Avir At Stephenville

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 1 of 4 residents (Resident #406) reviewed for medication consents. The facility failed to ensure Resident #406 or their representative signed consent for hormone medication medroxyprogesterone acetate (Provera) (a female hormone prescribed to women to prevent pregnancy, hormone replacement therapy and management of abnormal uterine bleeding. When prescribed to men, the medication reduced testosterone levels, lowering sexual drive) prior to administering the medication. This failure could affect residents by placing them at risk of not being informed of their health status, which would allow them to make informed decisions regarding their care.Findings include: Record review of Resident #406's electronic face sheet, dated 03/25/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #406 had a medical diagnosis of bipolar disorder (a chronic mental health condition characterized by intense, extreme shifts in mood, energy, and activity levels). Record review of Resident #406's Quarterly MDS, dated [DATE], revealed in Section C - Cognitive Patters, subsection C0500. BIMS Summary Score, of 15 out of 15 indicating intact cognition. Record review of Resident #406's comprehensive care plan, dated 03/25/2026, revealed no sexual behaviors were identified and/or addressed. Record review of Resident #406's electronic physician orders revealed Resident #406 was prescribed Provera 5 mg daily by mouth for sexual behaviors on 03/23/2026. The order was entered by the NP. Record review of Resident #406's MAR, dated March 2026, reflected Resident #406 received Provera 5 mg daily on 03/23/2026 and 03/24/2026 at 9:00 p.m. Record review of Resident #406's electronic medical chart, accessed on 03/25/2026, reflected no evidence he consented to Provera prior to receiving the medication starting on March 23, 2026, using HHSC Form 3713. Record review of Resident #406 Progress Notes, Psychiatric Periodic Evaluation dated 03/23/2026: This is a [AGE] year-old male resident was evaluated at staff request for a periodic psychiatric assessment due to reports of worsening depression and anxiety. Staff report intermittent episodes of hypersexual and inappropriate sexual behavior; however, these behaviors are not persistent and remain manageable with redirection. A comprehensive review of the medical record was completed. In response to ongoing depressive and anxiety symptoms, escitalopram (Lexapro) 10 mg orally daily was discontinued, and paroxetine [Paxil, an antidepressant] 20 mg orally daily was initiated. Record review Resident #406's progress notes dated 3/24/2026 at 06:10 a.m., Note Text: Resident started on Provera and Paroxetine. Educated resident on medications and provided printed information at resident request. Will monitor for adverse/allergic reactions x 3 days. Progress note entered by LVN-A. During an interview on 03/25/2026 at 8:55 a.m., the NP stated Resident #406 had a history of watching pornographic videos all day on his television and masturbating. She stated Resident #406 would not stop the activity or turn off the television when staff entered the room. She stated staff that was aware of these behaviors always knocked and waited for residents' permission before entering. She explained when she recently ordered a urinalysis for a suspected urinary tract infection, the first sample provided by the resident was nothing but semen. Observation and interview on 03/25/2026 at 12:31 p.m., Resident #406 was in the hall outside of the conference room discussing the new medication orders with RN-A. RN-A stated she was not aware of the Provera order. Resident #406 then came into the conference room with the generic name of Provera written down. Resident #406 stated the case manager from MHMR told him during a visit earlier in the day that he had been prescribed the medication without his knowledge. He stated he did not sign consent for Provera. Resident #406 stated he was not going to take the Provera I don't need anything for my sex drive. I don't even have a girlfriend in this place. During an interview on 03/252026 at 12:41 p.m., the DON stated the prescriber was responsible for obtaining the signed consent. Requested signed consents from DON for Resident #406 Paxil and Provera. During an interview and record review on 03/25/2026 at 12:43 p.m., the DON provided signed consent for Paxil but stated she did not have a signed consent for Provera. She stated Resident #406 informed her he was not going to take Provera, so she was going to discontinue it. During an interview on 03/27/2026 at 8:40 a.m., the DON stated she talked with Resident #406 yesterday about his concerns with signed consent. She stated Resident #406 threatened to take my nursing license. During an interview on 03/27/2026 at 8:55 a.m., Resident #406 stated he wanted to talk about this hormone thing. He stated he asked the NP 2 days ago and she told him she did not order the hormone, the psychiatric (psych) physician ordered it. He stated the psych physician talked to the nurses and NP about his behaviors. Resident #406 explained that the psych physician showed him the changes he was making to his medications and a hormone was not mentioned. He stated he had a night nurse look up the order to see who ordered the hormone and was told the NP ordered it. Resident #406 denied any adverse reactions to taking 2 doses of the hormone. During a phone interview on 03/27/2026 at 10:57 a.m., the psych physician stated he visited Resident #406 on 03/23/2026 at the facility. He stated he did not prescribe Provera. The physician stated he talked to the resident, educated him on the antidepressant prescribed, and briefly talked about the Provera prescribed by the NP. He stated the resident's response was whatever you think is appropriate, you are the professional and know what is best. The physician stated he did not obtain signed consents, the facility was responsible for obtaining a signed consent form. During an interview on 03/27/2026 at 11:21 a.m., the ADON stated the nurse that took the order was responsible for obtaining signed consent. She explained if the nurse was unable to get the resident to sign a consent, the nurse should ask one of us to get the resident to sign the form. The facility was unable to provide a policy on obtaining written consent to administer medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 (Resident #53) of 4 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included:*the certificate of terminal illness and the hospice election form; *how the communication will be documented between the facility and the hospice provider; and *the physician certification and recertification of the terminal illness. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Review of Resident #53's electronic face sheet dated 07/24/2025, revealed an [AGE] year-old female admitted to the facility on [DATE] and to hospice services on 07/01/2025 with diagnoses to include: Alzheimer's, kidney disease, and urinary tract infection. Review of Resident #53's Quarterly MDS dated [DATE], revealed a BIMS score of 03 which indicated severe cognitive impairment. Review of Section O: revealed Resident #53 was on hospice care. Review of Resident #53's Comprehensive Care Plan last review completed 03/07/2025, revealed no evidence of resident being on hospice services. Review of Resident #53's electronic Physicians Orders revealed: Resident has hospice services for diagnoses of Alzheimer's Disease, dated 07/01/2025. Review of Resident #53's clinical records from 02/24/2025 to 07/24/2025, revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness, hospice election form, or any form of communication between the facility and the hospice provider for Resident #53. During an interview on 07/24/2025 at 12:21 PM, the DON stated communication between hospice staff and facility staff was done verbally. She stated communication forms should be filled out daily to ensure that everyone was aware and the residents' status and care concerns. She stated the communication sheet should be filled out and she did not know why this was not being done. She stated the facility should have a copy of the election form and the certification of terminal illness. She stated it was her responsibility to ensure that the required documents were in the facility. Review of facility policy titled, Hospice Program, revised July 2017, revealed in part: Policy Statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation . 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual residents' needs. These responsibilities include the following .d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day .12. Our facility is responsible for a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process. B. Communicating with hospice representatives and other healthcare providers participating on the provision of care .d. Obtaining the following information from the hospice . 3.) Physician certification of the terminal illness specific to each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #5, Resident #20 and Resident #53) reviewed for care plans in that: The facility failed to ensure Resident #5 had a care plan in place for use of a mechanical lift.The facility failed to ensure Resident #20 had a care plan in place for use of a mechanical lift.The facility failed to ensure Resident #53 had a care plan in place for hospice services. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs safely.The findings included the following:Resident #5Review of Resident #5's Resident Face Sheet dated 07/24/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of heart failure, type 2 diabetes mellitus, stage 4 (an ulcer that extends through the muscle) pressure ulcer, peripheral vascular disease (insufficient blood circulation to the arms and legs), dementia, difficulty sleeping, anxiety, gout (a type of arthritis), major depressive disorder, amputation of left foot, weakness, iron deficiency, high blood pressure, alcohol abuse, nicotine dependence, and nausea. Review of Resident #5's Quarterly MDS assessment dated [DATE], Section C - Cognitive Patterns, subsection C0500 BIMS Score Summary revealed Resident #5 scored 15 out of 15 indicating intact cognition. Section GG - Functional Abilities, subsection GG0110 Prior Device Use C. Mechanical Lift was not selected. Record review of Resident #5's Comprehensive Care Plan reviewed/revised 07/22/2025 did not include use of a mechanical lift for transfers as a focus of care or intervention. During an interview and observation on 07/23/2025 at 10:10 AM, Resident #5 was sitting in his wheelchair in the dining room. Noted mechanical lift sling under the resident. Resident stated the staff got him out of bed using the mechanical lift due to his inability to bear weight related to the amputation of his left foot and his size. Resident #20Review of Resident #20's Resident Face Sheet dated 07/24/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of heart failure, high blood pressure, obesity, anxiety, major depressive disorder, atrial fibrillation, enlarged heart, chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), gastrointestinal (stomach and intestine) bleeding, chronic pulmonary embolism (blood clot in the lung), nerve pain, difficulty with coordination, and respiratory failure. Review of Resident #20's admission MDS Assessment, dated 05/05/2025, Section C - Cognitive Patterns, subsection C0500 BIMS Score Summary revealed Resident #20 scored 15 out of 15 indicating intact cognition. Section GG - Functional Abilities, subsection GG0110 Prior Device Use C. Mechanical Lift was not selected. Record review of Resident #20's Comprehensive Care Plan reviewed/revised 06/09/2025 did not include use of a mechanical lift for transfers as a focus of care or intervention. During an interview on 07/23/2025 at 6:34 AM, Resident #20 stated the staffed used a mechanical lift to transfer her from the bed to a chair and back again. Resident #53Review of Resident #53's electronic face sheet dated 07/24/2025, revealed an [AGE] year-old female admitted to the facility on [DATE] and to hospice services on 07/01/2025 with diagnoses to include: Alzheimer's, kidney disease, and urinary tract infection. Review of Resident #53's Quarterly MDS dated [DATE], revealed a BIMS score of 03 out of 15 which indicated severe cognitive impairment. Review of Section O - Special Treatments, Procedures, and Programs, subsection O0110, item K1 Hospice Care, column b. While a Resident was selected. Review of Resident #53's electronic Physicians Orders dated 07/01/2025 revealed: Resident has hospice services for diagnoses of Alzheimer's Disease. Review of Resident #53's Comprehensive Care Plan last review completed 03/07/2025, revealed no evidence of resident being on hospice services. During an interview on 07/24/2025 at 12:50 PM, the DON stated use of a mechanical lift to transfer residents should be on the comprehensive resident centered care plan. She stated the facility did not have a policy that she was aware of that specifically addressed requiring a physician's order for a mechanical lift or for inclusion of the mechanical lift on the care plan. The DON stated one possible reason for the failure to include use of a mechanical lift on care plan was due to all the changes the facility had been going through. She stated creation of the care plans was a joint effort that included the medical director, MDS Coordinator and DON. She stated her expectations were for an order to be obtained and the residents care plans updated. The DON stated training was a work in progress with the newly hired leadership team. She stated possible consequences of failing to include use of a mechanical lift on a care plan was that she felt care planning provided residents with a list of expectations, gave residents a voice to convey their concerns, needs and wants. Failing to include the use of a mechanical lift did not give residents a complete list of the care they should expect to receive from the facility or an opportunity to state their preferences. During an interview on 07/24/2025 at 1:00 PM, the RNC stated the reason for the failure to include the use of mechanical lifts on resident care plans was due to the recent turnover in the facility. She stated she did not consider the lack of a physician's order of any consequence to the residents. She stated the care plan was a communication tool but was rarely utilized by the staff. The RNC stated she felt there would be no repercussions related to the failure to care plan the use of a mechanical lift. The facility provided policies titled Activities of Daily Living (ADL), Supporting and Lifting Machine, Using a Mechanical. These policies did not address obtaining a physician's order to use a mechanical lift or including the use of a mechanical lift on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 (CNA-A, CNA-B, and CNA-C) staff observed during incontinent care.
The facility failed to ensure that staff (CNA-A, CNA-B and CNA-C) performed proper peri-care (incontinent care) for Resident #1 and Resident #2.
These failures placed residents of the facility at risk of infections from incontinent care.
Findings included:
Resident #1
Record Review of resident #1's Face Sheet dated 01/10/2025 revealed a [AGE] year-old male admitted on [DATE] and his latest admission on [DATE]. Review of Resident #28's diagnoses revealed: Hypertension (high blood pressure), and Lack of coordination.
Record review of Resident # 1's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 06 (severe cognitively impairment). Section H-Bladder and Bowel, resident always incontinent.
During an observation on 04/08/2025 at 2:35 PM, CNA-A and CNA-C performed peri-care for Resident #2. CNA-A folded each wipe and reused the folded wipe on the resident. CNA-A also did not pull back and clean the resident's foreskin while performing pericare.
During an interview on 04/08/2025 at 2:55 PM, CNA-A stated she had not performed pericare correctly because she folded the wipes and reused. She stated she also had not pulled back the resident foreskin and cleaned it incorrectly. CNA-A stated in not doing so could have caused buildup and lead to an infection.
During an interview on 04/08/2025 at 3:00 PM, the DON stated, pericare should have been performed using one wipe, one swipe technique. She stated the wipes were not to be folded. The DON stated pericare should have begun with pulling back the foreskin of the resident and in not doing so, could have resulted with a resident infection.
Resident #2
Record Review of resident #2's Face Sheet dated 06/14/2024 revealed a [AGE] year-old male admitted on [DATE] and his latest admission on [DATE]. Review of Resident #2's diagnoses revealed: Diabetes Mellitus, Generalized edema (swelling), Peripheral vascular disease, and noncompliance.
Record review of Resident # 2's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 15 (cognitively intact). Section H-Bladder and Bowel, resident always incontinent.
During an observation on 04/08/2025 at 4:19 PM, CNA-A and CNA-B performed pericare for Resident #2 and began from back to front of resident.
