Does GARNET HILL REHABILITATION AND SKILLED CARE have any serious inspection findings?

Yes, GARNET HILL REHABILITATION AND SKILLED CARE has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 43 total deficiencies from recent inspections.

What are the staffing levels at GARNET HILL REHABILITATION AND SKILLED CARE?

GARNET HILL REHABILITATION AND SKILLED CARE has a four-star staffing rating from CMS with 0.73 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is GARNET HILL REHABILITATION AND SKILLED CARE located?

GARNET HILL REHABILITATION AND SKILLED CARE is located in WYLIE, TX. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does GARNET HILL REHABILITATION AND SKILLED CARE have?

GARNET HILL REHABILITATION AND SKILLED CARE has 128 certified beds.

Who owns GARNET HILL REHABILITATION AND SKILLED CARE?

GARNET HILL REHABILITATION AND SKILLED CARE is a government - hospital district facility and is part of the STONEGATE SENIOR LIVING chain.

GARNET HILL REHABILITATION AND SKILLED CARE

Name: GARNET HILL REHABILITATION AND SKILLED CARE
Address: 1420 MCCREARY RD, WYLIE, TX, 75098, US
Telephone: (972) 442-6776
Rating: 2.0

1420 MCCREARY RD, WYLIE, TX 75098 · (972) 442-6776

Government - Hospital district 128 Beds STONEGATE SENIOR LIVING Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

13/100

#719 of 1168 in TX

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Last Inspection: January 2025

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

Overview

Garnet Hill Rehabilitation and Skilled Care has received a Trust Grade of F, indicating significant concerns and poor overall quality. They rank #719 out of 1168 facilities in Texas, placing them in the bottom half, and #47 out of 83 in Dallas County, meaning only a handful of local options are better. The facility is worsening, with the number of issues rising from 4 in 2024 to 12 in 2025. While staffing is a strength, rated at 4 out of 5 stars with a low turnover rate of 22%, there are serious concerns, including a critical incident where a resident was subjected to sexual abuse by a visitor. Other serious findings include failures to repair a water leak, leading to an injury, and significant medication errors that could affect the health of residents. Overall, families should weigh the strengths in staffing against the serious safety issues and declining quality of care.

Trust Score: F
In Texas: #719/1168
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 22% annual turnover. Excellent stability, 26 points below Texas's 48% average. Staff who stay learn residents' needs.
Penalties: $40,290 in fines. Higher than 75% of Texas facilities, suggesting repeated compliance issues.
Skilled Nurses: Each resident gets 43 minutes of Registered Nurse (RN) attention daily — more than average for Texas. RNs are trained to catch health problems early.
Violations: 43 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★☆☆

3.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 4 issues

2025: 12 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
Low Staff Turnover (22%) · Staff stability means consistent care
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover is low (22%)
26 points below Texas average of 48%

Facility shows strength in staffing levels, staff retention, fire safety.

The Bad

2-Star Overall Rating

Below Texas average (2.8)

Below average - review inspection findings carefully

Federal Fines: $40,290

Above median ($33,413)

Moderate penalties - review what triggered them

Chain: STONEGATE SENIOR LIVING

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 43 deficiencies on record

1 life-threatening 2 actual harm

Jul 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #1) reviewed for accident hazards.Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure CNA D did not transfer Resident #1 using a Hoyer lift (a mechanical lift used to transfer an individual with limited mobility) by herself on 07/16/2025. This failure could place residents at risk of injury. Findings include: Record review of Resident #1's face sheet, dated 07/16/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included muscle weakness. Record review of Resident #1's Comprehensive MDS Assessment, dated 07/01/25, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment reflected the resident required extensive assistance with ADL care. Record review of Resident #1's Comprehensive Care Plan, dated 07/16/25, reflected the resident was incontinent of urine and bowel one of the approaches was for hygiene as needed after every incontinent episode to maintain dignity. In an observation and interview on 07/16/25 at 11:20 AM, Resident #1 was observed lying in bed and the Hoyer lift still positioned over her bed. There was only 1 CNA observed in the room. CNA D stated she and CNA S had assisted her in using the Hoyer lift to move the resident from her wheelchair to her bed. CNA D stated CNA S had just left the room. In an interview on 07/16/25 at 11:25 AM, Resident #1 stated it was only CNA D who was in the room using the Hoyer lift. She stated a lot of the time there was only 1 staff member using the Hoyer lift to get her out of and into her bed. In an interview on 07/16/25 at 12:20 PM, CNA she stated she did not assist CNA D with the transfer of Resident #1 from her wheelchair to the bed. She stated two people were required to operate the Hoyer lift to prevent the resident from falling. In an interview on 07/16/25 at 12:15 PM, ADON K was advised CNA D was observed in Resident #1's room with a Hoyer lift, the resident was apparently moved from her wheelchair to her bed, and she was the only staff member in the room. She was advised the resident stated CNA D was the only staff member who operated the Hoyer lift to move her into the bed. She stated they had just completed an in-service on Hoyer lifts, and the requirement was for two staff members to always use it. She stated the risk of not having two people, could result in the resident falling and getting injured. In an interview on 07/16/25 at 12:50 PM, CNA D was advised that CNA S was interviewed, and she denied assisting her with the Hoyer lift for Resident #1. CNA D stated she was trying to find someone else to assist her but could not. She stated they were supposed to use two people to operate the Hoyer lift for safety and to avoid the resident falling. In an interview on 07/16/25 at 2:17 PM, the DON stated two staff members were always required to use the Hoyer lift when lifting the resident. She stated it was for safety purposes. She stated they reviewed Hoyer lift procedures every year for the annual training and as needed but she could not recall the last time this was done. Record review of the facility's policy, Mechanical Lifts (Hoyer/Sit-To-Stand) reviewed 05/12/23, reflected Residents will be assisted with their Activities of Daily Living, utilizing lifts according to manufacturer's guidelines. Gather necessary equipment and second person to assist.

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

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 a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of 4 residents (Resident #1 and Resident #2) reviewed for respiratory care. Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of 4 residents (Resident #1 and Resident #2) reviewed for respiratory care. The facility failed to ensure Resident #1 and Resident #2's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) and breathing mask (used to receive medications by breathing in mist through nose and mouth), were properly stored when not in use on 04/16/25. This failure could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #1's face sheet, dated 07/16/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident #1's Comprehensive MDS Assessment, dated 07/01/25, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment reflected the resident had Chronic Obstructive Pulmonary Disease. Record review of Resident #1's Comprehensive Care Plan, dated 07/16/25, reflected the resident had a respiratory diagnosis and one of the approaches was to administer oxygen as ordered. Record review of Resident #1's Physician's Order, dated 07/16/25, reflected D/C @ 1 LPM via NC Every Shift. In an observation and interview on 07/16/25 at 10:35 AM, Resident #1 was observed with an Oxygen device in her room. The device was not in use and her nasal canula was observed hanging on the bedrail, unbagged. She stated she only used the oxygen device at night and had not used it since 6:30 AM. In an observation and interview on 07/16/25 at 10:40 AM, LVN [TF1] S stated she had been at the facility for 2 years. She stated Resident #1 used the oxygen device on an as needed basis. She stated they had to bag the resident's nasal canula when it was not in use. She was shown the nasal canula hanging from the resident's bedrail and she stated the bag was in the nightstand for storage and the nasal canula should have been stored in it for infection control. 2. Record review of Resident #2's face sheet, dated 07/16/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident #2's Comprehensive MDS Assessment, dated 01/30/25, reflected the resident was cognitively moderately impaired with a BIMS score of 11. The Comprehensive MDS Assessment reflected the resident had Chronic Obstructive Pulmonary Disease. Record review of Resident #2's Comprehensive Care Plan, dated 02/06/25, did not reflect an intervention for oxygen use. Record review of Resident #2's Physician's Order, dated 07/16/25, reflected D/C O2 at 2LPM by NC Every Shift [Time: Shift 2, Shift 1] Chronic obstructive pulmonarydisease, unspecified. In an observation on 07/16/25 at 11:20 AM, revealed Resident #2 was not in her room and her nasal canula was observed sitting on top of the resident's bed, unbagged. In an interview and observation on 07/16/25 at 11:25 AM, ADON K stated Resident #2 used an Oxygen device and when it was not in use, the nasal canula should be bagged to avoid an infection. She observed Resident #2's nasal canula sitting on top of the resident's bed, unbagged and the resident was not in the room. She stated the resident may have just left the room. She stated the nursing staff was responsible for checking to ensure oxygen masks and nasal cannulas were bagged when not in use. In an interview on 07/16/25 at 2:17 PM, the DON stated there was not a policy but it was common practice for staff to check to ensure the nasal cannulas were placed in a bag to avoid infection. Record review of the facility's policy, Oxygen Therapy - Discontinuation revised 01/12/20, reflecting The nursing licensed staff will discontinue oxygen therapy when ordered by physician, and according to practice guidelines. Remove cannula prong or mask from humidifier or regulator. (Discard if oxygen is not to be given again; or place in plastic bag if oxygen is to be administered on a PRN basis. Label and date.)

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one of 3 residents (Resident #1) reviewed for pharmaceutical services. Based interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one of 3 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure Resident #1's Farxiga medication was in stock. This failure could place residents at risk of not receiving medication as ordered by the physician and having high glucose levels. Findings include: Record review of Resident #1's face sheet, dated 07/16/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included Diabetes. (condition that happens when blood sugar (glucose) is too high and develops when the pancreas doesn't make enough insulin or any at all, or when the body isn't responding to the effects of insulin properly.) Record review of Resident #1's Comprehensive MDS Assessment, dated 07/01/25, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had Diabetes. Record review of Resident #1's Comprehensive Care Plan, dated 07/16/25, reflected the resident had potential for hyperglycemic (high blood sugar) or hypoglycemic (low blood sugar) episodes secondary to Diabetes and one of the approaches was to administer medications as ordered. Record review of Resident #1's Physician's Order, dated 07/16/25, reflected Farxiga 10 mg tablet, 1 tablet by mouth one time daily [Time: 08:00 AM]. In an interview on 07/16/25 at 10:30 AM, Resident #1 stated she was scheduled to take medication to treat her Diabetes daily but was advised this morning the medication was not available and needed to be reordered. In an interview on 07/16/25 at 10:40 AM, LVN S stated she had been at the facility for 2 years. She stated Resident #1 was prescribed Farxiga to take daily. She stated the resident was required to take the medication for her diabetes. She stated the resident was not able to take the medication this morning because the facility did not have it in stock. She stated the medication aide was responsible for re-ordering the medication and did not. She stated she was working on re-ordering the medication for the resident. She stated the risk if not getting medication could cause water in lungs. In an interview on 06/16/25 at 10:45 AM, LVN M stated he was filling in for the medication aide today because he was scheduled off. He stated Resident #1 was unable to receive her medication of Farxiga because it was not in stock. He stated the medication aide was responsible for re-ordering the medication and should have re-ordered it when there were 3 or 4 doses left. He stated he re-ordered the medication for the resident and was waiting for the prescription to be filled. He stated the risk of her not receiving the medication could result in a spike in her sugar level. In an interview on 07/16/25 at 2:17 PM, the DON was advised of Resident #1 not having her Farxiga medication and she stated she checked and found out the medication was only provided 14 days at a time. She stated she did not know why it was not ordered in advance. She stated most medication was 30, 60, 90 days in supply but her insurance only allowed 14 days at a time and it was ordered on the 7/01/25 but was somehow not received. She stated it was the medication aide's responsibility to re-order medication and to follow up to ensure the medication was ordered on 07/01/25. She stated she was unsure of the time period when they should re-order medication when it ran low. She stated the missed medication could impact the resident's sugar level Record review of the facility's policy, Medication Administration revised 01/2023 reflected Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Record review of the facility's policy, Medication Ordering And Receiving From Pharmacy Provider revised 01/12/2020 reflected Staff will order and receive medications from pharmacy providers in accordance with standard practice guidelines.

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 interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #1) reviewed for ADL care provided to dependent residents. Based on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #1) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #1 received showers consistently for June and July 2025. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Include: Record review of Resident #1's face sheet, dated 07/16/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included muscle weakness. Record review of Resident #1's Comprehensive MDS Assessment, dated 07/01/25, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment reflected the resident required extensive assistance with ADL care. Record review of Resident #1's Comprehensive Care Plan, dated 07/16/25, reflected the resident was incontinent of urine and bowel. One of the approaches was for hygiene as needed after every incontinent episode to maintain dignity. Record review of Resident #1's Bath/Shower Sheets for the month of June and July 2025, reflected the resident received a shower on 06/14/25, 06/21/25, and 06/25/25. The resident was scheduled to received three showers a week on Monday. Wednesday and Friday. In an interview on 07/16/25 at 10:35 AM, Resident #1 stated she had only received bed baths since last year September 2024 and she and her RP [TF1] had been requesting for her to receive showers, with the most recent request being made during a Care plan meeting on 07/07/25. In a record review and interview on 07/16/25 at 10:40 AM, LVN S reviewed the shower sheets for July 2025 and none of them reflected the resident received a shower. She stated the resident was scheduled to receive her showers from the evening shift CNAs. She stated the CNA was not available at this time. She stated she thought the resident may have just requested bed baths but was not sure. She stated the nurses were responsible for checking to ensure residents received their showers. She stated if the resident was not receiving her scheduled showers on Monday, Wednesday, and Friday, they could have a skin breakdown. She stated various CNAs provided the resident her showers and was not really assigned to any specific person. She stated the CNAs were required to complete shower sheets whether the resident had received a shower, bed bath, or refused. In an interview on 07/16/25 at 10:49 AM, the RP for Resident #1 stated she attended the resident's care plan meeting on 07/07/25 and one of the concerns discussed was the resident not receiving showers since 2024 and the resident's desire to receive them as opposed to the bed baths. She stated the ADON K and DON stated they would ensure this would happen. She stated she was not aware of the resident ever refusing any showers and thought staff were avoiding using the Hoyer lift because they never had two people available to operate it. In an interview and record review on 07/16/25 at 11:15 AM, ADON K stated Resident #1 had been receiving showers and she had been requesting bed baths. She was advised the resident stated she had not received a shower since September 2024, and she stated she had been requesting a shower. She stated the shower sheets provided indicated the resident received showers and she followed up with staff to ensure they were providing showers to the residents when scheduled. She stated if the resident did not receive her showers, she could have skin problems. ADON K provided shower sheets which indicated the Resident received showers on 06/14/25, 06/21/25, and 06/25/25. She was advised this would be verified with Resident #1. In an interview on 07/16/25 at 11:50 AM, Resident #1 was asked if she received showers on 06/14/25, 06/21/25, and 06/26/25. She denied receiving any showers and repeated she had not received a shower since she arrived in September 2024 and only received bed baths. She stated she never refused a shower and would love to take showers. In an interview on 07/16/25 at 2:17 PM, the DON stated Resident #1 had an injury and initially wanted bed baths at the time, but this was some time ago. She stated the CNAs had gotten comfortable just giving her bed baths, had not asked her if she wanted a shower, and just assumed she wanted a bed bath. She stated she was told the resident refused showers, but it was never documented. She stated she was not aware the resident wanted showers until the care plan meeting. She stated the resident not getting a shower could be a dignity issue. Record review of the facility's policy, BATHING (NOT PARTIAL OR COMPLETED BED BATH) revised 01/23/23, revealed, Staff will provide bathing services for residents within standard practice guidelines. Residents have the right to choose if they want to be bathed at certain times and with certain methods in accordance to the care plan.

Mar 2025 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

Deficiency F0551 (Tag F0551)

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 representative had the right to exercise the resident's rights to the extent those rights are delegated to the representative for one of three residents (Resident #1) reviewed for resident rights. The facility failed to obtain consent from Resident #1's RR, prior to administering an antibiotic medication which resident was allergic to. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions. Findings Include: Record review of Resident #1's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1's face sheet identified her representative was a family member, RR. Resident #1's RR was listed as medical power of attorney. Resident #1 had diagnoses which included: Essential (primary) Hypertension (high blood pressure), Urinary Tract Infection (UTI), and AMS (Altered Mental Status). Resident #1's face sheet had 37 allergies listed including Sulfa. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS score of 10, which meant moderate cognitive impairment. Record review of Resident #1's Care Plan, dated 1/25/25, revealed the resident had Cognitive loss due to dementia. Resident #1 had potential for discomfort and side effects related to medication allergies. Resident #1 becomes easily agitated and anxious at times. Record review of Resident admission Agreement for Resident #1, entered into as of 08/15/2022, showed Resident #1 had RR listed as her Resident Representative. Record review Resident #1's Statutory Durable Power of Attorney dated 10/18/16, revealed the RR was Resident #1's power of attorney and stated, power of attorney is not affected by my subsequent disability or incapacity. Record review of Resident #1's Medical Power of Attorney, dated 1/11/18, revealed the RR was Resident #1's medical power of attorney. Record review of Resident #1's Notes, dated 3/14/25 at 1:29 a.m. by RN-E, revealed there was a new order per NP, Bactrim 1 [Tablet] .6 doses, start today. Asked NP if she was going to call and notify residents RR, she denied. Orders noted, transcribed and initial does [sic] given. Record review on Resident #1's notes dated 3/14/25 at 1:54 a.m. by RN-E, revealed at approximately 9:30 p.m., Resident #1's RR approached nursing with clear agitation and aggression asking what medication [Resident #1] was given and why. Explained to her that the NP ordered Bactrim 1 [Tablet] .6 doses and this nurse administered the first does, no adverse reactions noted by this nurse . [RR stated], she should have been consulted for consent. Record review of Notes dated 3/14/25 at 10:59 a.m. by RN-G revealed Morning antibiotic medication Bactrim not administered. Resident allergic to surfa [sic]. Call placed to NP new order received to stop medication. Medication discontinued as ordered by physician. Record review of Notes dated 3/14/25 at 11:18 a.m. by RN-G revealed Resident transferred to . hospital, per daughter request. NP notified. Record review of Notes on 3/17/25 at 4:26 p.m., as late entry from 3/14/25 at 11:00 a.m. by the DON revealed the Police officer arrived at the facility, unsure of who called for an officer. Discovered that .[RR], called the police to discuss events from previous night. Officer went in and spoke with .[RR], and stated that resident's vitals were WNL, but .[RR] still wanted resident to go to the ER. Resident transferred to .[hospital] and NP was notified. Per nurse, resident was still sleeping when .[RR] arrived but VS were assessed and stable. Record review of Notes on 3/18/25 at 7:47 p.m. by RN-F revealed Resident arrived Facility at 1705 from .[hospital] with DX: UTI, report received from nurse .that Resident received no treatment for UTI as her .[RR] refused meds that were prescribed for UTI. Record review of the facility's Incident Log Report revealed there was an incident regarding Resident #1 on 3/14/25 at 9:01 a.m. stating it was Medication Related with no apparent injury, abuse or neglect was ruled out and resident received medical treatment. Record review of the hospital Discharge summary, dated [DATE] at 9:31 a.m., revealed Resident #1 was discharged with diagnoses which included Acute encephalopathy (sudden and significant decline in brain function) due to transient hypovolemia (temporary reduction in blood volume), Hypotension (low blood pressure), Asymptomatic bacteriuria (presence of bacteria in urine), COPD (Chronic obstructive pulmonary disease; a group of lung diseases that cause airflow obstruction and breathing problems), Chronic memory impairment (persistent decline in ability to remember information over time) and MTHFR gene mutation. Under Hospital course: Patient is an 88 years [sic] old woman with history of atrial fibrillation (irregular heartbeat) COPD, hypertension, MTHFR gene mutation (change in DNA sequence can disrupt enzyme's normal function) and hand [sic} sulfa allergy who had abnormal urinalysis and was given Bactrim at the skilled nursing facility. Per RR, patient become [sic] confused afterwards and was brought to hospital. She was hypotensive requiring IV fluid bolus. She was admitted to ICU for pressor support but did not require that. Patient become [sic] alert afterwards remained without fever, dysuria (discomfort when urinating), frequency, or urgency. No leukocytosis (increased number of white blood cells). No antibiotics were administered in the hospital .There was no skin rash noted .She is medically ready to go back to her long-term residential facility. Sulfa drugs should be avoided in the future. Interview on 3/19/25 at 8:48 a.m. with Resident #1's RR revealed she was the medical and financial power of attorney. RR stated Resident #1 was unable to give consent because she had a learning disability. RR stated she went in the facility on 3/13/25 around 8:30 p.m. She stated the facility had given Resident #1 an antibiotic, Bactrim without getting her consent. RR stated the facility is supposed to get her consent prior to any medication changes or new medications. RR believed Resident #1 suffered neurotoxic side effects from the Bactrim as Resident #1 had a tremor in her right hand, she looked sedated, and the whites of her eyes were bloodshot. RR stated when she arrived the morning of 3/14/25, Resident #1 was unresponsive. Interview on 3/19/25 at 10:58 a.m. with the Admin and the DON. The Admin stated Resident #1 had a UTI, and she was started on Bactrim. She was given one dose and the RR wanted them to call to get permission before giving any medications. The Admin stated if Resident #1 could answer, they did not need to get permission from RR. The Admin stated on 3/14/25, Resident #1's RR felt Resident #1 needed medical care at the hospital. Resident #1 was sent to the hospital, and they gave Resident #1 a liter of fluids and that was about it. The Admin stated RR did not believe the resident had a UTI and refused the hospital from giving any antibiotics. The Admin stated the facility changed over their on-line documentation system and the sulfa drug allergy for Resident #1 was missed during the transition. He stated it was in the system now. The DON stated she went through all the residents' medications and there were no other errors besides Resident #1's. The DON stated Resident #1 was lucid at times. Interview on 3/19/25 at 11:42 a.m., Resident #1 stated she could not remember why she went to the hospital but said that was why she was in the facility. She stated staff treated her terrible, but she was not going to get into that and told the state surveyor to talk to her RR. Resident #1 did not recall if she had ever gotten the wrong medication. Interview on 3/19/25 at 12:41 p.m. with LVN-C, stated if she received a new medication order, the medication allergy list was in the system. LVN-C stated the doctor would have access to the allergy list in the system. LVN-C stated she would call the pharmacy to verify there was no allergy for the resident. LVN-C stated by the time the medication was ready to be administered, the medication would have been checked by the doctor and the nurse for allergies. LVN-C stated if a resident had a UTI, they may have had confusion, altered mental status, been off baseline, a change in condition or had a burning sensation. She stated if the resident was suspected of having a UTI, she would contact the doctor for further orders. LVN-C was familiar with Resident #1 since her admission. She stated there was nothing done without her RR being aware. LVN-C stated she would check with the RR to see if she consented to any medication prior to giving it. Interview on 3/19/25 at 1:08 p.m., CMA-D stated the medication allergy list was checked by the doctor and the nurse before it was administered. He stated he did not give medication to Resident #1 because the nurses did. CMA-D stated some family members wanted the nurses to give residents their medications. Attempted telephone call on 3/19/25 at 3:33 p.m. to RN-E, left message and sent text. Attempted telephone call on 3/19/25 at 3:48 p.m. to RN-F, left message and sent text. Interview on 3/19/25 at 3:52 p.m., NP stated regarding Resident #1, the Sulfa allergy was not on her list when she made the orders for Bactrim. The NP stated she did not know Resident #1 had the allergy to Sulfa drugs until the pharmacy let her know. The NP stated if she had known there was a Sulfa allergy, she would not have ordered Bactrim. Interview on 3/19/25 at 8:22 p.m., RN-F stated if a resident had a drug allergy, when a new prescription was put in the computer system, it would pop up showing there was an allergy. She stated both the NP, and she would have called the RR for consent to give a medication. RN-F stated she would call the RR herself to make sure she had knowledge of any medications because there were issues in the past. Interview on 3/19/25 at 8:29 p.m., RN-E stated on 3/13/25 Resident #1's UTI cultures came back positive. She stated Sulfa drugs were not listed on her allergy list in the computer system. The NP prescribed Bactrim, 6 doses with the 1st dose started that night. She stated the order started that night, so she got it out of the facility's emergency kit. RN-E stated when the NP made the order, she asked if she was going to call the RR. The NP stated she would not because the RR hinders Resident #1's care. RN-E stated she was in the room with the NP when she explained to Resident #1 what she was going to give her, the resident agreed, and she exited the room. RN-E stated when she got the medication, she explained to Resident #1 what the medication was for prior to giving it to her and Resident #1 said okay. RN-E stated the RR came in later and asked what had been given to Resident #1. She let her know the NP had given orders for Bactrim. RN-E stated RR started raising her voice and yelling she had not given consent for the medication. RN-E stated the RR called the police to the facility which she had done 3 or 4 times in a row because she did not feel they were doing their job correctly. The police wound up escorting the RR out of the facility for the night and allowed things to calm down. RN-E stated she did not see Resident #1's hands shake at all that night. RN-E stated she was not working the next morning when Resident #1 was sent to the hospital. RN-E stated the hospital discharge notes stated the RR refused to give any antibiotics while Resident #1 was there. RN-E stated the RR was worried about altered mental status from the Bactrim, but it could have been from the UTI. RN-E stated the NP had always called for approval from the RR in the past. She stated the NP, or the DON would call for consent from the RR. Record review of the facility's Resident Rights, dated 8/14/20, stated under Policy: The staff will abide by and protect resident rights in accordance with state and federal guidelines .Procedure: Staff will abide by resident rights as outlined within CMS State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities Record review of the facility's Resident admission Agreement, dated 9/24/21, revealed under Resident Representative is defined in the federal regulations governing nursing facilities as any of the following: a. an individual chosen by the resident or a person authorized by State of Federal law .to act on behalf of the resident in order to (i) support the resident in decision-making; (ii) access medical, social or other personal information of the resident .

