use was not logged into the antibiotic log. ADON E was unsure if Resident #5 met criteria for antibiotic use. ADON E stated it was important to ensure antibiotic stewardship policies were followed to protect the residents from unnecessary antibiotic use or super infections from inappropriate antibiotic use. During an interview on 03/02/2024 beginning at 3:33 PM, the Pharmacy Consultant stated her role in antibiotic stewardship for the facility was to run an antibiotic report from the facility and make dosing recommendations as needed. The Pharmacy Consultant stated she could not speak on Resident #5 unless she had the chart in front of her and she was unable to pull it up. The Pharmacy Consultant stated she was unable to answer any further questions. During an interview on 03/02/2024, beginning at 4:51 PM, the DON stated her role in the antibiotic stewardship program was to ensure antibiotic orders were entered into the electronic charting system and to ensure the antibiotics met McGeer's criteria and were logged on the antibiotic logs. The DON stated the assessment to determine if antibiotics met McGeer's criteria were located in the electronic charting system under assessments and should have been completed. The DON stated and SBAR should have been completed as an infection was considered a change in condition. The DON stated the ADONs and herself were responsible for monitoring to ensure the appropriate forms were completed for antibiotic stewardship. The DON stated it was important to ensure antibiotic stewardship policies were implemented to help identify proper antibiotic use and to ensure antibiotics were not received unnecessarily. During an interview on 03/02/2024 beginning at 5:04 PM, the Interim Administrator stated his role in antibiotic stewardship was to ensure it was reviewed. The Interim Administrator stated he expected the antibiotic stewardship policies to be implemented to ensure residents were receiving what they needed. Record review of the Antimicrobial Stewardship policy, undated, revealed When facility staff suspects a resident has an infection, the nurse should perform and document a complete assessment of the resident using established and accepted assessment protocols to determine if the resident's status meets minimum criteria for initiated antibiotics .this facility uses the Loeb Minimum Criteria .when a nurse contacts a physician/prescriber to communicate a resident's change in condition and a suspected infection, the nurse should have the medical record available and should perform an SBAR assessment .the facility will track antibiotic usage for the facility using the infection/antibiotic log .

CONCERN (E) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure 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 5 of 11 residents (Resident #'s 44, 47, 52, 57, 179) reviewed for abuse and neglect reporting. The facility failed to report to the state agency when Resident #44's large bruise and fractured hip were found on 6/21/2024. The facility failed to report to the state agency when Resident #52 was cursed at and not allowed in his room by Resident #47 who had a history of verbal abuse. The DON was notified of this incident and failed to report the abuse. The facility failed to ensure the DON reported the abuse to HHSC within 2 hours, after LVN C reported abuse to her on 02/19/2024. The facility failed to report to the state agency when Resident #57 had shearing, hematoma, bruising, and a skin tear. The facility failed to ensure the DON reported physical and verbal abuse and neglect to the abuse coordinator immediately after Resident #179 reported it to her in February 2024. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet dated 2/27/2024 indicated Resident #44 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness, reduced mobility, anxiety disorder. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was sometimes understood and usually understands others. The MDS indicated Resident #44 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #44 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #44 had no behavioral symptoms but wandered 1-3 days during the assessment period. The MDS indicated Resident #44 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. The MDS indicated Resident #44 had a history of falls with fractures within the last 6 months. Record review of the comprehensive care plan dated 12/13/2023 and updated on 1/07/2024 indicated Resident #44 was at risk to fall related to unsteady gait/balance, generalized weakness, and poor safety awareness. The care plan indicated Resident #44 was at risk to wander related to a history of attempts to leave the facility related to poor safety awareness and resides on the secured unit. Record review of a Weekly Skin assessment dated [DATE] and documented by LVN CCC, indicated Resident #44's skin was normal with no bruising. The note indicated Resident #44's had a surgical incision to the right hip with staples and steri-strips in place with no drainage and no signs of infection. Record review of a Fall Nurses Note dated 6/12/2023 and documented by LVN YY indicated Resident #44 had a fall with a bump on the right side of her head. Record review of a Weekly Skin assessment dated [DATE] documented by LVN DDD, indicated Resident #44's skin was normal with no bruising. Record review of a SBAR note dated 6/18/2024 documented by LVN YY indicated Resident #44 had swelling and pain to the right hip replacement. The note indicated Resident #44 was ordered a mild pain reliever and an x-ray to the right hip. Record review of a right hip x-ray dated 6/19/2023 indicated Resident #44's prosthetic right femoral head (hip joint) was in proper alignment. Resident #44's x-ray revealed there were no fractures or acute dislocation. The x-ray indicated Resident #44's prothesis was properly situated without any loosing. The x-ray conclusion indicated the right hip arthroplasty (restoration repair) was intact. Record review of a progress note dated 6/21/2023 at 6:15 a.m., LVN YY documented Resident #44 had a bruise to the inner thigh on the right leg measuring 17 centimeters x approximately 11 centimeters with pain. LVN YY noted she administered a mild pain reliever to Resident #44. Record review of an Event Nurses' note dated 6/21/2023 at 6:15 a.m., LVN YY documented a bruise was found to Resident #44's right inner thigh measuring 17 centimeters x approximately 11 centimeters. The note indicated Resident #44's bruise was blue/purple and painful. LVN YY documented Resident #44 could not provide a statement related to her cognitive impairment. LVN YY said previous factors included previous falls. Record review of an incident note dated 6/21/2023 documented by LVN YY indicated Resident #44 had a large purple bruise on her inner right thigh (front) measuring 17 centimeters x approximately 11 centimeters. LVN YY said Resident #44 was unable to state what had happened. LVN YY documented there were no predisposing environmental factors, and the predisposing physiological factor was Resident #44 had memory impairment. Record review of a Weekly Skin assessment dated [DATE] indicated Resident #44 skin color was normal, temperature was normal, with a large purple bruise to the right inner thigh with a firm center with bruising to her knee. Record review of a Consultation note dated 6/21/2023 indicated the orthopedic physician documented he knew Resident #44. The physician said he had treated her femoral neck fracture a month previous. The physician wrote he had seen Resident #44 a week ago and the x-rays showed a well-fitted well-fixed bipolar hip. The physician wrote he had plans to surgically repair Resident #44's right hip by removing the prothesis, wire her with cables then reimplant the prothesis and then put a plate and screws with wires and screws around the periprosthetic fracture. During an interview on 2/29/2024 at 11:42 a.m., LVN YY said she was notified of Resident #44's by CNA K. LVN YY said she assessed and measured the bruising and notified the physician, family, DON, and Administrator (previous). LVN YY said she was unsure how Resident #44 sustained the bruise and unsure why no one else had seen the bruise. During an interview on 2/29/2024 at 3:22 p.m., CNA K said she had found the bruising to Resident #44's right leg and reported to LVN YY. CNA K said while she was providing incontinent care for Resident #44, she moved the pillow between Resident #44's legs when she found a large purple bruise. During an interview on 2/29/2023 at 3:40 p.m., the DON said she was not the DON during the incident on 6/21/2023 with Resident #44 but she indicated she would have investigated and report the bruising to the state agency within the two-hour window. During an interview on 03/01/2024 at 8:52 AM, previous Administrator ZZ said she always did an investigation when something was reported to her but depending on her investigation if she reported. Administrator ZZ said if she had not reported the incident with Resident #44's bruising/hip fracture it had to be for a reason. Administrator ZZ said she did not remember the specifics off the top of her head, and she kept a soft file in the administrator's office with her investigations . Administrator ZZ said a bruise that was not correlated with an incident was considered an injury of unknown injury and should be reported within 2 hours of finding it or being notified. 2) Record review of the face sheet, dated 02/29/2024, revealed Resident #47 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and altered mental status (broad term used to indicate an abnormal state of alertness or awareness). Record review of the significant change MDS assessment, dated 12/20/2023, revealed Resident #47 had clear speech and was usually understood by others. The MDS revealed Resident #47 was sometimes able to understand others. The MDS revealed Resident #47 had short-term and long-term memory problems. The MDS revealed Resident #47 was not able to recall the current season, the location of his room, staff names or faces, and that he was in a nursing facility. The MDS revealed Resident #47 had severely impaired decision-making skills. The MDS revealed Resident #47 had continuous inattention and disorganized thinking. The MDS revealed Resident #47 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 02/21/2024, revealed Resident #47 had potential to demonstrate verbally abuse behaviors. The interventions included: analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document .assess resident's coping skills and support system .evaluate for side effects of medications .notify the charge nurse of any abusive behaviors .provide positive feedback for good behavior, emphasize the positive aspects of compliance .psychiatric/psychogeriatric consult as indicated. Record review of the nursing progress note on 02/19/2024 at 12:20 AM, revealed Resident #47 was repeatedly yelling at his roommate [Resident #52] You son-of-a-bitch get out of my room! The nursing progress note further revealed the DON was notified immediately and told LVN C to notify the Medical Director because there was no abuse coordinator at the facility. The progress note revealed the Medical Director was notified and Resident #47 was placed in a different room. 3) Record review of Resident #57's face sheet dated 02/29/24, indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included heart failure (progressive heart disease that affects pumping action of the heart muscles), atrial fibrillation (abnormal heart rhythm), weakness, protein-calorie malnutrition (not consuming enough protein or calories), and anxiety. Record review of Resident #57's comprehensive care plan dated 12/28/2023 and revised on 02/22/2024, indicated Resident #57 had a bruise with interventions to attempt to determine the cause of bruising, if known attempt to alleviate that factor. The care plan indicated Resident #57 had a skin tear, laceration, or abrasion with interventions to assess reason for skin injury occurrence, notify staff of cause and determine measures to prevent further skin injuries. The care plan indicated Resident #57 was on anticoagulant therapy for atrial fibrillation and to report any bruising to the charge nurse immediately. Record review of Resident #57's progress note dated 02/05/24 at 9:58 PM and signed by ADON E indicated MD (medical director) visit to resident room and assessment of resident, with MD requesting myself and DON to resident's room for skin assessment findings. Resident noted to have area to right upper arm appearing to be shearing with hematoma (blood filled swelling) pooling at posterior upper arm measuring 22 cm x 19 cm and a 1 cm x 6 cm skin tear to right, anterior upper arm. Telfa (clear wound dressing) nonadherent dressing with wrap in place noted. Multiple areas of discoloration to the upper back and one noted to the upper, center chest. Blanchable reddened areas to inner thighs bilateral from the brief. New orders for zinc oxide to bilateral arms, upper back, peri area, and any reddened areas for skin integrity. Ace bandage wraps to bilateral legs beginning above toes and extending above knees for compression to lessen edema. CNA documentation notes skin discoloration areas. A new order from MD was received for a left arm x-ray and change ABT to begin in a.m. Record review of Resident #57's weekly skin assessment dated [DATE] at 09:40 PM, indicated Resident #57 had no bruising. The skin assessment indicated Resident #57 had a skin tear to left arm measuring 11.4 cm x 8.0 cm. The skin assessment did not indicate the new shearing with hematoma measuring 22 cm x 19 cm, 1 cm x 6 cm skin tear to right upper arm, reddened areas to inner thighs, or discolorations to upper back and center chest found on Resident #57 at 09:58 PM that night. Record review of Resident #57's quarterly MDS assessment dated [DATE], indicated Resident #57 was usually understood and usually understood others. The MDS assessment indicated Resident #57 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS indicated Resident #57 required partial/moderate assistance with toileting, bathing, dressing, and personal hygiene. Resident #57 required substantial/maximal assistance with chair/bed to chair transfer. The MDS assessment indicated Resident #57 had one venous or arterial ulcers present and skin tears. The MDS assessment indicated Resident #57 received anticoagulant medications within the 7-day look back period. During an interview on 02/28/2024 at 9:24 PM, the Medical Director said one evening he had been in to assess Resident #57, and he had noticed Resident #57 had 2 spots on her skin as if somebody had grabbed her strong and a very large skin tear on her body. The Medical Director said he told the staff those were traction marks as if somebody had been holding her too tight. The Medical Director said he had told the staff they might have to use the Hoyer lift to transfer her. The Medical Director said the incident happened earlier in February 2024. Record review of Resident #57's order summary report dated 02/29/24, indicated Resident #57 had the following orders: *Apixaban (anticoagulant medication) 2.5mg tablet by mouth twice a day related to atrial fibrillation with an order start date of 12/27/2023. During an interview on 02/29/2024 at 01:08 PM, ADON E said Resident #57's skin was so fragile. ADON E said on February 5, 2024, the MD came and got her because he wanted the DON and herself to look at Resident #57's skin since Resident #57 had different scattered bruising. She said Resident #57's legs were swollen and as a group he wanted them to see what they could do to care for Resident #57. ADON E said at the time of the findings they did not know how Resident #57 had sustained the injuries. ADON E said the bruising, hematoma, shearing, and skin tear were considered injuries of unknown origin and should have had been reported immediately to the Administrator. ADON E said the DON was in Resident #57's room with her and she was the co-abuse coordinator, so she felt she was aware. ADON E said she was unable to recall if she had reported those injuries to the administrator. ADON E said it was important to report injuries of unknown origin immediately and then investigate for resident safety. ADON E said she was unaware if the injuries of unknown origin were reported to the state agency. During an interview on 03/01/2024 at 01:53 PM, the DON said when an injury of unknown origin was found, the facility must notify the state agency and investigate it. The DON said Resident #57 constantly had bruising and said she was unable to recall if the injuries found on 02/05/2024 were a new discovery. The DON said she was unsure of how Resident #57 had sustained them but believed Resident #57 had constant multiple discolored areas due to her condition. The DON said she did not believe the bruising or injuries to Resident #57 were suspicious and were due to her condition so therefore did not believe they should have been reported to the state agency . During an interview on 03/02/24 at 08:50 AM, the Regional Compliance Nurse said Resident #57's injuries should have been reported to the state agency timely when they were found. The Regional Compliance Nurse said it was the responsibility of the Administrator to have reported it to the state agency for Resident #57's safety. 