During an interview on 04/08/2025 at 4:45 PM, the DON stated, for male residents that were uncircumcised, staff should have pulled the foreskin back and clean and returning the foreskin afterward. She stated she had trained her staff to use the one wipe, one swipe method for all residents. She stated all pericare should have begun from front to back. The DON state it was the DON who monitored with random checkoffs and quarterly. She stated the negative impact of not having pulled back the foreskin and not having performed the one wipe one swipe on residents was possibly infection and a possible uti (urinary tract infection). She stated biggest concern for her was the foreskin not being retracted and could have caused a significant infection. The DON stated she in serviced the staff on pericare just a couple of weeks ago. She stated her expectations was for staff to perform pericare correctly every time whether they was being watched or not. The DON stated the failure occurred the with the staff not having followed the policy on how pericare was to be provided.
Record review of the CNA-A, CNA-B, and CNA'C's Pericare competencies revealed:
CNA-A dated 03/17/2025 with all pericare skills having been met.
CNA-B dated 03/25/2025 with all pericare skills having been met.
CNA-C dated 03/25/2025 with all pericare skills having been met.
Record review of the facility policy titled Perineal Care with a revised date of February 2018 revealed:
Male
1.
Follow steps below:
Take the wipe in one hand and gently grasp the penis shaft.
If, the resident is uncircumcised gently pull back the foreskin and wipe the head of the penus beginning at the urethral opening working outward and away from the penis head (circular motion).
Use new wipe with each stroke.
After cleaning is complete gently move the foreskin back into it's natural position if uncircumcised.
Cleanse the penis shaft with wipe from the top of the shaft towards the rectum, including the scrotum.
Using a new wipe with each stroke clean from the upper part of the leg to the hip.
Repeat on the other side and then once from hip bone to hip bone.
Turn the resident over and repeat on the back side

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to have evidence that all violations in response to abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse and neglect.
The facility failed to investigate the allegation of verbal abuse by CNA D on 07/04/2024 towards Resident #4 and Resident #5 witnessed by RN C.
The failure could place residents at risk of allegation of abuse not being thoroughly investigated and at risk of ongoing abuse.
Findings included:
Record review of Resident #4's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with of diagnoses of Ataxic (lack of voluntary muscle control) cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture) , Other speech and language deficits following nontraumatic subarachnoid hemorrhage (bleeding in the area between the brain and spinal cord) and cerebral infarction (condition that occurs when blood flow to the brain is disrupted, causing tissue death in the brain), Anxiety disorder (mental health condition that can cause significant and uncontrollable feelings of fear and anxiety), unspecified (do not meet the exact criteria for any other anxiety disorder), and Dysphagia (difficulty swallowing), unspecified
Record review of Resident #4's Quarterly MDS Assessment, dated 06/13/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 09, which indicated a moderate impairment response.
Record review of Resident #5's Face Sheet, dated 07/23/2024, revealed an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture), unspecified-Infantile (occurred before, during, or shortly after birth), Parkinsonism (brain condition that cause slowed movements, stiffness, and tremors), unspecified, Unspecified voice and resonance disorder (can involve issues with the quality, pitch, or volume of the voice).
Record review of Resident #5's Annual MDS Assessment, dated 06/27/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 05, which indicated a moderate impairment response.
During an interview on 07/17/2024 at 2:25 p.m., RN C said she witnessed CNA D as she walked by the nurses' station and enter the room of Resident #4 and Resident #5 and yell at the residents in loud, irritated tone of voice. RN C said she witnessed CNA D as she slammed the door and continued to yell and scream so loud she could hear through the wall. RN C said CNA D told Resident #4 and Resident #5, to calm down, stop repeating questions, you already had your medication. RN C said when CNA D came out, she told CNA D that the screaming was unacceptable. RN C said CNA D voice tone was loud at times, but at during the specific incident on 07/04/2024, that time, CNA D sounded harsh, rude, and hateful. RN C said she notified Administrator, DON and ADON and reported what she witnessed immediately or less than hour after she witnessed the incident. RN C said she was never questioned about the incident and continued to observe CNA D work the floor.
During an interview 07/18/2024 at 2:42 p.m., the Administrator identified himself as the facility's Abuse Coordinator. The Administrator said the allegation that CNA D was verbally aggressive to Resident #4 and Resident #5 was not reported to him but was reported to the DON. The Administrator said the DON had informed him she had interviewed Resident #4 and Resident #5 and they denied the allegation. The Administrator said he did not investigate the incident further based on the statement of the DON and no documentation was obtained.
During a group interview on 07/18/2024 at 2:52 p.m., the DON said RN C reported to her that RN C had witnessed, in RN C's opinion, CNA D open Resident #4 and Resident #5's door and yell and scream at the resident and slam the door. The DON said she first checked on the residents and interviewed Resident #4 and Resident #5 and asked specific questions in regard to CNA D. The DON said Resident #4 and Resident #5 denied all the allegations. The DON said she reported to the incident to the Administrator. The DON said she spoke with CNA D about the allegation and details. The DON said CNA D denied and said she had witnesses. The DON said she did not interview RN C because Resident #4 and Resident #5 denied the allegation. The DON said CNA D was not removed from the floor because there was not an investigation. The DON said she did not document the incident or investigate the incident any further, including the witnesses CNA D had reported.
Record review of the facility's policy, Preventing Resident Abuse, dated 12/2013, revealed the facility would condone any form of resident abuse and continually monitor the facility's policies and procedures. The abuse prevention/intervention program includes: encouraging all personnel to report any signs or suspected incidents of abuse to facility management immediately; training all staff and practitioners how to resolve conflict appropriately; training staff to understand and manage a resident's verbal and physical aggression.
Record review of the facility policy, Abuse Investigations, dated 11/2010, revealed all reports of resident abuse and neglect shall be promptly and thoroughly investigated by facility management.
1. Should an incident or suspect incident of resident abuse or neglect be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident.
2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the of the investigation.
3. The individual conducting the investigation will, as a minimum:
c. Interview the person reporting the incident;
d. Interview the witnesses;
e. Interview staff members (on all shifts) who have had contact with the resident;
f. Interview other residents to who the accused employee provides care or services to;
g. Review all events leading up to the event
k. Focusing the investigation on determining if abuse or neglect has occurred, the extent, the cause;
l. Provide complete and thorough documentation of the investigation.
7. Employee(s) who had been accused of resident abuse would be suspended from duty until the results of the investigation had been reviewed by the administrator.
Record review of the facility's policy, Reporting Abuse to Facility Management, dated 04/2012, revealed:
4. Employees must immediately report any suspected abuse or incidents of abuse to the Director of Nursing or in absence of the Director of Nursing, to the Nurse Supervisor on duty. Failure to report such an incident may result in legal/criminal action being filed against individual(s) withholding such information.
12. A completed copy of documentation forms and written statements from witnesses must be provided to the administrator within two hours of the occurrence of an incident or suspected abuse. An immediate investigation will be made in a copy of the findings of such investigation will be provided to the administrator within three to five days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the resident environment remains free of accident hazards as possible 2 (Resident #7 and Resident #8) of 6 reviewed for accidents
The DON brought a dog to work at the facility that bit Resident #7 on the ankle and was aggressive toward Resident #8.
This was determined at no actual harm with the potential for more than minimal harm at past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation dated on 07/08/2024 when staff were in-serviced no dogs were allowed at the facility.
This deficient practice could place residents at risk of an unsafe environment that could lead to a diminished quality of life.
Findings included:
Record review of Resident #7's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Major depressive disorder (a mental illness that can cause a persistent low mood and loss of interest in activities that are usually enjoyable), recurrent severe without psychotic features, Chronic (persisting) obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), and Dysphagia (difficulty swallowing), oropharyngeal phase (the first phase of swallowing and involves the mouth and throat).
Record review of Resident #7's Quarterly MDS Assessment, dated 05/17/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 15, which indicated intact cognitive response.
Record review of Resident #8's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Acute (sudden) upper respiratory infection (a viral infection that affects the nose, sinuses, or throat), Complete lesion of L2 level of lumbar spinal cord (a spinal cord injury (SCI) that can cause permanent disability, significant morbidity, or even mortality), sequela (a condition which was the consequence of a previous disease or injury), Hypoglycemia (condition in which your blood sugar level is lower than the standard range), Acute (sudden) diastolic (congestive) heart failure (the left ventricle has become stiffer than normal), and Spinal stenosis (occurs when the space inside the backbone is too small), lumbar region (the part of the spine that's located between the ribs and pelvic) without neurogenic claudication (without the spinal nerves in the lower spine compressed).
Record review of Resident #8's Quarterly MDS Assessment, dated 06/21/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 13, which indicated intact cognitive response.
During an observation on 07/17/2024 at 5:48 a.m., observed a small, silver bowl in the floor of the DON's office and a small dog crate under the desk with a blanket. Observed there was no dog present.
During an interview on 07/17/2024 at 5:50 a.m., the DON said she previously brought her dog to work but did not at the present time. The DON said the last time she brought her dog to the facility was approximately 11 or 12 days prior.
During an interview on 07/17/2024 at 10:25 a.m., NA A said the DON brought her dog to the facility in the past. NA A said the dog snapped at her in an aggressive way on one occasion because she walked up and startled the dog. NA A said the dog did not make contact with her. NA A said she did not report the incident to the DON or Administrator because she did not think the incident was relevant. NA A said the incident had occurred within the last two months, but she could not remember the date.
During an interview on 07/17/2024 at 2:25 p.m., RN C said the DON's dog had snapped at her in an aggressive manner on Hall 5 one day and she put her foot out to block the dog. RN C said she was not in-serviced on whether or not it was allowed for staff to bring a pet to work. RN C said she did not think it was appropriate for a staff member to bring a pet to the facility because the staff needed to concentrate on their assigned tasks. RN C said the incident had occurred within the last month, but she could not remember the date.
During an interview on 07/18/2024 at 10:34 a.m., Resident #8 said approximately a month prior, as he sat on his scooter by the nurses' station, he was approached by the DON's dog. Resident #8 said he was sitting by the birdcage and the dog ran up to him like it wanted to be petted and Resident #8 reached down, and the dog snapped at him in a defensive manner. Resident #8 said he was not afraid of dogs, but the incident made him mad because he did not want other residents to be bitten.
During an interview on 07/18/2024 at 11:40 a.m., the DON said she was not aware that her dog had nipped or snapped residents or was aggressive toward residents or other people.
During an interview on 07/18/2024 at 12:23 p.m., the Business Office Manager said she was aware the DON brought her dog to work, and she kept the dog in her office 99% of the time. The Business Office Manager said the dog would approach residents, visit resident in their rooms, and laid on their beds. The Business Office Manager said the dog's favorite place to run up to was to the bird cage in the rotunda area or the side door where the dog went out to go the restroom. The Business Office Manager said the dog at one time ran up to a resident's family member and pressed his nose to back of her leg, but the dog never nipped. The Business Office Manager said the dog approached others.
During an interview 07/18/2024 at 3:58 p.m., Resident #7 said she was bit on the ankle by the DON's dog a couple of months prior. She said she was walking by the nurses' station and the dog reached out and bit her on the right ankle on the outside of the ankle. Resident #7 said the bite broke the skin. Resident #7 said she did not tell anyone because she did not want to cause trouble. When asked to explain, Resident #7 she said she had to go to the nurses to get her meds and she wanted to keep the peace. Resident #7 said she was afraid of the dog after the incident. Observation no scar on Resident #7's right ankle, on outer side where Resident #7 pointed when she showed where the dog had bitten her.
Record review of Resident #7's Progress Notes, dated 03/12/2024 to 07/17/2024, revealed no injury or open area to Resident #7's ankle.
Record review of a facility in-service sign-in sheet, dated 07/08/2024, revealed staff were informed, No dogs allowed by staff. Do not bring your pets to work day or night by the Administrator.
Record review of the facility's dog policy, [Facility Name] and [Facility Name] Doggie Contract, not dated, revealed if the dog is a disturbance to the resident population, the dog must leave. This could include but it's not limited to barking, biting, pooping, smelling, growling, chasing, aggravating, spitting, howling, peeing, humping, rolling, hunting, etc.
4. revealed the dog must be: friendly to all residents, staff, and family members.
5. revealed the dog must be: not allowed to wander the facility alone without the resident with the dog.
There was no policy that outlined and directed situations when employees brought dogs to the facility provided to this investigator when requested multiple times while on-site 07/17/2024 - 07/23/2024.
Record review revealed the DON did not have a contract or facility documentation signed that indicated she would agree to the [Facility Name] Doggie Contract and facility policy. Record review revealed the DON's dog was up to date on vaccinations.
This was identified as PNC, correction date of in-service (07/08/24)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment for 2 ( Resident #8 and Resident #10) of 6 residents reviewed for rights in that:
1. Resident #8's bathroom was observed to be unsafe and unsanitary.
2. Resident #8 and Resident #10 complained of roaches in their rooms and bathrooms.
This deficient practice could place residents at risk of living in an unsanitary environment, and psychosocial harm due to diminished quality of life.
Findings included:
Record review of Resident #8's Face Sheet, dated [DATE], revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Acute (sudden) upper respiratory infection (a viral infection that affects the nose, sinuses, or throat), Complete lesion of L2 level of lumbar spinal cord (a spinal cord injury (SCI) that can cause permanent disability, significant morbidity, or even mortality), sequela (a condition which was the consequence of a previous disease or injury), Hypoglycemia (condition in which your blood sugar level is lower than the standard range), Acute (sudden) diastolic (congestive) heart failure (the left ventricle has become stiffer than normal), and Spinal stenosis (occurs when the space inside the backbone is too small), lumbar region (the part of the spine that's located between the ribs and pelvic) without neurogenic claudication (without the spinal nerves in the lower spine compressed).