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of three residents (Resident #1) reviewed for pharmacy services. 1) The facility failed to update Resident #1's allergy list completely when they manually transcribed the information into their new operating system. 2) The facility failed to ensure Resident #1 was not administered Bactrim (Sulfa drug) on 3/13/25 when Resident #1 had an allergy to Sulfa. These failures could place residents at risk of receiving medications they have allergies to which could contribute to adverse reactions resulting in a decline in health and/or hospitalization. Findings Included: Record review of Resident #1's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1's face sheet identified her representative was a family member. Resident #1 had 37 allergies listed which included: Albuterol, Methocarbamol, Levodopa, Acetaminophen, Oxycodone, Hydrocodone, Lidocaine, Docusate, Senna, Calcium Carbonate, Carbidopa, Ferrous Sulfate, Potassium Chloride, Iodine, Penicillin G, Polyethylene Glycol, Pantoprazole, Melatonin, Fluticasone, Cefazolin, Megestrol, Ketorolac, Ondansetron, Diphenhydramine, Tramadol, Zolpidem, Loratadine, Cefpodoxime, Fentanyl, Naproxen, Maltodextrin, Xanthan Gum, Furosemide, Prednisone, Morphine, Sulfa (Sulfonamide) and Propoxyphene. Resident #1 had diagnoses which included: Essential (primary) Hypertension (High Blood Pressure), UTI (an illness in any part of the urinary tract), and AMS (Altered Mental Status). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS score of 10, which indicated moderate cognitive impairment. Record review of Resident #1's Care Plan, dated 1/25/25, revealed the resident had Cognitive loss due to Dementia. Resident #1 had potential for discomfort and side effects related to medication allergies. Resident #1 becomes easily agitated and anxious at times. Record review of Resident #1's Notes, dated 3/14/25 at 1:29 a.m. by RN-F, revealed there was a new order per NP, Bactrim DS 1 Tab .6 doses, start today. Asked NP if she was going to call and notify residents /RR, she denied. Orders noted, transcribed and initial does [sic] given. Record review on Resident #1's notes dated 3/14/25 at 1:54 a.m. by RN-F, revealed at approximately 9:30 p.m., Resident #1's RR approached nursing with clear agitation and aggression asking what medication her [Resident #1] was given and why. Explained to her the NP ordered Bactrim 1 Tab .6 doses and this nurse administered the first dose, no adverse reactions noted by this nurse RR stated, she should have been consulted for consent and because of the antibiotic [ Resident #1's] hands are shaking. Record review of Resident #1's eMar for Bactrim revealed the medication was ordered on 3/13/25 and was administered at 8 p.m. The eMar showed the medication was discontinued on 3/14/25. Record review of Notes dated 3/14/25 at 10:59 a.m. by RN-G revealed Morning antibiotic medication Bactrim DS not administered. Resident allergic to surfa [sic]. Call placed to NP new order received to stop medication. Medication discontinued as ordered by physician. Record review of Notes, dated 3/14/25 at 11:18 a.m. by RN-G, revealed Resident transferred to .hospital, per . [RR] request. NP notified. Record review of Notes dated 3/17/25 at 4:26 p.m., as late entry, from 3/14/25 11 a.m. by the DON, revealed Police officer arrived at facility, unsure of who called for an officer. Discovered that .[RR], called the police to discuss events from previous night. Officer went in and spoke with . [RR,] and stated that residents vitals were WNL, but . [RR] still wanted resident to go to the ER. Resident transferred to[hospital]and NP was notified. Per nurse, resident was still sleeping when [RR] arrived, but VS were assessed and stable. Record review of Notes, dated 3/18/25 at 7:47 p.m. by RN-E, revealed Resident arrived Facility at 1705 [5:05 p.m.] from [hospital] with DX: UTI, report received from nurse .that Resident received no treatment for UTI as her [RR] refused meds that were prescribed for UTI. Record review of the facility's Incident Log Report revealed there was an incident regarding Resident #1 on 3/14/25 at 9:01 a.m. which stated it was Medication Related with no apparent injury, abuse or neglect ruled out and resident received medical treatment Record review of hospital Clinical Notes, dated 3/17/25, revealed Resident #1 had Delirium/encephalopathy, metabolic and toxic (change in mental status): In the context of someone who is very frail, severe malnutrition and probably pretty advanced dementia, very debilitated. Potential causes and contributors: It is possible this is a side effect of medication. Also possible for UTI but no fevers and no leukocytosis .Avoid sulfa drugs, doubt if patient's current symptoms are related to Bactrim .The patient had to get fluid bolus in the ER .The patient also started on ceftriaxone for UTI, but [RR] refused antibiotics. Record review of hospital Discharge summary, dated [DATE] at 9:31 a.m., revealed Resident #1 had sulfa allergy who had abnormal urinalysis and was given Bactrim at the skilled nursing facility. Per RR patient become [sic] confused afterwards and was brought to hospital. She was hypotensive requiring IV fluid bolus .she was admitted to ICU for pressor support but did not require that .there was no skin rash noted. Interview on 3/19/25 at 10:58 a.m. with the Admin and the DON. The Admin stated Resident #1 had a UTI, and she was started on Bactrim. She was given one dose and the RR wanted them to call to get permission before giving any medications. The Admin stated if Resident #1 could answer, they did not need to get permission from RR. The Admin stated on 3/14/25, Resident #1's RR felt Resident #1 needed medical care at the hospital. Resident #1 was sent to the hospital, and they gave Resident #1 a liter of fluids and that was about it. The Admin stated RR did not believe the resident had a UTI and refused the hospital from giving any antibiotics. The Admin stated the facility changed over their on-line documentation system manually and the sulfa drug allergy for Resident #1 was missed during the transition. He stated it was in the system now. The Admin stated they did not know the medication was missed until Resident #1's RR stated there was an adverse reaction to the Bactrim. The DON stated she went through all the residents' medications and there were no other errors besides Resident #1's. The DON stated Resident #1 was lucid at times. Interview on 3/19/25 at 11:42 a.m., Resident #1 stated she could not remember why she went to the hospital but said that was why she was in the facility. She stated staff treated her terrible, but she was not going to get into that and told the state surveyor to talk to her RR. Resident #1 did not recall if she had ever gotten the wrong medication. Interview on 3/19/25 at 12:41 p.m., LVN-C stated if a resident was prescribed a new medication order by the doctor, the resident's allergy list was in the system. LVN-C stated she would call the pharmacy to verify there were no drug allergies if she was in question. Interview on 3/19/25 at 1:08 p.m., CMA-D stated a resident's allergy list was checked by the doctor and the nurse before a medication was ordered. He stated the nurses gave medication to Resident #1 as the RR requested. Attempted interview on 3/19/25 at 3:33 p.m. with RN-E, left message and sent text. Attempted interview on 3/19/25 at 3:48 p.m. with RN-F, left message and sent text. Interview on 3/19/25 at 3:52 p.m. with NP, stated regarding Resident #1, the Sulfa allergy was not on her list when she made the orders for Bactrim. NP stated she did not know Resident #1 had the allergy to Sulfa drugs until the pharmacy let her know. NP stated if she had known there was a Sulfa allergy, she would not have ordered Bactrim. Interview on 3/19/25 at 4:37 p.m., the Admin stated it was a simple human error that the Sulfa drug allergy was not switched over to the new medical documentation system. Interview on 3/19/25 at 8:22 p.m., RN-F stated a medication technician or nurse would give a resident their medications unless a family member wanted a nurse to administer medications. She stated if a resident had an allergy, when a new prescription was put in the system, the system would have a pop-up showing there was an allergy listed. RN-F stated there was concern Resident #1's RR was not allowing staff to provide care. She stated the RR had so many drug allergies listed, it was difficult to find an antibiotic that could be given to Resident #1. RN-F stated the RR told her the medications made Resident #1's eyes red. Interview on 3/19/25 at 8:29 p.m., RN-E stated last Thursday, 3/13/25, Resident #1's UTI cultures came back positive. She stated Sulfa drugs were not listed on Resident #1's allergy list. RN-E stated the NP prescribed Bactrim with the 1st dose started that night. RN-E asked the NP if she was going to call the RR, but she said no because the RR hinders the resident's care. RN-E stated she obtained the Bactrim medication out of their emergency kit. RN-E stated the RR called the police after she arrived and found out the medication was given without her consent. She stated the police officer wound up escorting RR out of the building to deescalate the situation that night. RN-E stated she was not working when Resident #1 was sent out to the hospital the next morning. She stated she did not see Resident #1's hands shake at all night before. Attempted interview on 3/20/25 at 11:52 a.m. with the police department/PD, stated Officer-H and Officer-I worked the scene when Resident #1 was sent out to the hospital, but Officer-H was on vacation this week and Officer-I did not work until 7 p.m. tonight. Interview on 3/20/25 at 8:37 p.m. with Officer-I, stated he was present the evening of 3/13/25, but was not there on 3/14/25 when Resident #1 was sent to the hospital. Officer-I stated RR was complaining about several different things regarding the treatment of Resident #1, including staff not consulting her prior to giving medications.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain medical records on each resident that were accurately documented for one (Resident #1) of three residents reviewed for accuracy of records. The facility failed to add one of Resident #1's medication allergies, Sulfa, into the new operating system when they transferred the information. This failure could place residents at risk of not receiving medications as ordered which could cause a decline in the resident's overall health. Findings Included: Record review of Resident #1's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1's face sheet identified her representative was a family member. Resident #1 had 37 allergies listed which included: Albuterol, Methocarbamol, Levodopa, Acetaminophen, Oxycodone, Hydrocodone, Lidocaine, Docusate, Senna, Calcium Carbonate, Carbidopa, Ferrous Sulfate, Potassium Chloride, Iodine, Penicillin G, Polyethylene Glycol, Pantoprazole, Melatonin, Fluticasone, Cefazolin, Megestrol, Ketorolac, Ondansetron, Diphenhydramine, Tramadol, Zolpidem, Loratadine, Cefpodoxime, Fentanyl, Naproxen, Maltodextrin, Xanthan Gum, Furosemide, Prednisone, Morphine, Sulfa (Sulfonamide) and Propoxyphene. Resident #1 had diagnoses which included: Essential (primary) Hypertension (High Blood Pressure), UTI (an illness in any part of the urinary tract), and AMS (Altered Mental Status). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS score of 10, which indicated moderate cognitive impairment. Record review of Resident #1's Care Plan, dated 1/25/25, revealed the resident had Cognitive loss due to Dementia. Resident #1 had potential for discomfort and side effects related to medication allergies. Resident #1 becomes easily agitated and anxious at times. Record review of Resident #1's eMar for Bactrim revealed the medication was ordered on 3/13/25 and was administered at 8 p.m. The eMar showed the medication was discontinued on 3/14/25. Record review of Notes dated 3/14/25 at 10:59 a.m. by RN-G revealed Morning antibiotic medication Bactrim DS not administered. Resident allergic to surfa [sic]. Call placed to NP new order received to stop medication. Medication discontinued as ordered by physician. Record review of Notes, dated 3/14/25 at 11:18 a.m. by RN-G, revealed Resident transferred to .hospital, per . [RR] request. NP notified. Record review of Notes dated 3/17/25 at 4:26 p.m., as late entry, from 3/14/25 11 a.m. by the DON, revealed Police officer arrived at facility, unsure of who called for an officer. Discovered that .[RR], called the police to discuss events from previous night. Officer went in and spoke with . [RR,] and stated that residents vitals were WNL, but . [RR] still wanted resident to go to the ER. Resident transferred to [hospital] and NP was notified. Per nurse, resident was still sleeping when [RR] arrived, but VS were assessed and stable. Record review of the facility's Incident Log Report revealed there was an incident regarding Resident #1 on 3/14/25 at 9:01 a.m. which stated it was Medication Related with no apparent injury, abuse or neglect ruled out and resident received medical treatment Record review of hospital Clinical Notes, dated 3/17/25, revealed Resident #1 had Delirium/encephalopathy, metabolic and toxic (change in mental status): In the context of someone who is very frail, severe malnutrition and probably pretty advanced dementia, very debilitated. Potential causes and contributors: It is possible this is a side effect of medication. Also possible for UTI but no fevers and no leukocytosis .Avoid sulfa drugs, doubt if patient's current symptoms are related to Bactrim .The patient had to get fluid bolus (a single, large dose) in the ER .The patient also started on ceftriaxone for UTI, but [RR] refused antibiotics. Record review of hospital Discharge summary, dated [DATE] at 9:31 a.m., revealed Resident #1 had sulfa allergy who had abnormal urinalysis and was given Bactrim at the skilled nursing facility. Per RR patient become [sic] confused afterwards and was brought to hospital. She was hypotensive requiring IV fluid bolus .she was admitted to ICU for pressor support (use of medications called vasopressors to increase blood pressure and improve blood flow) but did not require that .there was no skin rash noted. Interview on 3/19/25 at 10:58 a.m. with the Admin and the DON. The Admin stated the facility changed over their on-line documentation system manually and the sulfa drug allergy for Resident #1 was missed during the transition. He stated it was in the system now. The Admin stated they did not know the medication was missed until Resident #1's RR stated she had an allergy to Sulfa drugs. The DON stated she went through all the residents' medications and there were no other errors besides Resident #1's. Interview on 3/19/25 at 11:42 a.m., Resident #1 stated she could not remember why she went to the hospital but said that was why she was in the facility. She stated staff treated her terrible, but she was not going to get into that and told the state surveyor to talk to her RR. Resident #1 did not recall if she had ever gotten the wrong medication. Interview on 3/19/25 at 12:41 p.m., LVN-C stated if a resident was prescribed a new medication order by the doctor, the resident's allergy list was in the system. LVN-C stated she would call the pharmacy to verify there were no drug allergies if she was in question. Interview on 3/19/25 at 1:08 p.m., CMA-D stated a resident's allergy list was checked by the doctor and the nurse before a medication was ordered. He stated the nurses gave medication to Resident #1 as the RR requested. Attempted interview on 3/19/25 at 3:33 p.m. with RN-E, left message and sent text. Attempted interview on 3/19/25 at 3:48 p.m. with RN-F, left message and sent text. Interview on 3/19/25 at 3:52 p.m. with NP, stated regarding Resident #1, the Sulfa allergy was not on her list when she made the orders for Bactrim. NP stated she did not know Resident #1 had the allergy to Sulfa drugs until the pharmacy let her know. NP stated if she had known there was a Sulfa allergy, she would not have ordered Bactrim. Interview on 3/19/25 at 4:37 p.m., the Admin stated it was a simple human error that the Sulfa drug allergy was not switched over to the new medical documentation system. Interview on 3/19/25 at 8:22 p.m., RN-F stated a medication technician or nurse would give a resident their medications unless a family member wanted a nurse to administer medications. She stated if a resident had an allergy, when a new prescription was put in the system, the system would have a pop-up showing there was an allergy listed. Interview on 3/19/25 at 8:29 p.m., RN-E stated last Thursday, 3/13/25, Resident #1's UTI cultures came back positive. She stated Sulfa drugs were not listed on Resident #1's allergy list. RN-E stated the NP prescribed Bactrim with the 1st dose started that night.

Jan 2025 5 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

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 observation, interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for two (Resident #20 and Resident #49) of eight residents reviewed for Accuracy of Assessments. 1. The facility failed to ensure Resident #20's Quarterly MDS assessment dated [DATE] accurately reflected that the resident had an external catheter (non-invasive device used to manage urinary incontinence) and was on oxygen therapy. 2. The facility failed to ensure Resident #49's Quarterly MDS assessment dated [DATE] accurately reflected that the resident was receiving Hospice Care (end of life care). This failure could place the resident at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: 1. Review of Resident #20's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old resident admitted to the facility on [DATE]. Resident #20 was diagnosed with overactive bladder (sudden urges to urinate) and respiratory failure. Review of Resident #20's Quarterly MDS Assessment, dated 12/24/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. Resident #20's Quarterly MDS Assessment did not indicate that the resident was using an external catheter and was on oxygen administration. Review of Resident #20's Comprehensive Care Plan, dated 10/09/2024, reflected the resident was at risk for problems with elimination and one of the interventions was to assist with PureWick (non-invasive urinary drainage device that uses suction to collect urine from the body) as per orders and resident request. The Comprehensive Care Plan also indicated the resident was on oxygen therapy and one of the interventions was administer oxygen as ordered. Review of Resident #20's Physician Order, dated 01/22/2025, reflected purewick drain On Night Shift. Review of Resident #20's Physician Order, dated 11/01/2024, reflected O2 at 2 LPM by NC at Bedtime [Time: 08:00 PM] for Acute respiratory failure with hypercapnia (increased amount of carbon dioxide to the body). Observation and interview with Resident #20 on 01/22/2025 at 10:15 AM revealed Resident #20 was in her bed, awake. It was observed that a purewick system was at the resident's bedside. The resident said she used it every night and she had been using it since last year. It was also observed that the resident was on oxygen therapy via nasal cannula. In an interview with LVN B on 01/22/2025 at 10:47 AM, she said the Purewick system was an external catheter used by Resident #20 every night. She said the family was the one who requested that the resident use it. She said the resident had the purewick since she was admitted to the facility last year. She also said the resident was on oxygen for respiratory failure. 2. Record review of Resident #49's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #49 was diagnosed with CVA (cerebrovascular disease: blood supply to the brain was interrupted). Record review of Resident #49's Quarterly MDS Assessment, dated 01/13/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 04. The Quarterly MDS Assessment did not indicated that the resident was receiving hospice care while a resident of the facility. Record review of Resident #49's Comprehensive Care Plan, dated 12/24/2024, reflected the resident was admitted to hospice related to CVA and one of the interventions was to help the resident access hospice services. Observation and interview with Resident #49 on 01/22/2025 at 2:00 PM revealed Resident #49 was in her bed, awake. it was observed that there was a suction machine (medical device that is primarily used for removing mucus or saliva) under the resident's bed. In an interview with LVN B on 01/22/2025 at 2:16 PM, LVN B stated Resident #49 was in hospice and hospice was the one who provided the suction machine. Observation and interview with MDS Nurse G on 01/24/2025 at 8:30 AM, MDS Nurse G stated the MDS Assessment should reflect if a resident had an external catheter, was using oxygen, and was in hospice. She said the medical diagnosis, physician order, MDS, and the care plan should match to provide an understandable overview of the resident's current condition. She said, by doing so, correct goals and interventions would be provided. She opened Resident #20's profile and saw that the resident had orders for the external catheter (Purewick) and for oxygen therapy. MDS Nurse G also checked the resident's care plan and saw that the resident was care planned for the external catheter and oxygen therapy. She then checked the resident's MDS and saw that the external catheter and oxygen were not triggered. MDS Nurse G also checked Resident #49's profile and saw that her MDS was not triggered for hospice. She said if the residents were not properly assessed, the proper care and needs would not be met. She said she was not responsible for Resident #20 and #49's MDS but she would audit the residents entrusted to her and check if they were properly assessed. Observation and interview with MDS Nurse H on 01/24/2025 at 8:47 AM, MDS Nurse H stated the MDS was not just for reimbursement but a means for the staff to properly assess the residents. She opened Resident #20's MDS and saw that the resident was not triggered for external catheter and oxygen. She also opened Resident #49's MDS and saw the resident was not triggered for hospice. She said all the above mentioned should be reflected in the MDS. She said she would review the residents MDS and would make the appropriate changes. She said she would also audit the MDS of the other residents. She said if the residents were not properly assessed, the needs would not be met and there could be confusion in the provision of care. In an interview with the Administrator on 01/24/2025 at 10:09 AM, the Administrator stated the MDS to reflect the current condition of the resident. He said if there was no accurate assessment, there could be a misunderstanding about the care needed. He said coordinate with the DON and the MDS Nurses to evaluate the situation. Record review of facility policy, Resident Assessment Policy and Procedure revised January 12, 2020, revealed Purpose: To assess each resident's strengths, weaknesses, and care needs. To use this assessment data to develop a person-centered comprehensive plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible . Procedure . The assessment process includes direct observation, the medical record, as well as communication with the resident and direct care staff across all shifts.

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

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 observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of (Resident #20) two residents reviewed for Incontinent Care. The facility failed to ensure that Resident #20's external catheter was properly stored on 01/22/2025. This failure could place residents at risk of cross-contamination and development of urinary tract infections. Findings included: Review of Resident #20's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old resident admitted to the facility on [DATE]. Resident #20 was diagnosed with overactive bladder. Review of Resident #20's Quarterly MDS Assessment, dated 12/24/2024, reflected the had a moderate impairment in cognition with a BIMS score of 11. Resident #20's Quarterly MDS Assessment did not indicate that the resident was using an external catheter. Review of Resident #20's Comprehensive Care Plan, dated 10/09/2024, reflected the resident was at risk for problems with elimination and one of the interventions was to assist with PureWick as per orders and resident request. Review of Resident #20's Physician Order, dated 01/22/2025, reflected purewick drain On Night Shift. Observation and interview with Resident #20 on 01/22/2025 at 10:15 AM revealed Resident #20 was in her bed, awake. It was observed that a PureWick system was at the resident's bedside. The resident said she used it every night. In an interview with LVN B on 01/22/2025 at 10:47 AM, she stated Resident #20 used a urine collection system called PureWick. She said the PureWick urine collection system was an external catheter used by the resident every night. She said the nurse would connect the external catheter to a tube connected to the collection canister. She went inside resident's room and saw the tube where the external catheter was on the floor. She said the connector tube should not be on the floor because the germs from the floor would be on the tube and could possibly transfer also to the catheter that would have a direct contact with the resident's perineal (area between the legs) area. She said she did not notice the tube connector of the PureWick was on the floor when she did her round. She said she would be mindful during rounds that the tube connector used to collect urine was properly stored to prevent infections. In an interview with ADON A 01/23/2025 at 1:39 PM, ADON A stated the tube connector should be cleaned and properly stored when not in use to prevent cross contamination and urinary tract infection. She said the expectation was for the staff to properly store the tube connector. She said the whole PureWick urine collection system should not be on the floor for the same reason. In an interview with the DON on 01/23/2025 at 1:57 PM, the DON stated Resident #20 used an external catheter every night. She said the collection system had a connecting tube to put the external catheter. She said every part of the urine collection system should be kept clean to prevent cross contamination and urinary tract infection. She said the connecting tube should be stored properly when not in use. She said the expectation was for the staff to clean the connecting tube when the external catheter was disconnected and store it properly. She said she would educate the staff the importance of ensuring the connecting tube was properly stored. In an interview with the Administrator on 01/24/2025 at 10:09 AM, the Administrator stated whatever the resident was using should be kept clean to prevent infection. He said the expectation was for the staff to do the right procedure. He said he was not a clinician and would let the DON handle the issue about the external catheter. Record review of the facility's policy, Perineal Care/Incontinent Care Restorative Policy revised 04/2012 reflected Provisions . 2. Set up clean field . 10. Remove gloves and wash hands or alcohol gel and re-glove hands. Policy for external catheter requested on 01/23/2025 at 2:07 PM via email to the Administrator but was not provided during exit.

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

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 needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #49 and Resident #64) of five residents reviewed for Respiratory Care. 1. The facility failed to ensure Resident #49's suction machine and the Yankauer suction tip (oral suctioning tool used to remove fluid and secretions from the airway) connected to it was properly stored on 01/22/2025. 2. The facility failed to ensure Resident #64's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) connected to the oxygen concentrator was properly stored on 01/22/2025. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #49's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #49 was diagnosed with disturbances with salivary secretions. Record review of Resident #49's Quarterly MDS Assessment, dated 01/13/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 04. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #49's Comprehensive Care Plan, dated 12/24/2024, reflected breathing pattern as one of the resident's problem list and one of the interventions was to monitor lung sounds, cough, and character of sputum. Observation and interview with Resident #49 on 01/22/2025 at 2:00 PM revealed Resident #49 was in her bed, awake. It was observed that there was a suction machine on the floor, under the resident's bed. A Yankauer was connected to the tubing of the suction machine and the tubing was coiled around the machine. The Yankauer was not properly stored. When asked about her suction machine, the resident did not reply. In an interview with LVN B on 01/22/2025 at 2:16 PM, LVN B stated Resident #49 was in hospice and hospice was the one who provided the suction machine. She said the suction machine should not be on the floor and the yankauer should be bagged when not in use. She said the issue was not if the resident was using it or not but if it was kept clean in case the resident needed it. 2. Record review of Resident #64's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #64 was diagnosed with shortness of breath. Record review of Resident #64's Quarterly MDS Assessment, dated 01/13/2025, reflected the resident had a Brief Interview for Mental Status score of 99 indicating the resident was not able to finish the interview to determine the BIMS score. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #64's Comprehensive Care Plan, dated 12/02/2024, reflected the resident had an impaired gas exchange and of the interventions was to auscultate lung sounds. Record review of Resident #64's Physician Orders, dated 11/13/2024, reflected O2 at 2 LPM by NC PRN shortness of breath FOR O2 SAT <90%. Observation on 01/23/2025 at 1:11 PM revealed Resident #64 was not inside the room. An oxygen concentrator with a nasal cannula connected was observed at the resident's bedside. The nasal cannula was hanging on top of the oxygen concentrator and was not bagged with the prongs of the nasal cannula almost touching the floor. Observation and interview with LVN C on 01/23/2025 at 1:19 PM, LVN C stated the Resident #64 was in hospice and hospice was the one who provided for the oxygen concentrator. She said the resident did not usually use the oxygen. She said even though the resident was using it as needed, the nasal cannula should be properly stored when the resident was not using it. LVN C disconnected the nasal cannula and threw it in the trash can. She said if the nasal was exposed, germs from the oxygen concentrator or even the floor could transfer to the nasal cannula and might cause infection. In an interview with ADON A on 01/23/2025 at 1:39 PM, the ADON A stated the nasal cannula and the yankauer should be bagged whenever the resident was not using it to prevent cross contamination and eventually infection. She said the nasal cannula was inserted to the nose and the Yankauer to the mouth, and if they were dirty, it was just like introducing germs to the inside of the body. She said the expectation was for the staff to ensure the equipment used for respiratory care were properly stored. She said she would do an in-service about bagging the nasal cannula and the Yankauer when not in use. In an interview with the DON on 01/23/2025 at 1:57 PM, the DON stated the nasal cannula and the yankauer were supposed to be in a bag when the resident was not using it to prevent cross contamination and respiratory infections If the staff would prefer to have them near the residents, they should be stored properly. She said the expectation was for the staff to be mindful and make sure the nasal cannula and the yankauer were kept clean and bagged when the residents were not using them. She said she would conduct an in-service about respiratory care. In an interview with Hospice Nurse I on 01/24/2025 at 8:56 AM, Hospice Nurse I stated when a resident was admitted on hospice, hospice would provide some equipment that would facilitate comfort during end-of-life care. She said hospice would provide, but the facility was responsible in taking care of the equipment. Just like the nasal cannula and the yankauer of the suction machine, the staff of the facility should make sure that they were clean and properly stored to prevent cross contamination and respiratory infection. In an interview with the Administrator on 01/24/2025 at 10:09 AM, the Administrator stated everything the residents were using should be kept clean to prevent infection. He said he was not a clinician but would coordinate with the DON on how to go forward about the respiratory care issue. Record review of the facility's policy, Departmental (Respiratory Therapy) - Prevention of Infection 2001 MED-PASS, Inc. revised October 2012, reflected Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment . 7. Store the circuit in plastic bag, marked with date and resident's name.

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 F0583 (Tag F0583)

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 provide the right to personal privacy and confidentiality which includes privacy during medical treatment and confidentiality of medical records for four (Resident #31, Resident #42, Resident #79, and Resident #91) of eighteen residents reviewed for Privacy and Confidentiality. 1. The facility failed to ensure RN E and RN F closed the door while administering Resident #79's breathing treatment on 01/23/2025. 2. The facility failed to ensure RN E closed the door while administering Resident #91's medication through g-tube on 01/23/2025. 3. The facility failed to ensure MA I did not leave Resident #31's and Resident #42's health information on top of the medication cart unattended on 01/23/25. These failures could place the residents at risk of not having their personal privacy maintained during medical treatment and their medical information exposed to unauthorized individuals. Findings included: 1. Review of Resident #79's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old male resident admitted to the facility on [DATE]. Resident #79's was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident #79's Quarterly MDS Assessment, dated 12/11/2024, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Review of Resident #79's Care Plan, dated 12/31/2024, reflected the resident used a respiratory medication and one of the interventions was to administer medications as ordered. Review of Resident #79's Physician Order, dated 11/18/2024, reflected ALBUTEROL SULFATE 0.083% SOLUTION (Albuterol Sulfate) 3 ml Inhalation nebulization Three times a day [Time: 08:00 AM, 12:00 PM, 08:00 PM] for Chronic obstructive pulmonary disease, unspecified. Observation and interview with RN E on 01/23/2025 at 8:18 AM revealed RN E and RN F were about to administer breathing treatment to Resident #79. RN E and RN F sanitized their hands, put on their gowns and gloves, and went inside the resident's room. RN E took the resident's breathing mask from the plastic bag, poured the breathing treatment solution to the nebulizer cap, and put it on the resident's face covering the mouth and the nose. RN E went to the bathroom and washed her hands. After washing her hands, RN E went out of the resident's room. RN E said RN F would wait for the breathing treatment to be done. From the hallway, it could be seen that the resident was having his breathing treatment. It could also be seen that RN F was sitting in a chair across the room. In an interview with RN E on 01/23/2025 at 8:50 AM, RN E stated doors should be closed when providing care to the residents to provide them privacy and dignity. She said she thought she closed the door after washing her hands. She said she should have doubled check if the door was close or have told RN F to close the door. She said it did not matter if the resident would mind or not, the door should be closed. She said Resident #79 was non-verbal and would not be able to tell her if he wanted the door closed or not and if he was embarrassed or not. 2. Review of Resident #91's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old female resident admitted to the facility on [DATE]. Resident #91's was diagnosed with gastrostomy status. Review of Resident #91's Quarterly MDS Assessment, dated 11/25/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 01. The Quarterly MDS Assessment indicated the resident was on feeding tube (delivery of food through a tube to the stomach) while a resident of the facility. Review of Resident #91's Care Plan, dated 11/26/2024, reflected the resident used anticonvulsant and one of the interventions was to administer medication as ordered. Review of Resident #91's Physician Order, dated 01/09/2025, reflected GABAPENTIN 300 MG CAPSULE (Gabapentin) 1 capsule Gastrostomy Tube (a tube that is surgically inserted through the skin of the belly and into the stomach) Three times a day [Time: 08:00 AM, 12:00 PM, 08:00 PM]. Observation and interview with RN E on 01/23/2025 at 12:03 PM revealed RN E was about to administer Resident #91's medication through g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach). She went inside the room and told the resident that she would be giving her the 12:00 PM medication. RN E went to the bathroom to wash her hands. She said the resident would only have one medication for 12 PM. She then put one capsule of gabapentin to a small plastic cup and then opened it and placed the content of the capsule into the small plastic cup. She then put some water on a plastic cup. She said she would use the water to dissolve the gabapentin and to flush the g-tube before and after the medication administration. After preparing the water, she sanitized the bell of her stethoscope and let it dry. She went inside the room and took with her the medication, the cup of water, and some small cups. She placed the things that she would be using on the resident's overbed table, took the resident's syringe from the resident's bedside, and placed it also on the overbed table. RN E positioned herself and the overbed table on the resident's left side. RN E was facing the door. She did not close the door and the privacy curtain was not pulled all the way through. From the hallway, it could be observed that RN E pulled the resident's gown up to expose the feeding port, checked for placement and residual, dissolved the medication, flushed the g-tube, administer the medication, and flushed again after the medication was give. RN E said she forgot to close the door again or at least pulled the privacy curtain all the way through while administering the resident's medication. She said the door should be closed or the privacy curtain pulled all the way through to provide privacy and give dignity to the resident. She said she would make sure she would close the door every time she was providing care. In an interview with ADON A on 01/23/2025 at 1:39 PM, ADON A stated all care should be done in the privacy of the residents' room to promote dignity. She said every care done by the staff should be behind the door so other staff, other residents, or even the visitors would not see or speculate the medical condition of the residents. She said it did not matter if the residents care or not, the door should still be closed while providing care. She said it was important that the residents would be safe and would not be embarrassed. She said the expectation was for the staff be mindful when they were providing care. She said she would coordinate with the DON to do an in-service closing the door while providing care to enable a dignified existence because the facility was their home. In an interview with the DON on 01/23/2025 at 1:57 PM, the DON stated the door should be closed when administering the breathing treatment and medication. She said the privacy curtain should be pulled all the way so that even though the door was open, nobody could see the care being provided. She said the door should be closed to provide dignity to the residents and to avoid embarrassment. The DON said all the staff, including her, were responsible in providing dignity to the residents. The DON said the expectation was for the staff to make sure that when they were providing care, the residents' door was closed, or the privacy curtain were pulled all the way. She concluded that she would continually remind the staff the importance of providing privacy and dignity through an in-service. In an interview with the Administrator on 01/24/2025 at 10:09 AM, the Administrator stated the staff must make sure that the residents were provided privacy when providing care to prevent embarrassment. She said the expectation was for the staff to close the door, not only during medication administration, but during all care provided. He said he would collaborate with the DON and the ADON to do an in-service about closing the door to provide dignity. In an interview with RN F on 01/24/2025 at 2:39 PM, RN F stated the door should be closed every time a staff was providing care to the residents. RN F said some residents could not communicate and even though they were feeling embarrassed, they could not verbalize it. RN F said she should have closed the door when RN E left Resident #79's room. 3. Review of Resident #31's face sheet, dated 01/23/2025, reflected a [AGE] year-old female resident admitted to the facility on [DATE] with Non-Alzheimer's Dementia. Review of Resident #31's Quarterly MDS Assessment, dated 12/20/2024, reflected severely impaired cognition with a BIMS score of 1. Section I reflected an active diagnosis was Non-Alzheimer's Dementia. Review of Resident #31's Care Plan, dated 12/24/2024, reflected the resident had cognitive deficit related to dementia. One intervention was allow ample time for task completion. Review of Resident #42's face sheet, dated 01/23/2025, reflected an [AGE] year-old female resident admitted to the facility on [DATE] with Non-Alzheimer's Dementia. Review of Resident #42's Quarterly MDS Assessment, dated 12/31/2024, reflected a BIMS test was not conducted for the resident. Section I reflected an active diagnosis was Non-Alzheimer's Dementia. Review of Resident #42's Care Plan, dated 12/10/2024, reflected the resident had cognitive deficit related to dementia. One intervention was encourage simple leisure activities. An observation and interview on 01/23/25 at 03:19 PM revealed a document on top of the medication cart with residents' personal health information on it. The medication cart was parked at the beginning of the 400 hall and next to a resident sitting area. No staff member was near the medication cart. There were 3 labels affixed to the blank sheet of paper on top of the medication cart. Each label reflected a resident's name, room number, and the name of a medication. Two of the labels reflected a medication refill for Resident #31 and the other label reflected a medication refill for Resident #42. During the observation, MA I approached the cart and was asked about the resident information on top of the medication cart. MA I stated she was going to fax the document to the pharmacy to request medication refills for the residents. She stated she accidentally left it out. She stated it was confidential information and that no one needed to see it. MA I immediately removed the document. During an interview on 01/24/25 at 09:27 AM, ADON B stated it was a HIPAA violation to leave residents' health information out for everyone to see. She stated it was a violation of the residents' rights to have their personal information accessible to others. She stated the facility will provide in-service training to remind staff of this. During an interview on 01/24/25 at 10:22 AM, the Administrator stated when MA I was not at the medication cart, his expectation was for any resident information to be covered up. He stated MA I should have turned the paper over or removed it so resident health information was not seen. The Administrator stated he had the same expectation for a paper document with resident information as he did for a computer screen with resident information visible. He stated he would expect a computer screen to be closed if staff was not using it. In an interview on 01/24/25 at 03:38 PM, the DON stated it was a HIPAA violation to leave residents' personal information out where someone could walk by and see it. The DON stated her expectation was for all staff members to protect residents' personal health information. Record review of facility's policy, Resident Rights Policy and Procedure revised August 14, 2022, revealed Policy: The staff will abide by and protect resident rights in accordance with state and federal guidelines . the resident has the right for a dignified existence.