4) Record review of a face sheet dated 03/02/2024 indicated Resident #52 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, with other behavioral disturbance (deterioration of memory, language, and other thinking abilities with behaviors) , anxiety disorder, and depression. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #52 was usually able to understand others and was usually understood by others. The MDS assessment indicated Resident #52 had a BIMS score of 5, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #52 had no physical, verbal, or other behaviors directed toward others. The MDS assessment indicated Resident #52 required setup or cleanup assistance with eating, supervision for oral, toileting, and personal hygiene, and partial to moderate assistance with showering and dressing. Record review of Resident #52's care plan last revised 02/02/2024 indicated Resident #52 had impaired cognitive function/dementia or impaired thought processes. Record review of Resident #52's progress notes indicated: o 02/19/2024 12:20 AM Resident #52 was very forgetful and usually confused. He was pacing, wandering, and coming in and out of his room. This resident was redirected numerous times back to his room and to bed. The last time resident was redirected back to his room, his roommate was cursing, repeatedly telling this resident, You son-of-a-bitch get out of my room! Which explained why Resident #52 would not stay in his room. CNA remained in the room with both residents until the DON and doctor were notified. DON notified immediately and stated to call the Medical Director. 12:35 AM both residents were separated with the roommate moved to another room. o Strike out note dated 2/23/2024, effective date for the note prior to strike out 02/19/2024 created by LVN C indicated, 12:20 AM the DON stated they did not have an abuse coordinator at the time, that their new administrator was supposed to start work that day (02/19/24). The DON stated to call the Medical Director and report it to him. During an observation and attempted interview on 02/23/2024 at 3:48 PM Resident #52 was observed walking down the hall with his rollator (walker with wheels). Resident #52 did not want to be interviewed at the time. During an interview on 02/26/2024 at 9:07 PM, LVN C said Resident #52 kept getting up and coming out of his room, and she kept telling him to go back to his room because it was in the middle of the night. LVN C said she finally decided to take him back to his room, and that was when she realized Resident #52's roommate, Resident #47, was yelling and cursing at Resident #52 to get out of the room and calling him a son of a bitch'. LVN C said this was really confusing Resident #52. LVN C said she called the DON, who was the abuse coordinator at the time, and she told her to keep them separated. LVN C said she called the Medical Director, and he told her to separate them and place them in 2 different rooms. Regarding the struck out note about the incident, LVN C said when she called the DON, she did not know the DON was the abuse coordinator. LVN C said the DON told her they currently did not have an abuse coordinator, but the new administrator was starting that day to notify the Medical Director. LVN C said she learned the DON was the abuse coordinator after talking to the DON on the phone. LVN C said one of her co-workers informed her if there was no administrator it automatically fell on the DON to be the abuse coordinator. LVN C said ADON E instructed her to correct her note to show that she did call the DON immediately. LVN C said after notifying the DON of the incident the night it occurred, the DON never talk to her about the incident again. LVN C said there had been a lot of changes in administrators and administration and they were not providing education on who was the abuse coordinator. LVN C said in the past she had called to report other incidents of abuse to who she thought was the abuse coordinator for them to tell her they were no longer employed at the facility. During an interview on 02/27/2024 at 8:46 AM, the DON said she was not able to recall any incident with Resident #47 and Resident #52. The DON said she did not remember an incident where Resident #47 cursed out Resident #52. The DON said the staff were supposed to report abuse to the Administrator and herself. The DON said the staff were notified when there were changes in administration one-on-one. The DON denied LVN C calling her to report when Resident #47 cursed at Resident #52. The DON said if the Administrator was not in the facility, she was the abuse coordinator. During an interview on 02/28/2024 at 3:33 PM, the Area Director of Operations said she was a consultant for the facility. The Area Director of Operations said she was there as a resource for the facility administration to reach out to her with assistance regarding the policies and procedures. The Area Director of Operations said the administrators were responsible for the facility and that is why when one administrator left an interim was put in place. The Area Director of Operations said she did not provide oversight for the facility that was the administrators responsibility because she had 10 other facilities, she was over. The Area Director of Operations said she made sure the facilities were in the green and monitored their spending to help them reach their financial goals. During an interview on 02/28/2024 at 9:24 PM, the Medical Director said there had been at least 5 administrators and half a dozen DONs and several ADONs in the past year. The Medical Director said there was no consistency, and the staff were unfamiliar with the residents and left often, which resulted in difficulty maintaining staff stability. The Medical Director said resident to resident altercations were a regular situation on the secured unit and was directly related to lack of supervision. The Medical Director said the residents should never have been left unsupervised. The Medical Director said the issue with the resident-to-resident altercations was staffing, and the facility being understaffed. The Medical Director said he had expressed his concerns regarding staffing to upper management. The Medical Director said amongst all the changes in administrators and DONs he did not know who was supposed to be keeping the facility together to prevent system failures, but he knew the Area Director of Operations was one of the major decision makers. The Medical Director said one evening he had been in to assess Resident #57, and he had noticed Resident #57 had 2 spots on her skin as if somebody had grabbed her strong and a very large skin tear on her body. The Medical Director said he told the staff those were traction marks as if somebody had been holding her too tight. The Medical Director said he had told the staff they might have to use the Hoyer lift to transfer her. The Medical Director said the incident happened earlier in February 2024 . During an interview on 03/01/2024 at 1:22 PM, the Administrator said he expected bruises to be automatically reported to him, and if not to him directly to the DON or nursing supervisor and they would report it to him. The Administrator said when he was notified of an injury of unknown injury, he would investigate it and report it within the 2 hours. The Administrator said he had not had a chance to look for Resident #44's soft file in his office (the soft file was never provided exit date 03/02/2024). The Administrator said they reviewed incidents and accidents every morning in the morning meetings and care plan the issues. The Administrator said if there was an injury of unknown origin, they should look at the last skin assessment to try to piece together a timeline, staff would be interviewed, the resident would be interviewed, if able to be interviewed. The Administrator said he expected the staff to call him and report to him any abuse concerns no matter the time of day. The Administrator said in his absence the staff should report to the DON, and the DON should report it per the requirements to HHSC and to him . During an interview on 03/01/2024 at 1:50 PM, the DON said she had started at the facility on January 13, 2024. The DON said if the nurses found a new bruise, she expected them to notify the Administrator or herself, so it could be reported to HHSC within 2 hours and investigated. The DON said the staff should report abuse to the abuse coordinator, the Administrator, and in his absence to her. During an interview on 03/02/2024 at 10:04 AM, Resident #52 said he did not remember his roommate (Resident #47) yelling and cursing at him. During an interview on 03/02/2024 at 5:36 PM, ADON E said she had been employed at the facility for 3 years, but she had been out for several months for medical reasons. ADON E said she had told LVN C to edit her note regarding notifying the DON about Resident #47 cursing at Resident #52 because the DON had denied LVN C notifying her about the incident. ADON E proceeded to say they called her and told her to tell LVN C to change her documentation. ADON E said she often gets called and instructed to tell the nurses to edit their documentation. ADON E said she could not remember who called her to instruct her to tell the nurses to edit their documentation. 5) Record review of a face sheet dated 03/02/2024 indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body), congenital insufficiency of aortic valve (heart defect that prevents blood from flowing backward through the heart), neuromuscular dysfunction of the bladder (condition where a person lacks bladder control due to brain, spinal cord, or nerve problems), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and anxiety disorder. Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #179's speech was unclear, was sometimes able to make himself understood, and understood others. The MDS assessment indicated Resident #179 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #179 was dependent on staff for all ADLs. Record review of the care plan last revised 02/23/2024 indicated Resident #179 had quadriplegia to assist with ADLs and locomotion as required. During an observation and interview on 02/26/2024 at 10:46 AM, Resident #179 said he did not like it at night. Resident #179 said CNA B was mean to him, and she throws me around with the sheet. He said CNA B ignored his call light and did not provide incontinent care. Resident #179 became very emotional and started crying because he said CNA B said she was not going to take care of him, and he had to wait to be changed until 6 AM the next morning. Resident #179 said he was not able to remember the exact day of the incident, but he had told the DON one night she had worked on the floor. Resident #179 said the DON told him she would handle it, but she never returned to tell him how she handled it. Resident #179 said CNA B was still supposed to provide care for him, but she refused to provide care to him. Resident #179 remained tearful throughout the rest of the interview. During an interview on 02/26/2024 at 12:22 PM, the DON said she had worked on the floor on the night shift to help the CNAs provide ADL care (the DON did not specify the date). The DON said no residents had reported to her any abuse allegations. The DON said if a resident reported an abuse allegation to her, she would start and investigation, fill out a grievance, and notify the abuse coordinator, the AIT, immediately, and call the Social Worker. The DON said she had talked to Resident #179, and he was a bit hard to understand, but he had not notified her of any abuse or neglect allegations. The DON said no residents had complained about CNA B to her. The DON said Resident #179 could have reported the abuse to another staff member. During an interview on 02/27/2024 at 10:35 AM, CNA B said she had been employed at the facility since October 2022, and she worked the night shift. CNA B said she provided care to Resident #179. CNA B said she answered Resident #179's call light and denied any abuse towards Resident #179 . CNA B said there were times when she was not able to provide the care required to the residents because the facility was shorthanded. CNA B said sometimes from 6 PM-10PM the facility only had 2 CNAs. CNA B said Resident #179 was needy. CNA B said Resident #179 was very needy, and he required 2 staff assist with his ADLs. CNA B said she could do what he asked her to do and ask him if he was satisfied, and when she walked out, he would turn his call light on. CNA B repeated that Resident #179 was very needy, and she would have to tell him that she had other people to take care of and he would say ok. During an observation and interview on 02/27/2024 at 4:40 PM, CNA EE and SNA O were in Resident #179's room. Upon entering room, surveyor noticed Resident #179 was crying uncontrollably and emotionally distraught. CNA EE and SNA O were attempting to reassure and comfort Resident #179. CNA EE said Resident #179 was crying because he did not want them to leave for the day (referring to the 6 AM- 6PM shift) because the night shift would not turn him or answer his call light. Resident #179 started crying even more and said CNA OO had called him a rat for telling on CNA B, took his call light away, and told him nobody wanted to answer his call light the previous night (02/26/24). Resident #179 had not reported the incident to any other facility staff . During an interview on 03/02/2024 at 10:43 AM, CNA OO said Resident #179 was a high-risk care because he was a 2-person total assist with mobility and his ADLs. CNA OO said she had never had any issues with him, and she had not taken his call light away. CNA OO said generally when she went into Resident #179's room there was another staff member with her. CNA OO said she had not called Resident #179 a rat .