Record review of Resident #8's Quarterly MDS Assessment, dated [DATE], Section C- Cognitive Response Patterns revealed a BIMS score of 13, which indicated intact cognitive response.
Record review of Resident #10's Face Sheet, dated, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Essential (primary) hypertension, Dysphagia (difficulty swallowing), unspecified; Chronic kidney disease, stage 4 (severe), Chronic obstructive pulmonary disease, and Cerebral infarction (stroke caused by a blockage or interruption of blood flow to the brain), unspecified.
Record Review of Resident #10's Quarterly MDS Assessment, dated [DATE], Section C- Cognitive Response Patterns revealed a BIMS score of 08, which indicated a moderate impairment response.
During an interview on [DATE] at 10:22 a.m., Resident #10 said the night prior she had seen a large roach crawl under her chest of drawers that was across the room from her bed. Resident #10 said the bug was not a water roach but a large regular cock roach. Resident #10 said she saw large roaches in her bathroom often. Resident #10 said this bothered her because she did not like roaches. Resident #10 said she always kept her house and bathroom clean when she lived at home. Resident #10 said her mom told her when she was growing up that if you had roaches in your house, you were unclean.
During an interview on [DATE] at 10:34 a.m., Resident #8 said he was upset about the water roaches in the facility. Resident #8 said he had cock roaches in bathroom and the roaches came out at night. Resident #8 said he would turn on the light and the roaches would run everywhere. Resident #8 said his sink in his bathroom was about to fall off the wall and the toilet was unsteady. Resident #8 said someone needed to replace the base of his toilet. As investigator opened the bathroom door, Resident #8 said he was glad someone looked at his bathroom because he had reported the need for repairs to the housekeeper and no one had fixed the sink or toilet. Resident #8 said he was a large man and he had to lean on something to go to the bathroom and he felt unsafe that the sink would fall off and he would hit his face on the floor and bust his chin. Resident #8 said he was also afraid his toilet would fall over, and he would fall and would not be able to get off the floor.
During on observation on [DATE] beginning at 10:40 a.m., of Resident #8's bathroom, observed the sink was a wall mounted porcelain type attached only at the back of the sink. Observed the sink tilted slightly downward in front. Observed the sink was unsteady and moved when pressure was applied to the front. Observed the sink was attached to the wall behind the faucet with a board, approximately 12 inches long by 2 inches in width. Observed the board was screwed into the drywall on each end of the board. Observed the area across the top of sink between the board and faucet and along the sides where the sink met with the drywall, a thick layer of caulk had been applied to attach the sink to the wall. Observed on the right side of the sink, at the top the sink, a ½ inch gap where the sink had pulled away from the wall. Observed the toilet and observed a black substance and old off-white caulking material around the entire base of the toilet. When toilet was touched, the unit moved and was unsteady at the base of the toilet. Observed the toilet lid was lose and unsteady. Observed the right side of the toilet, between the unit and the wall and saw a piece of caulking material that was covered in a black substance, pulled away from the toilet approximately 6 inches in length. Observed the floor was covered in a yellow substance with dirt and fuzz. The area where the tile and drywall met was covered in a yellow, dark stain. Observed a died roach under the sink.
During an interview on [DATE] at 2:52 p.m., the Administrator said he was not aware Resident #8's sink and toilet were in need of repair. The Administrator said the facility had remounted Resident #8's sink in the past and Resident #8 put pressure on the sink when he went to bathroom because he was a large man. The Administrator said the facility would need to find a different way to mount Resident #8's sink to be more secure.
Record review of the facility pest control service log revealed an entry of log check and initials on [DATE] and the facility was serviced for roaches, spiders, and beetles based on a log check and documentation and initials on [DATE]
Record review of the facility's policy, Resident Rights, dated 08/2009, revealed employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be informed about rights and responsibilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to ensure resident had the right to be free from abuse for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse and neglect.
The facility failed to prevent CNA D from verbally abusing Resident #4 and Resident #5 on 07/04/2024 witnessed by RN C when she yelled, screamed, and slammed the door.
These failures could place residents at risk of fear, emotional distress, and decreased quality of life, and further abuse.
Findings included:
Record review of Resident #4's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with of diagnoses of Ataxic (lack of voluntary muscle control) cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture) , Other speech and language deficits following nontraumatic subarachnoid hemorrhage (bleeding in the area between the brain and spinal cord) and cerebral infarction (condition that occurs when blood flow to the brain is disrupted, causing tissue death in the brain), Anxiety disorder (mental health condition that can cause significant and uncontrollable feelings of fear and anxiety), unspecified (do not meet the exact criteria for any other anxiety disorder), and Dysphagia (difficulty swallowing), unspecified
Record review of Resident #4's Quarterly MDS Assessment, dated 06/13/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 09, which indicated a moderate impairment response.
Record review of Resident #5's Face Sheet, dated 07/23/2024, revealed an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture), unspecified-Infantile (occurred before, during, or shortly after birth), Parkinsonism (brain condition that cause slowed movements, stiffness, and tremors), unspecified, Unspecified voice and resonance disorder (can involve issues with the quality, pitch, or volume of the voice).
Record review of Resident #5's Annual MDS Assessment, dated 06/27/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 05, which indicated a moderate impairment response.
During an interview on 07/17/2024 at 4:47 a.m., LVN E said she had worked with CNA D and said CNA D's voice was loud and at times she talked to residents harshly. LVN E said she was not sure at times if CNA D was upset or stern.
During an interview on 07/17/2024 at 9:34 a.m., CNA D said she did not yell at Resident #4 or Resident #5 and denied she slammed the door. CNA D said RN C had threatened her that RN C was going to call the state and the police if she ever abused the residents. CNA D said the incident occurred on 07/04/2024. CNA D said she felt RN C was harassing her and she called the DON to report RN C. CNA D denied she ever yelled at any resident and said she had a loud voice naturally. CNA D said she had been trained and in-serviced on abuse and neglect.
During an interview on 07/17/2024 at 9:46 a.m., the DON said RN C had brought the concern that CNA D had yelled at Resident #4 and Resident #5 to her on 07/04/2024. The DON said CNA D had also called her that day as well to report she felt harassed by RN C because RN C had threatened to report her to the state. The DON said the allegation of verbal abuse was not reported to HHSC Regulatory because Resident #4 and Resident #5 denied the allegation that CNA D yelled at them and said CNA D was just loud. The DON said CNA D could be loud and abrasive and once the staff got to know her, differences could be worked out and staff were able to work with CNA D. The DON said she did not document her interview with Resident #4 and Resident #5.
During a confidential phone interview on 07/17/2024 at 1:01 p.m., the confidential person said RN C had reported she had witnessed CNA D yell and scream at Resident #4 and Resident #5 on 07/04/2024. The confidential person said she reported the incident to the DON and the Administrator per procedure. The confidential person said she had witnessed CNA D be loud, rude, and verbally aggressive toward residents in the past. The confidential person said she had filled out grievance forms about CNA D, but nothing became of them.
During a group interview on 07/17/2024 at 1:37 p.m., with Resident #4 and Resident #5, Resident #5 said she knew CNA D and called her by her first name. Resident #5 said CNA D talked loudly when she came in the room on 07/04/2024, but she also yelled at her and Resident #4. Resident #5 said CNA D did not like it when she or Resident #4 pulled their call light. Resident #5 said she did not want to get anyone in trouble. Resident #5 looked around the room and refused to make eye contact at this point. Resident #5 said it made her nervous to think she would be yelled at and said CNA D yelled at her and Resident #4 sometimes. Resident #5 said she did not tell anyone because she did not want to get anyone in trouble. Resident #4 was observed during the conversation to sit in her wheelchair, hunched down, and quiet. When engaged, Resident #4 said she remembered CNA D yelled at her, but the questions made her nervous. Resident #4 called CNA D by her first name. Resident #4 said CNA D yelled sometimes in a mean way, but she was nervous to talk about it.
During an interview on 07/17/2024 at 2:25 p.m., RN C said she witnessed CNA D as she walked by the nurses' station and enter the room of Resident #4 and Resident #5 and yell at the residents in loud, irritated tone of voice on the evening of 07/04/2024. RN C said she witnessed CNA D as she slammed the door and continued to yell and scream so loud she could hear CNA D's voice through the wall. RN C said CNA D told Resident #4 and Resident #5, to calm down, stop repeating questions, you already had your medication. RN C said when CNA D came out, RN C told CNA D that the screaming was unacceptable and if she did it again, RN C would report her to the state and the police. RN C said CNA D tone of voice was loud at times, but during the specific incident on 07/04/2024, CNA D sounded harsh, rude, and hateful. RN C said she reported the incident to the ADON, DON and Administrator immediately or less than hour after she witnessed the incident.
During an interview 07/18/2024 at 2:42 p.m., the Administrator said the allegation that CNA D was verbally aggressive to Resident #4 and Resident #5 was not reported to him but was reported to the DON. The Administrator said the DON had informed him she had interviewed Resident #4 and Resident #5 and they denied the allegation.
During an interview on 07/18/2024 at 2:52 p.m., the DON said RN C reported to her that RN C had witnessed, in RN C's opinion, CNA D open Resident #4 and Resident #5's door and yell and scream at the residents and slam the door. The DON said she first checked on the residents and interviewed Resident #4 and Resident #5 and asked specific questions in regard to CNA D. The DON said Resident #4 and Resident #5 denied all the allegations. The DON said she reported the incident to the Administrator. The DON said she spoke with CNA D about the allegation and details. The DON said CNA D denied all allegations and said she had witnesses. The DON said she did not interview RN C because Resident #4 and Resident #5 denied the allegation. The DON said CNA D was not removed from the floor because there was not an investigation. The DON said she did not document the incident or interview the witnesses CNA D said saw her during the alleged incident.
During a group interview on 07/18/2024 at 2:52 p.m., the Administrator said that he had not had any complaints or grievances forms from staff or residents concerning CNA D. The Administrator said he had never had any grievances forms that were filed to disappear. The DON said the facility did not have grievance forms disappear and all grievance forms were addressed promptly.
Record review of CNA D's employee record revealed CNA D had no relevant disciplinary actions.
Record review of the facility's policy, Preventing Resident Abuse, dated 12/2013, revealed the facility would condone any form of resident abuse and continually monitor the facility's policies and procedures. The abuse prevention/intervention program includes: encouraging all personnel to report any signs or suspected incidents of abuse to facility management immediately; training all staff and practitioners how to resolve conflict appropriately; training staff to understand and manage a resident's verbal and physical aggression.
Record review of the facility policy, Abuse Investigations, dated 11/2010, revealed all reports of resident abuse and neglect shall be promptly and thoroughly investigated by facility management.
1. Should an incident or suspect incident of resident abuse or neglect be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident.
2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the of the investigation.
3. The individual conducting the investigation will, as a minimum:
c. Interview the person reporting the incident;
d. Interview the witnesses;
e. Interview staff members (on all shifts) who have had contact with the resident;
f. Interview other residents to who the accused employee provides care or services to;
g. Review all events leading up to the event
k. Focusing the investigation on determining if abuse or neglect has occurred, the extent, the cause;
l. Provide complete and thorough documentation of the investigation.
7. Employee(s) who had been accused of resident abuse would be suspended from duty until the results of the investigation had been reviewed by the administrator.
Record review of the facility's policy, Reporting Abuse to Facility Management, dated 04/2012, revealed:
It is the responsibility of our employees, facility, consultants, Attending Physicians, family, visitors, etc., to promptly report any incident or suspected incident of neglect or residence abut to facility management without fear of retaliation.
4. Employees must immediately report any suspected abuse or incidents of abuse to the Director of Nursing or in absence of the Director of Nursing, to the Nurse Supervisor on duty. Failure to report such an incident may result in legal/criminal action being filed against individual(s) withholding such information.
8. The Administrator or Director of Nursing must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator or Director of Nursing must be called at home or paged and informed of such incident. The facility will take all necessary actions as a result of the investigation.
12. A completed copy of documentation forms and written statements from witnesses must be provided to the administrator within two hours of the occurrence of an incident or suspected abuse. An immediate investigation will be made in a copy of the findings of such investigation will be provided to the administrator within three to five days.
Record review of the facility's policy, Reporting Abuse to State Agencies and Other Entities/Individuals, dated 11/2010, revealed all suspected violations of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Policy Interpretation:
1. Should a suspected violation of abuse and neglect be reported, the facility administrator, or his/her designee, will promptly notify the following persons or agencies of such incident:
a. The State licensing/certification agency responsible for surveying/licensing the facility

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse and neglect.
The facility failed to report to the Health and Human Services Commission State Survey Agency and other officials when an alleged allegation of verbal abuse was reported by RN C when she witnessed CNA D verbally abuse Resident # on 07/04/2024.
This deficient practice could place residents at risk of ongoing neglect.
Findings included:
Record review of Resident #4's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with of diagnoses of Ataxic (lack of voluntary muscle control) cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture) , Other speech and language deficits following nontraumatic subarachnoid hemorrhage (bleeding in the area between the brain and spinal cord) and cerebral infarction (condition that occurs when blood flow to the brain is disrupted, causing tissue death in the brain), Anxiety disorder (mental health condition that can cause significant and uncontrollable feelings of fear and anxiety), unspecified (do not meet the exact criteria for any other anxiety disorder), and Dysphagia (difficulty swallowing), unspecified
Record review of Resident #4's Quarterly MDS Assessment, dated 06/13/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 09, which indicated a moderate impairment response.
Record review of Resident #5's Face Sheet, dated 07/23/2024, revealed an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture), unspecified-Infantile (occurred before, during, or shortly after birth), Parkinsonism (brain condition that cause slowed movements, stiffness, and tremors), unspecified, Unspecified voice and resonance disorder (can involve issues with the quality, pitch, or volume of the voice).