CONCERN (E) 📢 Someone Reported This

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

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based observation, interview, and record review, the facility failed to ensure proper handling of the ice to prevent contamination and the potential for waterborne illness by one CNA (CNA D) out of four staff attending to the residents during lunch time. The facility failed to ensure CNA D did not put the ice scooper on the bowl of ice while preparing drinks for the residents during lunch time on 01/22/2025. This failure could place the residents at risk of cross-contamination and development of infections. Findings included: An observation on 01/22/2025 at 12:03 PM revealed CNA D was preparing some drinks for the residents. At the middle of the dining area was a table with some boxes of milk, a bowl of ice, a small plate, and some pitchers of iced tea. She placed four glasses on a tray, scooped some ice from a bowl of ice, and put them on the glasses. She used an ice scooper to put the ice. After she put the ice on the glasses, she placed the scooper on the bowl of ice, and poured iced tea on the glasses. She put the scooper on top of the bowl of ice with the handle of the scooper touching the ice. She used her bare hands when she used the scooper. She gave the glasses to the residents. she went back to the table, placed five glasses on the tray, took the scooper on top of the ice, scooped some ice, put it on the glasses, returned the scooper on top of the ice, poured some iced tea on the glasses, and gave them to the residents. She returned to the table, placed four glasses on the tray, took the scooper on top of the ice, scooped some ice, put it on the glasses, returned the scooper on top of the ice, poured some iced tea on the glasses, and gave them to the residents. a small plate was noted beside the bowl of ice. In an observation and interview with ADON A on 01/22/2025 at 12:12 PM, ADON A stated the scooper should be placed on the plate beside the ice bowl and not on top of the ice that were inside the bowl of ice. She said putting the handle on the bowl of ice could contaminate the ice. She said germs could transfer from hands to ice scooper handle to ice. ADON A took the bowl of ice and replaced it. she also took the glasses of iced tea given to the residents and replaced them. She said she would talk to CNA D and would remind her to put the scooper on the small plate beside the bowl of ice. In an interview with CNA D on 01/22/2025 at 12:30 PM, CNA D stated the handle of the scooper that she held should not touch the ice to prevent transfer of germs. She said she also touched the tray she used to give the residents their drinks and she was not sure if the tray was clean. She said she should have put the ice scooper on the small plate beside the bowl of ice. In an interview with the DON on 01/23/2025 at 1:57 PM, the DON stated the ice scooper should be placed on the small plate beside the bowl of ice. She said placing the handle of the ice scooper inside the ice could contaminate the ice that were put in glasses for the residents. She said her expectation was for the staff to be mindful with the manner they served the residents. She said she would do an in-service about infection control and would include proper handling of the ice scooper because putting it on top of the ice could contribute to cross contamination and infection. In an interview with the Administrator on 01/24/2025 at 10:09 AM, the Administrator stated the ice scooper should be placed on the small plate beside the bowl of ice and not on top of the ice to prevent contaminating the ice that would be used for the residents' drinks. He said the expectation was for the staff to be mindful when they were preparing the drinks of the residents. He said he would collaborate with the DON about the infection control issue. Review of facility policy, Ice Storage . Sanitary Care . and DEPARTMENT: Infection Control Policy and Procedure revised August 2018 revealed Policy: Sanitary care . Procedures . B. Hold ice scoops by the handle; do not touch ice . C. Only ice scoops are used to obtain ice . F. Limit access to the handling of ice and ice-storage devices to minimize contamination . Ice Scoops: 1. Scoops are kept in a covered stainless steel, impervious plastic, or fiberglass tray when not in use.

Dec 2024 4 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of five residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from sexual abuse. Resident #1 was cognitively impaired and had diagnoses of Alzheimer's. Resident #1 was sexually assaulted by a visitor whom she did not know, on 11/28/24. An IJ was identified on 12/05/24. The IJ template was provided to the facility on [DATE] at 4:04 PM. While the IJ was removed on 12/06/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimum harm to resident health or safety because all staff had not been trained on the plan of removal. This failure placed residents at risk for abuse, mental anguish, and emotional distress. Findings included: Record review of Resident #1's electronic face sheet, printed 12/05/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis that included but not limited to Alzheimer's without behavioral disturbance, psychotic disturbance, or mood disturbance (the most common cause of dementia). Record review of Resident #1's Quarterly MDS Assessment, dated 10/18/24, reflected she had a BIMS score of 03 indicating severe cognitive impairment. Functional abilities section GG revealed Resident#1 needed assistance with eating, oral hygiene, partial moderate assistance with toileting, shower, bathing. Record review of Resident #1's care plan revised 10/07/24 reflected the following, Cognitive Deficit: Decision-making with interventions that included, monitor for any changes, or decline in cognitive, administer meds as ordered, allow ample time for task completion, assess for unmet need (pain, hunger, thirst, toileting), Decreased stimulation as needed, Encourage simple leisure activities. Wandering/At risk for elopement, Bracelet alarm for alarm door with interventions: Bracelet alarm for alarm doors, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, document all incidents of wandering, keep picture of resident at front desk, make sure all staff are aware of elopement risk, reorientation to person, place, and time prn. Review of Resident #1's clinical record did not reveal an incident report regarding sexual abuse. Interview on 12/05/24 at 11:15 AM with the Administrator stated there was a Male Visitor who did not know Resident #1 and had never visited her. The Male Visitor began coming to the facility about 4 weeks ago to visit Resident #3 once a week. The Administrator stated according to the video provide Resident #1's roommate, Resident #4's responsible party, on Thanksgiving Day (11/28/24) around 12:30pm the Male Visitor entered the facility. He was seen on camera interacting with Resident #1. Resident #1 and the Male Visitor interacted then went to her room to make out. They left her room, and he went to visit Resident #3's , and Resident #1 followed him. He alerted the nursing staff that Resident #1 was following him, and they intervened. He left Resident #3's room and went back to the Resident #1's room looking for her. The Male Visitor found Resident #1 in the hall, and they went back to Resident#1's room and were seen on camera disrobing. The Vale Visitor pulled the curtain and was seen after a few minutes naked and getting dressed and telling the resident to get dressed. The Male Visitor told Resident#1 he would be back on Tuesday( (12/03)24, and they could do it again. The Male Visitor left the building. The Social Worker was contacted on Friday ((11/29/24) by Resident #4's responsible party about the incident. Police were called and Resident #1 was taken home by her family. Resident #1 had not returned to the facility Wednesday (12/04/24). The Administrator stated staff were in-serviced on 11/29/24 on identifying the Male Visitor and notifying law enforcement should the Male Visitor be seen on the property. The Administrator stated staff was in-serviced on 11/30/24, 12/01/24 and 12/2/24 regarding identifying sexual abuse. The Administrator initiated safe surveys with residents on 11/30/24 and 12/01/24. The Administrator stated the facility did not have a procedure for tracking visitors in the building. The Administrator stated the door to Resident #1's room was typically closed therefore staff would not have thought it was unusual that the door was closed. The Administrator stated he was informed about the incident on 11/29/24 and a self-report was completed and investigated by a state surveyor on 12/01/24. The Administrator was asked to provide the internal investigation however stated the details of the investigation had not been type up and completed yet because he had not had time. The internal investigation notes were not provided. The Administrator stated the facility did not have a visitor log and did not track visitor upon entry. The code to the front door was posted outside the front door which allowed visitors access to the building at any time. Review of safe surveys with residents initiated on 11/30/24 and 12/1/24. Review of the in-service regarding identifying the male visitor and contact law enforcement and the administrator dated 12/29/24. Review of in-service regarding identifying sexual abuse dated 11/30/24, 12/01/24 and 12/2/24. Review of the video provided by Resident #1's room mate, Resident #4's responsible party, to facility on 12/01/24 was undated which and was 15 minutes an 44 seconds long revealed while in Resident #1's room the Male Visitor asked Resident #1 if she ever pulled the curtains for privacy and proceeded to kiss her and rub his hands over her body as they stood body to body near Resident #4's side of the room. The Male Visitor pointed at Resident #4's bed and asked how old she was, and Resident #1 stated I do not even know who she is. The Male Visitor stated he was going to see Resident #3, who was his mother, but before leaving told Resident #1 she was so beautiful. The Male Visitor proceeded to kiss and rub his hands over Resident #1's body and then told her he would come back in a little bit. The Male Visitor was seen closing the door of Resident #1's room and kissing and rubbing Resident #1 while body to body again. The Male Visitor told Resident #1 You're so sexy. You did well. and continued kissing and rubbing Resident #1's body while standing body to body. Resident #1 and the visitor were no longer in the room and another male appearing to be a resident entered the view of the camera and walked out of the room. The Male Visitor and Resident #1 returned to the room however the camera view does not show the room of the door being closed. The Male Visitor directed Resident #1 to close the blinds. The Male Visitor closed the curtains at 9 minutes and 38 seconds on the video and was seen coming back from behind the curtain fully naked at 10 minutes and 12 seconds on the video. The Male Visitor dressed and stated to Resident #1 I will see you on Tuesday and we can do a repeat. You can have me again. The Male Visitor reiterated to Resident #1 multiple times I will see you on Tuesday. I will see you in five days. The Male Visitor asked Resident#1 to repeat when she was going to see him again and when she stated 5 days he stated You got it. Good job. Give me a high five. The Male Visitor asked Resident #1 How many days would it be before you see me? Resident #1 responded 10 and the Male Visitor stated 5 and Resident #1 repeated 5. The Male Visitor reminded Resident #1 to get dressed and left the room. Resident #1 was seen fully naked and began getting dressed at 14 minutes and 8 seconds into the video. Review of the 2nd video titled angle 2 provided by Resident #4's responsible party was undated and was 6 minutes and 30 seconds long. At 2 minutes and 33 seconds the Male visitor was seen undressing and Resident#1 was seen fully nude. The curtains were closed, and the Male visitor was seen naked at 3 minutes and 34 seconds and Resident #1 was seen laying in bed. At 6 minutes and 01 second Resident #1 was seen naked and began getting dressed. Record review of the summary provided by the police department, undated, revealed: Sexual Assault Investigations at Assisted living Facility [City and state], December 4,2023- On November 28,2024 at approximately 2:44pm, [City/state] Police department responded to [facility name] at [facility address] in reference to a visitor possibly having sexual contact with a resident. Responding officers learned a family member of a resident installed a security camera inside that resident's room. The family member reported that while reviewing video from the camera, they observed an unknown male engaging in some type of sexual act with the family member's roommate. The family was aware of the lack of mental capacity of the roommate and contacted staff. [Facility name] staff contacted law enforcement and were able to identify the male wo was a visitor at the facility as [Male Visitor], age and of state/ city]. [name of police department] criminal investigation division began investigating the allegation immediately. The resident was moved from the facility by family. The Facility was asked to contact the policed department if [Male Visitor] returned. Detectives received information that [Male Visitor] would be back at the facility on December 4, 24, and set up surveillance. [Male Visitor] was taken into custody at 11:04 PM on December 4, 24 for a warrant obtained for indecent assault. After speaking with [Male Visitor], charges were also filed for aggravated sexual assault. [Facility name] has been cooperative throughout the investigation. They will be conducting an internal investigation, but at this time it is not believed that there are other victims. Interview on 12/06/24 at 5:25 AM with CNA A revealed she was made aware that there was an incident of sexual abuse in the facility however she was not informed of the details. She stated on 11/30/24 she was provided information regarding the Male Visitor and informed that if she saw him to contact law enforcement and the Administrator. CNA A stated she also completed a in- service regarding identifying sexual abuse. CNA A revealed visitors did not have sign in to visit residents. CNA A stated she did not received training on changes to how visitors accessed the building. Interview on 12/06/24 at 5:28 AM with RN B revealed she was informed on11/30/24 to alert the Administrator and law enforcement if she saw the Male Visitor. RN B stated she completed an in-service regarding recognizing sexual abuse however she had not completed any training regarding how visitors accessed the building. RN B stated staff were not currently tracking visitors in the building and visitors did not have to sign in to visit. Interview on 12/06/24 at 5:32 AM with RN C revealed she worked with Resident #3 and was informed that the family member was involved in the sexual assault however she did not know the details. RN C stated she had never seen the Male Visitor in the building and stated he only recently began visiting and calling the facility for Resident #3. RN C stated she was informed that if she saw the Male Visitor to contact law enforcement and she completed a training on sexual abuse. She stated she had not completed training regarding any changes to how visitors accessed the building however she did know that there was a person sitting near the front door who was screening visitors as they entered due to the sexual assault. RN C stated Resident #3 was verbal however due to cognitive ability would not likely be able to complete an interview. Interview on 12/06/24 at 5:36 AM with CNA J revealed she was informed about the sexual abuse in the facility and showed a picture of the Male Visitor and was told to contact law and the Administrator if she saw him. She stated she received training on sexual abuse and was informed that visitors would begin using a sign in sheet moving forward. Attempted interview on 12/06/24 at 9:35 AM with Resident #4 revealed she was unable to answer questions due to cognitive ability. A family member spoke through the camera and provided her contact information. Interview via phone on 12/06/24 with Resident #4's family member revealed she informed the facility about the sexual abuse. She stated she was not sure why staff kept asking Resident #4 about the incident because she did not know anything. She stated she was concerned that a random resident kept walking in the room and making Resident #4 uncomfortable. The family member stated she would like for the staff to be more aware of who was going into the rooms. Review of the facility policy ABUSE, NEGLECT AND EXPLOITATION AND MISAPPROPRIATION OF RESIDENT PROPERTY revised February 12, 2020 revealed: The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (ii) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. All managed healthcare facilities and all management company staff members or third parties providing services to such facilities and/or their residents. 1.Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. 2.Facility Duty to Protect Resident Rights. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. An Immediate Jeopardy was identified on 12/05/24. The Administrator and DON were notified of the Immediate Jeopardy on 12/05/24 at 4:04 PM. The IJ template was provided to the facility on [DATE] at 4:04 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of removal was accepted on 12/05/24 at 9:54 AM and revealed the following: [Facility name}] 3rd Draft Plan of Removal for F600 submitted on 12/05/24. What corrective action will be taken for those residents found to have been affected by the deficient practice; o The facility immediately notified the police of the allegation. o The resident was taken to an acute care hospital for sane exam by the resident's family member per police request. o After the resident's sane exam was completed at the acute care hospital, she went home with her family member and remains there today. o The perpetrator was immediately identified by the Administrator and Licensed Social Worker after viewing video that was provided by a family. The video was in place per the AEM programs. o The location of the perpetrator was unknown and all staff were trained on how to identify him and what actions needed to take place if he appeared on the property again. o A door monitor was initiated to monitor all visitors entering the facility to identify him if he enters the facility. The monitor was in place 24 hours a day. o The facility cooperated with the [City name] Police Detective and contacted the perpetrator to arrange a care plan meeting. This was an attempt to identify when he would return to the facility as he resides in [State name]. The care plan meeting was scheduled for 10:00 am on 12/04/24. The perpetrator arrived and the [City name] Police Department immediately arrested him, and he is currently in the [City name] City Jail after being charged with Aggravated Sexual Assault. o All staff were trained multiple time on sexual abuse, their responsibilities, and how to identify sexual assault. How other residents with the potential to be affected by the same deficient practice will be identified; o All residents have the potential to be affected by this practice. What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur; o On 12.06.24, the Administrator will implement a visitor log at the entrance to the facility for visitors to sign in and out. o On 12.06.24, the Administrator will place signage at the entrance of the facility that describes the requirement for the visitor to sign in and out. o Beginning on 12.06.24 all staff will be trained on this new visitation requirement. This training will be provided by their respective supervisors. o In the event that [Resident #1] request to be return to the facility the facility will take the following actions: o Resident #1's care plan will be updated to include: ? Increase visual checks of [Resident #1] to every hour by a designated staff member. ? If [Resident #1's] door to her room is found to be closed, staff will check resident status to ensure safety. ? If [Resident #1] is observed to be exhibiting overly friendly behavior with another resident or visitor, staff will redirect, as able. ? [Resident #1] will be assessed upon admission any additional care plan updates will be completed to ensure we meet the psychosocial needs of [Resident #1]. o [Resident #1's] representative will be informed of the right to have video surveillance in her room per Authorized Electronic Monitoring. How the corrective action(s) will be monitored to ensure the deficient practice is being corrected and will not recur; i.e., what program will be put into place to monitor the continued effectiveness of the system changes; o A designated staff member will make hourly rounds in the facility round and identify visitors in the facility. o This designated staff member will then review the visitor log to ensure the visitor has completed the log. If it is found the visitor has not, then they will be provided education on the requirement and complete the log. Monitoring is as follows: Observation on 12/06/24 at 10:20 AM and review of the visitor log dated 12/06/24 revealed visitors were signing the visitor log as they entered the building. Observation on 12/06/24 10:21 AM at of the signage outside the facility front door revealed it informed visitors of the requirements to be allowed in the building by staff and to complete the sign in sheet. Review of staff in- service completed 12/06/24 regarding visitor requirements. The In- service revealed all visitor would complete a sign in log. Staff were to report anything suspicion and a designated staff would make hourly rounds to ensure all visitor completed the sign in sheet. In the instance that a visitor is found not have completed the sign in sheet the visitor would be educated on the requirement and directed to complete the sign in sheet. Interviews on 12/06/24 between 10:20 AM- 11:15 AM with LVN D, MA E, CNA F, CNA G, and CNA H, revealed staff were trained on visitor requirements. Staff revealed visitors would be allowed access to the building by staff and would need to complete a sign in sheet. Staff revealed a designated staff member would complete hourly rounds to ensure all visitors signed in and would be educated on the new policy if they were not signed in. Interview on 12/06/24 at 11:25 AM with the Administrator In Training revealed he had been tasked to complete the hourly checks to ensure all visitors were accounted for and would educate and direct anyone who had not completed the sign in sheet to do so. The AIT stated he was designated to check the sign in sheet and verify that each visitor was with their family member and had completed the sign in sheet. The AIT stated if a visitor is found that had not completed the sign in sheet the visitor would be educated on the requirement and directed to complete the sign in sheet. An IJ was identified on 12/05/24. The IJ template was provided to the facility on [DATE] at 4:04 PM. While the IJ was removed on 12/06/24 at 12:00 PM the facility remained out of compliance at a scope of isolated and a potential for more than minimal harm to residents' health or safety because all staff had not been trained on the Plan of Removal.

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

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 observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one of one resident (Resident #1) reviewed for Incontinent Care. The facility failed to ensure CNA G did not use the same wipes used to clean Resident #5's lower abdomen to clean the resident's perineal area on 12/03/2024. This failure could place residents at risk of cross-contamination and development of urinary tract infections. Findings include: Record review of Resident #5's Face Sheet, dated 12/03/2024, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 was diagnosed with chronic kidney disease (loss of kidney function) and overactive bladder (frequent feeling of needing to urinate). Record review of Resident #5's Comprehensive MDS Assessment, dated 10/08/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment reflected Resident #5 was frequently incontinent for both bowel and bladder. Record review of Resident #5's Comprehensive Care Plan, dated 10/09/2024, reflected the resident was at risk for problems with bladder and bowel elimination and one of the interventions was to provide assistance as needed. Observation on 12/03/2024 at 9:17 AM revealed CNA G was about to do incontinent care for Resident #1. CNA G put on a pair of gloves and prepared the things needed for incontinent care. CNA G raised the bed and removed the resident's blanket and pillows and put them on the resident's recliner. She pulled the resident's dress up, unfastened the brief, and pushed it between the resident's legs. CNA G pulled some wipes and cleaned the resident's lower abdomen. After cleaning the resident's lower abdomen, she used the same wipes to clean the resident's front part. She did not get new wipes to clean the front part. In an interview with CNA G on 12/03/2024 at 9:33 AM, CNA G stated she used the front to back technique when she cleaned Resident #1's front part. CNA G said she pulled some wipes to clean the resident's belly and front part. She said she folded the same wipes used to clean the belly before using them to clean the resident's front part. She said she should have thrown the wipe away after each use to prevent the microorganisms from the belly to go to the front part. She said what she did could cause a urinary tract infection. She said she should be attentive of how she did incontinent care because the resident would be at risk for infection. She said they had in-services for incontinent care but she was not able to apply it. In an interview with ADON A on 12/03/2024 at 1:27 PM, ADON A stated the wipes should be discarded after every stroke and not be reused because it could cause cross contamination and probable infection. She said the expectation was for the staff to do incontinent care the right way which was using one wipe per stroke and then discard it. She said she would initiate an in-service as soon as the interview was over. In an interview with the DON on 12/03/2024 at 3:18 PM, the DON stated the wipes should not be folded for reuse during incontinent care. The wipes should be discarded with every stroke to prevent urinary tract infection. She said the expectation was for the staff to remember and practice the proper way of incontinent care. She said she would do an in-service for staff doing direct care and would do a one-on-one in-service with CNA G. In an interview with the Administrator on 12/03/2024 at 4:06 PM, the Administrator stated improper cleaning of the resident could cause infection. He said the expectation was for the staff to do the right procedure for incontinent care. He said he was not clinical and would let the DON handle the issue about improper incontinent care. Record review of the facility's policy, Perineal (area between the thighs) Care/Incontinent Care Restorative Policy revised 04/2012 reflected Policy Statement: Staff will perform perineal/incontinent care with each bath and after each incontinent episode . Provisions . 5. Start at waistband and clean upper abdomen, middle abdomen (lift folds), lower abdomen using side to side motion. (ONLY USE ONE WIPE PER SWIPE.) . 8. For female patient/resident . a. Separate the labia and wash downward (down the center of labia), then downward on each side of the labia using a different peri wipe with each stroke.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the medications for two of two residents (Resident #2 and Resident #3) were stored in locked compartments and permit only authorized personnel to have access to the keys. 1. The facility failed to ensure Resident #6's bottle of Nature Made Fish Oil was not left on resident's recliner on 12/03/2024. 2. The facility failed to ensure Resident #7's Equate Lubricant eye drops was not left on top of the resident's overbed table on 12/03/2024. 3. The facility failed to ensure Resident #7's bottle of Allegra tablets was not left on top of the resident's overbed table on 12/03/2024. These failures could place the residents at risk of not receiving medications, accidental overdose, or misuse of medications. Findings include: 1. Record review of Resident #6's Face Sheet, dated 12/03/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #6 was diagnosed with dementia (term used to describe a group of symptoms affecting memory and thinking) and depressive disorder. Record review of Resident #6's Comprehensive MDS Assessment, dated 10/29/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment reflected the resident had medically complex conditions. Record review of Resident #6's Comprehensive Care Plan, dated 10/29/2024, reflected the resident was taking antidepressants and one of the interventions was to monitor closely for worsening of depression. The care plan also reflected the resident had a cognitive deficit in decision-making and one of the interventions was to monitor for any decline in cognitive status. The resident did not have a care plan for self-medication. Record review of Resident #6's Physician Orders on 12/03/2024 reflected no order for fish oil. Record review of Resident #6's List of Assessments on 12/03/2024 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage his own medications. Observation and interview with Resident #6 on 12/03/2024 at 8:59 AM revealed the resident was in his wheelchair inside his room. It was noted that there was a bottle of fish oil in the resident's recliner. The resident said it was his supplement and he did take it once in a while. He said he always put the fish oil in his recliner for easy access. 2. Review of Resident #7's Face Sheet, dated 12/03/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. Resident #7 was diagnosed with anxiety disorder. Review of Resident #7's Comprehensive MDS Assessment, dated 10/07/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. Resident #7's Comprehensive MDS Assessment reflected the resident had anxiety. Review of Resident #7's Comprehensive Care Plan on 10/09/2024 reflected the resident was taking an anti-anxiety medication and one of the interventions was to monitor behaviors every shift. The resident did not have a care plan for self-medication. Review of Resident #7's Physician Orders on 10/22/2024 reflected the resident did not have an order for eyedrops. Review of Resident #7's Physician Orders, dated 11/26/2024, reflected ALLERGY RELIEF 180 MG TAB (Fexofenadine Hydrochloride) 1 Tablet by mouth One time daily. Review of Resident #7's List of Assessments on 12/03/2024 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage her own medications. Observation and interview with Resident #7 on 12/03/2024 at 9:46 AM revealed Resident #7 was in her bed, awake. It was observed that there was an eye drop container and a bottle of Allegra tablets on the resident's overbed table. She said she used her eye drops because her eyes were getting dry. She said Allegra was for allergy. Observation and interview with LVN B on 12/03/2024 at 12:16 PM, LVN B stated the residents were not supposed to self-medicate if there was no assessment and care plan that the resident could self-medicate. She said there should not be any medications inside the room to avoid overdose and choking. She said she did not notice that Resident #3 had eye drops and Allegra on her overbed table. She said she would talk to the resident, that she would take the eye drops and Allegra for now and would check if she had orders for the said medication. She said if there were no orders, she would call the doctor to get orders for the medications. She said if she remembered it right, the resident had an order for antihistamine. She said she did not know why Resident #3 had over the counter medications inside the room. She said she would also talk to the family, that for safety reasons, medication should be administered by the medication aide or the nurses. LVN B went inside Resident #3's room and talked to the resident and said that she had to take her eye drops and Allegra and would check if the doctor had orders for them. The resident refused at first and then complied. LVN B then went inside Resident #2's room and saw the fish oil sitting on the resident's recliner. She talked to the resident and said that she would take the fish oil for now and would call the doctor for an order for the fish oil. The resident complied. Resident #2 said he was taking the fish oil as a supplement. In an interview with LVN D on 12/03/2024 at 12:39 PM, LVN D stated she was the charge nurse on Resident #2's hall and did not notice that there was a bottle of fish oil on the resident's recliner. She said there should be no medications inside the resident's room to prevent overdose and accidental choking. She said it could be accidently ingested by confused residents or children could mistake it for candies. She said she would look at the rooms of other residents and make sure there were no medications inside the rooms. She said, also confused residents might overdose if they cannot remember if they had already taken the medication or not. In an interview with ADON A on 12/03/2024 at 1:27 PM, ADON A stated there should be no medications inside the room because it was not safe. She said it could result in overdose and overmedication. She said fish oil is a supplement but could still have adverse reactions when taking more than required. She said the resident could accidentally poke her eyes if she was doing her eye drops by herself. She said they would check if the residents had orders for the medication, would request an order if there was none, and would let the residents know that the medication aide or the nurses would administer the medication. She said the expectation was no medication would be inside the room and for the staff to be mindful if they saw medications inside the room. She said she would do an in-service about medication storage and would also check the room if there were medications with the residents. In an interview with the DON on 12/03/2024 at 3:18 PM, the DON stated all the medications should be inside the medication carts and administered by qualified staff. She said they should check the residents' rooms during their rounds to see if there were medications inside the rooms of which they were not aware. She said if a family member was the one bringing the medications, the family member should be educated of the harm if the medications were taken by the resident without supervision. She said the resident might overdose, another resident or a visitor might accidentally ingest the medication and there could be adverse reactions especially if somebody who accidentally ingested the medications was allergic to the medications. A child who accidentally swallowed the medication could choke from it. She said the expectation was no medications would be inside the room. She said another expectation was for the staff to be mindful and observant that if they see any medication, they should take appropriate actions to prevent adverse outcomes such as choking and overdose. She said they would collaborate with the physician if the medications were really needed, make orders for them, and place them in the cart for the nurses or aides to administer. She said she would do an in-service about medication administration and making sure no medications were inside the room. In an interview with the Administrator on 12/03/2024 at 4:06 PM, the Administrator stated all medications should be in the cart and not inside the residents' room. He said if there were medications inside the residents' rooms, it could result in accidental ingestion and overdose, especially if nobody was monitoring it. He said the residents could also choke if they were self-medicating and nobody would know. He said the expectation was for the staff to make sure no medications were inside the room or where easily accessible to other residents and visitors. Record review of facility policy, Medication Storage Nursing Care Center Pharmacy Policy & Procedure Manual revised 01/24 revealed POLICY: Medications and biologicals are stored properly . The medication supply shall be accessible only to licensed nursing personnel . or staff members lawfully authorized to administer medications.