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 of 24 residents (Residents #'s 33, 130 and 4), reviewed for care plans. 1. The facility failed to revise and update Resident #33's comprehensive care plan when his antidepressant was discontinued. 2. The facility failed to revise Resident #4's care plan after she fell on 2/24/2024, 2/26/2024, and 2/27/2024. 3. The facility failed to revise Resident #130's care plan after he fell on [DATE] and 11/27/2023. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: 1. Record review of Resident #33's face sheet dated 02/29/24, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #33's diagnoses included dementia (memory loss), unspecified protein calorie malnutrition (not consuming enough protein and calories), major depression, and bipolar disorder (serious mental illness characterized by extreme mood swings). Record review of Resident #33's comprehensive care plan dated 05/17/2019 and revised on 08/22/2019, indicated Resident #33 was taking antidepressant medication (Celexa) related to depression daily. The care plan interventions indicated to administer antidepressant medications as ordered by the physician. Record review of Resident #33's significant change in status MDS assessment dated [DATE], indicated Resident #33 was able to make himself understood and understood others. The MDS assessment indicated Resident #33's had a BIMS score of 13, which indicated his cognition was intact. The MDS assessment indicated Resident #33 had taken an antidepressant medication within the last 7 day look back period. Record review of Resident #33's order summary report dated 02/29/24, did not indicate Resident #33 had an order for an antidepressant medication. Record review of Resident #33's medication administration record for the month of January 2024, indicated Resident #33 received citalopram (Celexa) one time a day from 01/1/2024 until 01/16/2024 for diagnosis of major depressive disorder. The medication administration record indicated citalopram was discontinued on 01/27/2024. Record review of Resident #33's medication administration record for the month of February 2024, indicated Resident #33 did not receive any antidepressant medications for the month. During an interview on 03/01/2024 at 03:44 PM, MDS Coordinator N said since Resident #33's antidepressant was discontinued, then comprehensive care plan should have been updated to reflect as resolved. MDS Coordinator N said the MDS Coordinators were responsible for updating the comprehensive assessments when an MDS assessment was completed. MDS Coordinator N said the DON, ADON, and nurses were responsible for the acute care plans. MDS Coordinator N said by not revising and updating Resident #33's care plan when his antidepressant was discontinued, the person reading the care plan would not have accurate information. MDS Coordinator N said the comprehensive care plans were updated during their morning meeting for any acute changes. During an interview on 03/01/2024 at 3:54 PM, the DON said Resident #33's comprehensive care plan should have been updated and revised when his antidepressant medication was discontinued. The DON said the MDS Coordinator was responsible for updating and revising the care plans. The DON said failure to update Resident #33's care plan could have placed the resident at risk for receiving the antidepressant medication after it had been discontinued. During an interview on 03/02/2024 at 02:22 PM, the Interim Administrator said he expected Resident #33's comprehensive care plan to reflect he was no longer taking the antidepressant medication. The Interim Administrator said the IDT was responsible for updating and revising the care plans. The Interim Administrator said since Resident #33's care plan was not revised then it would have been assumed Resident #33 continued to receive antidepressant medication. 2. Record review of a face sheet dated 2/27/2024 indicated Resident #4 admitted on [DATE] and readmitted [DATE] with the diagnosis of diabetes, muscle weakness, lack of coordination, reduced mobility, repeated falls, dementia, and assistance with personal care. Record review of the comprehensive care plan dated 1/22/2024 and revised on 2/05/2024 indicated Resident #4 had an ADL self-care performance deficit. The goal of the care plan indicated Resident #4 would remain at her current level of function in transfers, and toileting. The care plan interventions included Resident #4 required one staff assistance with toileting. The comprehensive care plan indicated Resident #4 was at risk for falls related to weakness and impaired cognition. The goal of the care plan was Resident #4 would not sustain a serious injury. The care plan interventions included ensure Resident #4's call light was within reach dated 1/22/2024, ensure don't call fall sign at the foot of the bed visible by Resident #4 dated 1/31/2024, keep furniture in the lock position dated 1/22/2024, keep needed items, water in reach dated 1/22/2024, 1 staff to assist with transfers dated 1/22/2024, resident needs a safe environment dated 1/22/2024and frequent visual checks while in bed dated 1/21/2024 ensure proper foot wear dated 2/4/2024. The comprehensive care plan failed to address interventions for Resident #4's falls on 2/24/2024, 2/26/2024, and 2/27/2024. Record review of an admission MDS dated [DATE] indicated Resident #4 was usually understood and understands others. The MDS indicated Resident #4's cognition was moderately impaired. The MDS in section GG indicated Resident #4 required partial to moderate assistance with toileting, bed to chair transfers, toileting transfers and to sit and stand. Record review of a fall incident report dated 2/24/2024 at midnight, LVN D indicated Resident #4 ambulated without assistance and was not wearing any shoes or socks. Record review of a progress note dated 2/24/2023 at midnight, LVN D documented Resident #4 was sitting in the hallway on her bottom with her legs straight in front of her. LVN D said Resident #4 said she had slipped down. LVN D documented Resident #4 was not wearing shoes or socks. LVN D documented Resident #4 complained of right foot pain. Record review of a fall incident report dated 2/26/2024 at 10:30 p.m., LVN C indicated no injuries were observed. The incident report was left blank. Record review of a Fall-Risk assessment dated [DATE] at 10:30 p.m., LVN C documented Resident #4 was at high risk to fall. LVN C documented Resident #4 was disoriented, had 3 or more falls in the past 3 months, required assistance with elimination, had problems with balance, and took 3-4 medications which could cause falls. Record review of a Fall Nurses Note dated 2/26/2024 at 10:46 a.m., LVN F documented Resident #4 had a fall without injury. LVN F documented fall interventions were the bed low, interval monitoring, neurological checks, frequent visual checks, encourage and educate use of the call light. Record review of a progress note dated 2/26/2024 at 11:30 p.m., LVN C indicated Resident #4 said she had fallen on the floor, and she had been pulling up her pants. Record review of an incident report dated 2/27/2023 at 11:45 p.m., LVN C documented Resident #4 had a fall with no injuries noted. The incident report had no further documentation within. Record review of an Event Nurses' Note-Fall dated 2/27/2024 at 11:45 p.m., LVN C documented Resident #4 had an unwitnessed fall. LVN C documented Resident #4 was found on the floor, indicated Resident #4 said legs gave out, and Resident #4 attempted to self-toilet. LVN C documented in the area of Nursing Description: Resident #4 indicated she got up to use the bathroom, failed to call for help, denied bumping her head, and was found sitting on the floor. During an interview on 3/02/2024 at 2:46 p.m., the DON said Resident #4 should have had interventions added to her care plan for each fall. The DON said the MDS nurses were responsible for updating the care plan. The DON said she was unsure why Resident #4's care plan had not been updated with the last falls in February 2024. The DON said she was unaware LVN F was not familiar with how to update a resident's care plan. The DON said she had seen other nurses updating the care plans. The DON said the CNAs would learn of the needed fall interventions for Resident #4 and other residents by word of mouth during report. 3. Record review of a face sheet dated 2/29/2024 indicated Resident #130 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, lack of coordination, and a need for assistance with personal care. Record review of the Comprehensive Care Plan dated 9/07/2023 and revised on 12/09/2023 indicated Resident #130 was a high risk for falls related to wandering. The goal of the care plan was Resident #130 would be free of falls. The care plan interventions included to anticipate and met Resident #130's needs, ensure his call light was within reach, encourage the use of the call light, and have prompt response to the request for assistance, and ensure Resident #130 wore appropriate footwear. The comprehensive care plan failed to have interventions after the falls on 11/26/2023 and 11/27/2023. Record review of an incident report dated 11/26/2023 at 10:00 p.m., LVN C indicated Resident #130 was found by the CNA on the floor, with no signs of pain. The note indicated Resident #130 was limping on the left leg and was sent to the local emergency room at 10:35 p.m. via the ambulance. Record review of a fall risk assessment completed by LVN C on 11/26/2023 indicated Resident #130 was disoriented at all times to person, place, and time. The assessment indicated Resident #130 had no previous falls, was ambulatory, continent, had balance problems, decreased muscular coordination, and gait pattern changes. Record review of an incident report dated 11/27/2023 at 5:30 p.m., indicated Resident #130 was found with his head lying against the closet door by LVN HHH. The note indicated Resident #130 had a bruise to his right shoulder and a skin tear to his left hand. The note indicated the conclusion was Resident #130 had an unwitnessed fall with injuries. The note indicated his bed was changed to a low bed. Record review of an Event Nurses-Note dated 11/27/2023 at 6:39 p.m., indicated Resident #130 was found by LVN HHH when she was passing dining trays. The note indicated Resident #130 was lying with his head against the closet door. The note indicated Resident #130 had a skin tear. The note indicated Resident #130 had a purple bruise to his right shoulder. The note indicated Resident #130 was in pain noted by his occasional moans or groans, and facial grimacing. The note indicated Resident #130's physical factors included previous fall, urinary tract infection, pain, and incontinence. The note indicated Resident #130 required 1 staff with bed mobility, toileting, transferring, and walking. The note indicated Resident #130 leaned forward. During an interview on 3/02/2024 at 2:07 p.m., LVN F said she had never updated a resident's care plan. LVN F said she would not even know how to start. LVN F said she had been a nurse for 10 years and never had to complete an acute care plan for falls or injuries. LVN F said she relied on the nurse managers to update the care plans and said until the care plans were updated, she would use the report process to ensure other staff knew the interventions. During an interview on 3/02/2024 at 4:00 p.m., the Administrator said he was unsure how the care planning process took place in this facility since he had only been here a week. The Administrator said the care plans should be looked at with each fall to review the fall and assess the needed interventions. The Administrator said in the past the MDS nurses were responsible for updating the care plan. The Administrator said the DON was responsible. The Administrator said when the care plans were not updated with each fall, another fall could occur. During an interview on 3/02/2024 at 4:22 p.m., MDS Coordinator R said updating the care plans were a team effort. MDS Coordinator R said the nurse managers, dietary, and the social worker each update the care plan with acute care plan needs. The MDS Coordinator R said normally the falls and other changes were discussed in the morning clinical meeting and at this time the care plan should be updated. The MDS Coordinator R nurse said when the care plan was not updated with interventions more falls could occur and even falls with major injury. During an interview on 3/02/2024 at 4:29 p.m., the Regional Compliance Nurse said the DON was responsible for updating the acute care plans. The Regional Compliance Nurse said the floor nurses had not been responsible for completing the care plans. The Regional Compliance Nurse said a staff member would have an inaccurate picture of a resident's care when the care plan was not updated. Record review of an undated Comprehensive Care Planning policy indicated: The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. Interdisciplinary means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident. It does not mean that every goal must have an interdisciplinary approach. The mechanics of how the interdisciplinary team (IDT) meets its responsibilities in developing an interdisciplinary care plan (e.g., a face-to-face meeting, teleconference, written communication) is at the discretion of the facility. In instances where an IDT member participates in care plan development, review or revision via written communication, the written communication in the medical record will reflect involvement of the resident and resident representative, if applicable, and other members of the IDT, as appropriate.