Record review of Resident #5's Annual MDS Assessment, dated 06/27/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 05, which indicated a moderate impairment response.
During an interview on 07/17/2024 at 2:25 p.m., RN C said on the evening of 07/04/2024, she witnessed CNA D as she walked by the nurses' station and enter the room of Resident #4 and Resident #5 and yell at the residents in loud, irritated tone of voice. RN C said she witnessed CNA D as she slammed the door and continued to yell and scream so loud she could hear through the wall. RN C said CNA D told Resident #4 and Resident #5, to calm down, stop repeating questions, you already had your medication. RN C said when CNA D came out, she told CNA D that the screaming was unacceptable. RN C said CNA D tone of voice was loud at times, but during the specific incident on 07/04/2024, that time, CNA D sounded harsh, rude, and hateful. RN C said she notified the Administrator, DON and ADON and reported what she witnessed immediately or less than hour after she witnessed the incident. RN C said she was never questioned about the incident and continued to observe CNA D work the floor.
During an interview 07/18/2024 at 2:42 p.m., the Administrator identified himself as the facility's Abuse Coordinator. The Administrator said the allegation that CNA D was verbally aggressive to Resident #4 and Resident #5 was not reported to him but was reported to the DON. The Administrator said the DON had informed him she had interviewed Resident #4 and Resident #5 and they denied the allegation.
During a group interview on 07/18/2024 at 2:52 p.m., the DON said RN C reported to her that RN C had witnessed, in RN C's opinion, CNA D open Resident #4 and Resident #5's door and yell and scream at the residents and slam the door. The DON said she first checked on the residents and interviewed Resident #4 and Resident #5 and asked specific questions in regard to CNA D. The DON said Resident #4 and Resident #5 denied all the allegations. The DON said she reported to the incident to the Administrator. The DON said she spoke with CNA D about the allegation and details. The DON said CNA D denied and said she had witnesses. The DON said she did not interview RN C because Resident #4 and Resident #5 denied the allegation. The DON said CNA D was not removed from the floor because there was not an investigation. The DON said she did not document the incident or investigate the any further, including the witnesses CNA D had reported. The DON said she did not report the incident to the state.
Record review of the facility's policy, Preventing Resident Abuse, dated 12/2013, revealed the facility would condone any form of resident abuse and continually monitor the facility's policies and procedures. The abuse prevention/intervention program includes: encouraging all personnel to report any signs or suspected incidents of abuse to facility management immediately; training all staff and practitioners how to resolve conflict appropriately; training staff to understand and manage a resident's verbal and physical aggression.
Record review of the facility policy, Abuse Investigations, dated 11/2010, revealed all reports of resident abuse and neglect shall be promptly and thoroughly investigated by facility management.
1. Should an incident or suspect incident of resident abuse or neglect be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident.
2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the of the investigation.
3. The individual conducting the investigation will, as a minimum:
c. Interview the person reporting the incident;
d. Interview the witnesses;
e. Interview staff members (on all shifts) who have had contact with the resident;
f. Interview other residents to who the accused employee provides care or services to;
g. Review all events leading up to the event
k. Focusing the investigation on determining if abuse or neglect has occurred, the extent, the cause;
l. Provide complete and thorough documentation of the investigation.
7. Employee(s) who had been accused of resident abuse would be suspended from duty until the results of the investigation had been reviewed by the administrator.
Record review of the facility's policy, Reporting Abuse to Facility Management, dated 04/2012, revealed:
It is the responsibility of our employees, facility, consultants, Attending Physicians, family, visitors, etc., to promptly report any incident or suspected incident of neglect or residence abut to facility management without fear of retaliation.
4. Employees must immediately report any suspected abuse or incidents of abuse to the Director of Nursing or in absence of the Director of Nursing, to the Nurse Supervisor on duty. Failure to report such an incident may result in legal/criminal action being filed against individual(s) withholding such information.
8. The Administrator or Director of Nursing must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator or Director of Nursing must be called at home or paged and informed of such incident. The facility will take all necessary actions as a result of the investigation.
Record review of the facility's policy, Reporting Abuse to State Agencies and Other Entities/Individuals, dated 11/2010, revealed all suspected violations of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Policy Interpretation:
1. Should a suspected violation of abuse and neglect be reported, the facility administrator, or his/her designee, will promptly notify the following persons or agencies of such incident:
a. The State licensing/certification agency responsible for surveying/licensing the facility

**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 possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #28) reviewed for accidents and supervision.
The facility failed to ensure CNA and NA locked (legs MUST BE in the maximum OPENED/LOCKED position) the Hoyer (mechanical) lift during the transfer of Resident #28.
This failure could place residents at risk of injuries.
Findings included:
Review of Resident # 28's face sheet dated 06/14/2024 revealed a [AGE] year-old male admitted on [DATE] and his latest admission on [DATE].
Review of Resident #28's diagnosis revealed: Hypertension (high blood pressure), Lack of coordination, and Diarrhea.
Review of Resident # 28's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 15 (cognitively intact). Section H-Bladder and Bowel, resident always incontinent. Section GG-Functional Abilities and Goals, Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
During an observation on 06/12/2024 at 10:15 AM, CNA L and the NA did not lock the Hoyer (mechanical) lift while Resident #28 was being transferred from his bed to his WC.
During an interview on 06/12/2024 at 10:28 AM with CNA L, she stated she was supposed to have locked the Hoyer lift while transferring the resident from the bed to his WC. She stated she had never locked the Hoyer (mechanical) lift prior to this time as well.
During an interview on 06/12/2024 at 11:00 AM with the ADON, she stated all nursing staff were trained on the Hoyer (mechanical) lift. She stated CNA L should have applied the brakes on the lift which would have prevented a possible fall. She stated the brakes should have been locked while lifting the resident from the bed as well as being placed in his wheelchair during all Hoyer (mechanical) lift transfers. The ADON stated she checks the CNAs and NAs off on their skilled checkoff sheets with the DON to aid in random checks when needed. She stated her last trainings for the Hoyer (mechanical) lifts were 02/27-02/29 2024. She stated not having the Hoyer (mechanical) lift locked, when needed, could have harmed the resident by tipping over with the resident being hurt. She stated the failure occurred with CNA L not having taken the time to calm herself as she was being watched. The ADON stated she could not have said why the NA went in for resident care as she had not assigned her to that hall. She stated her expectations were for the Hoyer (mechanical) lift to have locked breaks.
Record Review of CNA L's Staff education/orientation dated 03/21/2024 revealed: Topic Equipment Portable Lift- 3. Portable Lift Operation-Lock wheels-when? V (verbal Verification) given with Meets Criteria marked per ADON's signature.
Record Review of Hoyer lift equipment manual on 06/14/2024 https://learn.medcareequipment.com/en_US/drive-patient-lift-owners-manual revealed:
When using an adjustable base lift, the legs MUST BE in the maximum OPENED/LOCKED position BEFORE
lifting the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 2 residents (Resident #7 and #51) reviewed for medication errors.
The facility failed to administer Resident #7's IV (intravenous) antibiotics as ordered by the physician on [DATE], [DATE] (two doses), [DATE], and [DATE].
An Immediate Jeopardy (IJ) was identified on [DATE] at 3:23 p.m. While the IJ was lowered on [DATE] at 11:22 p.m., the facility remained out of compliance at a severity level of no actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions.
The facility failed to ensure nursing staff administered Resident #51's Insulin Glargine as ordered by the physician. LVN N failed to administer Resident #51's Insulin Glargine 7 times during a 2-month review period, per physician order. RN F failed to administer Resident #51's Insulin Glargine 4 times during a 2-month review period, per physician order. LVN D failed to administer Resident #51's Insulin Glargine 1 time during a 2-month review period, per physician order. LVN M failed to administer Resident #51's Insulin Glargine 1 time during a 2-month review period, per physician order.
These failures placed residents at risk of relapse of an ongoing infection and developing a secondary infection, and at risk of diabetic complications.
Findings include:
Resident #7
Record review of Resident #7's face sheet dated [DATE] revealed [AGE] year-old female originally admitted on [DATE] with most recent readmission on date [DATE]. Resident #7's diagnoses included: encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (surgery involving skin and below skin tissue), presence of left artificial knee joint (previous left knee surgery), encounter for removal of internal fixation device (surgery revision), methicillin resistant staphylococcus aureus infection (antibiotic resistant infection), and pain.
Record review of Resident #7's quarterly MDS assessment dated [DATE] revealed: BIMS score of 13 which indicated cognition was intact. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed resident received IV medication.
Record review of Resident #7's care plan dated [DATE] revealed resident had right chest central line and was at risk for infection, pain, infiltration, cardiac, and respiratory issues. The goal was for Resident #7 to be free from infections, infiltration, and adverse effects. The facility staff approach included for staff to assess IV site q shift and prn. Further review of care plan revealed Resident #7 had post-surgical history of infection. The goal was for Resident #7's infection to be cleared by the target date and for complications related to the infection. The facility staff approach included staff will administer medications as ordered, monitor lab work as ordered and report results to physician.
Resident #7's electronic physician orders dated [DATE] revealed: meropenem 1 gram to be administered IV every 8 hours for diagnosis of infection and inflammatory reaction due to internal left knee prosthesis (left artificial knee infection).
Record review of Resident #7's electronic MAR for the months of [DATE] and [DATE] revealed meropenem had been administered:
1.
[DATE] at 4:00 p.m. by LVN A
2.
[DATE] at 8:00 a.m. by LVN A
3.
[DATE] at 4:00 p.m. by LVN A
4.
[DATE] at 12:00 a.m. by LVN A
5.
[DATE] at 8:00 p.m. by LVN A
Record review of Resident #7's lab results dated [DATE] revealed WBC was 7.97 (acceptable range between 4.0 - 11.0), ESR was 37 (acceptable range between 0 - 30), and CRP was 0.4 (acceptable range between 0.0 - 0.6).
Record review of Resident #7's lab results dated [DATE] revealed WBC was 11.42 (acceptable range between 4.0 - 11.0) indicated infection, ESR was 30 (acceptable range between 4.0 - 11.0), and CRP was 0.6 (acceptable range between 0.0 - 0.6).
Record review of Resident #7's hospital discharge paperwork dated [DATE] revealed a progress note from the IDP revealed she had original left total knee arthroplasty (surgical procedure in which parts of a damaged joint are removed and replaced) (in 2007, followed by revision in February 2020, then followed by two subsequent incision and drainage procedures in 2020. In [DATE], she underwent explant (removal of surgical hardware) of left knee arthroplasty and spacer placement. On [DATE] she underwent revision of left total knee arthroplasty. The plan was to continue meropenem (antibiotic medication), follow up on cultures, six weeks of antibiotic with end of treatment [DATE], monitor labs, supportive care, and placement of tunneled catheter ordered. Discharge planning included meropenem 1 gram every 8 hours with end date [DATE]. Patient to follow up in the ID (Infectious Disease) clinic in 3 weeks. Check lab CBC (a blood test that measures red blood cell count, white blood cell count and platelet count), CMP (a blood test that measures the body's fluid balance, electrolytes like sodium and potassium, and how well the kidneys and liver are working), ESR (a blood test that measures the level of inflammation in the body), CRP (a blood test that can measure a protein produced by the liver in response to inflammation or infection in the body) while on IV antibiotics. Provide central line dressing weekly and prn.
During an observation and interview on [DATE] at 10:49 a.m., Resident #7 had IV bag of 100 mL of NS infusing into right chest double lumen central line. On the medication bag there were instructions to *ACTIVATE VIAL PRIOR TO USE*. In the vial white powder (meropenem 1 gram) was observed and was dry. No date and time were written on IV tubing or on IV bag and it was being infused at 100 mL/hr using IV pump. There was approximately 25 mL left of NS in bag. The central line dressing loose, pulled away from skin toward bottom of the dressing, was not sealed to maintain sterile environment and moved when Resident #7 lifted shirt. Resident #7 stated she did not know when the dressing had been changed last. She stated she did not remember if facility staff had ever changed out the dressing. Date observed on central line dressing to be [DATE].
During an interview on [DATE] at 11:14 a.m., the DON stated the powdered medication in vial should have been activated by popping the seal from IV bag to powdered vial, then mixing into the solution in IV bag prior to medication being administered. She stated she had personally checked off LVN A on IV medication administration and did not know why she failed to mix medication into the bag. She stated that sometimes the pharmacy would send already mixed medication in solution and LVN A may have thought it was already mixed. She stated not mixing medication meant that resident did not get antibiotic as ordered and she had instructed LVN A to call physician to notify of missed dose. The DON stated she monitored IV medication was given correctly.
During an interview on [DATE] at 11:21 a.m., LVN A stated she had administered IV medication that morning. She stated she hung medication with new tubing but did not label tubing with date or time. She stated the central line dressing should be intact and tight to skin. She stated she would change the central line dressing. LVN A stated loose central line dressing could cause resident to have infection and should be sealed. She stated she did not mix up the medication from vial into IV bag because it was coming premixed, and she thought medication was in the bag without her having to mix it. She stated not mixing the medication meant that resident did not get antibiotic dose.
During an interview on [DATE] at 12:28 p.m., the Pharmacy Director with contracted pharmacy the facility used stated the pharmacy record showed as long as the pharmacy had been filling meropenem (antibiotic) medication to Resident #7, the facility had received medication in a snap together vial. He stated typically it was an insurance issue on how the medication was filled. He stated the pharmacy had written instructions on the bag label to activate vial prior to use but no separate instructions were sent to the facility. He stated the effect of facility staff not activating vial would interfere with mixing the medication and no antibiotic would have been infused if it was not activated prior to infusion. He stated the effect on the resident would be she would have gotten hydration with a little bit of sodium, and it would not have harmed her. He stated whatever the medication in the vial was prescribed to treat, would not have been treated and could have interfered with wound healing if Resident #7 missed doses.