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 observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of one resident (Resident #1) reviewed for Infection Control. 1. The facility failed to ensure CNA G changed her gloves and performed hand hygiene while providing incontinent care to Resident #5 on 12/03/2024. 2. The facility failed to ensure CNA G did not hang Resident #1's new brief on the wooden frame of the bed on 12/03/2024. These failures could place residents at risk of cross-contamination and development of infections. Findings include: Record review of Resident #5's Face Sheet, dated 12/03/2024, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 was diagnosed with chronic kidney disease (loss of kidney function) and overactive bladder (frequent feeling of needing to urinate). Record review of Resident #5's Comprehensive MDS Assessment, dated 10/08/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment reflected Resident #1 was frequently incontinent for both bowel and bladder. Record review of Resident #5's Comprehensive Care Plan, dated 10/09/2024, reflected the resident was at risk for problems with bladder and bowel elimination and one of the interventions was to provide assistance as needed. Observation on 12/03/2024 at 9:17 AM revealed CNA G was about to do incontinent care for Resident #1. CNA G entered the resident's room, put on a pair of gloves, and prepared the things needed for incontinent care. She placed the folded brief beside the resident's left leg. She did not wash her hands before putting on the gloves. CNA G raised the bed and removed the resident's blanket and pillows and put them on the resident's recliner. After putting the blanket and pillows on the recliner, she hung the brief on the wooded frame of the bed's foot side. The inside of the brief was in contact with the wooden frame. She pulled the resident's dress up, unfastened the brief, and pushed it between the resident's legs. CNA G pulled some wipes and cleaned the resident's perineal area (female external reproductive organs). After cleaning the resident's vulva, CNA G changed her gloves and assisted the resident to roll to her side. She did not sanitize her hands before putting on a new pair of gloves. CNA G cleaned the resident's bottom. After cleaning the resident's bottom, she took the brief hanging on the wooden frame and placed it under the resident. She rolled back the resident, fixed the brief, and fastened it on both sides. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. She rolled the resident back and cleaned the resident's vulva some more. After cleaning the vulva of the resident some more, CNA G fixed the brief and then taped it on both sides. She washed her hands. In an interview with CNA G on 12/03/2024 at 9:33 AM, CNA G stated hands should be washed before and after doing incontinent care. She said gloves should be changed after cleaning the resident's bottom and before touching the new brief. She said hands should be sanitized in between changing of gloves. She said she forgot to wash her hands before performing incontinent care, sanitize her hands when she changed her gloves, and change her gloves after cleaning the resident's bottom. She said her actions could result in cross contamination and infection. She said she knew the reasons why the staff needed to do hand hygiene but forgot to do so. She said she had in-services about incontinent care and hand hygiene but failed to practice it. She also said hanging the brief on the wooden frame could also cause cross contamination. In an interview with ADON A on 12/03/2024 at 1:27 PM, ADON A stated hand hygiene was included in all the procedures of any care. She said the staff should do hand hygiene before and after incontinent care. She said gloves should be changed after cleaning the residents' bottom and hands should be sanitized before putting on a new pair of gloves. She said not performing hand hygiene and not changing the gloves could result in cross contamination and probable infections. She also said the brief should not be hung on the wooden frame because the wooden frame was presumed dirty. So in theory, whatever germs were on the wooden frame would transfer to the brief. She said the expectation was for the staff to do hand hygiene before and after every care, after changing their gloves, and would change their gloves when transitioning from a dirty site to a clean site. She said another expectation was not to put the brief on anything presumed dirty. She said the expectation was for the staff to be mindful when they performed incontinent care to prevent infection. ADON A said she would do in-services about infection control and hand hygiene as soon as the interview was done In an interview with the DON on 12/03/2024 at 3:18 PM, the DON stated hand hygiene was the most effective way to prevent cross contamination and infection. She said hands should be washed before and after incontinent care. She said gloves should be changed after cleaning the resident's bottom and hands should be sanitized before putting on a new pair of gloves. She said the brief should not be hung anywhere to prevent transfer of anything dirty. She said the expectation was for the staff to wash their hands before and after incontinent care, change their gloves when going from dirty to clean, and ensure the brief was clean before putting it on the resident. She said she would do an in-service and skills check-off for infection control and hand hygiene. In an interview with the Administrator on 12/03/2024 at 4:06 PM, the Administrator stated staff should wash their hands, change their gloves after touching anything soiled and sanitize their hands before putting on new gloves. He said not washing the hands, not changing the gloves after touching soiled items, and not sanitizing the hands, could contribute to cross contamination and infection. He said the expectation was for the staff to follow the policy and procedures pertaining to infection control. He said he was not clinical and would let the DON handle the issue about infection control. Record review of the facility's policy, Perineal Care/Incontinent Care Restorative Policy revised 04/2012 reflected Policy Statement: Staff will perform perineal/incontinent care with each bath and after each incontinent episode . Provisions . 2. Set up clean field . 10. Remove gloves and wash hands or alcohol gel and re-glove hands. Record review of the facility policy, Hand Hygiene for Staff and Residents Infection Control revised August 2018 reflected Purpose: To reduce the spread of infection with proper hand hygiene . Policy: Proper hand hygiene technique is completed whenever hand hygiene is indicated . NOTE: Hand Hygiene is the most important component for preventing the spread of infection . Procedures . 1. Hand hygiene is done . Before . A. resident contact . After . A. contact with soiled article . B. resident contact . H. removal of medical/surgical or utility gloves.

Dec 2023 16 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · 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 that the residents environment remained free of accident and hazards for 2 of 6 residents (Resident #12 and #97) reviewed for accident and hazard free environment. The facility failed to ensure a water leak in Resident #12's bathroom was properly repaired, and the Resident had an accident as a result of the continued water leak. Resident #12 had a hematoma to the front right side of head and a and a bruise to her right arm. The facility failed to prevent employees from bringing their personal dogs into the facility and allowed them to roam unsupervised in the facility's courtyard, which resulted in Resident #97 sustaining an injury. These deficient practices could place the residents at risk for harm, or serious injury. The findings were: A record review of Resident #12's face sheet dated 12/08/23 reflected an [AGE] year-old female admitted on [DATE] with Diagnoses which included: Parkinson's disease (nervous system disorder), muscle weakness, and lack of coordination. Review of Resident #12's quarterly MDS assessment, dated 10/31/23, reflected resident had a BIMS of 13 (cognitively intact), and the Resident required assistance to perform ADL care. Review of Resident #12's Care Plan dated 11/15/23, reflected the resident was care planned for falls and the intervention included Resident at Risk for Falls resident safety will be maintained. Assist resident with toileting needs as needed. A record review of Resident #12's consolidated order dated 12/08/23 reflected additional diagnoses, including rheumatoid arthritis, restless legs syndrome. A record review of the Nurse Notes for Resident #12, dated 11/23/23 by RN L, reflected, 11/23/2023 At about 2am, this Nurse was notified by the assigned CNA that this resident was on the floor. This Nurse observed resident sitting on the floor in the resident's restroom by the commode. Resident stated that she slipped because of wet floor around the commode. Upon assessment, this nurse observed a hematoma to the front right side of head; skin tear to the right arm, and bruise to the right arm. Skin tear cleaned with normal saline, pat dry and sterile strip applied. NP notified; STAT skull series and right arm x-ray ordered. PRN pain medication administered. Vital signs obtained; temp=98.2, hr=63, 02=95%, bp=152/99. SON notified A record review of the Nurses Notes for Resident #12, dated 11/23/2023 by RN L reflected, [PRN (as needed) Administration] 11/23/2023 02:57 AM acetaminophen 500 mg tablet (ACETAMINOPHEN) 1 tablet by mouth every 4 hours As Needed PAIN A record review of the Nurses Notes for Resident #12, dated 11/23/2023 by LVN M reflected, 11/23/2023 F/U (follow-up) related to fall in previous shift, Skull series and x ray to right arm is performed and waiting for results. Right arm bruised and seen 2 skin tears with steri strips and hematoma to right side of forehead. A record review of the Nurses Notes for Resident #12, dated 11/27/2023 by RN L reflected, 11/27/2023 X-ray results collected. Impression shows negative result. A record review of Wound Care Treatments for Resident #12, dated 11/27/23 by LPN /LVN R reflected, Start: 11/27/23 Skin Tear 1 time per day Skin tear to right forearm- clean with normal saline, pat dry, apply xeroform dressing and cover with dry protective dressing until it resolved Dx : Laceration without foreign body of right forearm, initial encounter In an interview on 12/05/23 at 12:25 PM with Resident #12, she stated her toilet had been leaking and she reported it to staff. She stated the Maintenance Director came to fix it, but he only caulked it. She stated the leaking started again, and she told her son about it and he reported it. She stated the bruise on her face was due to a fall she had in the bathroom, which was a result of her bending over to keep her clothes from getting wet from the water on the floor. She stated she lost her balance and fell. She stated her face hit the wall and she landed on her arm. She stated her arm had a dark bruise on it, but she was healing and there was only dark reddish/purplish bruising around the edge of what she said had been a much larger area. She stated staff came to help her up and they checked her out and helped her to bed. She stated they had X-rays taken and she had not broken anything. She stated she did not have to go to the hospital. She stated after her fall, the Maintenance Director came back to fix the leak again, and there hadn't been any more leaks. In an interview on 12/08/23 at 10:27 AM with Resident #12's family member, he stated that stated he did not know about the leaky toilet until after the resident's fall. He stated he talked to the Administrator about the leak and was told by him that they had re-caulked the base of the toilet; however, the toilet started leaking again, and the resident told the family member about her leaking toilet. The family member stated he had contacted the Administrator to let him know that the toilet was leaking again. He stated the Administrator followed up with him, after the fall to let him know that the seal had been replaced and there should be no more leaks. He stated the resident's fall was around Thanksgiving, but he could not recall the exact date. He stated the resident had not said anything else about the toilet leaking. A record review of Resident #97's face sheet dated 12/08/23 reflected a [AGE] year-old female admitted on [DATE] with Diagnoses which included: Dementia (mental impairment), Weakness of gait and mobility. Review of Resident #97's quarterly MDS assessment, dated 10/12/23, reflected resident had a BIMS of 10 (moderately cognitive), impaired vision, and required touching assistance with most ADLs. Resident required partial/moderate assistance with shower/bathe self and lower body dressing. Review of Resident #97's Care Plan dated 10/18/23, reflected resident was a fall risk and interventions including Assessing the environment to maximize safety. In an interview on 12/05/23 at 11:44 AM with Resident #108 (BIM: 15) he stated he had concerns with dogs running around outside in the courtyard unsupervised. He stated that he would like to go outside some days when it was nice, but he cannot because there were dogs running around, unsupervised, and he did not want to be harmed by them or have an injury as a result of them. He stated that the dogs had been roaming the Resident courtyard since he had been admitted to the facility on [DATE]. Observation on 12/05/23 revealed a medium sized black dog (poodle) was observed roaming the facility's only courtyard, unsupervised. On 12/06/23, two dogs were observed roaming around the facility's only courtyard unsupervised. One of the dogs was the same from the previous day and the other was a medium sized dog that was a pit bull mixed with another breed. Both dogs weighed approximately 50 to 60 LBS each. During the Survey Resident council meeting on 12/06/23 at 3:00 PM, seven of the nine Resident (Residents #97, #99, #96, #5, #58, #18, #16) voiced concerns for the dogs roaming around the courtyard most of the week unsupervised, because they were fearful of the dogs jumping up on them and causing them to fall or sustain an injury. During the Resident council meeting, Resident #97 stated she had an incident with the pit bull while she was out in the courtyard, and it resulted in her requiring first aid. An interview on 12/07/23 at 9:37 AM with Resident #97, she stated she could not remember when she got the skin tear from the dog. She stated she just remembered she was outside in the courtyard. She stated it was not a small dog, it was one of the two dogs who play in the courtyard. She stated she did not complain to anyone about the dogs because they were sweet dogs, and she did not fear them. She stated she only went to the nurse because she noticed her arm was bleeding and she tried to wipe the blood away with a tissue, but it continued to bleed. She stated she went to the nurse for help and the nurse asked her what happened. She stated kept a notebook of events to help her refer to what happened each day because she would forget. She looked in her book to see if she wrote anything on 11/22/23, which was the day she sustained the scratch. She had documented the event with the dog. She stated she believed it was the brown and white dog because the black one is more calm. She stated she could not really be sure. She then left her room and asked another resident if he remembered which dog, she said scratched her and he said the brown and white one. Her notation in the notebook read, [DATE] Wed. Got a scare from the dog, so they had to really do it up right. I will live. In an interview on 12/07/23 at 09:56 AM with Resident #40, he stated he and Resident #97 sat at the table together for meals. He stated she told them that the brown and white dog was jumping up a lot and she scratched her and caused her to arm to bleed, so the nurse had to fix her up. He stated she did not seem upset, just surprised. He stated she did not get an infection or anything from the scratch. He stated she said she was outside in the courtyard when the dog scratched her. In an interview on 12/07/23 at 11:39 AM with Resident #97's family member, she stated she was told that Resident #97 went out to play with the dogs and one of them jumped up on her while playing with her and accidentally scratched her arm. She stated they told her that the scratch broke the skin and they cleaned the area and put a bandage on it. She stated she came to the facility the next day, 11/23/23, to see her mother and she saw that her arm was clean and there was a folded square of gauze with a piece of clear tape across it, covering the scratched area. She stated the area was small, so she felt better about it, after seeing it. She stated her mother had told her about the two dogs a while ago and she spoke of them with excitement and said they were very playful. She stated the resident asked her to buy tennis balls, so she could throw them around while playing with the dogs. She stated she was not concerned about her mother's safety at the facility or around the dogs. In an interview on 12/07/23 at 12:46 PM with LVN N, she stated Resident #97 told her that the dog was playing with her out in the courtyard and the dog jumped up on her and scratched her on the elbow. She stated the injury was just a small scratch and the skin was slightly raised, and it was bleeding, not a lot, but it was bleeding. She stated she treated the wound by washing it with soap and water, then she bandaged it. She stated she then called the physician, the resident's family member, and she reported it to the Administrator and DON. She stated she did not witness the accident. In an interview on 12/07/23 at 10:37 AM with the Resident #31, she stated the residents had not complained about the dogs. She stated they just talked about the dogs being playful and always jumping around. She stated she did not know if anyone ever reported a complaint or concern about the dogs to staff. She stated the only staff who knew what the residents said about the dogs, was the Activities Coordinator. An interview on 12/07/23 at 10:50 AM with the Activities Coordinator, she stated she had been bringing her dog to the facility for about a year. She stated the brown and white dog was her dog. She stated she would bring her dog on Mondays, Wednesdays, and Fridays. She stated the dog was usually either with her, in her office or outside in the courtyard. She stated she did not ask permission to bring the dog to the facility. She stated she knew that the Administrator loved dogs and he never told her that she could not bring the dog to the facility. She stated the dog had been fully vaccinated. She stated residents had not complained about the dog. She stated they usually just commented on the dog's activities, which they observed through the window. She stated she took the dog to the rooms of the residents who enjoyed seeing her. She stated she thought it was good for the residents because they seemed to light up when dogs were in the building. An interview on 12/07/23 at 11:22 AM with the Administrator, he stated they had a decade-long history of dogs being at the facility. He stated the two dogs observed, had been coming for at least a year. He stated the staff talked to him about bringing the dogs to the facility. He stated the dogs were puppies when they started coming to the facility, so they grew up there. He stated none of the residents had ever expressed any complaints or concerns about the dogs to him. He stated the dogs' owners told him the dogs were fully vaccinated (verified). He stated he had never been concerned about the residents' safety around the dogs. He stated he was not aware that some residents felt uncomfortable going to the courtyard. He stated had he known, he would have made accommodations because the residents came before the dogs. He stated a possible risk of the presence of the dogs in the facility, would depend on the dog, and if the dog showed aggression. He stated if a dog showed aggression toward residents, they would not be allowed at the facility. He was aware that Resident #97 was scratched by one of the dogs. He stated his understanding was that the resident was outside playing with the dog. He stated the feedback from the residents had always been positive. He stated the residents loved the dogs because they are loving, and the residents like to watch them play. In an interview on 12/07/23 at 10:00 AM with the Administrator, he stated he had no policy regarding employees bringing their pets into the facility, he stated he had no discussions with the employees regarding bringing pets into work, and the facility had no requirements for employee's pet to meet prior to gaining approval to bring pets into the facility. In an interview on 12/08/23 02:46 PM the Social Worker , she stated she had been bringing her dog for about eight months. She stated she did not bring her dog every day. She stated she brought her dog sporadically at first and then more regularly. She stated the dog was fully vaccinated. She stated she did not ask permission because she was told the facility had been pet friendly for years. She stated having pets in the facility was pretty much encouraged by the Administrator. She stated residents would say that they enjoyed watching the dogs play from their windows, especially when they were small puppies.

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat residents with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 (Resident #26 and Resident #63) of 8 residents reviewed for resident rights. The facility failed to ensure CNA Z did not provide dining assistance to Resident #63 and Resident #26 at the same time during the dining observation on 12/05/2023. This failure could affect residents that require dining assistance during mealtimes, placing them at risk for not receiving care and services with dignity. Findings Included: Review of Resident #26's Face Sheet dated 12/06/2023 revealed she was an [AGE] year-old female re-admitted to the facility on [DATE]. Relevant diagnoses included metabolic encephalopathy (syndrome of a chemical imbalance in the blood that causes neurological deficits), right side contractures (abnormal thickening of the tissues which causes decease in movement and mobility,) and aphasia following cerebral infarction (loss of ability to understand or express speech caused by brain damage). Review of Resident #26's quarterly MDS assessments dated 10/29/2023 revealed she was severely cognitively impaired with a BIMS score of 02. She required limited assistance of one staff member for eating. Review of Resident #26's comprehensive care plan on 12/06/2023 at 3:11 PM revealed she had altered nutritional status . 10/24/2023 Her goal included she would be comfortable with food and fluids provided over the next 90 days and would have snacks provided between meals . daily. Additional review revealed she had Impaired Physical Mobility 10/24/2023 . related to History of Stroke. Resident #26's goal included to maintain or improve physical function .locomotion, and ROM over the next 90 days. Related intervention included to Provide appropriate level of assistance to promote safety of resident. No evidence of care interventions related to dining and/or assistance related to dining was determined. Review of Resident #26's vital signs on 12/06/2023 at 3:16 PM revealed she weighed 157.4 pounds on 12/01/2023 at 3:04 PM. No evidence of significant weight loss was determined. Review of Resident #26's Nutritional assessment dated [DATE] revealed resident is consuming 75% of meals per staff. Independent with staff supervision for meals. Weight of 159.4 on 11/1/23, gain of +2.57% x 1 month, +2.44% x 3 months and +3.78% x 6 months. Review of Resident #63's face sheet dated 12/06/2023 revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included cerebral infarction (disruption of blood flow to the brain due to problems with the blood vessels that supply the brain,) malaise (general feeling of discomfort,) edema (swelling caused by too much fluid trapped in the body's tissues,) stage 2 kidney disease (mild kidney damage,) flaccid hemiplegia affecting the left side (decreased muscle tone that cannot be actively moved by the patient,) dementia (group of conditions characterized by impairment of brain functions,) and epilepsy (disorder of brain activity.) Review of Resident #63's admission MDS dated [DATE] revealed she was unable to complete the BIMS assessment but was documented as having short- and long-term memory problems. Resident #63 required extensive assistance of two or more staff members for bed mobility and transfers. She required extensive assistance of one staff member for eating. Review of Resident #63's comprehensive care plan on 12/06/2023 at 3:05 PM revealed she had altered nutritional status . 11/27/2023 . related to dentures, chewing difficulty, and use of diuretics, laxatives, and/or cardiovascular drugs. Her goal included she would maintain her weight over the next 90 days. Relevant intervention included provide necessary assistance with food and fluids. Review of Resident #63's vital signs on 12/06/2023 at 2:59 PM revealed she weighed 157.8 pounds on 12/04/2023 at 10:41 AM. In observation on 12/05/2023 at 12:19 PM, CNA Z was sitting in a chair in the dining room, positioned between Resident #26 and Resident #63. CNA Z assisted Resident #26 and Resident #63 by taking her right hand, obtaining resident spoon, and providing a spoon full of food to their mouth. CNA Z assisted Resident #26 with eating then helped Resident #63; going back and forth while feeding them. This was repeated approximately 7 times during the dining observation. In interview with CNA Z on 12/05/2023 at 12:37 PM, she stated that she was aware it was not best practice to assist two residents simultaneously. She stated she did not know why necessarily, but it was not best practice. She stated that she had to assist two residents today because of short staffing. She stated the need to assist multiple people at once does not occur very often, but it occurred that day. She stated she did not seek out leadership or other staff for additional assistance and did not provide any reason or potential outcome upon follow-up inquiry. Attempts to interview Resident #26 and Resident #62 occurred 12/05/2023 at 1:00 PM and 12/06/2023 3:00 PM were unsuccessful due to residents' communication and cognitive limitations. In interview with ADON K on 12/07/2023 at 3:29 PM, she stated her expectations were for staff to only help one resident at a time but did not give specifics as to the reason. She stated that the facility had been well staffed and would have expected CNA Z to come to her for more help if she needed it. In interview with ADON E on 12/07/2023 at 3:30 PM, she stated her expectations were for staff to only provide assistance to one resident at a time for dignity purposes. She denied any staffing issues and stated she would have preferred if CNA Z asked her for help to get each resident assisted individually and in a timely manner. In interview with DON on 12/07/2023 at 3:39 PM she stated she prefers staff not to provide assistance for two residents in the dining room at the same time. She stated her facility had been well staffed and denied any staffing issues. She stated she expected CNA Z to request additional help from leadership instead of assisting multiple residents at the same time. She stated it could be a dignity issue if each resident was not assisted individually. Review of the facility's policy, Assisting Residents with Eating, dated 01/12/2018 revealed Standard of Practice: Qualified nursing staff . will assist the Resident who is unable to feed self in order to promote adequate nutrition and to help the resident enjoy a satisfying meal . Procedure: Perform Hand Hygiene . Provide assistance to resident . Perform Hand Hygiene. Review of facility policy, Resident Rights, rev. 08/14/2023 revealed Staff will abide by resident rights as outlined within the CMS State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev. 11-22-17. Review of CMS State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities rev. 11/22/2017 revealed F550 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.10(a) Resident Rights. 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 section. §483.10(a)(1) 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.

CONCERN (D)

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

Deficiency F0604 (Tag F0604)

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 and interviews, the facility failed to ensure the resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 6 (Resident #49) residents reviewed for restraints. The facility failed to ensure Resident #49 was not left sitting in a Geriatric (elderly) Chair (with the feeding tray still fully attached, while the resident was sitting in the media room. This failure could unnecessarily inhibit the resident's freedom of movement or activity. Findings included: Record review of Resident #49's Face Sheet, dated 12/08/23, revealed she was an 81 -year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's disease (severe memory loss), and difficulty in walking. Record review of Resident #49's MDS comprehensive assessment, dated 10/14/18, revealed she had a Brief Interview for Mental Status (BIMS) score of 05 (severe cognitive impairment) and for Activities for Daily Living (ADL) care it stated, for transfers, toileting, and bathing, the resident required assistance and a mechanical lift. Record Review of Resident #49's Care Plan, updated 09/28/23, stated the resident was at Fall risk and an intervention was to Assess for potential fall-related injury prevention. Observation on 12/05/23 at 09:30 AM of Resident #49 revealed, she was sitting in the media room in a Geri chair. The resident was not eating any food, but the feeding tray was still fully attached to the Geriry Chair. The tray was empty and had no food on it. In an interview on 12/08/23 at 01:25 PM with LVN J, she stated she observed Resident #49 had a feeding tray attached to her Geri chair on 12/05/23, while the resident was sitting in the media area. She stated she had removed the tray once it had been brought to her attention, but she did not think that the CNA was doing it as a form of restraint. LVN J stated she thought the CNA had just finished feeding the resident and forgot to remove the tray. She stated the risk of leaving the tray attached to the Geriry chair was a form of restraint and could harm the resident. In an interview on 12/08/23 at 01:45 PM with CNA S, she stated she had been at the facility for over 10 years. She stated she normally brought Resident #49 to the dining area for feeding assistance. She stated that the resident did have a feeding tray attached to her Geri chair to eat, and she usually removed it immediately after the resident finished eating. She stated she did not recall leaving the feeding tray attached to the Geri chair, but she remembered she had to assist another resident, and when she observed Resident #49 again the tray was gone. She stated she was not trying to restrain the resident, but she stated not removing the tray could restrict the resident's movement. In an interview on 12/08/23 at 03:09 PM with the DON, she stated she had been at the facility since 2019. She stated her staff informed her about Resident #49 observed on 12/05/23 in a Geri Chair while a feeding tray was attached, and she was not being fed. She stated the CNA should have removed the feeding tray once she was done feeding the resident. She stated the resident was a fall risk but had a decline in health, so she was not much of a fall risk now. She stated that it is a form of restraint, although it was not the intent. Record review of facility's policy on Restraint /Seclusion, dated January 18 2018, stated Chemical/Physical restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative, WITH THE EXCEPTION OF TEMPORARY BEHAVIORAL EMERGENCY

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 interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately for 1 of 1 Resident (Residents #12) reviewed for neglect, and exploitation or misappropriation. The facility failed to report Resident #12's fall to the Texas Department of Health and Human Services Commission (HHSC) on 11/23/23. This failure could place residents at risk of sustaining an injury and not receiving all services . Findings included: A record review of Resident #12's face sheet dated 12/08/23 reflected an [AGE] year-old female admitted on [DATE] with Diagnoses which included: Parkinson's disease (nervous system disorder), muscle weakness, and lack of coordination. Review of Resident #12's quarterly MDS assessment, dated 10/31/23, reflected resident had a BIMS of 13 (cognitively intact), and the Resident required assistance to perform ADL care. Review of Resident #12's Care Plan dated 11/15/23, reflected the resident was care planned for falls and the intervention included Resident at Risk for Falls resident safety will be maintained. Assist resident with toileting needs as needed. A record review of Resident #12's consolidated order dated 12/08/23 reflected additional diagnoses, including rheumatoid arthritis, restless legs syndrome. A record review of the Nurse Notes for Resident #12, dated 11/23/23 by RN L, reflected, 11/23/2023 At about 2am, this Nurse was notified by the assigned CNA that this resident was on the floor. This Nurse observed resident sitting on the floor in the resident's restroom by the commode. Resident stated that she slipped because of wet floor around the commode. Upon assessment, this nurse observed a hematoma to the front right side of head; skin tear to the right arm, and bruise to the right arm. Skin tear cleaned with normal saline, pat dry and sterile strip applied. NP notified; STAT skull series and right arm x-ray ordered. PRN pain medication administered. Vital signs obtained; temp=98.2, hr=63, 02=95%, bp=152/99. SON notified A record review of the Nurses Notes for Resident #12, dated 11/23/2023 by RN L reflected, [PRN Needed) Administration] 11/23/2023 02:57 AM acetaminophen 500 mg tablet (ACETAMINOPHEN) 1 tablet by mouth every 4 hours As Needed PAIN A record review of the Nurses Notes for Resident #12, dated 11/23/2023 by LVN M reflected, 11/23/2023 F/U (follow-up) related to fall in previous shift, Skull series and x ray to right arm is performed and waiting for results. Right arm bruised and seen 2 skin tears with steri strips and hematoma to right side of forehead. A record review of the Nurses Notes for Resident #12, dated 11/27/2023 by RN L reflected, 11/27/2023 X-ray results collected. Impression shows negative result. A record review of Wound Care Treatments for Resident #12, dated 11/27/23 by LPN /LVN R reflected, Start: 11/27/23 Skin Tear 1 time per day Skin tear to right forearm- clean with normal saline, pat dry, apply xeroform dressing and cover with dry protective dressing until it resolved Dx : Laceration without foreign body of right forearm, initial encounter In an interview on 12/05/23 at 12:25 PM with Resident #12, she stated her toilet had been leaking and she reported it to staff. She stated the Maintenance Director came to fix it, but he only caulked it. She stated the leaking started again, and she told her son about it and he reported it. She stated the bruise on her face was due to a fall she had in the bathroom, which was a result of her bending over to keep her clothes from getting wet from the water on the floor. She stated she lost her balance and fell. She stated her face hit the wall and she landed on her arm. She stated her arm had a dark bruise on it, but she was healing and there was only dark reddish/purplish bruising around the edge of what she said had been a much larger area. She stated staff came to help her up and they checked her out and helped her to bed. She stated they had X-rays taken and she had not broken anything. She stated she did not have to go to the hospital. She stated after her fall, the Maintenance Director came back to fix the leak again, and there hadn't been any more leaks. In an interview on 12/08/23 at 10:27 AM with Resident #12's Family Member, he stated that stated he did not know about the leaky toilet until after the resident's fall. He stated he talked to the Administrator about the leak and was told by him that they had re-caulked the base of the toilet; however, the toilet started leaking again, and the resident told the family member about her leaking toilet. The family member stated he had contacted the Administrator to let him know that the toilet was leaking again. He stated the Administrator followed up with him, after the fall to let him know that the seal had been replaced and there should be no more leaks. He stated the resident's fall was around Thanksgiving, but he could not recall the exact date. He stated the resident had not said anything else about the toilet leaking. In an interview on 12/07/23 at 11:22 AM with the Administrator, he stated he was aware of the incidents that occurred with Resident #12. He stated that Resident #12's injuries did not require her to receive hospitalization and no serious injury occurred, so he did not feel this was a reportable incident. He stated that the resident did sustain a head contusion as a result of her fall and he contacted notified Resident 12's Physician and Responsible party of the incident. He stated that the risk of not reporting reportable incidents according to Texas Department of Health and Human Services Commission (HHSC) guidelines, but he refused to state there was a risk because he felt that the incident was not reportable. He stated there was no policy and they followed stated guidelines on what was reportable and what was not.