CONCERN (E)

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

ADL Care (Tag F0677)

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 necessary services to maintain grooming and personal hygiene were provided for 7 of 9 residents reviewed for ADLs. (Resident #'s 9, 22, 36, 41, 57, 67, and 179) 1. The facility failed to ensure Resident #'s 9, 22, 36, 57, 67, and 179 were routinely showered/bathed. 2. The facility failed to ensure Resident # 41 was shaved. These failures could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. Findings included: 1A. Record review of Resident #22's face sheet dated 02/29/2024, indicated an [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #22 had pneumonia (infection of the air sacs in one or both lungs), cerebral infarction (stroke), hemiplegia affecting left dominant side (left sided paralysis), open wound of unspecified buttock, and need for assistance with personal care. Record review of Resident #22's comprehensive care plan dated 02/19/2021, indicated Resident #22 had a self-care performance deficit related to late effects of CVA (stroke), Hemiplegia (paralysis)/hemiparesis (weakness) to left side. The care plan interventions indicated Resident #22 required extensive to total assistance of 1 to 2 staff members as indicated for bathing/showering. Record review of Resident #22's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated Resident #22 had a BIMS score of 12, which indicated his cognition was moderately impaired. The MDS assessment did not indicate Resident #22 had behaviors or refused care. The MDS assessment indicated Resident #22 was totally dependent on staff with toileting, bathing, and dressing. The MDS assessment indicated Resident #22 was incontinent of bowel and bladder and was at risk for developing pressure ulcers/injuries. The MDS assessment indicated Resident #22 had moisture associated skin damage. During an observation and interview on 02/26/2024 at 10:11 AM, Resident #22 was lying in bed and had approximately 0.5-inch facial hair. Resident #22 said he shaved himself. Resident #22 said he had not received a bed bath in 3 weeks. Resident #22 said he felt dirty for not receiving a bed bath as desired. Record review of Resident #22's progress notes dated 01/30/2024 to 03/01/2024 did not indicate Resident #22 had refused any baths. Record review of Resident #22's follow-up question report dated 02/01/2024-02/28/2024, indicated Resident #22 received a bed bath on 02/03/2024 and 02/17/2024. Resident #22's scheduled bath days were on Tuesday, Thursday, and Saturday on the 2:00 PM- 10:00 PM shift. The facility failed to provide Resident #22 a bath/shower on 02/13/2024, 02/15/2024, 02/20/2024, 02/22/2024, 02/24/2024, and 02/27/2024 (since his last readmission to the facility on [DATE]). 1B. Record review of Resident #67's face sheet dated 02/29/2024, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #67's diagnoses included muscle weakness, unspecified protein-calorie malnutrition (not consuming enough protein or calories), cerebrovascular disease (stroke), diabetes (condition when blood sugar is too high), and lung cancer. Record review of Resident #67's admission MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated Resident #67 had a BIMS score of 12, which indicated his cognition was moderately impaired. The MDS assessment did not indicated Resident #67 had behaviors or refused care. The MDS assessment indicated Resident #67 required substantial/maximal assistance with bathing and partial/moderate assistance with toileting, dressing and personal hygiene. Resident #67 was at risk for developing pressure ulcers/injuries. Record review of Resident #67's comprehensive care plan dated 02/07/2024, indicated he had hemiplegia/hemiparesis left upper and lower extremities related to late effects of CVA with interventions to assist with ADLs/mobility as needed. During an observation and interview on 02/26/2024 at 10:05 AM, Resident # 67 was lying in bed. He appeared well groomed, and no odors were noted. However, Resident #67 said he did not know when he was scheduled to receive a bath/shower. Resident #67 said he had been receiving his baths/showers at least 2 times a week. Resident #67 said he would have liked to receive his showers/baths daily but was okay if he received them at least 3 times a week. Resident #67 said not receiving his showers/baths regularly made him feel unclean. Record review of Resident #67's progress notes dated 01/30/2024-03/01/2024 did not indicate Resident #67 had refused any showers/baths. Record review of Resident #67's follow-up question report dated 02/1/2024-02/28/2024 indicated Resident #67 received a bed bath on 02/16/2024, 02/21/2024 and 02/26/2024. Resident #67's scheduled bath days were on Monday, Wednesday, Friday on the 2:00 PM-10:00 PM shift. The facility failed to provide Resident #67 a bath/shower on 02/14/2024, 02/19/2024, and 02/23/2024 (since his last readmission to the facility on [DATE]). During an interview on 02/29/2024 at 4:11 PM, CNA BB said he worked from 2:00 PM- 6:00 PM on Resident #22's and Resident #67's hall. CNA BB said after that he went to work on another hall. He said resident shower schedules were in the resident electronic medical record. CNA BB said he provided a bath to Resident #22 a week ago. CNA BB said he had not given Resident #67 a bath. CNA BB said the nurse and the CNAs were responsible for ensuring the baths/showers were being provided as per their bath schedule. CNA BB said if a resident refused a bath/shower they would report it to the charge nurse. CNA BB said Resident #22 refused his baths at times. CNA BB said if a resident was not receiving their baths/showers regularly they were at risk for infection, skin issues and bed sores. During an interview on 02/29/2024 at 04:15 PM, SNA PPP said she worked the 6:00 AM- 6:00 PM shift and worked the hall where Resident #22 and #67 resided. SNA PPP said she was responsible for providing the showers/baths that were scheduled for 6:00 AM- 2:00 PM and was told to provide as many showers as possible for the residents that were scheduled on 2:00 PM - 10:00PM shift. SNA PPP said the 6:00 PM- 6:00 AM CAN was responsible for the showers that she could not complete on the 2:00 PM- 10:00 PM shift. SNA PPP said she had not given Resident #22 a bed bath since Resident #22 was scheduled to receive his showers/baths at night. SNA PPP said the 6:00 PM- 6:00AM shift usually did not have the staff to provide all the showers/baths that were scheduled for the 2:00 PM- 10:00 PM shift. SNA PPP said she sometimes had to work 2 halls by herself. SNA PPP said if a resident did not receive their baths/showers regularly they were at risk for buildup, urinary tract infections, skin issues and breakdown. SNA PPP said if a resident was to refuse a shower/bath after 3 times of encouraging them, she would notify the charge nurse. SNA PPP said she had given Resident #67 multiple bed baths for the month of February 2024, but if it was not documented then it did not happen. During an interview on 02/29/2024 at 04:18 PM, LVN QQQ said she was unsure of who was responsible for the residents that had baths scheduled for the 2:00 PM- 10:00 PM shift. LVN QQQ said the 6:00 AM- 6:00 PM CNAs provided as many showers/baths as possible to the residents that had their baths/showers scheduled for the 2:00 PM-10:00 PM shift. LVN QQQ said the 6:00 PM- 6:00 AM CNA was responsible for the showers/baths that the morning shift did not complete. LVN QQQ said she had questioned the previous administration staff on who was responsible for the 2:00- 10:00 PM baths previous and it was frustrating not knowing. LVN QQQ said if a resident did not receive their baths/showers as scheduled then it was a dignity issue and could cause the residents to have skin issues and breakdown. LVN QQQ said the nurse and the CNAs were responsible for ensuring the baths/showers were being provided. LVN QQQ said if the resident refused their showers/baths the resident and nurse signed the refusal sheet and be documented in their electronic medical record. LVN QQQ said Resident #22 refused his bed baths a lot of the time and Resident #67 would sometimes say he would like to wait until later that day. 1C. Record review of Resident #57's face sheet dated 02/29/24, indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included heart failure (progressive heart disease that affects pumping action of the heart muscles), atrial fibrillation (abnormal heart rhythm), weakness, protein-calorie malnutrition (not consuming enough protein or calories), and anxiety. Record review of Resident #57's comprehensive care plan dated 12/28/2023 and revised on 02/22/2024 indicated Resident #57 had an ADL self-care performance deficit with interventions she required one staff member for assistance with bathing. Record review of Resident #57's quarterly MDS assessment dated [DATE], indicated Resident #57 was usually understood and usually understood others. The MDS assessment indicated Resident #57 had a BIMS score of 12 which indicated her cognition was moderately impaired. The MDS indicated Resident #57 required partial/moderate assistance with toileting, bathing, dressing, and personal hygiene. Resident #57 required substantial/maximal assistance with chair/bed to chair transfer. The MDS assessment indicated Resident #57 had one venous or arterial ulcers present and skin tears. The MDS assessment did not indicate Resident #57 had any behaviors or refused care. During an interview on 02/28/2024 at 09:00 AM, Resident #57's family member said Resident #57 was not on a bath schedule. Resident #57's family member said Resident #57 has had to ask for a bath in the past. Resident #57's family member said they would prefer for Resident #57's showers/baths to be somewhat consistent and it was not happening. Resident #57's family member said all they had asked for, from the facility staff, was for Resident #57 to be provided a reasonable level of care and for them to have the confidence that Resident #57 was being provided the care she deserved. During an interview on 02/28/24 at 11:45 AM, Resident #57's family member they were very involved in Resident #57's care. Resident #57's family member said they had thought of putting a sign in Resident #57's room as a reminder for staff of Resident #57's scheduled bath days. Resident #57's family member said they felt they needed to remind staff of when Resident #57's baths/showers were scheduled so her baths would not be missed. Resident #57's family member said they had voiced their concerns to the corporate staff and never received a follow up phone call. Resident #57's family member said they had also reported their concerns regarding Resident #57's care to the previous administrator and her response was we can help you find another facility. Record review of Resident #57's progress notes dated 01/30/2024-03/01/2024 did not indicate Resident #57 had refused any showers/baths. Record review of Resident #57's follow-up question report dated 02/01/2024-02/28/2024 indicated Resident #57 received a bath/shower on 02/02/24, 02/05/2024, 02/07/2024, 02/12/2024, 02/14/2024, 02/16/2024, 02/19/2024, 02/23/2024, and 02/28/2024. Resident #57's scheduled bath days were on Monday, Wednesday, Friday on the 6:00 AM- 2:00 PM shift. The facility failed to provide a bath/shower to Resident #57 on 02/09/2024, 02/21/2024, and 02/26/2024. During an interview on 03/02/2024 at 02:04 PM, the DON said she expected the baths/showers to be completed according to their bath schedule unless there was an extraneous circumstance the bath/shower could not be provided. The DON said she expected the resident to have a file if they refused their bath/shower. The DON said the charge nurses and aides were responsible for ensuring the baths/showers were being provided as scheduled. The DON said there was a report she could print to indicate if the showers were being completed but she did not review it. The DON said she believed the ADONs were responsible for reviewing the report. The DON said if a resident was not receiving their bath/showers as desired, they could become upset, and it could lead to skin issues. During an interview on 03/02/2024 at 02:22 PM, the Interim Administrator said he expected the residents to receive their showers/baths on their scheduled bath day. The Interim Administrator said if a resident was to refuse their bath/shower, he expected staff to ask again or get a staff member that had a better report with the resident to ask. The Interim Administrator said if the resident continued to refuse then he expected the staff to document the refusal. The Interim Administrator said he was unsure, if a resident was to receive their baths as scheduled, helped with skin breakdown, or preventing skin issues since he was not clinical. The Interim Administrator said residents not receiving their baths/showers as scheduled was an infection control issue. 1D. Record review of Resident #36's face sheet dated 02/27/2024, indicate Resident # 36 was a [AGE] year-old female admitted to the facility on [DATE], with a diagnosis which include Metabolic Encephalopathy (a problem in the brain), morbid severe obesity due to excess calories (BMI greater than 40, a BMI of greater than 35 with at least one serious obesity-related condition, or being more than 100 pounds over your recommended weight), abnormal posture (rigid body movements and chronic abnormal positions of the body), muscle weakness (commonly due to lack of exercise, aging, muscle injury) chronic obstructive pulmonary disease (disease that causes airflow blockage and breathing-related problems). Bipolar disorder, current episode depressed, severe, without psychotic features (depressed, as in severe depressive episode without psychotic symptoms, and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past). Record review of Resident # 36's Quarterly MDS assessment dated [DATE], indicated Resident #36 was understood and was able to understand others. The MDS assessment indicated Resident #36 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #36 needs substantial or maximal assistance with showers. Record review of Resident #36's a care plan with dated 02/26/2024, indicated Resident #36 indicates Resident #36 prefers a bed bath on shower days. Staff will continue to encourage resident to utilize shower but will honor Resident #36 preference for bed bath. Record review of Resident #36's progress notes dated 02/27/2024, indicated Resident #36 requested showers on Monday, Wednesday, and Thursday between 6 AM to 2:00 PM on 2/12/2024. During an observation and interview on 02/26/204 at 10:23 A.M. Resident # 36 stated she gets her bath on Monday, Wednesday, and Friday when the facility had enough staff. Resident #36 stated she prefers a shower however it takes two staff members to use the Hoyer lift to get her up. Resident # 36 stated she prefers a shower to a bed bath because of her size. And she did not feel the staff got her clean when they gave her a bed bath. Resident #36 stated she spoke with the DON regarding getting her showers on time, but she could not remember when. 1E. Record review of Resident #9's face sheet dated 02/27/2024, indicate Resident # 9 was a [AGE] year-old female admitted to the facility on [DATE], with a diagnosis which include unspecified Dementia (mild cognitive impairment has yet to be diagnosed as a specific type of dementia), Diverticulitis of large intestine without perforation or abscess without bleeding ( a complication that can affect people with diverticulosis, small pockets on the inside of their colon), type to Diabetes Mellitus without complication ( a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), muscle weakness (a lack of muscle strength). Record review of Resident # 9's Quarterly MDS assessment dated [DATE], indicated Resident #9 was understood and was able to understand others. The MDS assessment indicated Resident #9 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #9 needed assistance with shower setup and supervision during shower time. Record review of Resident #9's a care plan with dated 08/01/2023, indicated Resident #9 was able to bathe with supervision for safety. During an observation and interview on 02/26/2024 at 12:45 P.M., Resident # 9 stated she gets her bath on Tuesday, Thursday, and Saturday unless the CNAs were too busy then she would take a wash off. Resident # 9 stated she did not get a shower on Thursday or Saturday. Resident #9 stated has not had a bath since last Tuesday. During an observation and interview on 02/29/2024 at 2:00 P.M., Resident # 9 appeared well groomed but stated she still has not had a shower. During an interview on 03/02/2024 at 2:01 P.M, CNA Z stated the CNAs are responsible for the residents' showers. CNA Z stated she was responsible for her residents on her hall and will help with showers for the 6p to 6a shift when needed. CNA Z stated it was important for resident so get showers for personal hygiene and it makes them feel better. CNA Z stated she did not know why some residents was not getting showered and could not say what other CNA's do on their shift. CNA Z stated the harm could be infections or skin break down. During an interview on 03/02/2024 at 2:24 P.M, LVN L stated it was true the residents were not getting their showers on their shower days. LVN L stated it was the charge nurse's responsibility to make sure the CNAs gave the showers on time. LVN L stated it was almost impossible to get everyone showered with the staff scheduled and would report to the ADON. LVN L stated it was important for the residents to get their showers to feel clean and comfortable. LVN L stated it could cause emotional harm and skin break down. During an interview on 03/02/2024 at 3:00 P.M, ADON E stated it was the CNAs responsibility to shower the residents and the chare nurse was to follow up. ADON E stated she expected the residents to get their shower on the scheduled day, time and in between when needed. ADON E stated it was important to shower the residents to maintain skin integrity. ADON E stated the harm could be skin break down or wounds. During an interview on 03/02/2024 at 3:33 P.M, the Administrator stated it was he expected the CNAs to shower residents on their scheduled days. The Administrator stated it was it was nursing responsibility to make sure residents get their showers. The Administrator stated it was important for resident to get showers for cleanliness. The Administrator stated it was he was unsure of the harm. The Administrator stated he would monitor by making a list and doing rounds. During an interview on 03/02/2024 at 4:15 P.M, the DON stated she expected the residents to be showered according to their schedule or request. The DON stated showers were important for skin hygiene and identifying any skin issues. The DON stated she did not know why the residents were not getting showered. If they refused or just did not remember. The DON state she would pull up a list to monitor showers. The DON stated the harm could be skin issues. 1F Record review of a face sheet dated 03/02/2024 indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body), congenital insufficiency of aortic valve (heart defect that prevents blood from flowing backward through the heart), neuromuscular dysfunction of the bladder (condition where a person lacks bladder control due to brain, spinal cord, or nerve problems). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #179's speech was unclear, was sometimes able to make himself understood, and understood others. The MDS assessment indicated Resident #179 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #179 was dependent on staff for all ADLs, including bathing. Record review of the care plan last revised 02/23/2024 indicated Resident #179 had quadriplegia to assist with ADLs and locomotion as required. The care plan indicated Resident #179 required 2 staff assistance for bathing. Record review of the Follow Up Question Report for Bathing dated 02/01/2024-02/29/2024 indicated Resident #179 was scheduled for his baths on Tuesday, Thursday, and Saturday on the 6 AM-2 PM shift. The report indicated Resident #179 received a bed bath on 02/14/2024, 02/15/2024, 02/22/2024, 02/24/2024, and 02/27/2024, which indicated he did not receive a bed bath on 02/16/2024, 02/19/2024, 02/21/2024, 02/23/2024, 02/26/2024. During an observation and interview on 02/26/2024 at 10:46 AM, Resident #179 said he was not getting his baths as scheduled. Resident #179 was noted to have musty body odor. During an interview on 02/29/2024 at 12:25 PM, ADON S said the CNAs documented the baths/showers in the resident's electronic health record. ADON S said there was not one person in charge of monitoring bathing. ADON S said she tried to make sure the residents were getting their baths/showers by getting out on the floor and checking the residents. ADON S said she checked through the documentation 2-3 times a week, and she had not noticed any missed baths. ADON S said the charge nurses and nurse management were responsible for ensuring the residents received their baths. ADON S said it was important for the residents to get their baths/showers for infection control, to make them feel better about themselves, and to prevent skin breakdown, rashes, odors, and the chances of illnesses. During an interview on 03/02/2024 at 2:08 PM, CNA EE said Resident #179 was scheduled for a bed bath on Tuesday, Thursday, and Saturday on the 6 AM-2 PM shift or the 2 PM to 10 PM shift. CNA EE said she had given Resident #179 a bed bath on Tuesday 02/27/2024. CNA EE said she had noticed sometimes Resident #179 did not get his bed baths as scheduled, and she would give him one when she noticed he had not received his bed bath. CNA EE said she had reported to management that she had noticed Resident #179 and other residents were not receiving their baths/showers as scheduled when she was not working. CNA EE said it was important for the residents to receive their bed baths/showers, so they did not have an odor, for them to be clean, and to prevent skin breakdown. During an attempted interview regarding Resident #179's baths on 03/02/2024 at 2:23 PM, CNA GGG did not answer the phone. During an interview on 03/02/2024 at 4:23 PM, the Administrator said nursing was responsible for ensuring the residents received their bathes/showers. The Administrator said it was important for the residents to receive their bathes/showers for hygiene purposes. During an interview on 03/02/2024 at 4:45 PM, LVN W said ultimately the charge nurses were responsible for ensuring the residents received their baths/showers, but the CNAs were supposed to know the schedule so they could provide the baths/showers. LVN W said she monitored to ensure the bathes were given by asking the residents, making observations of the residents, and asking the CNAs if they had given the baths/showers. LVN W said it was important for the residents to receive their baths/showers for their dignity and skin to prevent infections and skin breakdown. LVN W said showers/baths made the residents feel better and more comfortable. During an interview on 03/02/2024 at 5:15 PM, the DON said first the CNAs and the nurses were responsible for ensuring the residents received their baths/showers, and then the ADONs and herself. The DON said she monitored the bathing by checking the reports to ensure the residents were receiving their baths/showers weekly. The DON said on occasions she had noticed some of the baths were missed. The DON said she started asking the residents and making observations of the residents to see if they had received their baths/showers. The DON said it was important for the residents to receive their baths/showers to prevent skin breakdown, for cleanliness, and to prevent infection. 2. Record review of a face sheet dated 3/2/2024 indicated Resident #41 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, the need for continuous supervision, and high blood pressure. Record review of a Significant Change MDS dated [DATE] indicated Resident #41 was usually understood and sometimes understands. The MDS indicated Resident #41's cognition was severely impaired. The MDS indicated in Section E Behaviors Resident #41 had not rejected care during the assessment period. The MDS in Section GG indicated Resident #41 required substantial to maximal assistance with his personal hygiene. Record review of the comprehensive care plan dated 8/08/2023 and revised on 9/08/2023 indicated Resident #41 had a self-care performance deficit. Resident #41's care planned goal was he would maintain or improve his current level of function with his ADLs. Resident #4's care plan failed to address his preferences and assistance need for shaving. During an observation on 2/26/2024 at 9:31 a.m., Resident #41 was lying in his bed his face had ¼ inch growth of facial hair. Resident #41 said when asked if he enjoyed being clean shaven, he replied yes. Resident #41 said when asked if he shaved daily in the past, he replied yes. During an observation, and interview on 3/02/2024 at 1:59 p.m., Resident #41 was lying in his bed. CNA H viewed Resident #4's facial hair and said he needed to be shaved. CNA H said the staff had misplaced his electric razor. CNA H said the razor had been missing for approximately a week. CNA H said the care provider and responsible party was going to purchase another razor. During an interview on 3/02/2024 at 2:04 p.m., LVN F said she expected Resident #41 to be shaved on their shower days or as often as the resident desired. LVN F said the CNAs were responsible for the ADLs including personal hygiene. LVN F said Resident #41's razor had been stolen or lost was the reasoning why he had not been shaved. LVN F said she had not completed a grievance on behalf of Resident #41's lost razor. During an interview on 3/02/2024 at 2:36 p.m., the DON said the CNAs, and NAs were responsible for the personal hygiene tasks for the residents. The DON said the nurses were responsible for monitoring to ensure the ADLs were completed. The DON said the department heads completed champion rounds where they would report ADL concerns. The DON said a resident could become upset when their personal hygiene needs were not being met. During an interview on 3/02/2024 at 3:31 p.m., the Administrator said when a resident wanted to be shaved, he expected the resident to get help with this task. The Administrator said a resident could have skin issues arise when ADLs like shaving was not completed. The Administrator said the nursing department was responsible for ensuring ADLs were completed. The Administrator said the ADLs were monitored during rounds, champion rounds, and by monitoring data from the computerized systems. Record review of the facility's policy Bath, Tub/Shower dated 2003, indicated . Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from skin, and body odor to promote comfort, cleanliness, circulation, and relaxation . The frequency and type of bathing depends on resident preference, skin condition, tolerance, and energy level. The policy did no address shaving.