During a follow up interview on [DATE] at 02:49 p.m., the DON stated IV Certificate education should include management of the IV access site including central lines, and administration of IV medication including how to prepare medication. The DON stated IV Certification education was provided outside of the facility, but the curriculum matched what the contracted pharmacy had in their training. She stated no other residents in the facility had IV medication ordered currently that had to be activated prior to administration currently. The DON stated she talked to the nurse that was responsible for changing the central line dressing on [DATE]. She stated LVN B told her the central line dressing was not changed by LVN B due to there was a treatment nurse that day and LVN B assumed the treatment nurse would change the dressing. The DON stated she expected the nurses signing the MAR to verify that all treatments had been performed prior to leaving for the day and LVN B had been in-serviced on that. She stated Resident #7's wound had been healing and the surgeon had been pleased with the progress. She stated Resident #7 continued to have a wound vac in place and no impaired healing had been observed. The DON stated the facility reached out to Resident #7's attending physician that prescribed medication to notify her of the delayed meropenem dose and the facility was awaiting response. She stated the Medical Director of facility had been informed of delayed meropenem dose and new order obtained for medication dose to be rescheduled for 1300, 2100, and 0500 because of the medication error earlier.
During a follow up interview at [DATE] at 03:30 p.m., LVN A stated it had been over a year ago when she was certified on IV medication and that she would assume that the IV Certification went over mixing IV medication. LVN A stated in the last month and a half she had been floating and working in different areas and times. She stated she usually did not work on the hall Resident #7 resided on and she had filled in 2 nights shifts on that hall. She stated she did notice the central line dressing was loose prior to administering IV meropenem medication that morning but had not noticed the date on the dressing. She stated the central line dressing was not secured to the skin and she had planned to change the dressing after medication had been administered. She stated central line dressing being loose could cause site infection. She stated she had administered meropenem to Resident #7 previously and medication had been delivered premixed with no need to activate the vial. She stated she did not feel that any negative outcome occurred to the resident from central line dressing not being changed or medication error. She stated she had called the Medical Director when she could not get ahold of the ordering physician, and a new order was received to administer another dose at 1:00 pm so that Resident #7 did not miss a dose, and then retime medication every 8 hours after the 1:00 p.m. dose.
During a phone interview on [DATE] at 04:32 p.m., the Medical Director stated he expected staff to follow pharmacy instructions when administering medications. He stated that he was not familiar with the specifics of IV medication that had snap together vials but that he expected nurses to be trained on how to prepare medications that were being administered. The MD stated the effect of not getting meropenem as ordered for sepsis or infection may aggravate the infection and could have caused a flare up from the infection or relapse of an ongoing infection. He stated he assumed the nurses and the ADON, and the DON were who monitored medication was given as directed. He stated he was notified that medication was delayed and he did give directions to give medication and readjust every 8 hours with new time so that medication would not be missed. He expected IV tubing to be changed per protocol and not changing tubing could lead to secondary infection. He stated he expected tubing and medication bag to be labeled with a date because staff will get busy and may forget when bag / tubing was hung. He stated he expected central line dressings to be changed every 7 days per protocol and that it would be changed if dressing was compromised. He expected that dressing be secured to the skin and not changing could lead to secondary infection and insertion site infection risk.
During an attempted telephone interview on [DATE] at 10:25 a.m., the Attending Physician did not answer the phone. Left message with office staff to please have her return phone call. The Attending Physician did not return call.
During an attempted phone interview on [DATE] at 10:48 a.m., LVN D did not answer the phone and a message to return the call was left. The LVN D did not return call.
During an attempted phone interview on [DATE] at 10:51 a.m., LVN B did not answer the phone and there was no option to leave a voice message.
During a phone interview on [DATE] at 10:54 a.m., LVN C stated he had worked for the facility on and off for the last 3 years. He stated that if medication came with instructions to activate vial prior to use, there was a blue stem that needed to be snapped to break the seal. LVN C stated after seal broken then he would get NS into vial and mix with powdered medication. He stated the mixed liquid and medication in the vial would be drained back into IV bag prior to being administer. He stated he did not remember any of Resident #7's IV medication being delivered to facility pre-mixed, but the pharmacy had done that in the past for other residents. He stated when medication is pre-mixed, it is time sensitive so medication would only be delivered in lesser amounts. He stated he had not noticed medication not being prepared per instructions. He stated if medications were not mixed prior to administration, the effect on the resident would be that they only received hydration. He stated central line dressings should be changed once a week and as needed. He stated central line dressing would need to be changed if it was loose and could become looser with clothing changes. He stated the effect of not changing central line dressings every 7 days or as needed is hard to determine because if the dressings were still sealed, he believed the port of entry would not be exposed in some cases, but it could lead to skin breakdown from skin not being allowed to breath. He stated he had not changed the central line dressing and that if he had signed that he had performed it was signed in error. He stated he would sign off on task in MAR prior to performing task and would have made his best effort to perform the task. He stated the error may have been due to there are a lot of distractions in the facility and may have forgotten to perform. He felt that the facility had enough staff and was not shorthanded. He stated that distractions resulted from him trying to make himself available to all residents and would be approached routinely by residents even if they were not assigned to him and he would attempt to help them.
During an interview on [DATE] at 11:15 a.m., LVN F stated she had worked at the facility for a little over a year. LVN F stated she had IV medication training prior to working at the facility and had a refresher on [DATE]. She stated if the medication label stated activate vial prior to use that meant the nurse must break seal then mix with the saline prior to IV administration. She stated Resident #7's IV medication had never come from pharmacy pre-mixed. LVN F stated she had not had any concerns about other nursing staff related to administering IV medication administration. She stated that not activating vial prior to medication administration could cause Resident #7 to not get medication, her wound may not have healed quickly, or the infection to become worse. She stated the central line dressing should be replaced every 72 hours. She stated nurses should change the central line dressing if dressing was loose, and not changing as ordered or as needed could cause infection. She stated nurses should document treatment performed in MAR after the nurse had completed the treatment.
During a phone interview on [DATE] at 11:18 a.m., RN E stated that she was the nurse at the IDP's office. She stated her expectation would be for central line dressing changes to occur every 7 days or prn for any soiled, loose, wet dressings. She stated loose meant that insertion cite was exposed by clear part of dressing becoming compromised. She stated the central line dressing site should be monitored every shift. RN E stated the effect of not changing the central line dressing routinely and as needed would cause highly increased risk for central line infection in the blood stream. She stated IDP was using meropenem to treat an active infection and she expected IV antibiotics to be administered per physician's orders. She stated IDP should be notified when IV antibiotics were missed, or medication was delayed, and she had not received any notification from the facility of the medication error. She stated the effect of missing or delaying doses of meropenem could cause Resident #7's active diagnosis to be not treated properly, delayed healing, cause the infection to worsen, and risk hurting the resident. Could also cause prolonged antibiotic treatment, rehospitalization, and incision site failure. RN E stated she was unsure if missing antibiotic doses would cause any risk for surgery hardware failure. She stated the failure of not administering antibiotics as ordered could expose residents to extended treatments. RN E stated she had made two attempts to contact facility requesting lab results as IDP ordered lab CBC w/Diff (a blood test that measures red blood cell count, white blood cell count and platelet count), CMP (a blood test that measures the body's fluid balance, electrolytes like sodium and potassium, and how well the kidneys and liver are working), ESR (a blood test that measures the level of inflammation in the body), CRP (a blood test that can measure a protein produced by the liver in response to inflammation or infection in the body) labs to be drawn weekly on Monday while on IV therapy. At that time, she stated she had not received any lab results from the facility and as a result IDP planned on drawing labs in their office during post hospitalization visit.
During a follow up interview on [DATE] at 2:49 p.m., the DON stated the only labs that the facility had drawn from Resident #7 were done on [DATE]. She stated the facility had gotten a call from IDP office requesting labs on [DATE] and she did not know that labs had not been performed. She stated the facility should have drawn labs as ordered and the order would have been found on hospital discharge paperwork. She was unsure how often the order was for at that time. She stated the facility would be drawing labs when resident returned from physicians' visits in another town and would send results to IDP office. She stated it was her expectation that documentation in EMR be done after treatment had been performed. She stated she did not know why nurses had documented without performing the treatment. She stated nurses should not document something another nurse had stated they had performed. She stated the effect on the resident could be missed treatments. She stated that she monitors treatments are done by running EMR reports that would show when treatment had been missed and observing staff perform treatments.
During an interview on [DATE] at 2:51 p.m., LVN B stated she had worked for the facility for 3 years in [DATE]. She stated she had received IV antibiotic medication administration training. LVN B stated when an IV was labeled activate prior to use and it was the antibiotic that Resident #7 used, the nurse should have snapped the connection from IV bag to vial, squeezed solution from IV bag into vial and mixed with powder, then with bag upside down squeezed bag to allow mixed solution into IV bag to prepare medication prior to it being infused. She stated she had not remembered seeing any premixed medication in the facility for Resident #7 after her most recent hospitalization. LVN B stated she had not had any concerns about other nursing staff not activating IV medication, but she would usually be the nurse who started medication dose in the morning with fresh tubing, so night nurse would not leave empty medication bag for her to observe. She stated tubing should be changed every 24 hours. She stated when new IV tubing was used then it should have a date, time, and nurses initial on it so that other staff know when it was first used. She stated missing IV antibiotic dose could cause Resident #7 to have longer healing time and would be considered a medication error. She was unsure what policy stated about central line dressing frequency but stated that it should be changed as ordered and prn when dressing was loose. LVN B stated not changing central line dressing when ordered or needed could cause another type of infection and significant problems by leaving area open for bacteria to get into insertion site. She stated she worked on [DATE] and she did sign that central line dressing had been changed since the facility had a RN performing treatments that day and she thought the RN changed the dressing. She stated usually the RN treatment nurse would let her know treatment had been performed and she would sign that it had been completed. She stated that she should have verified by observing central line dressing had been changed and did not remember why she did not verify it prior to signing that it was completed in MAR. She stated she had been in-serviced about central line dressings yesterday on changing dressing per orders and verifying treatment done prior to checking off it had been performed. She stated she should not check off treatments she had not performed.
During a follow up interview on [DATE] at 3:00 PM, the DON stated there were no labs drawn for Resident #7 since being discharged from the hospital and admitted into facility. She stated she expected the nurse to look at the EMAR to know when the lab was ordered and that if a nurse signed off the EMAR that lab was collected after procedure had been performed. She stated the nurse should send lab to the hospital if they signed off that lab was collected. She stated the order revealed labs were to be drawn by an RN as it was to be drawn from central line and should have been done weekly. The DON stated it was her as DON that did the lab trackers and with the nurses being flagged in the EMAR to alert them to draw the labs. She stated there would be potential harm to the resident based off of her labs not being drawn, which could have caused the resident to have become septic.
During a telephone interview on [DATE] at 3:26 p.m., LVN D stated she had worked for the facility for four or five years. She stated she had completed IV class but did not remember the date of original training, but the DON had a copy of certification. She stated she had received more training in IV administration on [DATE]. LVN D stated when an IV was labeled activate prior to use the seal needed to be broken and medication in vial mixed with solution from IV bag prior to administration. She stated the pharmacy had only delivered IV antibiotic medication that needed to be activated for Resident #7 since her most recent surgery. She stated she had no concerns about other nursing staff not mixing antibiotic medication prior to administering. She stated the effect of not mixing IV antibiotic could cause resident to not to get medication that she needed, and medication would not help whatever Resident #7 receiving medication for. She stated she believed the central line dressing needed to be changed every 7 days but would have to look at facility policy to verify that information. She stated the central line dressing would need to be changed if it had become loose, soiled, or damaged to prevent infection by bacteria getting under the dressing. She stated she assessed the dressing every time she administered IV medication and at least once a shift. LVN D stated she only documents completion of treatment in MAR when she completed the treatment that was ordered.
During an attempted telephone interview on [DATE] at 3:52 p.m., Resident #7's emergency family member could not be reached with directions. The phone number dialed was not a working number.
During a follow-up interview on [DATE] at 4:04 p.m., the DON stated Resident #7 was back from the ID physician's appointment and orthopedic surgeon's appointment. She provided paperwork the facility had received from ID physician's appointment but stated orthopedic surgeon did not send any additional paperwork from office visit. She stated that she was not sure why a new order from ID physician for PO antibiotic after IV antibiotic was completed. She stated Resident #7 was alert and more than likely would be able to answer basic questions about office visits. The DON stated she had started the afternoon dose of IV meropenem when the resident returned to facility after she had drawn blood from central line for lab work.
During a follow up observation and interview on [DATE] at 4:09 p.m., Resident #7 sat in wheelchair in her room with an immobilizing brace on her left leg. IV pump on and alarm beeped with IV tubing connected to her central line. A staff member entered the room and informed the resident that she had notified the nurse of the pump alarm, and she was not allowed to touch the pump. IV meropenem had been pre-mixed prior to infusion and tubing labeled with paper tape. Resident #7 stated that she had a plastic surgeon appointment scheduled for [DATE] and that appointment was made prior to her ID physician and orthopedic surgeon's appointments. She stated she did not know why ID had ordered oral antibiotic in addition to IV antibiotic. Resident #7 stated that the orthopedic surgeon did not think that the wound vac had been healing her left knee surgical wound and that was why she was scheduled to see plastic surgeon tomorrow to discuss surgical options. She stated she was nervous about having another surgery since she almost died during the last surgery. The call light was in reach.
Record review of summary of infectious disease physicians visit dated [DATE] revealed: Complete IV antibiotic on 6/20 as scheduled and we will send orders to remove PICC line. Start Levaquin 500mg PO daily on 6/21. Follow up with orthopedic surgeon in 6 weeks .next appointment [DATE].