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 interviews and record review, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for 1 of 8 residents (Resident #26) reviewed for Accuracy of Assessments. The facility failed to ensure Resident #26's Quarterly MDS assessment dated [DATE] and 10/29/2023 accurately reflected that Resident #26 had impairments to the upper extremity and lower extremity on one side of the body. This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Resident #26 Review of Resident #26's Face Sheet, dated 12/06/2023, revealed she was an [AGE] year-old female re-admitted to the facility on [DATE]. One of the relevant diagnosis was unspecified joint contracture (tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Review of Resident #26's Quarterly MDS Assessment, dated 10/29/2023, revealed the resident had a severe impairment in cognition with a BIMS score of 02. Resident #26 was totally dependent upon two or more staff for bed mobility and transfers. She required limited assistance of one staff member for eating. Review of Resident #26's Comprehensive Care Plan, dated 11/02/2023, reflected the resident had a limited range of motion as evidenced by right shoulder subluxation (partial dislocation of your shoulder), right hand resting splint, and right ankle plantarflexion (movement of the foot in which the foot or toes flex downward toward the sole) due to foot drop (inability to raise the front of the foot due to weakness or paralysis). One of the interventions was to use devices, appliances, splints, or positioning pillows as indicated. Review of Resident #26's Physician's order for hand/wrist splint dated 10/26/2023 reflected MONITOR 1 time per day APPLY Right Hand/Wrist Splint in morning Please check skin integrity under splint. Review of Resident #26's Physician's order for hand/wrist splint dated 10/26/2023 reflected MONITOR at bedtime REMOVE Right Hand/Wrist Rest Splint at bedtime. Please check skin integrity under splint. Review of Resident #26's Physician Order on 12/06/2023 revealed no order for boots for resident's footdrop to right ankle. Review of Resident #26's Minimum Data Set, Section G - Functional Status G0400, dated 05/16/2023, revealed Resident #26 had no impairment to one side of the body in the upper extremity and lower extremity. Review of Resident #26's Minimum Data Set, Section GG - Functional Abilities and Goals GG0110, dated 10/29/2023,revealed Resident #26 had an impairment to one side of the upper extremity but no impairment to one side of the lower extremity. Observation on 12/07/2023 at 9:40 AM revealed Resident #26 was being transferred to the wheelchair via Hoyer lift. It was noted Resident #26 had a contracture to the right hand. Before transferring the resident to the wheelchair, CNA Y put a boot on Resident #26's right foot. It was noted there was a hand splint at the bed side table for Resident #26. In an interview with CNA Y on 12/07/2023 at 10:05 AM, CNA Y stated they put the boot on Resident #26 every time they would get her up. CNA Y said she was not sure the exact reason why but what she knew was the boot prevented Resident #26's foot from always pointing. CNA Y said the resident had the boot for a long time, but she could not remember exactly how long. CNA Y added they would put a pillow under Resident#26's right arm when in bed and when the resident was in the wheelchair. According to CNA Y, the nurse was the one that placedthe hand splint on as soon as the resident was up. CNA Y said she would inform the nurse the resident was already in her wheelchair. In an interview with RN P on 12/07/2023 at 11:19 AM, RN P stated she already placed the splint on Resident #26's right hand. RN P said she would put it on once the resident was up from the bed. RN P added the resident had a splint on because she had contractures on the right hand, and she had a boot on the right foot because of foot drop. In an interview with MDS Nurse R on 12/07/2023 at 1:54 PM, MDS Nurse R stated the MDS should reflect the current status of the resident. The functional status must reflect if the resident had any impairment or not. MDS Nurse R said Resident #26' care plan should also reflect the problem area and the specific interventions being done for the medical issue. MDS Nurse R added the assessments were done by the nurse during admission. The MDS Nurse R would base the MDS from the assessment of the nurse. She added every department had a role in completing the MDS. MDS Nurse R further added the care plan would be based on the MDS. She said an accurate MDS was important because it would be the basis of the care needed by the resident. If the assessment was not accurate, the current status of the resident would not be correct resulting to confusion in her care. This could also result in the resident not getting the appropriate care needed. In an interview with MDS Nurse I on 12/07/2023 at 2:12 PM, MDS Nurse I stated the nurses would do the assessment upon admission of the resident. The MDS would be triggered depending on the assessment. MDS Nurse I added that the care plan would be based on the MDS. She said she would also go to the resident and assess the resident. MDS Nurse I further added that the MDS should reflect what exactly was being done to the resident to make sure the resident was getting the treatment needed. If the assessment was not accurate, the staff would not know the resident needed the treatment and the current condition of the resident could worsen. MDS Nurse I stated she was aware Resident #26 has a splint to the right arm but was not aware Resident #26 was using a boot to the right foot. She said she would go to Resident #26 to further assess the resident. In an interview with ADON E on 12/07/2023 at 2:19 PM, ADON E stated the nurses did the assessment upon admission. She said the MDS nurse would look at the notes on the system to know what should be care planned. ADON E said if there were impairments to the upper extremity and lower extremity, the MDS should have a record of it. ADON E said there should be proper communication between the staff to ensure proper assessments were done. If there was no accurate assessment, there could be a confusion about the care needed by the resident Observation on 12/07/2023 at 2:25 PM revealed both MDS Nurses with Resident #26 at the activity area doing an assessment. In an interview with DON on 12/07/2023 at 2:36 PM, the DON stated she was not sure if the care plan was based on the MDS. The DON said the MDS should reflect the actual functionality of the resident. She said if the resident had an impairment, it should have been assessed accurately and reflected on the MDS. If the residents were not properly assessed, the proper care and needs would not be met. The DON said the expectation was the residents were properly assessed not only during admission but every day to see if there was a change in condition, any refusal of care, or resident acting different than usual. In an interview with OT O on 12/08/2023 at 9:42 AM, OT O stated Resident #26 had the splint to her right hand for almost five years. She said Resident #26 had a splint on the right hand due to a contracture. OT O said Resident #26 had a stroke that affected the right side of her body. OT O added she did an assessment when she came back from the hospital ont 10/24/2023. OT O said an accurate assessment was important to know if the resident was declining, if there was a change in function, or if the resident had more pain. If there was no proper assessment, the resident might have an increased debility. In an interview with PT A on 12/08/2023 at 9:58 AM, PT A stated an accurate assessment was important to be able to do a proper care plan. If the resident had impairments, it should be precisely reflected in the system to address goals and the interventions needed. Assessments were done to note if there were changes in condition, if there were changes in balance, if there was a pressure ulcer, or if there was a limitation in the range of motion. PT A stated if the assessment was not accurate, the needed care of the resident would not be met. PT A said Resident #26 had the boot for a year and a half. PT A said the assessment should reflect Resident #26 had impairment on her right upper and lower extremities. Record review of facility policy, Care Process, Clinical Operations, rev. February 12. 2020, revealed Standard of Practice: The interdisciplinary team will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process within the required time frames . 4. Interdisciplinary Team meets & reviews the care plan as follows: Seven (7) days after the closure on the date of the admission MDS, Quarterly and annually, Within fourteen (14) days after a significant change MDS, and with any change of condition.

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

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 observation, interview and record review , the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #26) of 20 residents reviewed for care plans. The facility failed to ensure the comprehensive care plan for Residents #26 was developed and identified and implemented goals and interventions to accurately address the resident's need for dining assistance. This failure could place residents that require dining assistance at risk for not receiving care and services to meet their needs. Findings Included: Review of Resident #26's Face Sheet dated 12/06/2023 revealed she was an [AGE] year-old female re-admitted to the facility on [DATE]. Relevant diagnoses included metabolic encephalopathy (syndrome of a chemical imbalance in the blood that causes neurological deficits,) right side contractures (abnormal thickening of the tissues which causes decease in movement and mobility), and aphasia following cerebral infarction (loss of ability to understand or express speech caused by brain damage). Review of Resident #26's quarterly MDS assessment dated [DATE] revealed she was severely cognitively impaired with a BIMS score of 02. She required limited assistance of one staff member for eating . Review of Resident #26's comprehensive care plan revealed no evidence of care interventions related to dining and/or assistance related to dining was determined. Resident #26's comprehensive care plan stated: she had altered nutritional status . 10/24/2023 Her goal included she would be comfortable with food and fluids provided over the next 90 days and would have snacks provided between meals . daily. Additional review revealed she had Impaired Physical Mobility 10/24/2023 . related to History of Stroke. Resident #26's goal included to maintain or improve physical function .locomotion, and ROM over the next 90 days. Related intervention included to Provide appropriate level of assistance to promote safety of resident. Review of Resident #26's vital signs on 12/06/2023 at 3:16 PM revealed she weighed 157.4 pounds on 12/01/2023 at 3:04 PM. No evidence of significant weight loss was determined. Review of Resident #26's Nutritional assessment dated [DATE] revealed resident is consuming ~75% of meals per staff. Independent with staff supervision for meals. Weight of 159.4 on 11/1/23, gain of +2.57% x 1 month, +2.44% x 3 months and +3.78% x 6 months. Review of Resident #63's face sheet dated 12/06/2023 revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included cerebral infarction (disruption of blood flow to the brain due to problems with the blood vessels that supply the brain,) malaise (general feeling of discomfort,) edema (swelling caused by too much fluid trapped in the body's tissues,) stage 2 kidney disease (mild kidney damage,) flaccid hemiplegia affecting the left side (decreased muscle tone that cannot be actively moved by the patient,) dementia (group of conditions characterized by impairment of brain functions,) and epilepsy (disorder of brain activity.) Review of Resident #63's admission MDS dated [DATE] revealed she was unable to complete the BIMS assessment but was documented as having short and long-term memory problems. She required extensive assistance of one staff member for eating. Review of Resident #63's comprehensive care plan on 12/06/2023 at 3:05 PM revealed she had altered nutritional status . 11/27/2023 . related to dentures, chewing difficulty, and use of diuretics, laxatives, and/or cardiovascular drugs. Her goal included she would maintain her weight over the next 90 days. Relevant intervention included provide necessary assistance with food and fluids. Review of Resident #63's vital signs on 12/06/2023 at 2:59 PM revealed she weighed 157.8 pounds on 12/04/2023 at 10:41 AM. No evidence of significant weight loss was determined. In an observation on 12/05/2023 at 12:19 PM, CNA Z was sitting in a chair in the dining room, positioned between Resident #26 and Resident #63. CNA Z provided assistance to Resident #26 and Resident #63 by assisting Resident #26 then Resident #63 then going back to Resident #26 then back to Resident #63. This was repeated approximately 7 times during the dining observation. In interview with CNA Z on 12/05/2023 at 12:37 PM, she stated that she was not sure if Resident #26's comprehensive care plan included her dining assistance needs. She stated that she thought the ADONs were responsible for updating and implementing resident care plans. Attempts to interview Resident #26 and Resident #63 on 12/05/2023 at 1:00 PM and 12/06/2023 3:00 PM were unsuccessful due to residents' communication and cognitive limitations. In an interview with ADON K on 12/07/2023 at 3:29 PM, she stated it was the DONs responsibility to ensure resident comprehensive care plans were updated and accurately captured resident needs. In an interview with ADON E on 12/07/2023 at 3:30 PM, she stated that it was the DONs responsibility to ensure resident comprehensive care plans were updated and accurately captured resident needs. In an interview with the DON on 12/07/2023 at 3:39 PM, she stated Resident #26 required assistance for a while and that should have been reflected on her comprehensive care plan. She stated it was the ADONs responsibility to update resident care plans to ensure resident comprehensive care plans accurately captured resident needs. Review of facility census provided by the Administrator on 12/05/2023 revealed 108 residents residing at the facility upon entrance of the survey. Review of the email Requested Documents, authored by DON 12/08/2023 at 11:22 AM, she stated that approximately 20 residents required dining assistance in the facility. Review of facility staffing sheet, Amber Falls . Tuesday December 5, 2023, revealed 6 AM- 2 PM staffing on the unit: CMA (1,) Wound Nurse (1,) LVN (2,) and CNA (5.) Review of facility staffing sheet, Crystal Point . Tuesday December 5, 2023, revealed6 AM - 2 PM staffing on the unit: CMA (1,) Wound Nurse (1,) LVN (2,) and CNA (5.) Review of facility policy, Care Plan - Process, dated 02/12/2020 revealed 6. The Plan of Care identifies the: Date, Problem, Goals measurable and realistic, Time frames for achievement, Interventions discipline specific services and frequency, Resolution/goal analysis, and Discharge option.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for 1 (Resident #26) of 6 residents reviewed for Revised Care Plan. The facility failed to ensure Resident #26's care plan was revised to reflect the specific devices used for Resident #26's impairment. This failure could place the resident at risk of needs not being met. Findings included: Review of Resident #26's Face Sheet dated 12/06/2023 revealed she was an [AGE] year-old female re-admitted to the facility on [DATE]. One of the relevant diagnosis was unspecified joint contracture. Review of Resident #26's Quarterly MDS Assessment, dated 10/29/2023, revealed the resident had a severe impairment in cognition with a BIMS score of 02. Resident #26 was totally dependent upon two or more staff for bed mobility and transfers. She required limited assistance of one staff member for eating. Review of Resident #26's Comprehensive Care Plan, dated 11/02/2023, reflected the resident had a limited range of motion as evidenced by right shoulder subluxation, right hand resting splint, and right ankle plantarflexion due to foot drop. One of the interventions was to use devices, appliances, splints, or positioning pillows as indicated. Review of Resident #26's Physician's order for hand/wrist splint, dated 10/26/2023, reflected MONITOR 1 time per day APPLY Right Hand/Wrist Splint in morning Please check skin integrity under splint. Review of Resident #26's Physician's order for hand/wrist splint, dated 10/26/2023, reflected MONITOR at bedtime REMOVE Right Hand/Wrist Rest Splint at bedtime. Please check skin integrity under splint. Review of Resident #26's Physician Order on 12/06/2023 revealed no order for boots for resident's foot drop to right ankle. Observation on 12/07/2023 at 9:40 AM revealed Resident #26 was being transferred to the wheelchair via Hoyer lift. It was noted Resident #26 had a contracture to the right hand. Before transferring the resident to the wheelchair, CNA Y put a boot on Resident #26's right foot. It was noted there was a hand splint at the bed side table for Resident #26. In an interview with CNA Y on 12/07/2023 at 10:05 AM, CNA Y stated they put the boot on Resident #26 every time they would get her up. CNA Y said she was not sure the exact reason why but what she knew was the boot prevented Resident #26's foot from always pointing. CNA Y said the resident had the boot for a long time, but she could not remember exactly how long. CNA Y added they would put a pillow under Resident#26's right arm when in bed and when the resident was on the wheelchair. According to CNA Y, the nurse was the one that placed the hand splint on as soon as the resident was up. CNA Y said she would inform the nurse the resident was already on her wheelchair. In an interview with LVN A on 12/07/2023 at 1:05 PM, LVN A said it was important the staff did an accurate assessment because this was where the order and the care plan would be based off of. She added she did not know about care planning. She added the care plans were done by the ADON. In an interview with MDS Nurse R on 12/07/2023 at 1:54 PM, MDS Nurse R said Resident #26's care plan should reflect the problem area and the specific intervention being done. MDS Nurse R added the care plan should be revised to reflect the current status of the resident. If the care plan was not accurate, there could be a confusion in her care and there would be a risk of the resident not getting the care they needed. In an interview with MDS Nurse I on 12/07/2023 at 2:12 PM, MDS Nurse I added the care plan would be based on the MDS. She further added the care plan must be revised and updated if the resident had any change in condition or if there was a new diagnosis. She further added the care plan should reflect exactly what was being done to the resident to make sure the resident was getting the treatment needed. If the resident was wearing a splint, the care plan should reflect what kind of splint was being used. If the resident was using a boot, the care plan should reflect what kind of boot was being used. If the care plan was not accurate, the staff would not know the resident needed the treatment and the current condition of the resident could worsen. In an interview with DON on 12/07/2023 at 2:36 PM, the DON stated she was not sure if the care plan was based on the MDS. The DON said the care plan was important because this served as a guide for the staff to know what should be done for the resident. If the care plan was not accurate, the current needs of the resident would not be met. If there was a change in condition, fall, new diagnosis, the care plan should be updated. The DON added the care plan should precisely reflect the specific treatment being done for the resident. The DON concluded the expectation was the care plan was accurate and revised to display the current problem list of the resident and the current interventions being done to address the problems. In an interview with OT O on 12/08/2023 at 9:42 AM, OT O stated the care plan should contain accurate interventions for the resident. She said the care plan should specify what kind of splint or what kind of boots the resident was wearing. The intervention part should also reflect when to put it on and when to take it off. Since the resident was re-admitted on [DATE], the care plan should had been revised following the initial assessment. Since the resident had been with the facility for almost five years, the care plan should have been revised to reflect the exact treatment being done for the contracture and the foot drop. In an interview with PT A on 12/08/2023, PT A stated the care plan should reflect the kind of boot she was wearing as well when to put it on and when to take it off. When staff look at a care plan, the staff should have a clear picture of the treatment and not the general treatment. Record review of facility policy, Care Process, Clinical Operations, rev. February 12,. 2020, revealed Standard of Practice: The interdisciplinary team will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process within the required time frames . 4. Interdisciplinary Team meets & reviews the care plan as follows: Seven (7) days after the closure on the date of the admission MDS, Quarterly and annually, Within fourteen (14) days after a significant change MDS, and With any change of condition

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received services and assistance to prevent urinary tract infections for one (Resident #4) of two residents reviewed for urinary incontinence. The facility failed to place Resident #4's indwelling urinary foley catheter device below the bladder. This failure placed the resident at risk for the development of new or worsening urinary tract infections. Findings included: Review of Resident #4's Face Sheet, dated 12/06/2023, reflected resident was an [AGE] year-old female admitted on [DATE]. One of the relevant diagnosis was neuromuscular dysfunction of bladder (The muscles and nerves that control the bladder do not work properly due to illness). Review of Resident #4's Quarterly MDS Assessment, dated 11/22/2023, reflected the resident had a moderate intact cognition with a BIMS score of 10. Resident #4 required extensive assistance for bed mobility, transfer, walk in, dressing, toilet use, and personal hygiene. Section H of the Quarterly MDS Assessment indicated Resident #4 had an indwelling catheter. Review of Resident #4's Comprehensive Care Plan, dated 09/23/2023, reflected the resident had a suprapubic catheter (device inserted into the stomach to the bladder to drain urine) and one of the interventions was keep catheter tubing placed below level of bladder. Review of Resident #4's Physician's order for suprapubic catheter, dated 10/15/2023, reflected Suprapubic catheter 18 Fr (French: unit used to indicate the size of the catheter) every shift continuous gravity drainage and catheter care. Observation on 12/05/2023 at 10:54 AM revealed, Resident #4 was sitting on her wheelchair. Resident #4's indwelling suprapubic catheter bag was positioned to the resident's right side, hanging on the right arm rest of the wheelchair. The catheter bag was at the level of the resident's navel and the tube of the catheter bag was noted on a U-shaped formation. Observation and interview with Resident #4 on 12/05/2023 at 1:34 PM revealed, Resident #4 was still sitting on her wheelchair. Resident #4's indwelling suprapubic catheter was still hanging on the right arm rest of the wheelchair. Resident #4 was noted to have difficulty responding but was able to answer the staff would sometimes put the catheter bag at the bottom of the wheelchair and sometimes at the side of the wheelchair. In an interview with LVN A on 12/06/2023 at 1:52 PM, LVN A stated the catheter bag should be placed below the bladder so the urine would drain effectively. If the catheter bag was higher than the bladder, the urine might not flow efficiently causing urine retainment and urinary bladder infection. LVN A said she would check the placement of the catheter bag for Resident #4. In an interview with ADON E on 12/07/2023 at 7:32 AM, ADON E stated the correct placement of the catheter bag was below the bladder, so the urine would drain better and would not result to urine retainment. ADON E said putting the catheter bag below the level of the bladder would help keep the urine from flowing back to the bladder. ADON E added if there was backflow of the urine, the resident could suffer from a urinary tract infection. In an interview with the Administrator on 12/07/2023 at 7:51 AM, the Administrator stated he would let the clinician answer about the catheter. The Administrator said the staff should do the right practice with regards to catheter care and should adhere to the policy about catheter care to make sure they were providing the best care. In an interview with the DON on 12/07/2023 at 8:16 AM, the DON stated the catheter bag should be on the right level to ensure the urine would drain via gravity. The DON said the catheter bags should be positioned below the bladder to maintain an unobstructed flow of the urine and so that the bladder would be emptied appropriately. The DON added if the catheter bag is on the level of the bladder, the urine could flow back into the blader from the tubing, which could cause a urinary tract infection. The DON concluded the expectation was the staff would find a way to put the catheter bag below the bladder and said she would re-educate the staff about catheter care. Observation on 12/07/2023 at 5:02 PM revealed, Resident #4's catheter bag was placed at the bottom of the wheelchair. Resident #4 pointed at the catheter bag and made a thumbs up. No distress or refusal noted with the catheter bag being placed at the bottom of the wheelchair. Policy for catheter care and placement requested on 12/06/2023 and 12/07/203. No policy provided for Cather Care and placement but instead gave Care and Removal of an Indwelling Catheter.

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** Based on observations, interviews, and record review, the facility failed the medication was labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for one (Resident #4) of two residents reviewed for labelling of drugs and biologicals. The facility failed to ensure CMA W placed a change of instruction label for Resident #4's Phenytoin after a change to the order. This failure could place residents at risk of wrong medication administration, mismanagement of care, adverse effects, and physical harm. Findings included: Review of Resident #4's Face Sheet dated 12/06/2023 reflected the resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses include allergic rhinitis (an allergic reaction to tiny particles in the air called allergens) and seizures. Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected resident had a moderately impaired cognition with a BIMS score of 10. Resident #4 required extensive assistance for bed mobility, transfers, walk in room, dressing, toilet-use, and personal hygiene. Review of Resident #4's Comprehensive Care Plan dated 09/23/2023 reflected resident was taking an anticonvulsant and one of the intervention was to administer medication as ordered. Review of Resident #4's Physician's order for phenytoin dated 11/27/2023 reflected phenytoin sodium extended 100 mg capsule (PHENYTOIN SODIUM EXTENDED) 1 capsule by mouth 3 times per day. Review of Resident #4's discontinued Physician's order for phenytoin dated 11/27/2023 reflected phenytoin sodium extended 100 mg capsule (PHENYTOIN SODIUM EXTENDED) 2 capsules by mouth 1 time per day. Observation and interview on 12/06/2023 starting at 7:29 AM with CMA W revealed CMA W was preparing the medications for administration to Resident #4. The CMA pushed one capsule for Phenytoin 100 mg. The blister pack indicated to give 2 capsules. CNA W said the order in the system said to give 1 capsule. CMA W said there should have been a change in instruction note placed on the blister pack to ensure the right dosage of medication and avoid medication error. In an interview with ADON E on 12/07/2023 at 7:32 AM, ADON E stated in administering medications, the staff giving the medications should make sure they were reading the order and comparing the blister pack with the order in the system. ADON E said if there was change in order, the blister pack should have a note of change of direction to avoid medication error, undermedication, overmedication, or confusion among the staff. ADON E added the nurses or the CMAs could place a change in order instruction. ADON concluded she would monitor the staff administering the medications, give re-education, audit the medication carts, and make sure the medications correlate with the eMAR and the order in the package. In an interview with the Administrator on 12/07/2023 at 7:51 AM, the Administrator stated he would let the clinician answer about the administering medications. The Administrator said whatever the procedure was in giving the medications, it should have been followed to prevent any errors. In an interview with the DON on 12/07/2023 at 8:16 AM, the DON stated the staff should have placed a change in order instruction on the blister pack to avoid confusion. The DON said the staff should have been alerted if he saw there was a difference with the order in the blister pack and the order in the system. The DON said the risk were overmedication or undermedication which could have an adverse effect for the residents. The DON said the expectation was to provide the right dosage of medication as per order. Record review of facility's policy Medication Administration, Nursing Care Center Pharmacy Policy & Procedure Manual 2007 revealed Policy: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices . 3 . If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to label if directions have changed from the current label .