CONCERN (E)

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

Deficiency F0940 (Tag F0940)

Could have caused harm · This affected multiple residents

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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 4 of 21 employees (LVN QQQ, LVN C, SW, and Housekeeping Supervisor) reviewed for required annual trainings. The facility failed to ensure LVN QQQ, LVN C, the SW, and the Housekeeping Supervisor received their restraint training annually. This failure could place residents at risk for the inappropriate use of restraints. Findings included: Record review of the employee files indicated the following staff had not completed their annual restraint training: *LVN QQQ (hire date 02/01/2023), *LVN C (hire date 02/01/2023), *the SW (hire date 02/01/2023), *the Housekeeping Supervisor (hire date 02/01/2023). During an interview on 03/02/2024 at 10:23 AM the Corporate HR Specialist said LVN QQQ, LVN C, the SW and the Housekeeping Supervisor had not completed the required annual restraint training. The Corporate HR Specialist said the last restraint training that LVN QQQ and LVN C was completed on 01/25/2023. The SW and the Housekeeping last restraint trainings were completed on 01/23/2023. The Corporate HR Specialist said LVN QQQ, LVN C, the SW, and the Housekeeping Supervisors should have completed their annual restraint training in February 2024 based on their hire date. The Corporate HR Specialist said it was the responsibility of the HR Coordinator to ensure the required annual trainings were completed. The HR Specialist said staff who do not complete the required annual restraint trainings, would not be knowledgeable of restraints. During an interview on 03/02/2024 at 10:47 AM, the HR Coordinator said she was unsure how the annual required trainings for LVN QQQ, LVN C, the SW and the Housekeeping Supervisor were missed. The HR Coordinator said there was a time constraint for the staff to complete the required trainings online. The HR Coordinator said she checked the trainings daily and ensured the staff who had not completed the trainings were discussed among management. The HR Coordinator said staff who did not complete the required trainings were in serviced and disciplinary action was initiated. During an interview on 03/02/2024 at 02:04 PM, the DON said she expected restraint training to be completed upon hire and annually. The DON said the HR Coordinator was responsible for ensuring the trainings were completed timely. The DON said staff who did not complete the restraint trainings as required would not have the knowledge about restraints. During an interview on 03/02/2024 at 02:22 PM, the Interim Administrator said he expected restraint training to be completed upon hire and annually. The Interim Administrator said by staff not completing the required training annually they would be unaware of what constituted a restraint. The Interim Administrator said the HR Coordinator was responsible for ensuring the required trainings were completed. The Interim Administrator said the trainings automatically triggered for completion on the online continuing education program. Record review of the facility's policy titled New Employee Orientation dated 2015, did not address the required annual required trainings for staff.

CONCERN (F)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected most or all residents

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Based on observation, interviews, and record reviews, the facility failed provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 1 out of 1 kitchen reviewed for sufficient support personnel. 1. The facility failed to ensure the food temperatures for the chicken fried chicken patties, mechanical soft chicken fried chicken, pureed chicken fried chicken, pureed green beans and potatoes, and the mashed potatoes were held at a temperature outside the danger zone (135 degrees Fahrenheit or higher) while on the steam table. The facility did not reheat the food prior to serving. 2. The facility failed to ensure the lunch meal on 02/26/2024, 02/272024, and 02/28/2024 were served on time. There were 2 scheduled staff members each day. This failure could place residents at risks who consume food prepared in the kitchen at risk of foodborne illness. The findings included: Record review of the Meal Service Times, undated, revealed lunch meal was started at 12:00 PM for the secured unit, 12:15 PM for the dining room, and 12:20 PM for the hall trays. During an interview on 02/26/2024 beginning at 9:32 AM, [NAME] M stated the lunch meal was served at 12 PM. During an observation on 02/26/2024 between 12:19 PM and 12:59 AM, first trays were wheeled to the secured unit at 12:19 PM. The first dining room trays were served at 12:21 PM. The last trays on 400 Hall were served at 12:59 PM. During an observation on 02/27/2024 at 1:19 PM, the last meal tray was served at 1:19 PM on 400 Hall. During an observation and interview on 02/28/2024 between 12:05 PM and 12:17 PM, [NAME] M was checking the temperatures of the lunch meal that was held on the steam table. The temperatures were as follows: 1. The chicken fried chicken patties were held at 125 degrees Fahrenheit. 2. The mechanical soft chicken fried chicken was held at 130 degrees Fahrenheit. 3. The pureed chicken fried chicken was held at 132 degrees Fahrenheit. 4. The pureed green beans and potatoes were held at 128 degrees Fahrenheit. 5. The mashed potatoes were held at 125 degrees Fahrenheit. Cook M stated the temperatures should have been between 140- and 160-degrees Fahrenheit. The DM was observing [NAME] M check the temperatures at the steamtable. The DM stated the temperatures on the steamtable should have been greater or equal to 165 degrees Fahrenheit. The DM stated if the temperatures on the steam table were below 165 degrees Fahrenheit, the facility policy was to reheat the food. During an observation on 02/28/2024 beginning at 12:23 PM, [NAME] M began serving the lunch meal, while the DM called out the diet consistency needed for the meal plate. [NAME] M nor the DM reheated the food prior to serving. The last trays were served after 1 PM on the 400 Hall. During an interview on 02/28/2024 beginning at 1:21 PM, [NAME] M stated the process in the kitchen for checking temperatures was to check the temperature of the food as soon as it was finished cooking, and then just before the food was served on the steam table. [NAME] M stated she was made aware of what the temperatures should have been by reading it. [NAME] M stated if she was usure what the temperature should have been, she was supposed to have asked the DM. [NAME] M stated she has not asked the DM what the temperatures should have been on the steam table. [NAME] M stated she knew the things on the steam table were below temperatures and she should have heated them up before she served. [NAME] M stated she was stressed in the kitchen because she was the only cook and she had been working every other day double shifts. [NAME] M stated the other cook walked out and her help did not show up. [NAME] M stated she did not have the time to reheat the food and serve the food on time. [NAME] M stated the steam table did not work properly to regulate the temperatures. [NAME] M stated the food has been served late because of the lack of staff and available help in the kitchen. [NAME] M stated she tried to take her time because she did not want to serve sloppy plates to the residents. [NAME] M stated it was important to ensure food was served on time and at the proper temperatures to ensure resident did not become sick and enjoyed their food. During an interview on 03/02/2024 beginning at 4:28 PM, the DM stated reason meals had been served late during the week was because the staffing in the kitchen. The DM stated she had one cook that had been hired but until she had finished her orientation training, she was not allowed to start. The DM stated the steam table has had issues for years. The DM stated the steam table has had all kinds of repairs and still does not work sometimes. The DM stated she had no way to regulate the temperatures so she kept it as hot as she could and hoped for the best. The DM stated the week had been stressful because of the lack of staffing. The DM stated [NAME] M had been stressed because she was new to the cook position and had been working doubles all week because of the staffing problems. The DM stated it was important to ensure food was served on time and kept and served at the appropriate temperatures because the residents nutrition was important, and it affected their health and behaviors. The DM stated it was also important to ensure food was served on time and at appropriate temperatures because they were a highly susceptible age group, and it could have caused illness. During an interview on 03/02/2024 beginning at 5:04 PM, the Interim Administrator stated he expected the dietary staff to ensure food was served at the correct temperatures and cooked all the way through. The Interim Administrator stated hot food should have been hot and cold food should have been cold. The Interim Administrator stated he expected the dietary staff to ensure food was reheated per the facility policy. The Interim Administrator stated he believed the dietary staff had sufficient staffing. The Interim Administrator stated he had been in other buildings with that many staff members and they did it without issues. The Interim Administrator stated he expected the dietary staff to ensure meals were served on time and at appropriate temperatures with the number of staff the facility had. Record review of the Philosophy and Accountability of the Dietary Department policy, undated, revealed Sufficient Dietary Service personnel will be employed, oriented, trained and their working hours scheduled to provide for the nutritional needs of the residents. There must be sufficient personnel to maintain dietetic service areas. Record review of the Handling of Potential Hazardous Foods policy, undated, revealed When serving a tray line or buffet, keep .hot foods at least 140 degrees Fahrenheit . Record review of the Daily Food Temperature Control policy, undated, revealed all hot foods shall be cooked and held for service at temperatures of 140 degrees Fahrenheit or above. Record review of the Food Safety policy, undated, revealed Potential hazardous food shall be maintained at:140 degrees or above .