During a follow up interview on [DATE] at 11:12 a.m., the DON stated she did not think that increased WBC lab value on [DATE] had anything due to IV antibiotic administration and stated there was no way of proving Resident #7 had any missed doses just the delayed dose on 6/10. She stated she thought the WBC lab could have been related to Resident #7's emotional distress on [DATE] or how the DON drew the lab. The DON stated that she may have drawn lab too quickly and she believed that may have affected lab value. She stated the facility faxed over lab results to IDP office and she would call and speak with RN E at the clinic to see how IDP interpreted the lab results. She stated at that time she had no information on how IDP had interpreted the lab value. She stated that she had spoken to the orthopedic surgeon's office who stated oral antibiotic daily after IV antibiotic would need to be administered for the remainder of resident's life. She stated she was told that the antibiotic may change to different antibiotic medication, but the resident would need treatment for the rest of her life.
During a follow up interview on [DATE] at 03:12 p.m., Resident #7 stated she was seen by plastic surgeon for her left knee wound. She stated during the plastic surgeon's appointment, she was told the surgeon recommended a skin graft and if the graft did not work then they wanted to amputate. She said that she did not want an amputation.
During an attempted telephone interview on [DATE] 11:23 a.m. with the MD, the MD did not answer and a message to return call was left.
During an attempted telephone interview on [DATE] 11:23 a.m. with the IDP nurse, RN E, RN E did not answer and a message to return call was left.
During an interview on [DATE] at 08:13 p.m., the ADMN stated he expected staff to not sign off on treatments unless they verified the treatment was done. He stated staff should not sign off on treatments prior to performing them. The ADMN stated that he expected dressings to be looked at to verify the date on the dressing and assess the site. He stated he felt the failure occurred due to staff becoming busy and had intention of performing but then forgot. The ADMN stated ADON monitors that treatments are performed, and DON was who monitored also. He stated the effect of not performing treatments could lead to infection.
Record review of LVN A's certificate titled Texas IV Therapy Certification dated [DATE] revealed LVN A completed 14 contact hours of the course.
Record review of LVN A's skills check off titled Medication Administration dated [DATE] revealed no evidence of activating vial on snap vial system had been performed.
Record review of LVN A's skills check off titled Medication Administration dated [DATE] revealed no evidence of activating vial on snap vial system had been performed.
Record review of facility policy titled Lab and Diagnostic Results - Clinical Protocol revised on [DATE] revealed: The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.
Record review of facility policy titled Administration of IV Fluids and Medications Reconstituting and Adding Medications to an IV Bag dated 2011 revealed: Reconstituting and adding medications to an IV bag will be done by the professional nurse with documented IV education, as designated by the facility, and as allowed by state regulations. IV medication that is supplied in powdered form must be reconstituted prior to adding it to the IV bag. The nurse who administers the medication will be the same nurse who reconstituted the medication. The nurse reconstituting a medication must be aware of drug stability issues and administer the dose within the appropriate time frame. Consult with the IV pharmacist as needed. After reconstituting and adding medication to an IV bag the infusion must be started within one hour .Label IV bag with resident's name, medication added, dose, rate of infusion, date, time, and initials. Administer and document.
Record review of facility policy titled Dressing Change for Vascular Access Devices dated 2011 revealed: Central venous access device and midline dressing changes will be done at established intervals and [TRUNCATED]

Based on observations, interviews, and record review, the facility failed to store medications in a locked compartment for 3 of 6 (Medication Cart 1, 2 and 3) reviewed for medication storage.
The facility failed to keep each resident's medications in their original containers/packaging.
This failure could result in drug diversion.
Findings included:
During an observation on 06/10/24 at 8:45 PM, RN K was passing medications on hall 3. She was observed with 7 unlabeled pill cups, on top of medication cart #1, that contained resident medications outside of their original blister pack container that included heart, pain, thyroid, and muscle relaxer, antibiotic, and prostrate medications. There were also 3 unlabeled pill cups inside the first unlocked drawer that included narcotics Oxycodone, Hydromorphone and Trazadone outside of their original blister pack container and not locked behind 2 locks.
During an observation on 06/10/24 at 8:58 PM staff member RN J's medication cart #2 on Hall 4 had 2 unnamed pill cups with a Residents 10:00 PM crushed Hydrocodone (pain narcotic) in one and residents 3:00 AM crushed Adderall (stimulant amphetamine) in another unnamed pill cup in the top drawer. On Hall 6, cart #3, there was one Resident unlabeled pill cup with a Tizanidine outside of the original container.
During an interview on 06/10/24 at 8:50 PM RN J stated she was prefilling the resident medication pill cups because she was busy. RN J refused to answer any questions concerning being short staffed or fearing retaliation. She stated she did not know when her last training for medication storage was completed. RN J stated she was covering 3 halls and had 2 other carts that she was responsible for on halls 4 and 6. She stated the possible harm to residents could be a possibility of giving the resident a wrong medication. RN J stated she did not know when her last training was completed. She was then observed labeling the names of residents on the pill cups and placed them inside the top drawer of the Hall 3 med cart. The narcotics remained behind one lock.
During an interview on 06/10/24 at 9:00 PM the DON stated there should never had been open pre-popped medications on the medication carts. She stated it was absolutely unacceptable and was not their policy. She stated staff had orientation upon hire with annual competencies. The DON stated if more trainings were prompted, she would have done so. She stated the DON and ADON monitored the staff and performed check offs when needed as well as observing staff without them knowing from afar. She stated the negative impact to residents were that they could have possibly gotten the wrong medication. The DON stated in passing medications that way could have possibly been detrimental. The DON stated the failure occurred in pre-popping the medication and not administering them as she goes. She stated her expectations were for staff to go from room to room, to pass the medications to each resident before popping the next resident medications.
During an interview on 06/10/24 at 9:05 PM the ADMN stated his expectations were for staff to follow the policies they were provided. He stated if the resident refused, the medication should have been discarded properly or wasted with a second nurse. He stated the monitoring of staff passing meds was a team effort as in upper management.
Record review of facility policy Storage of Medications dated 2007 revealed:
Policy Statement: the facility shall store all drugs and biologicals in a safe, secure, and orderly manner.
Policy Interpretation and Implementation:
1.
Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.
2.
The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean safe and sanitary manner .
5.
Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications .
8.
Drugs shall be stored in an orderly manner in cabinets, drawers, cart, or automatic dispensing systems. Each residence medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 (CNA L and NA) staff observed during incontinent care.
The facility failed to ensure that staff (CNA L and NA) performed proper peri-care (incontinent care) or proper hand hygiene for Resident #28.
These failures placed residents of the facility at risk of infections from incontinent care.
Findings included:
Record Review of resident #28's Face Sheet dated 06/14/2024 revealed a [AGE] year-old male admitted on [DATE] and his latest admission on [DATE]. Review of Resident #28's diagnoses revealed: Hypertension (high blood pressure), Lack of coordination, and Diarrhea.
Record review of Resident # 28's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 15 (cognitively intact). Section H-Bladder and Bowel, resident always incontinent.
During an observation on 06/12/2024 at 10:15 AM, CNA L and the NA performed peri-care with no hand
hygiene or change of gloves between dirty and clean of resident care. The NA was observed in the resident room assisting CNA L with peri-care. CNA L and the NA had performed no hand hygiene or glove changes during the entire duration of resident care.
During an interview on 06/12/2024 at 10:30 AM, CNA L stated she was aware she did not change gloves or wash her hands between clean and dirty and knew she should have done so. She stated she did not have hand sanitizer or gloves in the resident room or in her pocket. CNA L stated she was nervous with more people being in the room.
During an interview on 06/12/2024 at 11:00 AM, the DON stated the staff were supposed to perform proper resident peri-care following all IC protocols. She stated in not doing so, the potential harm could have been spreading infections to other residents. She stated it was the ADON that monitored resident peri-care. The DON stated the failure was not making sure staff was in-serviced or not having random check offs.
She stated her expectations were for every resident to be safe from further infections with staff to use the proper IC protocols they were taught.
During an interview on 06/14/2024 at 10:43 AM, the ADON stated all staff should change their gloves when needed at all times. She stated with peri-care the policy was to change glove and sanitize hands after and in between when going from dirty to clean. The ADON stated it was herself and DON that monitored trainings and follow up. The ADON stated the harm to residents were possibilities of UTI's with the possibilities of spreading infections to other residents. She stated the failure was that staff were nervous as well as staff not having the proper supplies before resident care. The ADON stated her expectations were for staff to take enough gloves into the room and be prepared at all times.
Record review of the policy titled Standard Precautions Hand Washing and Glove Use dated with 06/11/2024 revealed:
All Employees are expected to practice standard precautions to reduce the risk of transmitting infections and the likelihood of exposure and contamination of self from bacteria and germs while in the facility.
To protect the health and welfare of the employees and resident, frequent washing of the employees' hands and required.
Any employee touching blood, body fluids, secretions, excretions and contaminated items must wear gloves. The employee must thoroughly wash their hands after the glove removal. Wearing of gloves does not insure total protection from contamination from germs. During the removal of gloves the potential exists for bodily contact with the infectious gloves. Clean gloves must be put on between each task and procedures involving the same residents. Hands must be washed promptly after glove removal.

**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, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 18 residents (Resident #4) reviewed for resident rights.
The facility failed to ensure staff treated Resident #4 with respect and dignity while performing wound care without the privacy curtain being pulled.
This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.
Findings included:
Resident #4
Review of Resident # 4's face sheet dated 06/14/2024 revealed an [AGE] year-old female admitted on [DATE] and her latest admission on [DATE].
Review of Resident #4's diagnosis revealed: Hypertension (high blood pressure), Pseudomonas (type of bacteria), Diarrhea, and Pruritis (itchy skin).
Review of Resident # 4's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 12 (moderately impaired). Section M-Skin Conditions revealed Skin and ulcer/Injury Treatments, G. Application of nonsurgical dressings, H. Applications of ointments/medications.
Review of Resident # 4's care plan dated 06/14/2023 revealed:
Psychosocial Well-Being: Problem-Resident admitted to facility with a stage 4 pressure wound to medial coccyx. Goal-Resident wound will be treated without complications.
Urinary Incontinence- Problem-resident is incontinent of bowel and bladder. Approach: explain plan of care. Remote dignity by ensuring privacy while providing care.
During an observation on 06/11/2024 at 2:47 PM, Resident #4's wound care was performed with LVN-B without pulling the privacy curtain closed.
During an interview on 06/11/2024 at 3:03 PM, LVN-B stated she should have closed the curtain for resident privacy. She stated even though she had closed the residents door, someone could have opened it, with resident being exposed.
During an interview on 06/11/2024 at 3:00sPM, Resident #4 stated she would prefer for the curtain to be pulled, so that if anyone opened the door, she would not feel embarrassed.
During an interview on 06/11/2024 at 3:05 PM, the DON stated the privacy curtain should have absolutely been pulled for privacy while performing resident wound care. She stated the ADON, and the DON monitored the privacy/dignity training and performed random checkoffs for staff members. The DON stated the negative impact could have been embarrassment for the resident. She stated her expectations were for the privacy curtain to be pulled. She stated the failure occurred when the aide didn't pull the curtain in order to prevent the resident from being seen when staff performed resident care.
During an interview on 06/14/24 at 10:43 AM, the ADON stated not pulling the curtain closed would be a dignity issue. She stated the curtain provided privacy for residents when staff performed resident care. The ADON stated she was in charge of trainings and monitored their education with random checks. She stated the negative impact for residents would have possibly made the resident uncomfortable if the curtain was not pulled. The ADON stated she could not say what the failure was. She stated her expectations were to give the resident privacy and give them the comfort they needed.
During an interview on 06/14/24 at 2:44 PM, the DON stated the curtains should be pulled for privacy while performing resident care as well as while transferring the resident from the bed to wheelchair. She stated the ADON, and the DON monitored the privacy/dignity training and performed random checkoffs for staff members. She stated the failure occurred when the aide didn't pull the curtain in order to prevent the resident from being seen when staff performed resident care. The DON stated the negative impact could have been embarrassment for the resident. She stated her expectations were for the privacy curtain to be pulled.
Review of facility policy Quality of Life-Dignity date August 2009 revealed:
Policy statement:
Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.
Policy Interpretation and Implementation:
1.
Resident shall be treated with dignity and respect at all times.
2.
Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth
10. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.
11. Demeaning practices and standards of care that compromise dignity are prohibited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services related to protecting the resident's privacy for 1 (Resident #28) of 18 residents reviewed for resident rights.
1. The facility failed to ensure staff treated Resident #28 with respect and dignity while performing peri-care without the privacy curtain being pulled.
2. The facility failed to ensure staff treated Resident #28 with respect and dignity while performing transferring of Resident from bed to chair with a Hoyer Lift without the privacy curtain being pulled.
This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.
Findings included:
Resident #28
Review of Review of Resident # 28's face sheet dated 06/14/2024 revealed a [AGE] year-old male admitted on [DATE] and her latest admission on [DATE].
Review of Resident #28's diagnosis revealed: Hypertension (high blood pressure), Lack of coordination, and Diarrhea.
Review of Resident # 28's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 15 (cognitively intact).
Section H-Bladder and Bowel, resident always incontinent.
Section GG-Functional Abilities and Goals, Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
Review of Resident # 28's care plan dated 03/13/2024 revealed:
No evidence of Category- Resident is continent of bladder uses urinal, and incontinent bowel.
Approach-Provide incontinent care as needed post each incontinent episode. Approach-provide privacy.
Admission-Resident requires use of Hoyer/mechanical lift and is at risk for injury. Goal-resident will be transferred safely and be free from significant injury through next quarter. Approach-Provide privacy.
During observation on 06/12/2024 at 10:15 AM, CNA L and the NA performed peri-care and did not pull the privacy curtain. During this time another CNA (unknown) opened the door and asked if they needed help. The curtain still had not been pulled for privacy of the resident.