CONCERN (E)

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 the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #91, Resident #92, Resident #93, and Resident #48) of eight residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #91, #92, #93 and #48's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #91 Review of Resident #91's Face Sheet, dated 12/07/2023, reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified transient ischemic attack (mini strokes) and generalized muscle weakness. Review of Resident #91's Quarterly MDS Assessment, dated 10/11/2023, reflected Resident #91 had a moderately impaired cognition with a BIMS score of 12. Resident #91 required extensive assistance for bed mobility, transfer, and toilet use. Review of Resident #91's Comprehensive Care Plan, dated 10/28/2023, reflected Resident #91 had a risk for falls and one of the interventions was to keep the call light and most frequently used personal items within reach. Review of Resident #91's Fall-Risk Assessment, dated 11/09/2023, reflected Resident #91 was at high risk for falls. Review of Resident #91's Incident Report denoted Resident #91 had falls on 06/18/2023 and 08/21/2023. Observation and Interview on 12/05/2023 at 10:18 AM revealed Resident #91 was sitting on the right side of her bed with her walker in front of her. Resident #91's call light was hanging on the left side of the bed with the call light button almost touching the floor. Resident #91 stated the CNA who just fixed her bed forgot to put the call light on top of the bed where she could reach it even though she was not lying on the bed. Resident #91 said she needed to stand up, go around her bed, and stoop down just to get her call light. Resident #91 added it was hard for her to bend over because of back pain and weakness. Resident #91 further said she hoped the CNA will put the call light on top of the bed even though she was out of the bed. Resident #93 Review of Resident #93's Face Sheet, dated 12/06/2023, reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient oxygen in the brain causing stroke) affecting right dominant side, and unspecified pain. Review of Resident #93's Quarterly MDS Assessment, dated 10/16/2023, reflected Resident #93 had a severe cognitive impairment with a BIMS score of 00. Resident #93 was totally dependent for bed mobility, transfer, and toilet use. Review of Resident #93's Comprehensive Care Plan, dated 10/29/2023, reflected Resident #93 had a risk for falls and one of the interventions was to keep the call light and most frequently used personal items within reach. Review of Resident #93's Fall-Risk Assessment, dated 10/29/2023, reflected Resident #93 was at high risk for falls. Review of Resident #93's Incident Report denoted Resident #93 had falls on 08/21/2023, 08/30/2023, 09/04/2023, and 09/28/2023. Observation on 12/05/2023 at 11:43 AM revealed Resident #93 was on his bed sleeping. The call light was noted on the bedside table of Resident #93's roommate. Observation on 12/05/2023 at 1:34 PM revealed resident was lying on the bed awake. The call light was still noted on the bedside table of Resident #93's roommate. Observation on 12/06/2023 at 2:34 PM revealed resident was on his bed awake. The call light was still noted on the bedside table of Resident #93's roommate. Resident #48 Review of Resident #48's Face Sheet, dated 12/06/2023, reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included arthritis with unspecified site, pain in the left knee, and muscle weakness. Review of Resident #48's Quarterly MDS Assessment, dated 11/21/2023, reflected Resident #48 had a moderate cognitive impairment with a BIMS score of 08. Resident #48 required extensive assistance for bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, and personal hygiene. Review of Resident #48's Comprehensive Care Plan, dated 08/11/2023, reflected Resident #48 had a risk for falls and one of the interventions was to keep the call light and most frequently used personal items within reach. Observation on 12/06/2023 at 9:36 AM revealed Resident #48 was sitting at the right side of her bed. Resident's call light was coiled and was hanging by the wall near the privacy curtain. Resident #48 said she could not find her call light and said the CNA forgot to put it on top of her bed again. Resident went out of the room and said she will find somebody to look for her call light. Resident #92 Review of Resident #92's Face Sheet, dated 12/08/2023, reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified lack of coordination, weakness, and age-related osteoporosis (A condition when bone strength weakens and is susceptible to fracture) without current pathological fracture (a broken bone that is caused by a disease). Review of Resident #92's Quarterly MDS Assessment, dated 11/21/2023, reflected Resident #92 had a severe cognitive impairment with a BIMS score of 04. Resident #92 required extensive assistance for bed mobility, transfer, and toilet use. Review of Resident #92's Comprehensive Care Plan, dated 11/22/2023, reflected Resident #92 had a risk for falls and one of the interventions was to keep the call light and most frequently used personal items within reach. Review of Resident #92's Fall-Risk Assessment, dated 12/12/2022, reflected Resident #92 was at high risk for falls. Review of Resident #92's Incident Report denoted Resident #91 had falls on 01/10/2023, 02/20/2023, 04/20/2023, 05/01/2023, 08/18/2023, and 09/30/2023. Observation and interview with Resident #92 on 12/06/2023 at 1:11 PM revealed the resident was on her bed resting. Resident #92's call light was on top of the right bedside table. Resident #92 stated the call light was on the table since she came back to the room after lunch. The resident said it was hard for her to reach it. The resident started to reach for the call light but was not able to reach it. The resident started to shake her head and went back to lay down on her bed. In an interview with CNA Y on 12/06/2023 at 1:46 PM, CNA Y stated that the call light should be within the reach of the residents at all times. CNA Y said that for some residents, the call light is their sense of protection. The call light gave them the notion that when they were in danger or there was an emergency, they could call the staff to help them. CNA Y added that the resident could fall if they tried to get to their call light that was far from them to call for assistance. CNA Y stated she might have forgotten to put the call lights on top of the bed when she made the residents bed. CNA Y said she would go for her rounds to check the call lights on her hall. In an interview with LVN A on 12/06/2023 at 1:52 PM, LVN A stated that the call light should not be on the table, hanging from the bed, or hanging by the wall. These placements were far from the residents, and they would have a hard time getting to them. LVN A said the call lights must be by the residents at all times. LVN A explained the call light was a method of communication between the resident and the staff. This was how the resident would communicate to the staff if they needed something and this was how the staff would know the residents needed something. LVN A said that without the call lights, the residents might try to get what they needed by themselves, and it could result in a fall, injury, and frustration. LVN A said she would check to see if her residents had their call lights. In an interview with ADON E on 12/07/2023 at 7:32 AM, ADON E stated the call lights were the resident's source of help, which was why the call lights should always be within the reach of the resident. ADON E said their call light was the lifeline of the residents. The residents use the call lights for basic reasons such as a glass of water, they need their remote, or they needed to be changed. ADON E added the call light could be used by the residents if they were not feeling well. If the call lights were far from the residents, the residents would not be able to call the staff and these needs would not be addressed. If the call lights were not with the residents, it could result in a fall, dehydration, and annoyance. ADON E said the expectation is for the staff to make sure the call lights were within the reach of all the residents and the call lights be placed on top of the bed when the residents were up. In an interview with Administrator on 12/07/2023 at 7:51 AM, the Administrator stated that it was not acceptable for the call lights to be far from the residents. The Administrator said the basic needs of the residents would not be addressed. The Administrator added the call light should be answered in a timely manner. The Administrator added he would monitor the staff for this concern and would re-educate the nurses and the CNAs to ensure call lights were within reach of the residents. In an interview with the DON on 12/07/2023 at 8:16 AM, the DON stated the call lights were inside the rooms for when the residents needed something, the residents could call the staff. The DON said the residents needed their call lights to let the staff know they needed a glass of water, a pain medication, or they needed to be changed. The DON added without the call lights, the residents would not be able to tell the staff they were thirsty, needed a snack, they were in pain, they need to go to the bathroom, or they were not feeling well. The DON further added that when the call lights were not within the reach of the residents, unfavorable incidents like falls, minor hurts, or major injuries could happen. The DON said the expectation was for the staff to ensure that the call lights were within reach of the residents. The DON concluded that moving forward, she would be on top of this issue to make sure the staff would make certain the call lights were with the residents at all times. In an interview with RN P on 12/07/2023 at 9:26 AM, RN P stated the call lights should be within the reach of the residents at all times. RN P said the call lights were used by the residents to call the attention of the staff, if they needed help to go to the restroom, if they needed a pain pill, or a refill on their water pitcher. If the call lights were far from the residents, the residents might try to get what they needed themselves and fall in the process. RN P then added she would be doing her rounds to check the call lights of the residents. In an interview with CNA Z on 12/07/2023 at 9:40 AM, CNA Z stated call lights were important for the residents because it was what they use to call when they need assistance. CNA Z said the call lights should be in a place where the residents could reach it and press the red button of the call light. If the call lights were not with the residents, they would not be able to call the staff. This may result in a fall. CNA Z said after fixing the bed, the call light should be placed on top of the bed. Record review of facility's policy Call Lights Answering, Clinical Operations, rev. January 19. 2020, revealed Policy: The staff will provide an environment that helps meet the resident's needs by answering call lights appropriately . Procedure . 7. When leaving the room, be sure the call light is placed within the resident's reach.

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 12 (Resident #'s 5, 6, 13, 19, 35, 42, 48, 49, 71, 81, 83, and 101's) of 24 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Resident #'s 5, 6, 13, 19, 35, 42, 48, 49, 71, 81, 83, and 101's rooms were cleaned, sanitized, and maintained. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: Observation of Residents #13 and #19's room on 12/05/23 at 10:50 AM revealed the wall alongside Resident #13's bed had grayish stains and the two deep scrapes mixed among the stains. Both bed side tables in the room had dried-up reddish fluid stains on the bottom of the frames. The bathroom wall between the sink and toilet had brownish and grayish stains midway and near the bottom of the wall. Observation of Residents #5 and #81's room on 12/05/23 at 10:59 AM revealed dark grayish stains on the corners of the bathroom floor, behind the toilet. There were grayish stains on the floor, along the edges of the toilet. There was a light brownish stain on the floor located in front of the toilet. The corner of the floor under the sink had dirt particles building up along the edges. Observation of Residents #42 and #71's room on 12/05/23 at 11:06 AM revealed a corner of the room floor, behind a waste basket, had white dirt particles and dust building up. The bathroom floor had a circular grayish stain behind the toilet, and in the corner of the floor behind the toilet had brownish and grayish stains. Observation of Residents #48 and #101's room on 12/05/23 at 11:10 AM revealed the bathroom floor had brownish and grayish stains going around the toilet. The bathroom floor in the corner of the room, behind the toilet, had yellowish and grayish stains. The handrails beside the toilet had black dirt particles and brownish stains. Observation of Residents #6 and #83's room on 12/05/23 at 11:19 AM revealed the top of the air-conditioned unit had black dirt particles sprinkled along the top. Just above the air-conditioned unit, along the wall had grayish stains sprayed along the wall. The bathroom floor had brownish stains going around the toilet. Observation of Residents #35 and #49's room on 12/05/23 at 11:25 AM revealed the wall alongside Resident 49's bed was scraped and measured about a 10-inch circle in diameter, and large grayish stains peppered along the wall. In an interview on 12/08/23 at 12:33 PM with the Housekeeping Supervisor, she stated she had been at the facility for almost two years but supervised for two months. She stated she used her tenured staff to assist in training the new hires. She stated staff were supposed to clean bathrooms, sweep, mop, wipe walls, and the air conditioning unit. She stated housekeeping cleans the room daily and she checked the rooms maybe once a day but not every day. She was shown the pictures of concerns observed in the resident rooms and she stated that her staff should be cleaning the areas mentioned because if the rooms were not cleaned thoroughly, residents could get sick. She stated she does not use a checklist to clean the rooms. In an interview on 12/08/23 at 12:45 PM with Housekeeper L, she stated she had been at the facility for three weeks. She stated she was trained by one of the oldest tenured housekeepers. She stated she was shown different areas of the facility to clean and was trained to clean rooms the days she started. She stated she was trained to dust the floor, sweep the floor, mop the floor, and tidy up. She stated she was trained to clean the air conditioning units, bed side tables, and walls if stained. She stated if she had observed anything damaged in the room, she would report it to the maintenance person. She stated if the rooms were not cleaned thoroughly, residents could get sick. She stated she does not normally clean the corners of the rooms on a regular basis . In an interview on 12/08/23 at 01:10 PM with the Director of Maintenance, he stated staff are to either place requests in the maintenance log or notify him. He was shown pictures of the scraped wall and he stated he was aware of the damages to the rooms mentioned and was trying to get to all of them. He stated that if things are not repaired correctly in the resident rooms, it would not be good because this is their home. In an interview on 12/08/23 at 01:33 PM with the Administrator, he stated he had not been made aware of any concerns regarding the cleanliness of rooms . He was shown pictures of the concerns observed in the rooms. He stated he would meet with his Housekeeping Supervisor to ensure the housekeeping staff were re-trained on thoroughly cleaning the rooms, including wiping down the walls, cleaning the floors thoroughly, and cleaning the corners of the rooms on the floors. He stated he was aware of repairs being needed and stated that maintenance was working their way around the facility making repairs based on priority. He stated the risk of these concerns not being addressed is not good for the residents. Review of the facility's policy on Resident Room Cleaning (November 2021) revealed To provide a clean, attractive, and safe environment for residents, visitors, and staff. High Dust Wall Articles: Damp Dust the Doors and Wall the tops of items along the resident's room and restroom walls (door frames, picture frames, clocks, over bed lighting, door closures, etc.) that are at or above your shoulder height. Clean and Disinfect the Room Furnishings: A. Clean all furnishings in the resident's room including the bed rails, IV poles, doorknobs, wheelchairs, walkers, and all other high contact surfaces.

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 observations, interviews, and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 6 residents (Residents #49, #50, and #111) reviewed for ADLs care provided to dependent residents. The facility failed to ensure Residents #49, #50, and #111 received showers consistently based on records reviewed for November 2023. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Included: Record review of Resident #49's Face Sheet, dated 12/08/23, revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's disease (severe memory loss), and difficulty in walking. Record review of Resident #49's MDS comprehensive assessment, dated 10/14/18, revealed she had a Brief Interview for Mental Status (BIMS) score of 05 (severe cognitive impairment) and for Activities for Daily Living (ADL) care it stated, for transfers, toileting, and bathing, the resident required assistance and a mechanical lift. Record Review of Resident #49's Care Plan, updated 09/28/23, stated the resident was at risk of skin breakdown and an intervention was to Inspect skin daily with care and bathing, and report any changes to the charge nurse. Observation on 12/05/23 at 11:24 AM of Resident #49, she was observed laying in her bed. Her hair looked ruffled and tangled. The white gown the resident was wearing appeared grimy as well as the linen on her bed. No bad odor was detected from her. Records review of Resident #49's Bath/Shower Sheets from 11/01/2023 - 11/30/2023, revealed the resident was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. The facility was unable to provide shower sheets for the resident. The only information provided was by the DON after she was advised that staff was unable to produce any documents indicating Resident #49 had received her scheduled showers for the month of November 2023. The DON provided the following document referencing the resident's ADL care. Report titled Result List, dated 12/08/23 reported the following for Bathing: 11/02/23: Does not indicate any type of bath given. 11/04/23: Indicated a bath was provided; however, it does not indicate bed bath or shower. 11/07/23: Indicated a bath was provided; however, it does not indicate bed bath or shower. 11/09/23: Indicated a bath was provided; however, it does not indicate bed bath or shower. 11/11/23: Indicated a bath was provided; however, it does not indicate bed bath or shower. 11/14/23: Indicated a bath was provided; however, it does not indicate bed bath or shower. 11/16/23: Indicated a bath was provided; however, it does not indicate bed bath or shower. 11/18/23: Indicated a bath was provided; however, it does not indicate bed bath or shower. 11/21/23: Indicated a bath was provided; however, it does not indicate bed bath or shower. 11/23/23: Indicated a bath was provided; however, it does not indicate bed bath or shower. 11/25/23: Indicated a bath was provided; however, it does not indicate bed bath or shower. 11/28/23: Indicated a bath was provided; however, it does not indicate bed bath or shower. 11/30/23: Indicated a bath was provided; however, it does not indicate bed bath or shower. Record review of Resident #50's Face Sheet, dated 12/08/23, revealed she was a 70 -year-old female initially admitted on [DATE]. Relevant diagnoses included fracture of right ankle, muscle weakness, and difficulty in walking. Record review of Resident #50's MDS comprehensive assessment, dated 11/12/23, revealed she had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and for Activities for Daily Living (ADL) care it stated, for transfers, toileting, and bathing, the resident required substantial assistance. In an interview on 12/05/23 at 11:54 AM with Resident #50, she stated she had been at the facility for nearly a month. She stated she was scheduled to received three showers a week on Tuesday, Thursday, Saturday. She stated she had only received two showers since she had been at the facility, and she would like more showers. She stated she had never refused any showers. She stated when she asked for showers, the CNAs would reply that they are very busy and would only be able to provide her a bed bath . Records review of Resident #50's Bath/Shower Sheets from 11/01/2023 - 11/30/2023, revealed the resident was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. The facility was unable to provide shower sheets for the resident. The only information provided was by the DON after she was advised that staff was unable to produce any documents indicating Resident #50 had received her scheduled showers for the month of November 2023. The DON provided the following document referencing the resident's ADL care. Report titled ADL Alert Report, dated 12/08/23 reported the following for Bathing: 11/09/23: The comments section stated RES. REFUSED 11/14/23: The comments section stated RES. REFUSED 11/16/23: The comments section stated RES. REFUSED 11/18/23: The comments section stated RES. REFUSED 11/21/23: The comments section stated RES. REFUSED 11/23/23: The comments section stated RES. REFUSED 11/25/23: The comments section stated RES. REFUSED 11/28/23: The comments section stated RES. REFUSED 11/30/23: The comments section stated RES. REFUSED Record review of Resident #111's Face Sheet, dated 12/08/23, revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle weakness, lack of coordination, and fall risk. Record review of Resident #111's MDS comprehensive assessment, dated 10/14/18, revealed she had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and for Activities for Daily Living (ADL) care it stated, for transfers, toileting, and bathing, the resident required substantial assistance. Record Review of Resident #111's Care Plan, updated 11/18/23, stated the resident was at risk of skin breakdown and an intervention was to Inspect skin daily with care and bathing, and report any changes to the charge nurse. In an interview on 12/05/23 at 11:58 AM with Resident #111, she stated she had been at the facility for a few weeks and had not received a shower yet. She stated she had never refused any showers and had asked the CNA for a shower instead of a bed bath, but the CNAs advised her that they did not have someone else available to assist or they did not have time. She stated she would really like a shower . Records review of Resident #111's Bath/Shower Sheets from 11/01/2023 - 11/30/2023, revealed the resident was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. The facility was only unable to provide shower sheets for the resident . In an interview on 12/08/23 at 01:45 PM with CNA S, she stated Residents #49, #50, and #111 were to receive their showers on Tuesdays, Thursdays, and Saturdays. She stated the CNAs are required to complete a shower sheet every time they provide the resident a shower and the nurse signs off on it as well. She stated that if a resident refused a shower, they must document it and the nurse must also sign it. She stated the residents had received at least bed baths from her and she trieds to give them at least one shower a week. She stated she filled out a shower sheet and turned it into her nurse. She stated the risk of the resident not getting their scheduled showers could result in damage to the skin. She stated she did not provide showers to Residents 49, #50, and #111. In an interview on 12/08/.23 at 02:13 PM with CNA A, she stated she had been at the facility for over a year, and she covered the hall of Resident #49, #50, and #111's. She stated she was familiar with Resident #49, #50, and #111. She stated they are to receive their showers on Tuesday, Thursday, and Saturday. She stated the CNA must complete a shower sheet form and fill it out completely. She stated they must also input the information into the nurses' notes. She stated that if a resident refuseds a shower, she would contacts a nurse, who attempted to get the resident to take a shower. She stated she had given the residents all their showers for the month of November, but she was unable to provide any shower sheets. In an interview on 12/08/23 at 02:43 PM with CNA C, she stated she had been at the facility for 3 years and had been covering Resident #49, #50, and #111's hall for three months. She stated she provided Resident #50 her showers on Tuesday, Thursday, and Saturdays in the afternoon. She stated the resident had been receiving her showers when she was working. She stated they were required to complete shower sheets and document everything. She stated the nurse had to review if the resident refused care. She stated the resident often refused showers. She stated she forgot to fill out the shower sheets for the resident, but she stated she provided at least two showers a week to the resident. She was asked the risk of the resident not receiving her showers and she stated the resident would not be clean and would not smell good. In an interview on 12/08/23 at 02:59 PM with CNA L, she stated she had been at the facility for two weeks. She stated she was unsure when all residents were scheduled to receive their showers. She stated the they were required to complete a shower sheet, whether the resident received a shower or refused. She stated if the resident refused a shower the they must notify the nurse, the nurse would try to talk to the resident, and if the resident still refused, the nurse would document it. She stated the they were required to fill out the shower sheets and the nurses checked to ensure that a shower was provided, and she knows it was being done because she got the shower sheets. She was asked about the shower sheets for Resident #49, 50 and #111 and she stated the CNA must have forgotten to fill it out. She stated the risk of the residents not receiving their showers could result in skin problems. In an interview on 12/08/23 at 03:05 PM with LVN J, she stated she was familiar with Resident #49, 50 and #111 and she stated that she thought the residents did receive their scheduled showers. She stated that the CNAs were not completing resident showers when scheduled so the ADON required all CNAs to complete shower sheets and enter the shower information into the nurses notes. She stated that CNAs are still not completing them consistently. She stated the reason the ADON wanted shower sheets completed was so that they could check the resident's body for any new marks, bruises, or wounds. She stated she was sure the residents had showers sheets filled out and she was sure showers were being conducted. She stated the risk of the resident not receiving their showers could result in skin breakdown. She stated the residents did have showers sheets and that she would locate them and bring them for review, but she never returned with the shower sheets . In an interview on 12/08/23 at 03:09 PM with the DON, she stated she had been at the facility since 2019. She stated residents were assigned even and odd days for showers, and their shifts can be on a Monday, Wednesday, and Friday, or Tuesday, Thursday, and Saturday. She stated residents were supposed to fill out an ADL plan of care which was the care plan that the CNAs work out of. She stated the ADON had an issue with showers not being done so she implemented a policy for the CNA to complete shower sheets. She stated Resident #49, 50 and #111 had received their scheduled showers or refused. She stated the ADON was out of the office and she could not follow up with her where the shower sheets were being stored. I advised her that residents had complained about not receiving their shower and she was also advised that the residents stated that they never refused a shower. The DON left the interview and returned with documents, but the documents did not indicate if the resident received a bed bath or shower. The form also showed resident #5 refused showers. The DON was unable to provide any shower sheets for any of the residents. She stated the risk of residents not receiving their showers could result in infection and skin damage . Record Review of facility policy on BATHING (NOT PARTIAL OR COMPLETED BED BATH), dated January 12, 2018, revealed Staff will provide bathing services for residents within standard practice guidelines. Document bath in EHR. Tasks commonly completed during the bathing process: o Inspect skin, especially those that are showing redness or signs of breakdown o Observe Range of Motion during the bathing process o If discomfort is present, ask the resident to describe and rate the discomfort o Record the procedure in the record o Report abnormal findings to the nurse in charge or the health care provider Multiple refusals of bathing needs shall be discussed with the resident and responsible party during care plan meetings with the interdisciplinary team in order to identify and implement proper hygiene habits and promote resident rights and dignity.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to ensure that three(Resident #4, Resident #91, and Resident #25) of six residents were provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of the residents. The facility failed to ensure CMA W re-ordered medications in a timely manner for Resident # 4 Resident #91, and Resident #25. This failure placed the residents at risk of not receiving medications as ordered by the physician. Findings included: Resident #4 Review of Resident #4's Face Sheet, dated 12/06/2023, reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified hyperlipidemia (a condition in which there are high levels of fat particles in the blood) and essential (primary) hypertension. Review of Resident #4's Quarterly MDS Assessment, dated 11/22/2023, reflected the resident had a moderate intact cognition with a BIMS score of 10. Resident #4 required extensive assistance for bed mobility, transfer, walk in, dressing, toilet use, and personal hygiene. Review of Resident #4's Comprehensive Care Plan, dated 09/23/2023, reflected the resident was hypertensive. The Comprehensive Care Plan disclosed that Resident #4 was taking clonidine, lisinopril, amlodipine, and labetalol for hypertension. Review of Resident #4's Physician's order for amlodipine, dated 10/15/2021, reflected amlodipine 10 mg tablet (AMLODIPINE BESYLATE) 1 tablet by mouth 1 time per day Hold if Systolic BP Less than 100 Hold if Diastolic BP Less than 60 Hold if Pulse Less than 60 MD Call. Review of Resident #4's Physician's order for lisinopril dated, 09/16/2021, reflected lisinopril 40 mg tablet (LISINOPRIL) 1 tablet by mouth 1 time per day Hold if Systolic BP Less than 100 Hold if Diastolic BP Less than 60 Hold if Pulse Less than 60 * MD Call. Observation on 12/06/2023 at 7:29 AM revealed CMA W was preparing Resident #4's medication. It was noted resident's blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) for lisinopril only had 3 tablets left and the blister pack for amlodipine had no medication left after CMA W took the last pill. Resident #91 Review of Resident #91's Face Sheet, dated 12/07/2023, reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included overactive bladder (A bladder control problem which leads to a sudden urge to urinate) and unspecified major depressive disorder. Review of Resident #91's Quarterly MDS Assessment, dated 10/11/2023, reflected Resident #91 had a moderately impaired cognition with a BIMS score of 12. Resident #91 required extensive assistance for bed mobility, transfer, and toilet use. Review of Resident #91's Comprehensive Care Plan, dated 10/28/2023, reflected Resident #91 was on antidepressant and one of the interventions was to administer medication as ordered. Review of Resident #91's Physician Order for sertraline, dated 05/02/2023, revealed sertraline 50 mg tablet (SERTRALINE HCL) 1.5 tablet by mouth 1 time per day give 1.5 tablets to =75mg. Review of Resident #91's Comprehensive Care Plan, dated 10/28/2023, reflected Resident #91 was with urinary incontinence medication and one of the interventions was to administer medication as ordered. Review of Resident #91's Physician Order for oxybutynin, dated 06/12/2023, revealed oxybutynin chloride ER (extend release: type of medication designed to slowly release a drug in the body over an extended period of time) 5 mg tablet, extended release 24 hr (OXYBUTYNIN CHLORIDE) 1 tablet extended release 24hr by mouth 1 time per day. Observation on 12/06/2023 at 7:52 AM revealed Resident #91's blister pack for oxybutynin had 3 tablets left and the blister pack for sertraline had 5 tablets left. Resident #25 Review of Resident #25's Face Sheet, dated 12/08/2023, reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified hypothyroidism and gastro-esophageal reflux disease without esophagitis. Review of Resident #25's Comprehensive MDS Assessment, dated 10/02/2023, reflected Resident #25 had severe impairment in cognition with a BIMS score of 03. Review of Resident #25's Comprehensive Care Plan, dated 10/21/2023, reflected resident with gastrointestinal discomfort and one of the interventions was to administer medication as ordered. Review of Resident #25's Physician Order for pantoprazole, dated 05/09/2023, reflected, pantoprazole 20 mg tablet, delayed release (PANTOPRAZOLE SODIUM) 1 tablet, delayed release by mouth 1 time per day. Observation on 12/06/2023 at 7:59 AM revealed Resident #25's blister pack for pantoprazole had 3 tablets left. In an interview on 12/06/2023 at 8:36 AM with CMA W, CMA W said he would check the overflow on the medication room to check if there were stocks of the medications that were almost done. He said if there were no stock in the medication room, the pharmacy should be informed so they could include the medications on the delivery. He said the medications should had been re-ordered when the tablets reach the dark blue portion of the blister pack. He added the CMAs and not nurses could re-order the medications. In an interview with ADON E on 12/06/2023 at 9:01 AM, ADON stated re-ordering the medications could be done in the system or through faxing. ADON E said CMAs and nurses must have a conscious effort to re-order the medications in a timely manner. They should not wait for the medications to run out before they re-order on the system or fax the pharmacy. ADON E said medications should not be re-ordered at the last minute because the residents would not have an adequate supply of medication in circumstances that the delivery was late. ADON E added if the residents do not have their medications, their medical concerns could get worse. ADON E said the expectation was the medications should be re-ordered in a timely manner to make sure that the residents have enough supply of medications. ADON said she would do a medication cart audit to check if the residents had ample number of medications needed. In an interview with LVN A on 12/06/2023 at 1:52 PM, LVN A stated the medications should have been re-ordered when the tablets reach the dark blue portion of the blister pack. LVN A said the medication should be re-ordered four to five days before the medications were consumed. LVN A said the staff who saw the medications were running low should re-order the medications. LVN A added if the medications were not re-ordered, the residents would not have any medications to take and skipping medications could result to exacerbation of the current medical concerns. In an interview on 12/006/2023 at 1:34 PM with CMA W, CMA W stated there were no blister packs in the medication room for Resident # 4 (Lisinopril and Amlodipine), Resident #91 (Oxybutynin and Sertraline), and Resident #25 (Pantoprazole). He said he would go ahead and re-order these medications to make sure the resident would not run out of medications. He said he needed to make sure Resident #4's amlodipine would be delivered today so the resident would have the medication for tomorrow. He added if the residents did not have their medications on time it could cause exacerbation of their current medical situation such as increased anxiety, pain, and blood pressure. In an interview with Administrator on 12/07/2023 at 7:51 AM, the Administrator stated he would let the clinicals answer the questions about re-ordering medications. The Administrator said the staff must make sure that the medications were re-ordered on a timely manner to make sure that the residents have the medications they needed. The Administrator stated the expectation is the resident would not run out of medications. In an interview with the DON on 12/07/2023 at 8:16 AM, the DON stated medications should be re-ordered 3 to 4 days before the pills run out. The DON said if the medications were not re-ordered in a timely manner, the resident would not have the medications they needed. The DON added if the resident did not have their medications, their condition could get worse. The DON said the expectation was to re-order the medications in a timely manner. Record review of facility policy, Ordering and receiving Non-Controlled Medications, Nursing Care Center Pharmacy Policy & Procedure Manual 2010 revealed Policy: Medications and related products are received from the provider pharmacy on a timely basis . b . Reorder routine medications by the re-order date on the label to assure an adequate supply is on hand.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5% for four medication administration errors identified out of 42 opportunities for one (Resident #26) out of five residents reviewed for pharmacy services. There were three medication errors out of forty two opportunities yielding a medication error of 7.14% 1. The facility failed to ensure CMA W administered 3 capsules of Duloxetine to Resident #26 as ordered. 2. The facility failed to ensure CMA W read the alternate order for Omeprazole for Resident #26. 3. The facility failed to ensure CMA W did not crush medication with do not crush instruction for Resident #26. These failures could place residents at risk of wrong medication administration, mismanagement of care, adverse effects, and physical harm. Findings included: Resident #26 Review of Resident #26's Face Sheet dated 12/06/2023 revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included major depressive disorder, gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach) without esophagitis (inflammation of the esophagus), and overactive bladder. Review of Resident #26's Quarterly MDS assessment dated [DATE] revealed the resident had a severe impairment in cognition with a BIMS score of 02. Resident #26 was totally dependent upon two or more staff for bed mobility and transfers. She required limited assistance of one staff member for eating. Review of Resident #26's Comprehensive Care Plan dated 10/24/2023 reflected resident was receiving an antidepressant. No care plan noted for gastro-esophageal reflux disease without esophagitis and overactive bladder. Review of Resident #26's Comprehensive Care Plan dated 10/24/2023 reflected resident's medications were crushed due to altered nutritional status. Review of Resident #26's Physician's order for duloxetine dated 10/24/2023 reflected duloxetine 30 mg capsule, delayed release (DULOXETINE HCL) 3 capsule, delayed release(DR/EC) by mouth 1 time per day (3 caps= 90mg total). Review of Resident #26's Physician's order for omeprazole dated 10/24/2023 reflected omeprazole 20 mg capsule, delayed release (OMEPRAZOLE) 1 capsule, delayed release(DR/EC) by mouth 1 time per day ok to interchange omeprazole OTC tab 20 mg for capsule 20mg. Review of Resident #26's Physician's order for oxybutynin dated 10/25/2023 reflected oxybutynin chloride ER 10 mg tablet, extended release 24 hr (OXYBUTYNIN CHLORIDE) 1 tablet by mouth 1 time per day. Observation and interview on 12/06/2023 with CMA W starting at 8:16 AM revealed CMA W was preparing the medications for Resident #26. CMA W said they crush the medications for Resident #26. It was observed CMA W was placing the medications to be crushed in a small plastic cup. CMA W said he would put the duloxetine in a separate cup because it was a capsule. During preparation, it was noted that CMA W placed 1 capsule of duloxetine in the small cup ( order said to give 3 capsules). CMA W continued to prepare for the other medications to be crushed. One of the medications he placed on the cup was oxybutynin. The blister pack of oxybutynin had an instruction of do not crush. CMA W continued to prepare for the medications to be crushed and was observed looking for the blister pack of omeprazole. CMA W said he did not have a blister pack for omeprazole. CMA W said he would not be able to give Resident #26 her omeprazole because it was not on the cart. CMA W crushed the medications, opened the capsule, put some apple sauce, and gave the medications to Resident #26. In an interview on 12/06/2023 at 1:32 PM with CMA W, CMA W was advised the blister pack for Resident #26's blister pack for oxybutynin indicated do not crush. CNA W stated he did not notice the instruction. He added there should have been an order for a crushable oxybutynin. CMA W said he should be careful and read the orders very well so he would give the right dosage and could follow the instructions. CMA W said that could have resulted in medication error and the residents would not receive the right medications. CMA W stated the medication error could lead to the residents not getting better. In an interview with ADON E on 12/07/2023 at 7:32 AM, ADON E stated in administering medications, the staff giving the medications should make sure they were reading the order and comparing the blister pack to the order in the system. Reading the order were needed to ensure it was the right resident, the right medication, the right dosage, the right route. This was also to check if there were instructions on how to give the medications. If the instruction said, do not crush, the medication should not have been crushed because the medication would lose its potency. If the order said to give three capsules, the staff should prepare 3 capsules of the medication because giving a less dose could make the medication ineffective. ADON E further added Resident #26's order indicated resident could have had over-the-counter omeprazole. ADON E continued CMA W must have missed it. ADON concluded she would monitor the staff administering the medications, give re-education, audit the medication carts, and make sure the medications correlate with the eMAR and the order in the package. In an interview with the Administrator on 12/07/2023 at 7:51 AM, the Administrator stated he would let the clinician answer about the administering medications. The Administrator said whatever the procedure was in giving the medications, it should have been followed to prevent any errors. In an interview with the DON on 12/07/2023 at 8:16 AM, The DON stated a medication should not be crushed if the instruction said do not crush. This would lessen the effectiveness of the medication. The DON said she called the MD to get an order for a crushable oxybutynin. The DON continued that whoever was administering the medications should read the order to ensure accurate medication preparation and if there was an alternate order. This should be done to prevent a medication error. The DON said the expectation was for the staff to check the orders to accurately prepare the medications. The DON concluded she would get on top of this issue, re-educate the staff, and conduct in-services. Observation and interview on 12/07/2023 at 8:39 AM with CMA W, CMA W stated he missed the order for Resident #26's order for omeprazole stating he could have given over-the-counter omeprazole. CMA W opened the first drawer and took the medication bottle for omeprazole. Record review of facility's policy Medication Administration, Nursing Care Center Pharmacy Policy & Procedure Manual 2007 revealed Policy: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices . 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to label if directions have changed from the current label . a. The need for crushing medications is indicated on the resident's orders and the MAR so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety and alternatives, if appropriate, during Medication Regimen Reviews . b. Long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought .

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 observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Residents #26, Resident #63, and Resident #4) of ten residents observed for infection control. 1. The facility failed to ensure CNA Z performed hand hygiene between resident (Resident #26 and Resident #63) care in the dining room on 12/05/2023 between 12:19 PM and 12:40 PM. 2. The facility failed to ensure CMA W sanitized the blood pressure cuff between Resident #4 and Resident #26. 3. The facility failed to ensure CMA W washed her hands wore gloves before administering nasal spray to Resident #4. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #26's Face Sheet dated 12/06/2023 revealed she was an [AGE] year-old female re-admitted to the facility on [DATE]. Relevant diagnoses included metabolic encephalopathy (syndrome of a chemical imbalance in the blood that causes neurological deficits,) right side contractures (abnormal thickening of the tissues which causes decease in movement and mobility,) and aphasia following cerebral infarction (loss of ability to understand or express speech caused by brain damage.) Review of Resident #26's Quarterly MDS assessment dated [DATE] revealed she was severely cognitively impaired with a BIMS score of 02. Resident #26 was totally dependent upon two or more staff for bed mobility and transfers. She required limited assistance of one staff member for eating. Review of Resident #26's comprehensive care plan revealed she had altered nutritional status . (dated) 10/24/2023 Her goal included she would be comfortable with food and fluids provided over the next 90 days and would have snacks provided between meals . daily. Additional review revealed she had Impaired Physical Mobility 10/24/2023 . related to History of Stroke. Resident #26's goal included to maintain or improve physical function .locomotion, and ROM over the next 90 days. Related intervention included to Provide appropriate level of assistance to promote safety of resident. There was no evidence of care interventions related to dining and/or assistance related to dining was determined. Review of Resident #63's face sheet dated 12/06/2023 revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included cerebral infarction (disruption of blood flow to the brain due to problems with the blood vessels that supply the brain,) malaise (general feeling of discomfort,) edema (swelling caused by too much fluid trapped in the body's tissues,) stage 2 kidney disease (mild kidney damage,) flaccid hemiplegia affecting the left side (decreased muscle tone that cannot be actively moved by the patient,) dementia (group of conditions characterized by impairment of brain functions,) and epilepsy (disorder of brain activity.) Review of Resident #63's admission MDS dated [DATE] revealed she was unable to complete the BIMS assessment but she was documented as having short and long-term memory problems. Resident #63 required extensive assistance of two or more staff members for bed mobility and transfers. She required extensive assistance of one staff member for eating. Review of Resident #63's comprehensive care plan on 12/06/2023 at 3:05 PM revealed she had altered nutritional status . (dated) 11/27/2023 . related to dentures, chewing difficulty, and use of diuretics, laxatives, and/or cardiovascular drugs. Her goal included she would maintain her weight over the next 90 days. Relevant intervention included provide necessary assistance with food and fluids. In an observation on 12/05/2023 at 12:19 PM, CNA Z was sitting in a chair in the dining room, positioned between Resident #26 and Resident #63. CNA Z assisted Resident #26 and Resident #63 by taking her right hand, obtaining resident spoon, and providing a spoon full of food to their mouths. CNA Z assisted Resident #26 then Resident #63 then going back to Resident #26 then back to Resident #63. This was repeated approximately 7 times during the dining observation. CNA Z failed to perform hand hygiene between each resident contact. In an interview with CNA Z on 12/05/2023 at 12:37 PM, she stated that she was aware it was not best practice to assist two residents simultaneously. She stated she did not know why necessarily, but it was not best practice. She stated on that day she had to assist two residents because of short staffing. She stated she did not need to perform hand hygiene between resident care because she used a spoon with each resident and her hand was protected with use of the spoon. In an interview with ADON K on 12/07/2023 at 3:29 PM, she stated her expectations were for staff to only provide assistance to one resident at a time. She stated that she expected staff to perform hand hygiene between resident assistance because there could be an infection control risk. In an interview with ADON E on 12/07/2023 at 3:30 PM, she stated her expectations were for staff to only provide assistance to one resident at a time. She stated she expected staff to perform hand hygiene between resident care and contact because there could be a risk of cross contamination and infection control. In an interview with DON on 12/07/2023 at 3:39 PM she stated she prefers staff not to provide assistance for two residents in the dining room at one time. She stated that she expected staff to perform hand hygiene between resident assistance because of the risk for infection control concerns. 2. Review of Resident #4's Face Sheet dated 12/06/2023 reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified hyperlipidemia and essential (primary) hypertension (blood pressure is consistently high). Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected resident had moderate intact cognition with a BIMS score of 10. Resident #4 required extensive assistance for bed mobility, transfer, walk in, dressing, toilet use, and personal hygiene. Review of Resident #4's Comprehensive Care Plan dated 09/23/2023 reflected resident was hypertensive. The Comprehensive Care Plan disclosed that Resident #4 was taking clonidine, lisinopril, amlodipine, and labetalol for hypertension. Review of Resident #4's Physician's order for clonidine dated 04/20/2021 reflected clonidine HCl 0.1 mg tablet (CLONIDINE HCL) 1 tablet by mouth 3 times per day As Needed HIGH BP If Systolic BP Greater than 160 Or Diastolic BP Greater than 90 MD Call. Review of Resident #4's Physician's order for amlodipine dated 10/15/2021 reflected amlodipine 10 mg tablet (AMLODIPINE BESYLATE) 1 tablet by mouth 1 time per day Hold if Systolic BP Less than 100 Hold if Diastolic BP Less than 60 Hold if Pulse Less than 60 MD Call. Review of Resident #4's Physician's order for lisinopril dated 09/16/2021 reflected lisinopril 40 mg tablet (LISINOPRIL) 1 tablet by mouth 1 time per day Hold if Systolic BP Less than 100 Hold if Diastolic BP Less than 60 Hold if Pulse Less than 60 * MD Call. Review of Resident #4's Physician's order for labetalol dated 11/26/2023 reflected labetalol 200 mg tablet (LABETALOL HCL) 1.5 tablet by mouth 2 times per day GIVE 1.5 TABLETS TO = 300MG TOTAL Hold if Systolic BP Less than 100 Hold if Diastolic BP Less than 60 Hold if Pulse Less than 60 * MD Call. Review of Resident #26's Face Sheet dated 12/06/2023 reflected resident was an [AGE] year-old female with diagnoses of cognitive communication deficit and essential (primary) hypertension. Review of Resident #26's Comprehensive Care Plan dated 10/24/2023 reflected resident was hypertensive and was taking amlodipine, losartan, and metoprolol. Review of Resident #26's Physician's order for amlodipine dated 10/24/2023 reflected amlodipine 5 mg tablet (AMLODIPINE BESYLATE) 1 tablet by mouth 1 time per day Hold if Systolic BP Less than 100 Hold if Diastolic BP Less than 60 Hold if Pulse Less than 60 * MD Call. Review of Resident #26's Physician's order for losartan dated 10/24/2023 reflected losartan 100 mg tablet (LOSARTAN POTASSIUM) 1 tablet by mouth 1 time per day Hold if Systolic BP Less than 100 Hold if Diastolic BP Less than 60 Hold if Pulse Less than 60 * MD Call. Review of Resident #26's Physician's order for metoprolol dated 10/24/2023 reflected metoprolol tartrate 25 mg tablet (METOPROLOL TARTRATE) 1 tablet by mouth 1 time per day Hold if Systolic BP Less than 100 Hold if Diastolic BP Less than 60 Hold if Pulse Less than 60 * MD Call. Observation on 12/06/2023 at 7:29 AM revealed CMA W picked up the blood pressure cuff from the medication cart. CMA W placed the blood pressure cuff on Resident #4's arm. After the blood pressure reading was completed, CMA W placed the blood pressure cuff on top of the medication cart and then prepared and gave the medications to Residents #4. Observation on 12/06/2023 at 8:16 AM revealed CMA W picked up the blood pressure cuff from the medication cart. The blood pressure cuff was not sanitized after using it for Resident #4. CMA W placed the blood pressure cuff on Resident #26's arm. After the blood pressure reading was completed, CMA W placed the blood pressure cuff on the medication cart. CMA W prepared and gave the medications to Resident #26. In an interview and observation with CMA W on 12/06/2023 at 1:34 PM, CMA W stated he obtained the blood pressure of the residents before giving the medication for hypertension to know if the medication needed to be held or not. CMA W said the right thing to do was to wash or sanitize hands before and after giving medications. When asked what should be done after using the blood pressure cuff, CMA W replied the blood pressure cuff should be sanitized after using it and before using it on another resident. CMA W then acknowledged he forgot to sanitize the blood pressure cuff in between residents when he passed medications that morning. CMA W pulled the last drawer of the medication cart and took a sanitizing container with a purple top. CMA W stated not sanitizing the blood pressure cuff in between residents could cause infection to transfer from one resident to another. In an interview with LVN A on 12/06/2023 at 1:52 PM, LVN A stated all the items being used for the resident should have been cleaned. LVN A said the principle of infection control was true even with the nasal cannula, the breathing masks, their bed, or their wheelchair. If the blood pressure cuff was not sanitized, it could result in many and various kinds of infection. LVN A added if a resident already had an infection, that infection could be transferred to another resident because the reusable item was not sanitized. 3. Review of Resident #4's Face Sheet dated 12/06/2023 reflected the resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses include allergic rhinitis (an allergic reaction to tiny particles in the air called allergens). Review of Resident #4's Physician's order for Flonase dated 12/15/2022 reflected Flonase Allergy Relief 50 mcg/actuation nasal spray, suspension (FLUTICASONE PROPIONATE) 1 Spray, Suspension Instill in Both Nares (nostrils) 1 time per day. Observation and interview on 12/06/2023 starting at 7:29 AM with CMA W revealed CMA W was preparing the medications for administration to Resident #4. CMA W took the nasal spray from the top of the medication cart. CMA W went to Resident #4 and administered the nasal spray to both nostrils. CMA W did not wash his hands before administering the nasal spray and did not wear gloves during administration of nasal spray. CMA W also did not wash his hands after administering the nasal spray. CMA W acknowledged that he did not wash his hands prior to giving the nasal spray and did not wear gloves during the administration of the nasal spray. He said not wearing gloves could result to cross contamination. In an interview with ADON E on 12/07/2023 at 7:32 AM, ADON E stated that the blood pressure cuff should have been sanitized after every use or after every resident. ADON E said that if the blood pressure cuff is not sanitized, it could cause cross contamination and infection could spread. ADON E said that the expectation was for the blood pressure cuff to be sanitized in between residents. ADON E added when providing a nasal spray, the one providing should wash their hands and wear gloves during administration to prevent infection and cross contamination. ADON E said the staff should also wear gloves when administering eye drops or anything that had a possible contact with body fluid. In an interview with the Administrator on 12/07/2023 at 7:51 AM, the Administrator stated that the expectation was for the staff to wear gloves when giving nasal spray and clean the blood pressre cuff in between residents to prevent infection. The Administrator said all staff should adhere to the policy of infection control to ensure the safety of the residents. In an interview with the DON on 12/07/2023 at 8:16 AM, the DON stated that ADON E made her aware of the infection control issues. The DON stated that the blood pressure cuff should have been sanitized every after use. She said that not sanitizing the blood pressure cuff could cause cross contamination or development of new infections. The DON added this could clearly cause a lot of medical issues. The DON said the staff should have washed their hands before administering the nasal spray and wear gloves during the process of giving the nasal spray. She said this was a standard precaution when touching an area with possible bodily fluid. She said this should be done to prevent infection and cross contamination among the residents and among the staff as well. The DON further added she would re-educate the staff regarding infection control and closely monitor if they were following the policy and procedure of infection control. In an interview with RN P on 12/07/2023 at 9:26 AM, RN P stated that he had been with the facility for a year. RN P stated that the blood pressure cuff should have been sanitized in between residents. If the blood pressure cuff was not sanitized, it could cause cross contaminations and infection control issues. Review of facility policy, Assisting Residents with Eating, dated 01/12/2018 revealed Standard of Practice: Qualified nursing staff . will assist the Resident who is unable to feed self in order to promote adequate nutrition and to help the resident enjoy a satisfying meal . Procedure: Perform Hand Hygiene . Provide assistance to resident . Perform Hand Hygiene. Record review of facility's policy Cleaning, Disinfecting and Sterilizing Resident Care Equipment, Policy and Procedure rev. August 2018 revealed Policy: Equipment will be maintained and kept sanitized or disinfected in accord with acceptable policies . Such items include blood pressure cuffs and other medical accessories . it is imperative that these items are clean. Record review of facility's policy Medication Administration, Nursing Care Center Pharmacy Policy & Procedure Manual 2007 revealed 11. Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, optic, parenteral, enteral, rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy. Note: Soap and water should always be used after.

CONCERN (F) 📢 Someone Reported This

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

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

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 observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerators, and freezer were labeled and dated according to guidelines and in a sanitary manner. The facility failed to ensure damaged food can was discarded according to guidelines. The facility failed to ensure the Dietary Manager wore a hair cover for his head. The facility failed to ensure the kitchen was clean and sanitized. These failures could place residents at risk for cross contamination and other foodborne illnesses. Findings included: Observations on 12/05/23 from 09:10 AM to 09:30 AM in the facility's only kitchen revealed: The ice machine had dark black dirt stains along the inside door of the machine and along the inside walls of the machine. The lid of the ice machine hinges had rust and brownish dirt [NAME] in the springs of the door hinges. Just above the ice was a white panel that had black dirt grit sprinkled along the edge. The outside of the ice machine had white water stains going down the machine. Two large pitchers of a red liquid and one large pitcher of an orange liquid were unlabeled and undated in the stand-alone refrigerator. Three sandwiches (could not identify type) were unlabeled and undated. Four small bowls of puddings were not labeled and dated. Four serving containers containing four types of salad dressing, were unlabeled and undated. One serving container of syrup was dated 05/03. Six small cups of milk in a standalone refrigerator had a use by date of 12/04. One large container of cheerios was uncovered and exposed to the air pollutants in the dry storage room. A kitchen staff's purse was observed on a kitchen shelf next to an opened and exposed container of ground cinnamon. One container of white powdery substance was unlabeled and not concealed from air pollutants. The front of the dual stove/oven, including the knobs to the stove had built up grease stains. There was also thick grease dirt build up abelong the bottom vents of the stove/oven. The floor in the dry food storage area under the food racks had thick black dirt [NAME], especially along the back walls. A large red cup with a white napkin covering it, belonging to a kitchen staff member, was in the dry storage area. A green jacket was laying on top of an opened box of foam plates. One 6 LB. can of salsa with a large dent. Two drawers full of serving utensils had dirt particles sprinkled along the bottom of the drawers. The grease in the fryer was dark brown in color and it had a burnt smell. Along the walls of the inside of the fryer had thick dark brown dirt greases. One of the fans in the freezer had thick ice built up between the blades. One loaf of Artisan Bread was undated and no visible expiration date. One package oif flour tortillas was undated and no visible expiration date. Fourteen individual bowls of yellowish pudding were unlabeled and undated. Eight individual bowls of a pinkish pudding were unlabeled and undated. One loaf of gluten free white bread was undated and no visible expiration date. The thermometer inside of the freezer showed a temperature of 54 degrees and the external thermometer attached to the freezer displayed a temperature of 41 degrees. Three package of corn tortillas with an expiration date of 09/28/23 was observed in the walk in refrigerator. In the walk-in refrigerator there was a Walmart bag with a can of coca cola and bottle of water in it. One zip locked bag of meat (unknown) was open to air pollutants and not concealed. One (approximately 1 lb.) loaf of ham was not concealed and opened to air pollutants in the walk-in refrigerator. One wrapped taco from a fast-food restaurant was in the walk-in refrigerator. One large tray containing a large stack of cheder cheese, a large stack of white cheese, a bowl of pickles, a bowl of red onions, a bowl of tomatoes, and a stack of lettuces was not concealed and was opened to air pollutants in the walk-in refrigerator. The kitchen floors had thick built-up black dirt particles along the corners of the walls. Observation and interview with the Dietary Manager on 12/05/23 at 09:15 AM revealed, he was observed working in the kitchen area without a head covering for the hair on his head. The DM was observed to have of at least an eighth of an inch in length of hair. He stated he normally shaved his head and had forgotten to do so. He stated the risk of not wearing a head covering could result in hair falling in the food and contaminating it. He was shown the personal foods and items that appeared to belong to staff in the dry storage area and walk-in refrigerators and he stated that they did belong to the kitchen staff but should not have been in those areas. He stated there was a risk of cross contamination . In an interview with the Dietary Manager on 12/07/23 at 2:00 PM, he stated he had addressed all of the concerns that were observed during the initial walk through. He advised that he had removed the expired foods and the damaged food cans. He stated he was still training his staff on proper labeling and dating the food as the inventory comes in and check for any foods that were expired. The DM was shown pictures referencing the cleanliness of the kitchen and he stated that they cleaned the kitchen weekly and had not cleaned it yet this week. He stated the concerns addressed could result in food contamination and the residents getting sick. He stated he had In-serviced his kitchen staff on food storage. In an interviews with the Administrator on 12/08/23 at 12:33 PM, he stated he had met with the Dietary Manager and advised of all the concerns observed on 12/05/23 in the facility's only kitchen and stated that he worked closely with the Dietary Manager to address the concerns observed. He stated the risk of not addressing the concerns could result in food contamination and residents getting sick. Record Review of the Facility's policy on Food Storage and Supplies dated August 1, 2018, revealed Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened. All foods are covered, labeled, and dated. Temperature for the freezer is 0 degrees Fahrenheit or below. Foods are covered, labeled, and dated. Any item out of the original case must be properly secured and labeled. Food and nutrition staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact the food. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from FDA Food Code 2022 Chapter 2. Management and Personnel Chapter 2 - 22 contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Jul 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

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 consult with the resident's physician and when there is a need to alter treatment significantly for 1 out of 5 residents (Resident #1) reviewed for notification of changes. The facility failed to notify and consult with the physician about the changes in Resident #1's wounds on his left lower extremity. This failure could place residents at the risk of not receiving appropriate medical interventions, which could result in severe illness or hospitalization. Findings include: A record review of Resident #1's electronic Face Sheet, dated 07/19/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with unspecified complications, pressure ulcer of right buttock stage 4, pressure ulcer of sacral region stage 4, partial amputation of right foot, hypo-osmolality and hyponatremia (occurs when the concentration of sodium in your blood is abnormally low), acute osteomyelitis right foot and ankle (a serious infection of the bone), and other skin changes. A record review of the Resident #1's MDS, dated [DATE], reflected a BIMS of 99, which indicated the resident was unable to complete the interview. The MDS reflected Resident #1 had 3 Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough [dead tissue, usually cream or yellow in color] or eschar [a dry, dark scab or falling away of dead skin] may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcers at the time of admission. Further review reflected Resident #1 had open lesion(s), other than ulcers, rashes, cuts. Resident #1 required extensive physical assistance of two or more staff for bed mobility. Resident #1 was total dependence by two or more staff for transfers, dressing, toilet use, and personal hygiene. A record review of Resident #1's Care Plan, dated 06/26/23, reflected a care area for skin breakdown related to: wounds on left foot, right buttock, left buttock, and sacrum; skin tear wound left forearm, history of bruises/skin tears; history of pressure injury; history of stroke, and history of cardiovascular disease. The interventions included: assist resident to turn and reposition frequently; condition of each area of skin breakdown to be documented with every treatment and/or dressing change; inspect skin complete body head to toe every week and document results; inspect skin daily with care and bathing, and report any changes to charge nurse; notify physician of any worsening of skin breakdown; treatments and dressings as ordered per physician; and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. A record review of Resident #1's nurses notes did not reflect any documentation regarding a change in condition of the wound on resident's lower left extremity, the wound having access drainage, or the wound draining and required a bandage. A record review of Resident #1's nurses notes, dated 07/17/23, written by RN A, reflected 4.00 resident is alert, refused breakfast, lunch and dinner. Resident kept yelling. Comfort care rendered, denies any pain. VS (vitals): 109/67, 98, 22, 98, 2.62. At 4:55, nurse received call from [family member] and requested that pt (patient) be transferred to [hospital]. Hospice called and gave order to transfer pt as required by family. [NP] is notified . Nurse called [Transport] [Transport's phone number]. Endorsed to in-coming nurse. A record review of Resident #1's TAR, dated July 2023, did not reflect any documentation of abrasions, skin tear, or wound to Resident #1's left lower extremity. The TAR reflected resident #1 had various other wounds and had received wound care by RN B on 07/16/23. A record review of the EMS Transport Report, dated 07/17/23, reflected EMS noted bandage on left knee which had been saturated and soaked through with yellow drainage. Bandage had the date: 7/16/2023 on it. Under the bandage, there were three abrasions with white puss. Knee was visibly swollen. A record review of Resident #1's admitting hospital records, dated 07/17/23, reflected Pt has left leg swelling and redness. He has chronic wound and drainage noted on L (left) knee. Musculoskeletal: Left Lower Leg: Swelling present. Comments: Patient has discharge on his left knee. Diagnosis: [R41.01] Delirium [S81.802A] Wound of left lower extremity, initial encounter. The hospital Wound Care Initial Consult reflected Wound Description: various abrasions; Location: left leg; Size: 2 cm x 2cm 0.1 cm; Wound Base: pink moist with yellow slough (necrotic tissue that needs to be removed from the wound for healing to take place); Exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation): scant yellow slough. In an interview on 07/19/23 at 2:34 PM, RN A stated on 07/17/23 Resident #1 was not acting like his normal self. RN A stated he was agitated but he was not complaining of pain. She stated the CNAs reported he did not eat his breakfast, and she noticed his hands were swollen, but he had chronic edema. RN A stated she assessed him, and his vitals were normal, but he seemed uncomfortable. RN A stated she notified the family and contacted his hospice nurse, who came and assessed Resident #1 around lunch time. She stated the hospice nurse contacted the physician and she was provided new orders for his medication. RN A stated she put in the new order, but it would not take effect until 07/18/23. She stated she was doing rounds like every 1-2 hrs. to check vitals. RN A stated his vitals remained normal. RN A stated he had skin tears all over his body, but she did not notice any excessive draining. She stated she could not recall if there was a dressing on his left leg/knee area. She stated the wound care nurse handles his wound care daily. RN A stated later in the evening she received a call from his family, who stated they had declined hospice and requested he be sent out to the hospital. She stated she verified with hospice, notified the MD and DON, and contacted the transport company. In an interview on 07/20/23 at 2:39 PM, RN B stated he did provide wound care to Resident #1 on 07/16/23. He stated he had wounds on his sacrum, buttocks, left foot, and his arm, which he believed was the right arm. RN B stated he has skin tears and abrasions all over his body at various stages of healing. He stated some are almost healed, some had scabs, and some are opened. RN B stated Resident #1 would scratch and pick at his skin, which caused skin tears and abrasions. He stated the open wounds would drain. RN B stated if he noticed Resident #1 was picking at the wounds, then he would wrap his arms and legs to avoid him picking at the wounds, which could cause them to get infected. He initially stated he did not recall seeing any wounds on John's left leg or knee. When RN B was asked why would it be reported that there was a dressing dated 07/16/23 on his left knee area, which was reported to have yellow drainage and white pus, he stated he did recall cleaning and putting a dressing in that area. He stated the knee area had skin tears and they were draining a lot, so he cleaned it and put on a dressing. RN B stated he could not recall what the drainage looked like. He stated when this happened, he was supposed to notify the wound doctor and wait for any new orders. RN B stated he did not notify the wound care doctor because he was busy and forgot. He stated he had other residents to provide wound care for. In an interview on 07/24/23 at 11:11 PM, RN C stated she was a PRN wound care nurse. She stated on Monday 07/17/23 she was told Resident #1 was sent to the hospital at his family's request. RN C stated she had provided wound care to Resident #1 on Friday 07/14/23 with the Wound Doctor (WD). She stated they did wound care to the wounds on Resident #1's bottom, left toe, and his arm. RN C stated Resident #1 had small skin tears all over his body because he picked at his skin. She stated she did recall seeing skin tears on his left knee and around the knee area. RN C stated she did not recall seeing the skin tears draining. She stated if wounds, including skin tears or abrasions, had new yellow drainage or white pus, they were supposed to notify the Wound Doctor and the DON and wait for orders. In an interview on 07/24/23 at 12:06 PM, the DON stated wounds, skin tears, and abrasions should be documented and reported to the wound nurse and wound doctor. She stated changes in the wounds, such as yellow drainage or white pus, should be reported to the wound nurse and wound doctor. She stated yellow drainage or white pus, redness, and inflammation are signs of infection, so should be reported to the wound doctor and her. The DON stated Resident #1 had multiple abrasions on his body due to him picking and scratching at his skin. She stated RN B never notified her of any changes to Resident #1's wounds or abrasions. In an interview on 07/24/23 at 3:09 PM, the WD stated a change in condition for wounds included deterioration, swelling, and increase in serious drainage. He stated open wounds drain which is a sign of healing, but he is concerned when it is excessive drainage or purulent drainage (a white, yellow, or brown fluid and might be slightly thick in texture) or white pus. The WD stated Resident #1 was non-complaint with his care and often picked at his skin, which caused abrasions. He stated Resident #1 had open wounds all over his body, which always drained. The WD stated he did not treat skin tears or abrasions and those were handled by the wound nurse. He stated they had standard orders for caring for skin tears and abrasions. The WD stated if the skin tear or abrasion had excessive draining, purulent drainage or pus, then he should be notified. The WD stated he last saw Resident #1 on Friday 07/14/23, and he did not see any of the skin tears or abrasions opened with excessive draining, purulent drainage, or white pus. He stated he was not notified on 07/16/23 that Resident #1's abrasions on his left lower extremity had yellow drainage or pus. The WD stated, if he was notified of this hew would have provided orders for an antibiotic because that was signs of infections and Resident #1 had a history of infection. A record review of the facility's policy titled Change of Condition, dated 02/13/23, reflected Changes in condition of the patient are determined by current and past medical conditions, medical orders, patient safety factors and/or by assessments utilizing defined parameters as outlined by the INTERACT 4.5 Change in Condition . Categories are listed as: . 3. Signs and Symptom . Notification categorized as: Immediate Notification: Any symptoms, sign or apparent discomfort that is Acute or sudden in onset, and: A marked change (i.e. more severe) in relation to usually symptoms and signs or Unrelieved by measures already prescribed. A record review of the facility's policy titled NON- Pressure Wounds: Skin Tears and Lacerations, dated July 2018, reflected Procedure: . 2. Follow standard precautions and infection control methods depending on the appropriate type of transmission based precautions. 7. In the event of a change in the wound, the physician is to be notified.