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for kitchen sanitation. The facility did not ensure: 1. Meat was thawing in the appropriate container and sink under constant flow of cool, running water during the initial tour on 02/26/2024. 2. The three-compartment-sink was properly used while preparing the pureed food for the lunch meal on 02/28/2024. 3. Unpasteurized eggs were used for sunny-side up and over easy eggs. 4. Food temperatures for the chicken fried chicken patties, mechanical soft chicken fried chicken, pureed chicken fried chicken, pureed green beans and potatoes, and the mashed potatoes were held at a temperature outside the danger zone (135 degrees Fahrenheit or higher) while on the steam table for the lunch meal on 02/28/2024. These failures could place residents at risk for cross contamination and food-borne illness. The findings included: During an initial tour observation in the kitchen on 02/26/2024 between 9:32 AM and 9:43 AM, there were two 10-pound packages of ground hamburger meat floating in approximately 12 inches of cool water in the sanitization sink on the three-compartment sink. During an observation and interview on 02/28/2024 at 9:36 AM, a brown cardboard box with certified eggs and an [NAME] Farms logo printed on the side was opened. Inside the box were approximately 4 crates of hard-shelled, white eggs with no P located on the eggs. There were approximately 2 crates (approximately 24 eggs per crate) missing from the opened box. [NAME] M stated she believed the eggs were pasteurized but was unable to show the surveyor where it stated that on the box or eggs. The DM stated the hard-shelled eggs were pasteurized and stated she was going to pull the order logs. The DM stated the order logs did not say if the eggs were pasteurized so she was going to call the food [NAME] where she ordered the eggs for confirmation. The DM stated several residents received sunny-side up and over easy eggs for breakfast. During an observation and interview on 02/28/2024 between 11:44 AM and 12:05 PM, [NAME] M pureed the food for the lunch meal, which included the chicken fried chicken patties, green beans and potatoes, and a roll. Between each pureed dish, [NAME] M placed the blender parts in the wash part of the three-compartment sink. There was no standing water and [NAME] M held the blender parts while she poured soap directly on the dishes, scrubbed them with a steel wool pad, and rinsed them under the running water. [NAME] M then held the blender parts over the sanitization side of the three-compartment sink, which was empty and poured the sanitizer directly on the blender parts, then placed them on the tray, while she got some paper towels. [NAME] M then used the paper towels to dry the blender parts to start on the next pureed dish. [NAME] M stated she normally used paper towels to dry the dishes because it was faster. [NAME] M stated she was running behind. During an observation and interview on 02/28/2024 between 12:05 PM and 12:17 PM, [NAME] M was checking the temperatures of the lunch meal that was held on the steam table. The temperatures were as follows: 1. The chicken fried chicken patties were held at 125 degrees Fahrenheit. 2. The mechanical soft chicken fried chicken was held at 130 degrees Fahrenheit. 3. The pureed chicken fried chicken was held at 132 degrees Fahrenheit. 4. The pureed green beans and potatoes were held at 128 degrees Fahrenheit. 5. The mashed potatoes were held at 125 degrees Fahrenheit. Cook M stated the temperatures should have been between 140- and 160-degrees Fahrenheit. The DM was observing [NAME] M check the temperatures at the steamtable. The DM stated the temperatures on the steamtable should have been greater or equal to 165 degrees Fahrenheit. The DM stated if the temperatures on the steam table were below 165 degrees Fahrenheit, the facility policy was to reheat the food. During an observation on 02/28/2024 beginning at 12:23 PM, [NAME] M began serving the lunch meal, while the DM called out the diet consistency needed for the meal plate. [NAME] M nor the DM reheated the food prior to serving. During an interview on 02/28/2024 beginning at 1:21 PM, [NAME] M stated the process in the kitchen for checking temperatures was to check the temperature of the food as soon as it was finished cooking, and then just before the food was served on the steam table. [NAME] M stated she was made aware of what the temperatures should have been by reading it. [NAME] M stated if she was usure what the temperature should have been, she was supposed to have asked the DM. [NAME] M stated she has not asked the DM what the temperatures should have been on the steam table. [NAME] M stated she knew the things on the steam table were below temperatures and she should have heated them up before she served. [NAME] M stated she did not have the time to reheat the food and serve the food on time. [NAME] M stated the steam table did not work properly to regulate the temperatures. [NAME] M stated she should not have thawed the meat in the sanitization sink. [NAME] M stated she did not normally do that but because the night staff did not take her meat out to the thaw, she needed to thaw it quickly for lunch. [NAME] M stated it was not the correct way to thaw the hamburger meat. [NAME] M stated the hamburger meat should have been in a container in the food preparation sink under cool running water. [NAME] M stated she was aware she did not properly use the three-compartment sink but was in a hurry. [NAME] M stated she was running behind and should have let the blender parts air dry. [NAME] M stated it was important to ensure food was served at the proper temperatures to ensure resident did not become sick. [NAME] M stated it was important to ensure meat was thawed correctly to prevent sickness from food-borne illness. [NAME] M stated it was important to ensure the three-compartment sink was properly used to ensure the equipment was sanitary and safe to prevent cross-contamination. During an interview on 03/02/2024 beginning at 2:23 PM, the DM stated the hard-shell eggs were not pasteurized, which she verified though the lending food company she was ordering from. The DM stated they were taken out of the building, and she would not be ordering them anymore. The DM stated she had been ordering the eggs from the time they had switched companies. The DM stated it was an honest mistake and she was not aware there were not pasteurized. The DM stated she assumed they were pasteurized. During an interview on 03/02/2024 beginning at 4:28 PM, the DM stated the steam table has had issues for years. The DM stated the steam table has had all kinds of repairs and still does not work sometimes. The DM stated she had no way to regulate the temperatures so she kept it as hot as she could and hoped for the best. The DM stated meat should not have been thawing in the sanitization side of the three-compartment sink. The DM stated she educated [NAME] M when she found out. The DM stated the meat should have been thawing in the preparation sink under cold running water. The DM stated she expected staff to ensure the three-compartment sink was utilized correctly. The DM stated all the sink sections should have had hot water. The DM stated the first sink was for washing, the second sink was for rinsing, and the third sink was for sanitization. The DM stated after the dishes were sanitize it should have been placed on the tray to air dry. The DM stated it was important to ensure food was kept and served at the appropriate temperatures because the residents nutrition was important, and it affected their health and behaviors. The DM stated it was important to ensure meat was thawed correctly to prevent bacteria from contaminating the meat. The DM stated it was also important to ensure food was served at appropriate temperatures because they were a highly susceptible age group, and it could have caused illness. The DM stated it was important to ensure the three-compartment sink was properly used to ensure dishes were sanitized to prevent contamination and food borne illness. The DM stated when the dietary department switched companies after the change of ownership, she was told the eggs ordered were pasteurized so she assumed they were pasteurized eggs. The DM stated when eggs were not pasteurized, could have held food borne illness causing bacteria that was dangerous for the elderly people who were eating sunny-side up or over easy eggs. During an interview on 03/02/2024 beginning at 5:04 PM, the Interim Administrator stated he expected the dietary staff to ensure food was served at the correct temperatures and cooked all the way through. The Interim Administrator stated hot food should have been hot and cold food should have been cold. The Interim Administrator stated he expected the dietary staff to ensure food was reheated per the facility policy. The Interim Administrator stated he expected meat to have been thawed correctly and to ensure eggs were ordered appropriately. The Interim Administrator stated he expected the dietary staff to ensure meals were served at appropriate temperatures and the three-compartment sink was utilized correctly to prevent food poisoning that could have made the residents sick. Record review of the Handling of Potential Hazardous Foods policy, undated, revealed When serving a tray line or buffet, keep .hot foods at least 140 degrees Fahrenheit .when preparing fried eggs (not pasteurized) .it is required to cook the yolk thoroughly despite possible decreased meal acceptance from residents in order to fully destroy any possible bacteria . Record review of the Daily Food Temperature Control policy, undated, revealed all hot foods shall be cooked and held for service at temperatures of 140 degrees Fahrenheit or above. Record review of the Food Safety policy, undated, revealed Potential hazardous food shall be maintained at:140 degrees or above . Record review of the Thawing Foods policy, undated, revealed foods may be thawed in the following manner .under portable running water of a temperature of 70 degrees or below, with sufficient velocity to agitate and float off loose food particles into the overflow, in a sealed package . Record review of the three-compartment sink manufactures website, titled How to Wash Dishes using a Triple sink, accessed on 03/02/2024, revealed Sink #1: press dispenser button to add the right amount of detergent for your water type and soil load .water temperature should be a tested 110 - 120 degrees Fahrenheit .Sink #3 spray or dip items into hot water until all traces of detergent and food are gone .Sink #3 soak in hot water, minimum temperature of 171 degrees Fahrenheit for 30 seconds .air drying is the only approved way of drying equipment and utensils .

Feb 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

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 4 of 20 residents (Resident's #1, #2, #3 and #4) reviewed for abuse. 1. The facility did not implement their policy on reporting abuse for a resident-to-resident altercation that occurred on 01/12/2024 between Resident #1 and Resident #2. 2. The facility did not implement their policy on reporting abuse for a resident-to-resident altercation that occurred on 11/25/2023 between Resident #3 and Resident #4. These deficient practices could place residents at risk for abuse, neglect, and not having their needs met. Findings included: Record review of the facility policy for Abuse/Neglect revised 03/29/2018, indicated, The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined in this subpart. This includes but was not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms the facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 07/10/2019 . a. If the allegations involve abuse or result in serios bodily injury, the report is to be made within 2 hours of the allegation . 1. Record review of Resident #1's face sheet, dated 02/07/2024, indicated Resident #1 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included metabolic encephalopathy (problems with metabolism cause brain dysfunction). Record review of Resident #1's quarterly MDS, dated [DATE], indicated Resident #1 understood others and made herself understood. Resident #1 had a BIMS score of 15, which indicated her cognition was intact. Record review of Resident #1's comprehensive care plan, revised 06/19/2023, indicated Resident #1 had impaired cognitive function related to the late effects of a CVA. The care plan interventions included, use the preferred name, identify yourself ay each interaction and use task segmentation to support shirt term memory deficits. Record review of Resident #2's face sheet, dated 02/07/2024, indicated Resident #2 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included encephalopathy (brain disease that alters brain function or structure). Record review of Resident #2's quarterly MDS, dated [DATE], indicated Resident #2 understood others and made himself understood. Resident #2 had a BIMS score of 10, which indicated his cognition was moderately impaired. Record review of Resident #2's comprehensive care plan, revised 12/11/2023, indicated Resident #2 had impaired cognitive function/dementia or impaired though processes possibly related to CVA (stroke). The care plan interventions included, administer medications as ordered, communicate with resident/family regarding capabilities and needs. Record review of the Provider Investigation Report dated on 01/14/2024 indicted an allegation of resident-to-resident incident on Resident #1 and #2 that occurred on 01/12/2024 at 6:00 p.m. Resident #1 reported to the nurse Resident #2 yelled at her across from the hall during the evening of 01/12/2024. Resident #1 stated Resident #2 was singing too loud and she told him to shut up, then he told her to shut up. Resident #1 stated she mumbled something back and Resident #2 stated he would kill her motherfucker. The report indicated no staff witnessed the incident. The incident was reported to the state agency on 01/14/2024 at 3:13 a.m. The provider investigation report stated the facility found the incident to be unconfirmed for abuse or neglect. Record review of the Event Nurse's Note dated 01/13/2024 at 9:40 a.m., by LVN E indicated Resident #1 stated to her that last night (01/12/2024) that man (Resident #2) was singing too loud, and she hollered and told him to shut up. Resident #1 stated he told her to shut up and she mumbled something back and then stated, I'll kill you motherfucker. During an interview on 02/07/2024 at 9:57 a.m., the previous Administrator G stated she was notified by LVN E via phone on 01/13/2024 regarding the incident that occurred between Resident #1 and Resident #2. Administrator G stated after hearing the details about the incident between Resident #1 and Resident #2, she contacted the Area Director of Operations and was instructed to report in 24 hours. Administrator G stated she should have reported within 2 hours. Administrator G stated it was important to report an allegation of abuse to verify if anyone was connected to the abuse or the perpetrator was separated from everyone else. During an interview on 02/07/2024 at 11:03 a.m., the Area Director of Operations stated she was notified by Administrator G regarding the incident between Resident #1 and Resident #2. The Area Director of Operations stated she never told her to report within 24 hours. The Area Director of Operations stated Administrator G was instructed that the incident was reportable and to see if Resident 1's family member witnessed the incident. The Area Director of Operations stated it was important to report allegations to ensure resident safety. 2. Record review of Resident #3's face sheet, dated 02/07/2024, indicated Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). Record review of Resident #3's quarterly MDS, dated [DATE], indicated Resident #3 understood others and usually made himself understood. The assessment indicated the BIMS score was not completed due to the resident unable to complete the interview. Record review of Resident #3's comprehensive care plan, revised 12/09/2023, indicated Resident #3 had potential to demonstrate physical behaviors related to dementia. The care plan interventions included provide physician and verbal cues to alleviate anxiety, give positive feedback, and assist verbalization of source of agitation. Record review of Resident #4's face sheet, dated 02/07/2024, indicated Resident #4 was an [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #4's quarterly MDS, dated [DATE], indicated Resident #4 usually understood others and made himself understood. The assessment indicated the BIMS score was not completed due to the resident unable to complete the interview. Record review of Resident #4's comprehensive care plan, revised 01/22/2024, indicated Resident #4 had impaired cognitive function/dementia or impaired though processes possibly related to dementia. The care plan interventions included, administer medications as ordered, use the resident preferred name, and identify yourself at each interaction. Record review of the Provider Investigation Report dated on 11/26/2023 indicted an allegation of resident-to-resident incident on Resident #3 and #4 that occurred on 11/25/2023 at 9:00 p.m. Resident #3 went into Resident #4's room while he was asleep and swung Resident #4 legs back and forth off the bed. The report indicated no staff witnessed the incident. The incident was reported to the state agency on 11/26/2023 at 9:28 a.m. Record review of the Event Nurses' note dated 11/25/2023 at 9:00 p.m., by LVN F indicated Resident #3 went into Resident #4's room and grabbed Resident #4 legs and swung them back and forth off the bed. During an interview on 02/07/2024 at 9:57 a.m., the previous Administrator G stated LVN F contacted her shortly after the incident around 9:11 p.m. via phone. Administrator G stated she should have reported the incident within 2 hours of the allegation. Administrator G stated the only thing she could think of why she did not report within 2 hours was to verify if the incident was considered abuse or not. Administrator G stated it was important to report allegations to verify if anyone was connected to the abuse or the perpetrator was separated from everyone else.