During an interview on 06/14/24 at 10:43 AM, the ADON stated not pulling the curtain closed would be a dignity issue. She stated the curtain provided privacy for residents when staff performed resident care. The ADON stated she was in charge of trainings and monitored their education with random checks. She stated the negative impact for residents would have possibly made the resident uncomfortable if the curtain was not pulled. The ADON stated she could not say what the failure was. She stated her expectations were to give the resident privacy and give them the comfort they needed.
During an interview on 06/14/24 at 2:44 PM, the DON stated the curtains should be pulled for privacy while performing resident care as well as while transferring the resident from the bed to wheelchair. She stated the ADON, and the DON monitored the privacy/dignity training and performed random checkoffs for staff members. She stated the failure occurred when the aide didn't pull the curtain in order to prevent the resident from being seen when staff performed resident care. The DON stated the negative impact could have been embarrassment for the resident. She stated her expectations were for the privacy curtain to be pulled.
Review of facility policy Quality of Life-Dignity date August 2009 revealed:
Policy statement:
Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.
Policy Interpretation and Implementation:
1.
Resident shall be treated with dignity and respect at all times.
2.
Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth
10. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.
11. Demeaning practices and standards of care that compromise dignity are prohibited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Resident #2, Resident #7, Resident #28, Resident #51) of 18 residents reviewed for comprehensive care plans.
The facility failed to develop a PASRR care plan Resident #2.
The facility failed to develop care plan goals for Resident #28 related to his ADL Functions.
The facility failed to ensure LVN N administered Resident #51's Insulin Glargine 7 times during a 2-month review period, per physician order.
The facility failed to ensure RN F administered Resident #51's Insulin Glargine 4 times during a 2-month review period, per physician order.
The facility failed to ensure LVN D administered Resident #51's Insulin Glargine 1 time during a 2-month review period, per physician order.
The facility failed to ensure LVN M administered Resident #51's Insulin Glargine 1 time during a 2-month review period, per physician order.
The facility failed to ensure LVN B changed Resident #7's central line dressing, when LVN B documented she had changed the central line dressing.
The Facility failed to ensure LVN C changed Resident #7's central line dressing, when LVN C documented he had changed the central line dressing.
These failures could affect residents by placing them at risk for not having their individual needs met.
Findings included:
Resident #2
Record review of Resident #2's face sheet dated [DATE] revealed a [AGE] year-old male originally admitted on [DATE], with the following diagnoses hypertension (high blood pressure), type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), pressure ulcer of right buttock, stage 3, muscle wasting, paranoid schizophrenia, and major depressive disorder.
Record review of Resident #2's admission MDS dated [DATE] revealed Section C- Cognitive Patterns, Resident #2 had a BIMS score of 0 meaning an interview was not conducted with resident because Resident #2 was rarely/never understood.
Record review of Resident #2's PASRR Level 1 Screening dated [DATE] revealed Resident #2 was PASRR positive and required PASRR services.
Record review of Resident #2's Comprehensive Care Plan dated [DATE] revealed no evidence of Resident #2's PASRR services identified in the Comprehensive Care Plan.
Resident #28
Review of Resident # 28's face sheet dated [DATE] revealed a [AGE] year-old male admitted on [DATE] and her latest admission on [DATE]. Resident #28's diagnosis was, Hypertension (high blood pressure), Lack of coordination, and Diarrhea.
Review of Resident # 28's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 15 (cognitively intact).
Section H-Bladder and Bowel, resident always incontinent.
Section GG-Functional Abilities and Goals, Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
Record review of Resident #28's Care Plan dated [DATE] revealed no evidence of goals for the target date for his ADL Functions.
Resident #51
Record review of Resident #51's face sheet dated [DATE] revealed a [AGE] year-old male originally admitted on [DATE], with the following diagnoses heart failure, hypertension (high blood pressure), type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), peripheral vascular disease, coronary artery disease and wound infection.
Record review of Resident #51's Annual MDS dated [DATE] revealed Section C- Cognitive Patterns Resident #51 had a BIMS score of 14 meaning cognitive intact.
Record review of Resident #51's care plan dated [DATE] revealed; Diabetic status will remain stable AEB by resident blood sugar staying within the resident's normal limits through next quarter. Edited on [DATE]. Interventions for Resident #51 revealed: Administer medications as ordered and monitor for side effects, effectiveness. Date Initiated: [DATE], Revision on: [DATE].
Record review of Resident #51's physician order dated [DATE] revealed: Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/ml (3ml) 25 units subcutaneous twice per day, with a start date of [DATE], no evidence of specific parameters.
Record review of Resident #51's electronic MAR for the months of [DATE] and [DATE] revealed insulins being held:
1.
[DATE] Lantus 25 units held at 7:00AM recorded by LVN N.
2.
[DATE] Lantus 25 units held at 7:00AM recorded by LVN N.
3.
[DATE] Lantus 13 units given at 8:00PM recorded by RN F.
4.
[DATE] Lantus 25 units held at 7:00AM recorded by LVN N.
5.
[DATE] Lantus 25 units held at 7:00AM recorded by LVN N.
6.
[DATE] Lantus 25 units held at 7:00AM recorded by LVN N.
7.
[DATE] Lantus 25 units held at 8:00PM recorded by LVN D.
8.
[DATE] Lantus 13 units given at 8:00PM recorded by RN F.
9.
[DATE] Lantus 12 units given at 8:00PM recorded by RN F.
10.
[DATE] Lantus 25 units held at 7:00AM recorded by LVN N.
11.
[DATE] Lantus 25 units held at 8:00PM recorded by LVN M.
12.
[DATE] Lantus 25 units held at 7:00AM recorded by LVN N.
13.
[DATE] Lantus 10 units given at 8:00PM recorded by RN F.
Review of Resident #51's electronic progress notes for [DATE] and [DATE] revealed no evidence of notification of physician for holding ordered insulin or adjusting units of insulin given.
Observation on [DATE] at 2:30 PM revealed Resident #41 sitting in wheelchair at nurses station. Resident #41 appeared to be clean and alert but would only respond with head nod to questions.
Resident #7
Record review of Resident #7's face sheet dated [DATE] revealed [AGE] year-old female originally admitted on [DATE] with most recent readmission on date [DATE]. Resident #7's diagnoses included: encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (surgery involving skin and below skin tissue), presence of left artificial knee joint (previous left knee surgery), encounter for removal of internal fixation device (surgery revision), methicillin resistant staphylococcus aureus infection (antibiotic resistant infection), and pain.
Record review of Resident #7's quarterly MDS dated [DATE] revealed: BIMS score of 13 which indicated cognitively intact. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed resident received IV medication.
Record review of Resident #7's care plan dated [DATE] revealed resident had right chest central line and was at risk for infection, pain, infiltration, cardiac and respiratory issues. The goal was for Resident #7 to be free from infections, infiltration, and adverse effects. The facility staff approach included for staff to assess IV site q shift and prn. Further review of care plan revealed Resident #7 had post-surgical history of infection. The goal was for Resident #7's infection to be cleared by the target date and for complications related to the infection. The facility staff approach included staff will administer medications as ordered, monitor lab work as ordered and report results to physician.
Record review of Resident #7's electronic physician orders dated [DATE] revealed: Midline catheter: change catheter site dressing / securement device every week on Monday and as needed with transparent dressing with start date of [DATE]. Further investigation revealed midline catheter was really a central line.
Record review of Resident #7's electronic MAR for the months of [DATE] and [DATE] revealed midline catheter dressing had been changed:
1.
[DATE] by LVN B
2.
[DATE] by LVN C
3.
[DATE] by LVN B
During an interview on [DATE] at 10:54 AM LVN C stated he had not changed the central line dressing and that if he had signed that he had performed it was signed in error. He stated he would sign off on task in MAR prior to performing task and would have made his best effort to perform the task. He stated the error may have been due to there were a lot of distractions in the facility and may have forgotten to perform. He stated that distractions resulted from him trying to make himself available to all residents and would be approached routinely by residents even if they were not assigned to him and he would attempt to help them.
During an interview on [DATE] at 2:51 PM LVN B stated she worked on [DATE] and she did sign that central line dressing had been changed since the facility had a RN performing treatments that day and she thought the RN changed the dressing. She stated usually the RN treatment nurse would let her know treatment had been performed and she would sign that it had been completed. She stated that she should have verified by observing central line dressing had been changed and did not remember why she did not verify it prior to signing that it was completed in MAR. She stated she had been in-serviced about central line dressings yesterday on changing dressing per orders and verifying treatment done prior to checking off it had been performed. She stated she should not check off treatments she had not performed.
During an attempted telephone interview on [DATE] at 3:10 PM with LVN B, LVN B did not answer and message to return call was left, LVN B did not return call.
During an attempted telephone interview on [DATE] at 3:12 PM with LVN C, LVN C did not answer and message to return call was left, LVN C did not return call.
During an interview on [DATE] at 9:56 AM LVN N stated she was an LVN N and had worked at the facility since [DATE]. LVN N stated she had received training on how to administer insulin. LVN N stated Lantus was a long-acting insulin that lasts for 8 to 10 hours and will be peak at 6 hours. LVN N stated there should have been parameters to follow in the physician's orders. LVN N stated Resident #51's Lantus order did not have parameters but would hold if his blood glucose was low. LVN N stated she had not contacted Resident #51's physician about holding his Lantus. LVN N stated she had used her nursing judgment from the history she had with Resident #51. LVN N stated her nursing judgement was based on the Texas Board of Nursing. LVN N stated she had never adjusted the units ordered for Lantus and the physician should have been contacted if the units were changed. LVN N stated the negative impact to residents for not following physician orders could have been residents could have been running high blood sugars, high blood sugars decrease wound healing, blood pressures be altered, could be eating and drinking more because sugars running high, and could have gone into diabetic coma.
During an interview on [DATE] at 10: 30 AM the DON stated her expectation was that nursing staff follow physician orders, if they make any changes to medication dosage, they should have contacted the physician and document conversation with Dr and his recommendations. The DON stated she had been the DON at the facility for the past 2 years. The DON stated she had received training (when she started at facility and from her nursing education) and her staff had received training on how to administer insulin. The DON stated nursing staff were trained as part of their checked off at hire and during the yearly competencies. The DON stated Lantus was a long-acting insulin. The DON stated the units of Lantus was based on each resident's needs. The DON stated nurses should have followed the physician's order. The DON stated if nurse felt they needed to hold Lantus they should have contacted the physician and the conversation with the physician should have been documented in Resident's progress notes or on the MAR. The DON stated the standard of practice the facility followed was the Board of Nursing standards of Practice. The DON stated the negative impact to residents for not following physician orders could have been not having good control of blood glucose, which could have been hard on the body, that could have led to detrimental effects if blood glucose was too high or too low for too long. The DON stated what led to failure of LVN N not contacting physician was LVN N had worked at facility for several months and knew the physicians orders and parameter and got complacent of what his normal parameters are and it did not trigger to contact the physician. The DON stated she did not know of any of her nurses who would have changed medication dosage without speaking to physician first, the failure happened because staff did not document those conversations. The DON stated changing medications dosage without speaking with physician would be nurses practicing out of their scope, this could have caused detrimental effects to residents.
During an interview on [DATE] at 11:27 am the MD stated his expectation was that nursing staff follow orders and contact him with any changes. The MD stated he did not have an issue with holding Lantus with a blood glucose below 100. The MD stated the Lantus dosage should not have been altered unless he was contacted. The MD stated Resident #51 missing the doses of Lantus did not have an adverse effect on resident.
During an interview on [DATE] at 03:38 PM RN F stated she had adjusted Resident #51's Lantus before based on his blood glucose and if he was going to eat a snack or not. RN F stated another nurse had told her it was ok to give him lower dose. RN F stated she did not know if she had messaged the physician or she failed to document conversation with physician. RN F stated at another facility a resident died because their blood glucose bottomed out, she stated she guessed that incident skewed her judgement.
During an interview on [DATE] at 8:13 PM the ADMN stated his expectation was nurses should have contacted physician before holding and/or changing dosage of medication. The ADMN stated residents could have been affected by infections not getting better, worsen, insulin being held could have caused them to have extremely low or extremely high blood glucose. The ADMN stated what led to failure was nurse staff used their judgement because they felt they knew the resident's routine and their blood sugar ranges. The ADMN stated his expectation was staff's documentation be done accurately, correctly and thorough. The ADMN stated staff should never assume someone else was going to complete a treatment and documents for them or you should not click prior to completing a treatment. The ADMN stated what led to failure was she had gotten busy and forgot to perform the task/treatment. The ADMN stated the effect on residents could have been treatments missed, infections or wounds could have gotten worse. The DON and the ADON were responsible for monitoring to ensure staff were performing tasks/treatment.
During an interview on [DATE] at 2:18 PM the MDS Coordinator stated that if a resident was PASSAR positive it should have been incorporated in the Comprehensive care plan. The MDS Coordinator stated she was responsible for ensuring the comprehensive care plans were complete. The MDS Coordinator stated she did not have an excuse to why the documents had not been uploaded into the care plan.
During an interview on [DATE] at 2:36 PM the DON stated the goal boxes should have been checked in the blanks and was an oversight the template had not been completed. She stated there were templates that the MDS applied, with it not being finished. The DON stated the potential for harm possibly could have been not giving the proper care to residents.
The DON stated the facility protocol was for staff to go look at the Care Plans and should have been caught by now. She stated the negative impact for residents was staff not knowing exactly what they were supposed to be working on for them.
During an interview on [DATE] at 2:30 PM the ADON stated the DON should have monitored as well as upper management that helped with resident Care plan. She stated staff should have followed up if they had seen there were no comment in the blanks. The ADON stated the failure occurred with staff not rechecking their work and with using a template, she stated it's a fill in the blank. She stated she felt the negative impact to residents could have been improper care with her expectations was for all goals and interventions to be completed.