Jun 2023 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Deficiency F0760 (Tag F0760)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents are free of significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. The facility failed to administer Resident #1 the prescribed quantity of fentanyl patches as ordered by the physician. This deficient practice could affect all residents who receive medication from the facility and place them at risk for negative side effects, decline in health, hospitalization, or death . Findings included: Record review of Resident #1's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] Resident #1's diagnoses included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), chronic heart failure, chronic pain syndrome, rheumatoid arthritis (immune system attacks healthy cells in your body causing painful swelling), lack of coordination, muscle weakness, polyneuropathy (malfunction of many peripheral nerves throughout the body causing a pins-and-needles sensation, numbness, burning pain, and loss of vibration senses), and poisoning by other opioids accidental (unintentional). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS reflected Resident #1 received scheduled opioid pain medication. Record review of Resident #1's Care Plan, dated 05/17/23, revealed Resident #1 had a care area for pain, with the intervention of administering pain medication as ordered. There was a care area which included Resident #1 received fentanyl transdermal patch and the interventions included: obtain pain history onset, intensity, frequency; obtain resident's pain tolerance and attempt to maintain pain tolerance level; and reassess interventions with any changes in response to pain or pain medication and with every assessment. Record review of Resident #1's physician's orders revealed an order for fentanyl (a potent synthetic opioid drug used for pain relief) 25 mcg/hr transdermal patch (fentanyl) 1 patch 72hr transdermal every 72 hours on 1 time per day DX: Pain, unspecified with a start date 10/01/22. Record review of Resident #1's physician's orders revealed naloxone (a medicine that rapidly reverses an opioid overdose) 4mg/actuation nasal spray (Naloxone HCL) 1 spray nasally as needed adverse effect of opioid use 1 actuation in 1 nostril x's 1 and may repeat every 3 minutes as needed. DX: Poisoning by other opioids, accidental (unintentional), initial encounter with start date 06/08/23. Record review of Resident #1's Medication Record for June 2023 revealed Resident #1 received a fentanyl patch on 06/01/23, 06/04/23, and 06/07/23. Record review of Resident #1's nurse's notes, dated 06/08/23 at 11:13 AM, revealed LVN A documented naloxone order injection updated to spray per [Nurse Practitioner] Electronically Signed by [ADON] 06/08/23 10:48 AM as per NP (nurse practitioner), to send her hospital. CN (certified nurse) spoke to family [family member] and as per family preferences to [hospital]. CN called 911 and EMS team is arrived in 5 minutes, and she sent out with med list, face sheet and recent labs. Record review of Resident #1's hospital paperwork, dated 06/08/23, revealed Resident #1's diagnosis included ARF (Acute Renal Failure), Hyponatremia (the sodium level in the blood is below normal), UTI (Urinary Tract Infection), Diastolic Echo (Echo in 82022 EF (ejection fraction) 55-60%), Afib (type of abnormal heartbeat), AMS (altered mental status), Jaundice (a condition produced when excess amounts of bilirubin circulating in the blood stream dissolve in the subcutaneous fat)/Transaminitis (an elevated level of certain liver enzymes), and Chronic pain/ RA (rheumatoid arthritis). The hospital paperwork revealed nurse's notes dated 06/08/23 at 12:09 PM stated Limited ROS (Review of Systems- an inventory of body systems obtained by asking a series of questions to identify signs and/or symptoms the patient may be experiencing or has experienced.) otherwise however patient was noted from the facility to have 2 transdermal fentanyl patches on with her MAR from the outside facility showing only supposed to be on 1 patch every 72 hours. In an interview on 06/09/23 at 3:23 PM, Resident #1's FM stated Resident #1 was hospitalized on [DATE] and the hospital nurse told her that resident was overdosed because she was admitted into the facility with two fentanyl patches. Resident #1's FM stated when they saw Resident #1 in the hospital, she was very lethargic and was unable to have a conversation. The FM stated this was not her normal baseline. In an interview on 06/12/23 at 10:45 AM, the NP stated multiple nurses reported that Resident #1's behavior had changed, and she seemed lethargic. She stated she assessed Resident #1 on 06/08/23. The NP stated Resident #1's skin was yellow, she had slurred speech, and her face was drooping. The NP stated Resident #1 received fentanyl patches and she thought maybe she had been overly medicated, so she ordered Narcan (naloxone). She stated after Resident #1 received the Narcan, she was more alert and was able to speak. The NP stated after Resident #1 was more alert, Resident #1 stated she was in pain, so she gave orders to send her to the ER. In an interview on 06/12/23 at 10:54 AM, LVN A stated it had been reported by staff that Resident #1's behavior had changed. She stated the NP assessed Resident #1 on 06/08/23. LVN A stated the NP had concerns that Resident #1 could have opioid overdose, so gave an order for naloxone, via nasal cavity. She stated after Resident #1 was provided the naloxone and the NP gave an order to send her out to the ER. LVN A stated she did provide the fentanyl patch on 06/07/23 and placed it on her right arm. She stated there was one already there and she removed it but did recall how she disposed of it. She stated they were allowed to either flush it down the toilet and or put it in the red disposal box on the medication cart. LVN A stated a lot of times she has the ADON to watch while she throws away the patch because it is best practice, but that day she was busy and did not have time to get the ADON. LVN A stated the DON asked her about this situation as well because Resident #1's FM reported Resident #1 had two patches at the hospital. LVN A stated on 06/07/23 there was only one patch on her arm. She stated the only explanation she could think of as to why Resident #1 had two patches is that maybe one fell off in the bed and one of the CNAs saw it and put it back on. LVN A stated there had not been any CNAs reporting a patch fell off. In an interview on 06/12/23 at 1:44 PM, the DON stated on 06/09/23 Resident #1's FM had reported she felt Resident #1 was overly medicated because she had two fentanyl patches on arm when she admitted to the hospital. She stated she immediately started an in-service on 06/09/23 about ensuring there is only one patch. The DON stated she did review the hospital paperwork for Resident #1 and saw that she admitted into the hospital with two patches. She stated she did review Resident #1's diagnosis from the hospital paperwork and this error did not contribute to her underlying health issues. The DON stated due to this situation she had changed the policy, which would require two nurses to verify the old patch was disposed of and the new patch was applied. The DON stated the risk to the resident is they could have an overdose. Record review of the facility's policy titled Documentation of Administration and Removal of Narcotic Transdermal Patches, undated, The Narcotic Transdermal Patches are powerful, Schedule II narcotics used to manage moderate to severe pain. Although available in other dosage forms, when used in the form of an extended?release transdermal patch it confers pain relief to individuals over a 72?hour period. Customarily, the patch is applied externally to the individual, left intact for 72 hours, and then replaced with a new patch. 4. Remove the patch 72 hours after application. This should be done at the same time every 72 hours. 7. Apply patch to non-irritated skin such as chest, back, flank or upper arm. 13. Documentation requirements: a. Documentation of patch placement q shift. b. Removal of old patch BEFORE placement of a new patch. c. Removal of old patch must be witnessed by 2 nurses and documented on the narcotic control sheet.14. Removed patches must be folded inward, medication to medication, and placed in the original sheath/package. a. Used patches are to be disposed according to the current facility policy regarding disposal of narcotic drugs. b. Dispose in secured pharmaceutical waste container per appropriate medical waste management regulations. c. Patches may not be disposed of in Sharps containers in the resident's room. They must remain under lock and key until destroyed or rendered unusable per current facility policy.

Oct 2022 9 deficiencies

CONCERN (D)

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

Deficiency F0635 (Tag F0635)

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 have physician's orders for the resident's immediate care for one (Resident #94) of two residents reviewed for admission physician orders. The facility failed to have physician's orders for Resident #94's foley catheter (a small tube inserted into the bladder to drain the urine into a collection bag) and care for the foley catheter. This failure could place residents at risk for not receiving appropriate care and urinary infection. Findings included: Review of Resident #94's quarterly MDS assessment dated [DATE] reflected an [AGE] year-old male readmitted to the facility on [DATE]. His cognitive states severely impairment. He was admitted without a foley catheter and was always incontinent of urine. Review of Resident #94's clinical notes dated 09/29/2022 in resident revealed LVN A entered Foley Catheter is replaced with 14 F, 30 cc Balloon. Secured Foley with adhesive tape on right thigh. Review of Resident #94's revised care plan dated 09/19/22 revealed he was always incontinent of bladder. The care plan did not address his need for foley catheter or care. Review of the Resident #94's admission physician's orders dated 07/30/22 did not include a diagnosis for the need of a foley catheter and no care for the foley catheter. Review of Resident #94's the consolidated physician orders dated from 08/01/2022 to 10/31/22 did not include a diagnosis for the need of a foley catheter and no care for the foley catheter. Observation on 10/04/22 at 9:20 AM, physical therapy staff was assisting Resident#94 back to bed from wheelchair noted foley catheter intact. Resident unable to answer question related to his foley catheter. Review of Resident #94's Treatment Record dated 08/01/22 -10/31/22 did not reveal orders for change of foley catheter or care. Review of Resident #94's nurses noted dated 09/29/22 revealed Foley Catheter is replaced with 14 F, 30 cc Balloon. Secured Foley with adhesive tape on right thigh. Interview on 10/05/22 at 1:50 PM with the DON revealed she was not aware Resident #94's had an foley catheter. The DON reviewed the resident chart and was unable to find physician orders or care for foley catheter and no proper diagnosis for a use of a foley catheter. The DON stated the resident was sent to the hospital and was re-admitted to the facility with the foley catheter on 07/30/22. Interview on 10/05/22 at 2:05 PM with Charge Nurse A revealed she did replace Resident #94's foley catheter on 09/29/22. She stated she was not aware there was not an order for a foley catheter at the time she replaced it. She stated she forgot to call the physician to obtain an order for the catheter. Interview with the DON on 10/06/22 at 10:20 AM revealed Resident #94 foley catheter will be removed after he has been checked for residual of urine by clamping off the tubing for 15 minutes and releasing then reclamping for 24 hours. The DON stated then re-insert a catheter to check for urine residual by reinserting catheter and if more than 400 fluid ounces of residual urine was seen, leave in place and notify provider. Review of the admission Physician Orders policy dated January 12,2020 revealed the licensed nurse will obtain and transcribe orders. The licensed nurse reviews orders from the transfer record from an acute care hospital . a call is placed to the physician to confirm the orders and request any additional orders as needed

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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan with services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and social well-being for one (Residents #94) of five residents reviewed for care plans. The facility failed to have a care plan for Resident #94's care regarding foley catheter ( a small tube inserted into the bladder to drain the urine into a collection bag) insertion and care. These failures could place residents at risk for infection. Findings included: Review of Resident #94's quarterly MDS assessment dated [DATE] reflected an [AGE] year-old male readmitted to the facility on [DATE]. His cognitive reflected he was severely impaired. He was admitted without a foley catheter and was always incontinent of urine. Review of Resident #94's revised care plan dated 09/19/22 revealed he was always incontinent of bladder. The care plan did not address his need for foley catheter or catheter care. Review of Resident #94's admission physician's orders dated 07/30/22 revealed the orders did not include a diagnosis for the need of a foley catheter and no care for the foley catheter. Review of the consolidated physician's orders dated from 08/01/2022 to 10/31/22 revealed the orders did not include a diagnosis for the need of a foley catheter and no care for the foley catheter. Observation on 10/04/22 at 9:20 AM revealed physical therapy staff assisting Resident#94 back to bed from his wheelchair and his foley catheter was intact. The resident was unable to answer questions related to his foley catheter. Review of Resident #94's Treatment Record dated 08/01/22 -10/31/22 did not reveal orders for the change of the foley catheter or care. Review of Resident #94's clinical notes dated 09/29/2022 in resident revealed LVN A entered Foley Catheter is replaced with 14 F, 30 cc Balloon. Secured Foley with adhesive tape on right thigh. Interview on 10/0/22 at 1:50 PM the DON revealed the DON was not aware that Resident #94 had a foley catheter. The DON reviewed the resident's chart and was unable to find physician's orders or care plan for his Foley catheter and no proper diagnosis for a use of a foley catheter. The DON stated the resident was sent to the hospital and was re-admitted with the foley catheter on 07/30/22. The DON stated there should be a care plan for a foley catheter for Resident #94. Review of facility's policy undated Person Centered Care Plan revised 2017 reflected the comprehensive care plan will be reviewed and updated as new needs are identified and after each MDS assessment.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene to a resident who is unable to carry out activities of daily living for one (Resident #29) of one resident reviewed for ADL care. The facility failed to provide Resident #29, who required extensive assistance, with timely and adequate incontinence care on 10/04/22 for at least an hour and allowed feces to dry and stick to Resident #29's thigh. This failure could place residents at risk of skin breakdown, pressure injuries, and urinary tract infections. Findings included: Resident #29's Quarterly MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: Cerebrovascular Accident (stroke) Seizure disorder, Hypertension, and Hemiplegia (paralysis). He was frequently incontinent. He was mildly cognitively impaired. Review of Resident #1's Comprehensive Care Plan dated 10/05/22, reflected, . [Resident #29] is incontinent of bowel and bladder and is at risk for skin breakdown .Keep skin clean, dry, and free of irritants Review of the ADL flow sheet for Resident #29 for the 10:00 p.m. to 6:00 a.m. shift for 10/03/22 reflected no documentation for incontinence care. No documentation of incontinence care from 6:00 a.m. until 10:40 a.m. (observation of incontinence care on 10/04/22). In an interview with Resident #29 on 10/04/22 at 10:26 a.m. revealed the resident pushed the call light twice within the past hour of interview and someone came in to clear the call light and never came back. Resident #29 was unable to identify which staff members. Resident #29 stated it had been at least an hour since he pushed the call light the first time to get changed due to a bowel movement. In an observation 10/04/22 at 10:40 a.m. revealed CNA D and CNA E entered Resident #29's room and told the resident she was there to change the resident and get him up for the day. CNA D rolled the resident onto his left side revealing the resident had feces on the draw sheet and his right thigh. CNA D stated she was not assigned to the hall but was helping and stated the ADON came to ger her to change the resident. CNA D pulled the dirty brief off the resident and rolled it along with the draw sheet and sheet toward the resident. CNA D then took a peri wipe and wiped several times to remove the bowel movement and had to scrub to remove some stool revealing stool to be dried to Resident #29's right leg. CNA D then removed her gloves and put on new ones , and placed a clean brief under the resident. CNA D then had the resident roll onto his back, cleaned his scrotum area, turned to right side to fully remove the brief, draw sheet, and pad, and then the resident rolled back to his back . CNA D pulled up the clean brief and fastened it. CNA D and CNA E then assisted the resident to put on his pants and his shoes, and then they assisted him to his wheelchair. Interview with CNA D on 10/04/22 at 10:40 a.m. and 10:56 a.m. revealed that she was not working Resident #29's hall today. CNA D stated the ADON came to get her to help with Resident #29. CNA D stated if staff a member turned the light off staff should be sure to come back to help the resident. In an interview with the DON on 10/05/22 at 10:29 a.m., she stated she expected staff to answer the call lights as soon as possible. She stated she did not have an issue with staff turning the light off as long as they intended to return to the resident, but if that was not their intention I am not okay with that. The DON stated residents should receive the help they need as soon as possible. Interview with the Administrator on 10/06/22 at 10:19 a.m. revealed he was unable to find a policy or training directly related to timely incontinent care.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one (Resident # 29) of one resident observed during a transfer. CNA D failed to transfer Resident #29 safely when she failed to use a gait belt and placed her arm under Resident #29's left armpit, and lifted him from the bed to wheelchair. This failure could affect the residents by placing the residents at risk for discomfort, pain and/or injury. Findings included: Resident #29's Quarterly MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: Cerebrovascular Accident (stroke), Seizure disorder, Hypertension, and Hemiplegia (partial paralysis). He required two-person physical assist to transfer. He was mildly cognitively impaired. Resident # 29's Care Plan dated 10/05/2022 reflected, .Resident requires assistance with ADLs .as needed Care plan did not reflect how much assistance. An observation on 10/04/2022 at 10:40 a.m. revealed CNA D helped Resident #29 to sit on the edge of his bed with the wheelchair to his right side slightly turned and locked in preparation to transfer him from his bed to wheelchair. CNA D then placed her arm under the Resident #29's left arm pit and lifted the resident from his bed and pivoted him to his wheelchair. There was another CNA in room but they did not help to assist the resident to wheelchair. Two gait belts were observed on the chair to the left of the bed. A gait belt was not used during the transfer . An interview on 10/04/2022 at 10:56 a.m. CNA D stated she always uses her arm and hand to transfer him. CNA D stated she does not normally use a gait belt with this resident. He needed two person assist. An interview on 10/04/2022 at 10:58 a.m. Resident #29 stated that normally a gait belt is not used although it has been used. He is normally transferred with two people assist. Review of the OSHA Lift Program Skills Check - off Sheet - Gait/Transfer Belt, dated 6/3/22, reflected .note and confirm application of gait/transfer belt is proper for resident .I have successfully completed the procedures above for using the gait belt. I have demonstrated the tasks and understand that I need to use a gait belt with any lift or transfer except the Hoyer transfer and are to be used to comply with the policy and procedures for the Providence Park transfer program. The sheet reflected CNA D signature below the statement. An interview on 10/05/2022 at 10:29 a.m. the DON said it was the expectation that staff use a gait belt when providing any help with transfers. She stated if the resident is not independent a gait belt should be used. A gait belt should be used to prevent injury. They have trained all staff on using gait belts within the last few months. An interview with the Rehabilitation Manager on 10/05/2022 at 10:10 a.m., she revealed the resident's armpits were not to be used during transfers because that could cause nerve damage or cause dislocated shoulder. Rehabilitation manager has not personally trained staff at the facility due to coming on board in July 2022 and was on medical leave for a month. Review of [NAME] and [NAME] Clinical Nursing Skills and Techniques 9th edition , 1/26/2017, page 276 reflected . Patients should never be lifted by or under their arms. Review of the facility's policy, ADL Care - Transfer Techniques, dated 02/12/20 reflected, Staff will provide safe and effective transfer techniques for residents .use stand-and-pivot technique with one caregiver .apply gait/transfer belt snugly and low so it circles the resident's waist

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 that medications were secure and inaccessible to unauthorized staff and residents for one (100/200 hall medication cart) of six medication carts reviewed for medication storage. 1. The facility failed to ensure medication supplies were secured or attended by authorized staff when the medication cart on hall 100/200 was left unlocked and unattended by LVN A. Theis failure could place residents at risk of having access to medications and/or lead to possible harm or drug diversion. Findings Included: 1. An observation on 10/04/22 at 10:42 a.m. revealed a medication cart #1 next to nurses' station with no nurse near the medication cart. The medication cart was unlocked . The narcotics book on top of the care reflected Nursing 200 & 100 Hall Narcotics counting book. The ADON walked by at the same time and locked cart. The ADON stated she knew whose cart it was and would address it. In an interview with LVN A on 10/04/22 at 03:27 p.m. revealed she left the cart unlocked on accident. LVN A stated, I know that it needs to be locked. I went to do something quickly and forgot. She stated that a resident could get into medication cart if left unlocked. In an interview on 10/05/22 at 10:29 a.m. with the DON, she stated, The medication cart should be locked at all times or within line of sight. The DON stated they have been trained on this and was unable to give a reason as to why it was not done. The DON stated not locking the cart could cause accidents like a resident getting into the medication cart. Review of the facility's policy titled Storage of Medication, dated September 2018, reflected, .medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to maintain a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #69 and Resident #51) of twenty-eight residents observed for environment. 1. Housekeeping C failed to provide sanitary and comfortable environment for Resident #69 and Resident #51 due to what appeared to be old dry bowel movement left on walls, floor, shower chair, toilet, and trash can. These failures placed residents at risk for spread of infection through cross-contamination. Findings included: 1. Observation on 10/04/22 at 11:01 a.m. of the restroom for Resident #69 revealed four large dried brown drops and four small dried brown drops of bowel movement on the inside and outside of the trash can. Trash can empty with trash bag placed over bowl movement . Six dark brown splashes of bowel movement were on the wall near the toilet paper dispenser. Smeared bowel movement on toilet seat. Shower chair to the left of the toilet covered in brown splatter all over the four legs, the side of the seat, and front half of the seat. 2. Observation on 10/04/22 at 11:13 a.m. of the restroom for Resident # 51 revealed 7 dried brown spots on the wall to the left of the toilet. Interview on 10/04/22 at 11:13 a.m. with Resident #51's family member revealed that bowel movement being left and not cleaned has been an issue. She stated she had to clean it up herself. She stated the bowel movement on the bathroom wall had been there for months. She was unable to give a more specific time frame. Interview on 10/04/22 at 11:27 a.m. with Housekeeper C revealed she tried to clean the trash can but the bowel movement would not come off. She stated it needs to be replaced. She contacted her Supervisor but she is out sick. Regarding the stool on the wall, she stated it can't be just scraped off, it has to be painted over. She stated she has not seen the maintenance guy today, so she has not told him . Interview with the DON on 10/05/22 at 10:29 a.m. revealed that in regards to bowel movements, she expects CNAs to clean up what they can when helping residents and that housekeeping is to clean it up as they clean. She stated the housekeeper should have removed the trash can and replaced it with a clean one. This is to stop spread of infection and to maintain a homelike environment. 4. Review of the facility's policy titled Hand Hygiene for Staff and Residents - Infection Control, revised January 2022, reflected, .Hand Hygiene is done after contact with soiled or contaminated articles . toileting or assisting others with toileting 5. Review of the facility's policy titled, Aseptic Technique Infection Control, revised January 2022, reflected, .Environment - Routine cleaning and disinfection of the environment will be done

CONCERN (E)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected multiple residents

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Based on interviews and record review the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect for two (LVN Q and Laundry Aide P) of 10 employees reviewed for employee files. 1. The facility failed to ensure an accurate criminal background check was completed upon hire for LVN Q. 2. The facility failed to conduct criminal background check prior to hire for Laundry Aide P. This failure could place residents at risk for abuse and receiving care from unemployable staff. Findings included: Review of facility's policy Criminal background screening - Texas dated 10/01/17 reflected the facility is to conduct criminal background checks on a post-offer, pre-employment basis for new employees .The community's criminal background check process must conform to all applicable law and regulations, including without limitation, The Texas Code regulations governing access to criminal history record information. 1. Review of LVN Q's personnel file reflected the hire date was 09/16/22 and a criminal background in his file completed on 09/16/22 was not ran with the correct name provided to facility. There was no criminal background check completed in his file with his correct name. 2. Review of Laundry Aide P's personnel file reflected the hire date was 08/19/22 and a criminal background check was completed on 08/23/22. Review of Laundry Aide P's timesheet reflected he was trained on 08/19/22 and started working on 08/21/22. 3. Interview with the HR Coordinator on 10/06/22 at 11:02 AM and 11:58 AM revealed criminal background checks should be completed upon hire. She stated she did not run the criminal background for LVN Q on 09/16/22 and the Administrator was the one responsible for completing it since she did not have access to the system to run them at the time. She stated the criminal background check completed on 09/16/22 for LVN Q did not have the correct name for LVN Q according to his employee file. She stated it should have been ran with the correct name to ensure the employee had no bars to employment upon hire. She stated LVN Q was a current employee at the facility. She stated Laundry Aide P's criminal background should have been completed on 08/19/22 when he started and his first day not in training was on 08/21/22. She stated criminal background checks should be completed with the correct information of the employee . Review of LVN Q's and Laundry Aide P's criminal background checks completed on 10/06/22 after surveyor intervention reflected both LVN Q and Laundry Aide P were employable and had no bars to employment. Interview on 10/06/22 at 12:03 PM with the Administrator revealed he did run LVN Q's criminal background on 09/16/22 with the incorrect name but did not realize he had put the wrong name on it. He stated it was ran today with the correct employee information. He stated new hires should have criminal background checks completed upon hire to ensure employees are employable.

CONCERN (E)

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

Deficiency F0849 (Tag F0849)

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 obtain from hospice the most recent hospice plan of care specific to each patient, the physician certification and recertification of the terminal illness specific to each patient and hospice medication information specific to each patient for two (Residents #2 and #56) of three residents reviewed for hospice records. 1. The facility failed to obtain the required hospice documentation of the current physician certification of terminal illness, plan of care and medication list from Hospice P for Resident #56. 2. The facility failed to obtain the required hospice documentation of the physician certification of terminal illness from Hospice N for Resident #2. These failures could result in services and treatments not being coordinated. Findings included: 1. Review of Resident #56's Quarterly MDS assessment dated [DATE] reflected Resident #56 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertension, dementia and chronic obstructive pulmonary disease . She required hospice services while at the facility . Review of Resident #56's Hospice P book reflected Resident #56's hospice election form dated 12/13/21 reflected Resident #56 had a terminal diagnosis of chronic obstructive pulmonary disease. Resident #56's hospice book reflected the last plan of care dated 04/06/22 included medication profile list. Resident #56's hospice certification of terminal illness reflected a certification start date of 06/11/22 with a benefit period of 06/11/22 to 08/09/22. Resident #56's hospice documentation did not have a current hospice physician recertification of terminal illness, plan of care and medication list. 2. Review of Resident #2's Annual MDS assessment dated [DATE] reflected Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of heart failure, hypertension and Alzheimer's disease. Resident #2 was on hospice services at the facility . Review of Resident #2's Hospice N book reflected Resident #2 was admitted on [DATE] to Hospice N. The Hospice book for Resident #2 reflected an election of benefit form dated 04/12/21. It reflected the last hospice physician certification of terminal illness dated 06/23/21 from 07/11/21 to 09/08/21. Resident #2's last hospice plan of care dated 09/06/22 reflected Resident #2 had diagnoses of Alzheimer's disease, dementia, hemiplegia affecting left nondominant side and heart disease with heart failure. There was no current re-certification of physician termination of illness. Interview on 10/06/22 at 11:18 AM with MDS Coordinator O revealed she was aware of the required hospice documentation needed for hospice residents. She stated she was the facility's hospice liaison and did not have access to Resident #2's and #56's hospice documentation. She stated she would have to contact Resident #2's and #56's hospice agencies to get the required hospice documentation which was missing. Review of facility's policy Hospice Program revised 01/12/20 reflected under procedure .6. The Hospice Agency will provide the following documentation: .b. Hospice election form c. Physician certification and recertification of terminal illness .7. Documentation will be housed in the electronic health record under the Hospice tab, or if an electronic medical record system is not in place, documentation will be placed in the designated place determined by the Director of Nursing or designee.

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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Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #29) of twenty-eight residents observed for infection control. CNA A failed to perform hand hygiene between glove changes during incontinence care for Resident #29. These failures placed residents at risk for spread of infection through cross-contamination. Findings included: In an observation 10/04/22 at 10:40 a.m. revealed CNA D entered Resident # 29's room and told the resident she was here to change the resident and get him up for the day. CNA D rolled the resident onto his left side revealing the resident had feces on the draw sheet and his leg. CNA D pulled the dirty brief off the resident, and rolled it along with the draw sheet and sheet toward the resident. CNA D then took a peri wipe and wiped several times to remove the bowel movement and had to scrub to remove some stool revealing stool to be dried to Resident #29's leg. CNA D then removed her gloves and put on new ones without performing hand hygiene. CNA D then placed a clean brief under the resident. CNA D then had the resident roll onto his back, cleaned his scrotum area, turned to right side to fully remove the brief, draw sheet, and pad, and then rolled back to his back. CNA D pulled up the clean brief and fastened it. CNA D and CNA E then assisted the resident to put on his pants, and his shoes, and assisted him to his wheelchair. Interview with CNA D on 10/04/22 at 10:56 a.m. revealed she was supposed to perform hand hygiene after changing the dirty brief. She stated she did not have hand sanitizer on her. That she was pulled from another hall, was in a hurry, and did not have all the supplies she needed when she came to this resident's room. She stated she was to do hand hygiene to prevent contamination. Interview with the DON on 10/05/22 at 10:29 a.m. revealed she expected staff to wash their hands before care, when they went from dirty to clean, and after care was completed . Review of the facility's policy titled Hand Hygiene for Staff and Residents - Infection Control, revised January 2022, reflected, .Hand Hygiene is done after contact with soiled or contaminated articles . toileting or assisting others with toileting

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

• 22% annual turnover. Excellent stability, 26 points below Texas's 48% average. Staff who stay learn residents' needs.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), 2 harm violation(s), $40,290 in fines. Review inspection reports carefully.
• 43 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $40,290 in fines. Higher than 94% of Texas facilities, suggesting repeated compliance issues.
• Grade F (13/100). 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 Garnet Hill Rehabilitation And Skilled Care's CMS Rating?

CMS assigns GARNET HILL REHABILITATION AND SKILLED CARE an overall rating of 2 out of 5 stars, which is considered 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 Garnet Hill Rehabilitation And Skilled Care Staffed?

CMS rates GARNET HILL REHABILITATION AND SKILLED CARE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 22%, compared to the Texas average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Garnet Hill Rehabilitation And Skilled Care?

State health inspectors documented 43 deficiencies at GARNET HILL REHABILITATION AND SKILLED CARE during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 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 Garnet Hill Rehabilitation And Skilled Care?

GARNET HILL REHABILITATION AND SKILLED CARE is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility is operated by STONEGATE SENIOR LIVING, a chain that manages multiple nursing homes. With 128 certified beds and approximately 101 residents (about 79% occupancy), it is a mid-sized facility located in WYLIE, Texas.

How Does Garnet Hill Rehabilitation And Skilled Care Compare to Other Texas Nursing Homes?

Compared to the 100 nursing homes in Texas, GARNET HILL REHABILITATION AND SKILLED CARE's overall rating (2 stars) is below the state average of 2.8, staff turnover (22%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Garnet Hill Rehabilitation And Skilled Care?

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 Garnet Hill Rehabilitation And Skilled Care Safe?

Based on CMS inspection data, GARNET HILL REHABILITATION AND SKILLED CARE 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 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-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 Garnet Hill Rehabilitation And Skilled Care Stick Around?

Staff at GARNET HILL REHABILITATION AND SKILLED CARE tend to stick around. With a turnover rate of 22%, the facility is 23 percentage points below the Texas average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 19%, meaning experienced RNs are available to handle complex medical needs.

Was Garnet Hill Rehabilitation And Skilled Care Ever Fined?

GARNET HILL REHABILITATION AND SKILLED CARE has been fined $40,290 across 3 penalty actions. The Texas average is $33,482. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Garnet Hill Rehabilitation And Skilled Care on Any Federal Watch List?

GARNET HILL REHABILITATION AND SKILLED CARE 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: 128
Avg. Residents: 101
Occupancy: 79.6%
Ownership: Government - Hospital district
Chain: STONEGATE SENIOR LIVING
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
Low Turnover: +5
1 Immediate Jeopardy citation: -12
2 Actual Harm citations: -10
43 Deficiencies: -10
Fines ($40,290): -5
Abuse Finding: -15
Final Score: 13/100

Nearby Alternatives

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 676192