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 4 of 20 residents (Residents #1, #2, #3 and #4) reviewed for abuse and neglect. 1. The facility did not report the resident-to-resident altercation between Resident #1 and Resident #2 to the State Survey Agency within 2 hours of being notified. 2. The facility did not report the resident-to-resident altercation between Resident #3 and Resident #4 to the State Survey Agency within 2 hours of being notified. These failures to report could place the residents at risk for abuse. Findings included: 1. Record review of Resident #1's face sheet, dated 02/07/2024, indicated Resident #1 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included metabolic encephalopathy (problems with metabolism cause brain dysfunction). Record review of Resident #1's quarterly MDS, dated [DATE], indicated Resident #1 understood others and made herself understood. Resident #1 had a BIMS score of 15, which indicated her cognition was intact. Record review of Resident #1's comprehensive care plan, revised 06/19/2023, indicated Resident #1 had impaired cognitive function related to the late effects of a CVA. The care plan interventions included, use the preferred name, identify yourself ay each interaction and use task segmentation to support shirt term memory deficits. Record review of Resident #2's face sheet, dated 02/07/2024, indicated Resident #2 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included encephalopathy (brain disease that alters brain function or structure). Record review of Resident #2's quarterly MDS, dated [DATE], indicated Resident #2 understood others and made himself understood. Resident #2 had a BIMS score of 10, which indicated his cognition was moderately impaired. Record review of Resident #2's comprehensive care plan, revised 12/11/2023, indicated Resident #2 had impaired cognitive function/dementia or impaired though processes possibly related to CVA (stroke). The care plan interventions included, administer medications as ordered, communicate with resident/family regarding capabilities and needs. Record review of the Provider Investigation Report dated on 01/14/2024 indicted an allegation of resident-to-resident incident on Resident #1 and #2 that occurred on 01/12/2024 at 6:00 p.m. Resident #1 reported to the nurse Resident #2 yelled at her across from the hall during the evening of 01/12/2024. Resident #1 stated Resident #2 was singing too loud and she told him to shut up, then he told her to shut up. Resident #1 stated she mumbled something back and Resident #2 stated he would kill her motherfucker. The report indicated no staff witnessed the incident. The incident was reported to the state agency on 01/14/2024 at 3:13 a.m. The provider investigation report stated the facility found the incident to be unconfirmed for abuse or neglect. Record review of the Event Nurse's Note dated 01/13/2024 at 9:40 a.m., by LVN E indicated Resident #1 stated to her that last night (01/12/2024) that man (Resident #2) was singing too loud, and she hollered and told him to shut up. Resident #1 stated he told her to shut up and she mumbled something back and then stated, I'll kill you motherfucker. During an interview on 02/07/2024 at 9:57 a.m., the previous Administrator G stated she was notified by LVN E via phone on 01/13/2024 regarding the incident that occurred between Resident #1 and Resident #2. Administrator G stated after hearing the details about the incident between Resident #1 and Resident #2, she contacted the Area Director of Operations and was instructed to report in 24 hours. Administrator G stated she should have reported within 2 hours. Administrator G stated it was important to report an allegation of abuse to verify if anyone was connected to the abuse or the perpetrator was separated from everyone else. During an interview on 02/07/2024 at 11:03 a.m., the Area Director of Operations stated she was notified by Administrator G regarding the incident between Resident #1 and Resident #2. The Area Director of Operations stated she never told her to report within 24 hours. The Area Director of Operations stated Administrator G was instructed that the incident was reportable and to see if Resident 1's family member witnessed the incident. The Area Director of Operations stated it was important to report allegations to ensure resident safety. 2. Record review of Resident #3's face sheet, dated 02/07/2024, indicated Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). Record review of Resident #3's quarterly MDS, dated [DATE], indicated Resident #3 understood others and usually made himself understood. The assessment indicated the BIMS score was not completed due to the resident unable to complete the interview. Record review of Resident #3's comprehensive care plan, revised 12/09/2023, indicated Resident #3 had potential to demonstrate physical behaviors related to dementia. The care plan interventions included provide physician and verbal cues to alleviate anxiety, give positive feedback, and assist verbalization of source of agitation. Record review of Resident #4's face sheet, dated 02/07/2024, indicated Resident #4 was an [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #4's quarterly MDS, dated [DATE], indicated Resident #4 usually understood others and made himself understood. The assessment indicated the BIMS score was not completed due to the resident unable to complete the interview. Record review of Resident #4's comprehensive care plan, revised 01/22/2024, indicated Resident #4 had impaired cognitive function/dementia or impaired though processes possibly related to dementia. The care plan interventions included, administer medications as ordered, use the resident preferred name, and identify yourself at each interaction. Record review of the Provider Investigation Report dated on 11/26/2023 indicted an allegation of resident-to-resident incident on Resident #3 and #4 that occurred on 11/25/2023 at 9:00 p.m. Resident #3 went into Resident #4's room while he was asleep and swung Resident #4 legs back and forth off the bed. The report indicated no staff witnessed the incident. The incident was reported to the state agency on 11/26/2023 at 9:28 a.m. Record review of the Event Nurses' note dated 11/25/2023 at 9:00 p.m., by LVN F indicated Resident #3 went into Resident #4's room and grabbed Resident #4 legs and swung them back and forth off the bed. During an interview on 02/07/2024 at 9:57 a.m., the previous Administrator G stated LVN F contacted her shortly after the incident around 9:11 p.m. via phone. Administrator G stated she should have reported the incident within 2 hours of the allegation. Administrator G stated the only thing she could think of why she did not report within 2 hours was to verify if the incident was considered abuse or not. Administrator G stated it was important to report allegations to verify if anyone was connected to the abuse or the perpetrator was separated from everyone else. Record review of the facility policy for Abuse/Neglect revised 03/29/2018, indicated, The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined in this subpart. This includes but was not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms the facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 07/10/2019 . a. If the allegations involve abuse or result in serios bodily injury, the report is to be made within 2 hours of the allegation .

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 4 (NA A, NA B, NA C, and Hospitality Aide D) of 4 staff reviewed for demonstration of skills and techniques necessary for residents' needs. The facility failed to conduct competency assessments for NA A, NA B, NA C, and Hospitality Aide D. These failures could place residents at risk for not receiving the appropriate care and services to maintain their health and safety. Findings included: Record review of personnel file for NA A with hire date [DATE] indicated no evidence of skill competency checkoffs. Record review of personnel file for NA B with hire date [DATE] indicated no evidence of skill competency checkoffs. Record review of personnel file for NA C with hire date [DATE] indicated no evidence of skill competency checkoffs. Record review of personnel file for Hospitality Aide D with hire date [DATE] indicated no evidence of skill competency checkoffs. During an interview on [DATE] at 5:57 PM, Hospitality Aide D said she was no longer employed at the facility. Hospitality Aide D said her CNA license was expired. Hospitality Aide D said she was not supposed to perform the job duties of a CNA, but she had worked on the secured unit multiple occasions and provided ADL care, such as incontinent care, to the residents on her own. Hospitality Aide D said she had performed the job duties of a CNA because the facility was sometimes short staffed. Hospitality Aide D said she did not know if a competency check off had been performed on her. During an interview on [DATE] 9:58 AM, the Unit Manager said the ADON and herself were responsible for completing the staff competencies. The Unit Manager said CNA A, CNA B, and CNA C were currently employed at the facility, and they had completed the student nurse aide class and were waiting to test to obtain their certification. The Unit Manager said CNA A, CNA B, and CNA C were able to work on the floor as nurse aides. The Unit Manager said she did not complete competency check offs for the nurse aides. The Unit Manager said it was important for the competency check offs to be completed for the safety and well being of the residents. During an interview on [DATE] at 12:01 PM, the Regional Clinical Consultant said nurse management (DON, ADON, Unit Manager) was responsible for completing the competency check offs. The Regional Clinical Consultant said she did not know if the competencies were completed because they had changes in DON and administrators. The Regional Clinical Consultant said the competencies were completed to ensure the staff were trained and knew how to perform the skills necessary to complete their job. The Regional Clinical Consultant said Hospitality Aide D was taking the nurse aide class, but she had not made it to the end of the class because she was terminated. The Regional Clinical Consultant said Hospitality Aide D received enough training so she could work on the floor. During an interview on [DATE] at 1:51 PM, the Administrator said her first day at the facility was Monday ([DATE]), and her expectations were for the nurse aides' competencies to be completed per the policy. The Administrator said typically the DON was responsible for ensuring the competencies were completed. The Administrator said it was important for the competencies to be completed for quality of care. During an interview on [DATE] at 1:55 PM, the DON said it was her third day in the building. The DON said the nurse aide competency check offs should be done on hire. The DON said the Unit Manager was responsible for completing the nursing staffs' competencies. The DON said it was important for the competencies to be completed to ensure they knew the policies, what they were doing and were not abusing the residents, and to correct the staff if they were doing something wrong. During an interview on [DATE] at 2:39 PM, the ADON said the Unit Manager normally did the competency check offs, but she had not been working and just returned to the facility in January. The ADON said the competency check offs should be completed while the nurse aides trained within the first three days of hire. The ADON said the nurse aides' competency check offs were not completed because she must have overlooked it upon the other tasks she had to perform in the facility. The ADON said Hospitality Aide D was only supposed to be passing ice and working alongside other CNAs in the facility. The ADON said to her knowledge Hospitality Aide D did not perform any patient care on her own. The ADON said it was important for the competency check offs to be completed to ensure all skill sets were met, and they knew what they were doing. During an interview on [DATE] at 2:11 PM, the Human Resource Coordinator said she did not collect the competency check offs that nursing was responsible for completing them. The Human Resource Coordinator said it was important for the competency check offs to be completed to ensure the staff understood their duties. Record review of the facility's Facility Assessment, Staff Competencies indicated Person-centered care All staff - on hire, annually and as needed, Activities of Daily Living Nursing staff - on hire, annually and as needed, Infection Control-Hand Hygiene All staff- on hire, annually and as needed, Infection Control Universal Precautions All staff- on hire, annually and as needed, Infection Control-Protective Equipment All staff- on hire, annually and as needed, Caring for People with Dementia. Alzheimer's and Cognitive Impairments All staff- on hire, annually and as needed, Caring for Residents with Mental and Psychosocial disorders All staff- on hire, annually and as needed, Non-Pharmacological management of Responsible Behaviors All staff- on hire, annually and as needed.

Nov 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0692 (Tag F0692)

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 maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 3 residents reviewed for nutritional status(Resident #1). The facility failed to ensure Resident #1 did not have a significant weight loss in 30 days. The facility failed to re-weigh Resident #1 after the Dietician recommended it on 10/21/23. This failure could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life. Findings Include: Record review of the consolidated physician orders dated 11/20/2023 indicated Resident #1 was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including unspecified dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities) with other behavioral disturbance, presence of right artificial hip joint, unspecified protein-calorie malnutrition, and lack of coordination. The consolidated physician orders indicated Resident #1 had a diet order on 11/15/2023 of regular, health shake 3x daily, PROSTAT (a concentrated liquid protein medical food) 30CC BID . The consolidated physician orders indicated Resident #1 had an order dated 08/08/23 to be weighed monthly. Record review of the MDS - Resident Assessment and care Screening - Nursing Home Comprehensive dated 11/06/23 indicated Resident #1 rarely/never understood others and was rarely/never understood by others. The MDS showed a BIMS score of 99 which indicated the resident was unable to complete the interview. The MDS indicated Resident #1 was dependent with toileting and required maximum assistance with bed mobility, transferring, dressing, personal hygiene. The MDS indicated Resident #1 required set-up and clean-up assistance with eating. The MDS indicated Resident # 1 was 71 inches in height and 153 pounds in weight. Record review of the care plan updated on 11/10/2023 indicated Resident #1 had a potential nutritional problem including weight loss and dehydration. The Care Plan interventions included to weigh the resident monthly and as indicated. The Care Plan did not address Resident #1's significant weight loss or gain. Record review of the monthly weights indicated in July 2023 Resident #1 weighed 144.2 pounds. The monthly weight report indicated in August 2023 he weighed133 pounds. The monthly weight report indicated in September 2023 Resident #1 weighed 135 pounds. The monthly weight report indicated in October Resident #1 weighed 152.6 pounds, which indicated a significant weight gain. The monthly weight report indicated in November 2023 he weighed 102 pounds, which indicated a significant weight loss. Record review of the Dietician's quarterly progress note dated 10/21/2023 indicated Resident #1 had a weight of 152.6 pounds. The progress noted indicated Resident #1 had a 13 percent weight gain x 1 month. The progress note indicated Resident #1's usual intake was 75% and he required assistance with feeding at times. The progress note indicated the Dietician recommended 1. Change Prostat to 30 milliliters twice a day 2. Reweigh to verify weight of 152 pounds. Record review of the monthly weights indicated Resident #1 had not been re-weighed in the month of October. Record Review of the progress noted dated 11/19/2023 indicated Resident #1 was sent to the hospital after a fall. Record review of the hospital admission record dated 11/20/2023 indicated Resident #1 was admitted on [DATE] with a diagnosis of dehydration. During an interview on 11/20/2023 at 10:13 a.m., CNA X said the assigned CNA weighed the residents in the facility. CNA X said the aides weigh the residents when assigned and turned the weight into the nurses. CNA X said it was the responsibility of the nurses and ADONs to ensure weights were being performed. CNA X said the importance of monitoring the residents' weights was to monitor for significant weight gain or loss. During an interview on 11/20/2023 at 12:48 p.m., LVN Y said the assigned CNA performed weights on residents in the facility. LVN Y said it was the responsibility of the DON and ADON's to ensure weights were being performed. LVN Y said the importance of monitoring the residents' weights was to monitor for significant weight gain or loss. LVN Y said Resident #1 required assistance with eating most of the time including set up and feeding. LVN Y said Resident #1 needed to be reminded to eat and drink. During an interview on 11/20/2023 at 11:58 a.m., the Regional Compliance Nurse said CNAs weighed the residents monthly and as ordered. The Regional Compliance Nurse said it was the nurse's responsibility to inform the CNA's who needed to be weighed and when. The Regional Compliance Nurse said the importance of weighing residents monthly and as ordered was to monitor for significant weight fluctuations which could indicate a need for change in diet consistency, trouble swallowing, and/or fluid overload. The Regional Compliance Nurse said the facility had standing orders if a resident had a significant change in weight to begin weighing them weekly for 4 weeks and to notify the dietician . The Regional Compliance Nurse said the ADON and DON were responsible for monitoring the weights and ensuring the residents were weighed. The Regional Compliance Nurse said the ADON and/or DON usually had an aide assist with weighing the residents. The Regional Compliance Nurse said if a resident had a significant change in weight the facility would notify the physician, dietician, and family. The Regional Compliance Nurse said it was the responsibility of the ADONs and DON to ensure orders were being followed and changes in condition including significant weight changes were reported to the physician, dietician (if indicated), and family. During an interview on 11/20/2023 at 3:32 p.m., the Regional Compliance Nurse said she was not aware the Dietician had requested Resident #1 be weighed again. The Regional Compliance Nurse said they needed to establish a new baseline for Resident #1's weight upon his return from the hospital. She stated she is currently working on getting the weights completed through out the facility since the ADON, DON and staff had quit on Tuesday, November 14, 2023. The Regional Compliance Nurse said she had covered the vacant positions with other employees from the sister companies. Record review of Nutrition policy revised 02/13/2007 indicated, All residents will be weighed by the 10th of the month and their weights documented correctly. The appropriate actions regarding significant changes will be carried out .The DON or designee will review all weights to determine the need for any re-weighs. Re-weighs will be completed within 24 hours of the first weight. Weight Loss: Significant weight loss (5% in 1 month, 7.5% in three months, or 10% in six months) .Significant Weight Gain - The facility review resident weights after monthly weights after monthly are obtained, to determine residents with significant weight changes .

Aug 2023 2 deficiencies

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

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 residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs were provided for 1 of 4 residents reviewed for accommodation of needs (Resident #2). The facility failed to ensure ADL dependent Resident #2's call light was placed within his reach. This failure could place dependent residents at risk of injuries and unmet needs. Findings included: 1. Record review of the face sheet for Resident #2 indicated he was [AGE] years old re-admitted to facility on 7/29/22 with diagnoses including dementia, schizophrenia, shortness of breath, anxiety, muscle weakness and need for assistance with personal care. Record review of Resident #2's MDS assessment dated [DATE] indicated Resident #2 sometimes made himself understood and sometimes understood others. The MDS indicated Resident #2 had severe cognitive impairment (BIMS of 4). The MDS indicated he had no behavior of rejecting care. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The MDS indicated he was totally dependent on staff for bathing. The MDS indicated Resident #2 was frequently incontinent of urine and bowel. Record review of the care plan revised on 7/5/23 indicated Resident #2 had a self-care deficit. The care plan indicated he required extensive to total assistance with ADLS including bathing/showering; bed mobility; dressing; toilet use, and transfers. During an observation on 8/3/23 at 1:45 p.m., Resident #2 laid asleep in his bed. Resident #2's call light was not in reach. Both call lights for the room were tied to Resident #2's roommate's bed. Resident #2 woke up as surveyor approached the side of his bed. When asked if needed anything Resident #2 said no. During an observation on 8/3/23 at 3:00 p.m., Resident #2 laid asleep in his bed. Resident #2's call light was not in reach. Both call lights for the room were tied to Resident #2's roommate's bed. During an observation on 8/4/23 at 9:30 a.m., Resident #2 was not in his room. Both call lights for the room were tied to Resident #2's roommate's bed. During an observation on 8/4/23 at 1:40 p.m., Resident #2 laid in his bed. When asked if he needed any help from the staff last night he said no I don't need anything. When asked if he knew where his call light was in order to call for help if needed, he replied I don't know. During an observation on 8/4/23 at 1:47 p.m., Resident #2 laid asleep in his bed. Resident #2's call light was not in reach. Both call lights for the room were tied to Resident #2's roommate's bed. During an interview on 8/4/23 at 1:50 CNA F said MA G had placed Resident #2 back in his bed after lunch to help her (CNA F). CNA F said she had recently checked on and provided incontinent care to Resident #2 and had not noticed the call light was not in reach and had not noticed the call light was tied to his (Resident #2's) roommate's bed. CNA F said she should have made sure the call light was in reach before leaving the room after she provided care. CNA F said it was important to ensure call lights were within residents' reach before leaving the room so that they could call if they needed anything. CNA F said Resident #2 did not really use his call light but said the call light should be within his reach. During an interview on 8/4/23 at 1:55 p.m., LVN E said she had been in Resident # 2's room earlier in the day and did not notice the call light was tied to Resident #'2s roommate's bed. LVN E said it was very important to ensure call lights were within the residents' reach before leaving the room so that they could call if they needed anything. LVN E said the resident's need could be as simple as needing a drink of water or could be in need due to an emergency. LVN E said she was not sure Resident #2 was really cognitive enough to use the call light, but said the call light should have been within his reach. During an interview on 8/4/23 at 2:10 p.m., MA G, said she was also a CNA. MA G said she assisted Resident #2 back to bed after lunch to help out LVN E and CNA F. MA G said she was in a hurry, placed him in the bed, and let LVN E and CNA F know she had just placed him in the bed and that he needed to be checked in order to determine if incontinent care was needed. MA G said she completely forgot to ensure his call light was within his reach before leaving the room. MA G said it was important to ensure resident call lights were within reach because they would not have any way to alert staff they needed assistance otherwise. During an interview on 8/4/23 at 2:22 p.m., the DON said it was not acceptable for Resident #2's call light to have been tied to his roommate's bed and should have been within his reach. The DON said the newly initiated Champion rounds would be checking for compliance with call light placement within the reach of the resident. The DON explained Champion Rounds by saying a group of residents were assigned to each department head, and the department heads would round on their assigned residents daily (Monday through Friday). In addition to the resident rounding, the assigned department head was to contact the resident's representative/family to discuss any concerns weekly. The DON said it was important for call lights to be within reach of all residents because a need could not be provided for if the resident could not alert the staff. The DON said she had started an in-service immediately upon being informed Resident #2's call light had been tied to his roommate's bed. During an interview on 8/4/23 at 2:50 p.m., the Administrator said she expected staff to ensure call lights were in reach of all residents, not just residents that were dependent on staff for ADL care. The Administrator said the Champion rounds would be checking for compliance with call light placement. During an interview on 8/4/23 at 2:55 p.m. the DON said the facility did not have a policy and procedure regarding the placement of call lights.

CONCERN (E) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

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 necessary services to maintain good grooming and personal hygiene for a resident who is unable to carry out activities of daily living were provided for 1 of 4 residents reviewed for activities daily living (Resident #1) The facility did not ensure Resident #1 was provided a bath or shower from 7/22/23 to 8/1/23. These failures could place dependent residents at risk of poor hygiene, infections, injuries and unmet needs. Findings included: 1.Record review of the face sheet for Resident #1 indicated he was [AGE] years old and re-admitted to the facility on [DATE] with diagnoses including history of stroke, hemiplegia/ hemiparesis affecting the left non-dominant side (muscle weakness or partial paralysis on one side of the body), reduced mobility, need for assistance with personal care, high blood pressure, and heart disease. Record review of Resident #1's MDS assessment dated [DATE] indicated Resident #1 made himself understood and understood others. The MDS indicated Resident #1 was cognitively intact (BIMS of 14). The MDS indicated he had no behavior of rejecting care. The MDS indicated he required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS indicated he was totally dependent on staff for transfers, locomotion in his wheelchair, and bathing. The MDS indicated he was frequently incontinent of urine and always incontinent of bowel. Record review of the care plan revised on 6/30/23 indicated Resident #1 had a self-care deficit related to hemiplegia/hemiparesis effects of stroke. The care plan indicated he required extensive to total assistance with ADLS including bathing/showering; dressing; and personal hygiene. During an interview on 8/3/23 at 10:27 a.m., Resident #1's visitor A said she was at the facility on 7/22/23 to visit Resident #1. Resident #1's visitor said he (Resident #1) wore a fluorescent orange wrangler brand shirt with a front pocket when she saw him that day (7/22/23). Visitor A said when she returned to the facility on 7/30/23 to visit Resident #1 he had the exact same shirt on. Visitor A said before leaving the facility on that day (7/30/23) she complained to facility staff that Resident #1 needed to be bathed and have his shirt changed. Visitor A said she did not know the name of the staff member to whom she made the complaint. Visitor A said it was not right it took her complaining for Resident #1 to have been bathed and his shirt changed. Visitor A said Resident #1 finally received a bath and had his shirt changed on 8/2/23. During an interview and observation on 8/3/23 at 11:35 a.m., Resident #1 laid in his bed. Resident #1 said he had received a bed bath and had his shirt changed yesterday (8/2/23). Resident #1 said before yesterday (8/2/23) it had been every bit of 2 weeks since he had been bathed. Resident #1 said he did not know how long he had the bright orange shirt on. Resident #1 said he did not recall if he had asked anyone to give him a bath or change his shirt during that time. During an interview on 8/4/23 at 12:46 p.m., Resident #1's visitor B said he was at the facility on Sunday 7/23/23; Monday 7/24/23; Wednesday 7/26/23; Friday 7/28/23; and Sunday 7/30/23. Visitor B said Resident #1 had the same shirt on every day he (visitor B) saw him (Resident #1). Visitor B said he noticed on Wednesday 7/26/23 the shirt had a spot of vomit on the right shoulder. Visitor B said he knew it was a spot of vomit on the shirt because he asked Resident #1 what was on his shirt (referencing the spot on the right shoulder). Visitor B said he (Resident #1) told him he had vomited earlier and could not reach his call light. Visitor B said he asked Resident #1 don't you think you should have them (facility staff) should change it? Visitor B said Resident #1 said, they probably should. Visitor B said he did not ask any of the facility staff about changing the shirt and thought he should not have to do so. Record review of the undated facility shower/bath schedule indicated Resident #1's shower schedule was every Tuesday, Thursday, and Saturday on the 2:00 p.m.-10:00 p.m. shift. Record review of the Bathing ADL documentation for Resident #1 from 7/20/23 to 7/29/23 indicated the following on the scheduled bath dates; 7/22/23 at 7:44 p.m., (Saturday)Resident #1 received a bed bath; 7/25/23 at 9:45 p.m., (Tuesday) Resident #1 refused a bed bath; 7/27/23 at 7:53 p.m., (Thursday) Resident #1 received a bed bath; and 7/29/23, (Saturday) - no documentation. Record review of the staffing sheet for 7/22/23 indicated Resident #1 was assigned to CNA C and NA D on the 2:00 p.m. to 10:00 p.m. shift. Record review of the staffing sheet for 7/25/23 indicated Resident #1 was assigned to CNA C and NA B on the 2:00 p.m. to 10:00 p.m. shift. The staffing sheet indicated LVN A was assigned to Resident #1 on the 6:00 p.m. to 6:00 a.m. shift. Record review of the staffing sheet for 7/27/23 indicated Resident #1 was assigned to CNA C on the 2:00 p.m. to 10:00 p.m. shift. Record review of the staffing sheet for 7/29/23 indicated Resident #1 was assigned to NA B on the 2:00 p.m. to 10:00 p.m. shift. During an interview on 8/4/23 at 12:35 p.m., CNA C said she regularly worked the hall Resident #1 resided on during the 2-10 p.m. shift. CNA C said Resident #1 would sometimes refuse a bath. CNA C said if she provided a bed bath to a resident she would not place the same shirt on the resident. CNA C said she could not recall what Resident #1 wore when she cared for him on 7/22/23, 7/25/23 and 7/27/23. CNA C said she could not even say for sure which if any of those days she provided direct care/ had been assigned to bathe Resident #1 during those dates. CNA C clarified, if another NA or CNA was also assigned to the hall Resident #1 resided on, the residents on the hall would be divided between the two of them. CNA C said she was not sure if Resident #1 refused a bath between 7/22/23 and 7/27/23. CNA C said if she had cared for Resident #1 and he refused a bath she would have notified the nurse. During an interview on 8/4/23 at 1:15 p.m., Resident #1 said he might have thrown up last week but was not sure. When asked about the having a spot on his shirt he said maybe it was food. Record review of the nursing progress notes for Resident #1 from 7/4/23 to 8/4/23 documented no episodes of vomiting and no refusals of care. Record review of the MAR for July 2023 indicated there had been no as needed antiemetic (anti-vomiting) medications administered to Resident #1. A phone interview with NA D was attempted on 8/4/23 but was not completed. A phone interview with NA B was attempted on 8/4/23 but was not completed. A phone interview with LVN A was attempted on 8/4/23 but was not completed. During an interview on 8/4/23 at 2:22 p.m., the DON said she was not aware Resident #1's visitors had made any complaint he had not had a bath nor his shirt changed since 7/22/23. The DON said if any resident refused a bath/shower she expected CNAs to chart the refusal in the ADL record and notify the charge nurse. The DON said the refusal did not necessarily have to be charted in a nursing progress note. The DON said the system in place to ensure residents received baths/showers had recently been implemented. The DON said this system was called champion rounds. The DON explained a group of residents were assigned to each department head, and the department heads would round on their assigned residents daily (Monday through Friday). In addition to the resident rounding, the assigned department head was to contact the resident's representative/family to discuss any concerns weekly. She said these rounds were not specifically over bathing/showering but ADL care among other items were to be assessed during these rounds. The DON said it was important for residents to receive scheduled baths/showers not only for hygiene but also for skin integrity. During an interview on 8/4/23 at 2:50 p.m., the Administrator said she expected staff to ensure residents' ADL needs were provided for including changing clothes and providing showers/baths. Record review of the undated facility policy and procedure titled Bath, Tub/Shower, stated .The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed.

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?"
"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, 8 life-threatening violation(s), $237,792 in fines, Payment denial on record. Review inspection reports carefully.
• 48 deficiencies on record, including 8 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $237,792 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 Brentwood Terrace Healthcare And Rehabilitation's CMS Rating?

CMS assigns BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION 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 Brentwood Terrace Healthcare And Rehabilitation Staffed?

CMS rates BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 46%, compared to the Texas average of 46%.

What Have Inspectors Found at Brentwood Terrace Healthcare And Rehabilitation?

State health inspectors documented 48 deficiencies at BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION during 2023 to 2025. These included: 8 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 40 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 Brentwood Terrace Healthcare And Rehabilitation?

BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION 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 CREATIVE SOLUTIONS IN HEALTHCARE, a chain that manages multiple nursing homes. With 119 certified beds and approximately 80 residents (about 67% occupancy), it is a mid-sized facility located in PARIS, Texas.

How Does Brentwood Terrace Healthcare And Rehabilitation Compare to Other Texas Nursing Homes?

Compared to the 100 nursing homes in Texas, BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION's overall rating (1 stars) is below the state average of 2.8, staff turnover (46%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Brentwood Terrace Healthcare And Rehabilitation?

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?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.

Is Brentwood Terrace Healthcare And Rehabilitation Safe?

Based on CMS inspection data, BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION 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 8 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 Brentwood Terrace Healthcare And Rehabilitation Stick Around?

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

Was Brentwood Terrace Healthcare And Rehabilitation Ever Fined?

BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION has been fined $237,792 across 2 penalty actions. This is 6.7x the Texas average of $35,457. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Brentwood Terrace Healthcare And Rehabilitation on Any Federal Watch List?

BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION 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: 119
Avg. Residents: 80
Occupancy: 67.5%
Ownership: For profit - Limited Liability company
Chain: CREATIVE SOLUTIONS IN HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
8 Immediate Jeopardy citations: -96
48 Deficiencies: -10
Fines ($237,792): -15
Abuse Finding: -15
Final Score: 0/100

Nearby Alternatives

HERITAGE HOUSE AT PARIS REHAB ... 3-star PARIS HEALTHCARE CENTER 2-star LEGEND HEALTHCARE AND REHABILI... 2-star

View all in PARIS →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 676045