Record review of Policy and Procedure for Comprehensive Person-Centered Care Plan dated 2010 revealed:
Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .
3.
Each resident's comprehensive care plan is designed to:
a.
Incorporate identified problem areas;
e. Reflect treatment goals, timetables and objectives in measurable outcomes;
Record review of Texas Board of Nursing website, https://www.bon.texas.gov accessed on [DATE] revealed A nurse has a duty to the patient which cannot be superseded by hospital policy or physician's order.
Record review of the Texas Board of Nursing website, https://www.bon.texas.gov/pdfs/practice_dept_, accessed on [DATE] revealed Scope of Practice Decision-Making Model dated [DATE]: 2. Is the activity or intervention authorized by a valid order If there is any question about the accuracy or appropriateness of an order, clarification must be sought [Board Rule 217.11(1)(N)]
Record review of Texas Board of Nursing website, https://www.bon.texas.gov/rr_current/217-11.asp.html, accessed on [DATE] revealed Board Rule 217.11(1)(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment;
Record review of facility job description titled Registered Nurse dated February 2024 revealed: Monitor medication passes and treatment schedules to assure that medications are being administered as ordered and that treatments are provided as scheduled. Consult with the resident's physician and planning resident care, treatment, rehabilitation, etc. Notify the resident's physician and responsible party when there is a change in their resident's condition or unusual incident Document in the nurses notes appropriate information to indicate that the plan of care is being followed Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long term care.
Record review of facility job description titled Licensed Vocational Nurse dated February 2024 revealed: Monitor medication passes and treatment schedules to assure that medications are being administered as ordered and that treatments are provided as scheduled. Consult with the resident's physician and planning resident care, treatment, rehabilitation, etc. Notify the resident's physician and responsible party when there is a change in their resident's condition or unusual incident Document in the nurses notes appropriate information to indicate that the plan of care is being followed Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long term care.

Based on interviews, and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance for 3 of 10 days reviewed for sufficient staffing.
The facility failed to maintain nurse staffing at the level indicated by the PPD budget on 05/04/2024, 05/12/2024 and 06/01/2024.
This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met.
Findings included:
Record review of timesheets dated 05/04/2024 revealed 168.65 hours worked by direct care staff. Per facility PPD and census, 222.30 direct care staff hours were needed.
Record review of timesheets dated 05/12/2024 revealed 199.39 hours worked by direct care staff. Per facility PPD and census, 228 direct care staff hours were needed.
Record review of timesheets dated 06/01/2024 revealed 170.84 hours worked by direct care staff. Per facility PPD and census, 228 direct care staff hours were needed.
During an interview on 06/10/2024 at 10:49 AM Resident # 7 stated there was not enough staff. Resident #7 stated at night she might have to wait an hour to be changed and she had issues with skin breakdown. Resident #7 stated she did not feel she was getting enough showers and normally got one shower a week but sometimes twice.
During an interview on 06/10/2024 at 4:38 PM Resident # 29 stated the facility was short staffed on the weekends and at night. Resident #29 stated she had a fall recently, during the day. Resident #29 stated it took several staff to take care of her, she was fearful that if she were to fall on the weekend or at night and another resident were to fall also there would not be enough staff to take care of them both.
During an interview on 06/10/24 at 8:50 PM RN K refused to answer any questions concerning the facility being short staffed or fear of retaliation. RN K stated, I value my job too much, and did not provide any other response.
During a confidential interview on 06/12/2024 at 10:38 AM stated they were happy the state surveyors where in the building because it meant they would have the help they needed to take care of residents. Confidential interview was tearful as they explained there have been several times that there were only 2 aides to take care of the residents on five of the 6 halls.
During an interview on 06/12/2024 at 2:52 PM Resident #4 stated it took staff a while to answer her call light. Resident #4 stated she felt they did not have enough people working at the facility. Resident #4 stated she had issues with her wound dressing falling off in the middle of the night and staff not putting another bandage on until the next afternoon. Resident #4 stated she was scared that loose stool would get into her wound.
During an interview on 06/14/24 at 7:35 PM the DON stated the ADON was responsible for completing the daily staffing schedule. The DON stated she was responsible to monitor staffing. The DON stated her expectation was to have one CNA per 5 of 6 halls and 2 CNA's on the secure unit for the day shift. 2-3 nurses' day shift. The DON stated her expectation for the night shift was 4 aides and 2 nurses and with partial nurse. The DON stated their cooperate has a rate that provides the goal for direct care staff, the PPD rate was 2.85. The DON stated you multiply the PPD by the census and that gives the total direct care staff hours needed. The DON stated being short staffed could have affected residents by higher risk of falls, call lights not being answered timely, or potential for residents missing showers. The DON stated what led to failure was not having enough staff and they have tried to hire more staff.
During an interview on 06/14/2024 at 8:13 PM the ADMN stated the ADON was responsible for scheduling and the DON will makes adjustments to the schedule. The ADMN stated his expectation was to reach the PPD goal daily or as close to it as they can. The ADMN stated not reaching the daily PPD goal could have caused skin break down from having to wait too long for peri care, people who fall could have had to lay in floor waiting to be evaluated. The ADMN stated he, the DON and the ADON monitored by using the staffing sheet. The ADMN stated what led to failure of being under the PPD goal was staff quit without giving notice, will call in, or will no show/no call. The ADMN stated he has a budget sheet, from corporate, that provided him with the PPD. The ADMN stated the PPD for direct care staff was 2.85.
Record review of facility policy titled, Staffing dated April 2007 revealed Our facility provides adequate staffing to meet needed care and services for our resident population. Our facility maintains adequate staffing on each shift to ensure that our residents needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. Certified Nursing Assistants are available ton each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan.
Record review of facility provided form revealed the direct care total (PPD) was 2.85.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure physician visits were conducted once every 30 days for 2 of 18 residents (Resident #2, Resident #73) and every 60 days for 4 of 18 residents (Resident #25, Resident #46, Resident #51, Resident #56) who were reviewed for physician visits.
The facility failed to have Resident #2 seen by physician at least once every 30 days for the first 90 days after admission on [DATE]. The facility failed to provide documentation that Resident #2 was seen in April 2024.
The facility failed to have Resident #73 seen by physician at least once every 30 days for the first 90 days after admission on [DATE]. The facility failed to provide documentation that Resident #73 was seen in March 2024, April 2024 and May 2024.
The facility failed to have Resident #25 seen by physician at least every 60 days after the first 90 days for the past year from March 2023. The facility failed to provide documentation that Resident #25 was seen April 2023 and August 2023.
The facility failed to have Resident #46 seen by physician at least every 60 days after the first 90 days for the past year from March 2023. The facility failed to provide documentation that Resident #46 was seen December 2023.
The facility failed to have Resident #51 seen by physician at least every 60 days after the first 90 days for the past year from March 2023. The facility failed to provide documentation that Resident #51 was seen April 2023.
The facility failed to have Resident #56 seen by physician at least every 60 days after the first 90 days for the past year from March 2023. The facility failed to provide documentation that Resident #56 was seen April 2023.
These failures could lead to a decline in health status or untreated conditions.
Findings included:
Resident #2
Record review of Resident #2's face sheet dated 06/14/2024 revealed a [AGE] year-old male originally admitted on [DATE], with the following diagnoses hypertension (high blood pressure), type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), pressure ulcer of right buttock, stage 3, muscle wasting, paranoid schizophrenia, and major depressive disorder.
Record review of Resident #2's admission MDS dated [DATE] revealed Section C- Cognitive Patterns Resident #2 had a BIMS score of 0 meaning an interview was not conducted with resident because Resident #2 was rarely/never understood.
Record review of Resident #2's electronic charting and paper review revealed no physician visit for April 2024.
Resident #73
Record review of Resident #73's face sheet dated 06/14/2024 revealed [AGE] year-old male originally admitted on [DATE] with the following diagnoses Alzheimer's disease, acute kidney failure, and hypertension (high blood pressure).
Record review of Resident #73's Quarterly MDS dated [DATE] revealed Section C- Cognitive Patterns Resident #73 had a BIMS score of 0 meaning an interview was not conducted with resident because Resident #2 was rarely/never understood.
Record review of Resident #73's electronic charting and paper review revealed no physician visits for March 2024, April 2024 and May 2024.
Resident # 25
Record review of Resident #25's face sheet dated 06/14/2024 revealed [AGE] year-old female originally admitted on [DATE] with the following diagnoses respiratory failure, anxiety disorder, pain, kidney failure and type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well).
Record review of Resident #25's Quarterly MDS dated [DATE] revealed Section C- Cognitive Patterns Resident #25 had a BIMS score of 15 meaning cognitively intact.
Record review of Resident #25's electronic charting and paper review revealed no physician visits for April 2023.
Resident #51
Record review of Resident #51's face sheet dated 06/14/2024 revealed a [AGE] year-old male originally admitted on [DATE], with the following diagnoses heart failure, hypertension (high blood pressure), type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), peripheral vascular disease, coronary artery disease and wound infection.
Record review of Resident #51's Annual MDS dated [DATE] revealed Section C- Cognitive Patterns Resident #51 had a BIMS score of 14 meaning cognitive intact.
Record review of Resident #51's electronic charting and paper review revealed no physician visit for April 2023.
Resident #56
Record review of Resident #56's face sheet dated 06/14/2024 revealed a [AGE] year-old male originally admitted on [DATE], with the following diagnoses hypertension (high blood pressure), major depressive disorder, anxiety, age related cognitive decline, pain and nicotine dependence.
Record review of Resident #56's Quarterly MDS dated [DATE] revealed Section C- Cognitive Patterns Resident #56 had a BIMS score of 8 meaning moderate cognitive impairment.
Record review of Resident #56's electronic charting and paper review revealed no physician visit for April 2023.
During an interview on 06/14/2024 at 7:35 PM the DON stated her expectation was that residents should have been seen within 30 days of their admission, then every 30 days within the first 90 days, and then every 60 days after. The DON stated she was responsible for monitoring and ensuring residents received their physician visits timely. The DON stated residents could have been affected by not receiving their physician visits by orders not being reviewed by physician, and residents may not have been assessed accurately. The DON stated what led to failure was physicians not coming in to see their residents. The DON stated she had realized physicians were not seeing residents per the required guidelines and had been working with their MD on how to better track visits. The DON stated she was not sure what happened in April 2023 because there were several missed visits missed by the MD.
During an interview on 06/14/2024 at 8:13 PM the ADMN stated his expectation was that residents be seen by physician per guidelines. The ADMN stated that residents should have been seen by their primary physician every 30 days for the first 90 days and then every 60 days thereafter. The ADMN stated he knew they had issues with physician visits not occurring in timely manner, but that the DON had been working on a better system to track physician visits.
The ADMN stated the DON was responsible for monitoring physician visits. The ADMN stated residents could have been affected by having missed physician visits, residents like to see their physician, missed medication changes, or wounds not being assessed. The ADMN stated what led to failure was not being able to get physicians to come in timely manner.
Record review of facility policy titled Physician Visits with the date of April 2013 revealed, The attending physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, 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/or the residents' goals and preferences, for 1 of 18 residents (Residents #70) reviewed for respiratory care.
The facility failed to ensure that Residents #70's oxygen tubing had been changed and dated once weekly.
This failure placed residents that used oxygen/treatments at risk of respiratory complications and/or possible respiratory infections.
Findings included:
Review of Resident # 70's face sheet dated 06/14/2024 revealed an [AGE] year-old female admitted on [DATE]. Resident #70's diagnoses was, Chronic respiratory failure, heart disease, upper respiratory infection, cough, pain, anxiety, and shortness of breath.
Review of Resident #70's
Review of Resident #70's open ended (no end date) orders, dated 07/12/2023, revealed: Change nebulizer tubing every week on Sunday, once a day on Sunday 6:00 PM-6:00AM shift.
Review of Resident # 70's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 09 (moderately impaired). Section O-Special Treatments-Respiratory Treatments-Oxygen Therapy.
Review of Resident # 70's care plan dated 04/26/2024 revealed: Category-Oxygen Therapy.
Problem-Potential for complications, s/sx (signs and symptoms) related to diagnosis of COPD.
Goal-Will have respiratory rate within normal limits, be free of s/sx of respiratory distress, and maintain optimal functioning within limitations imposed by disease process through review date.
Approach- Nebulizer treatments and/ or inhalers as ordered. Monitor for effectiveness, and side effects.
During an observation on 06/14/2024 at 2:55 PM with the DON of Resident#70's Nebulizer tubing revealed it had 05/06/2024 written on it.
During an interview on 06/14/2024 at 2:55 PM the DON stated the Nebulizer tubing should have been changed since 05/06/2024. She stated the tubing should have been removed from the nebulizer, and staff should never have dated the tubing per policy. The DON stated she did not know how to respond to who should have been monitored. She stated Oxygen tubing, should be changed every Sunday at night whether the resident used it, or not. The DON stated there were some controversies dating the tubing when changed or not because it pops up on the computer Sunday night for the staff to change out. She stated she felt there was not a need to place the date on the tubing. She stated the Interdisciplinary Team should have monitored making rounds. and they can tell with by looking and the way they look. The DON stated the negative effects could have placed residents at potential higher risk of respiratory infection as well as hovering bacteria. She stated the failure occurred with not following the EMAR and changing the tubing on the nebulizer when time.
The facility provided no evidence of a policy in which the respiratory tubing should be dated when changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 resident (Resident #7) reviewed for peripheral intravenous care.
1.
The facility failed to ensure LVN A administered Resident #7's IV (intravenous) antibiotics consistent with professional standards of practice and in accordance with physician orders.
2.
The facility did not ensure Residents #7's central line dressings were changed per the physician's order.
3.
The facility failed to draw labs weekly per physician orders while Resident #7 was on IV antibiotics.
An Immediate Jeopardy (IJ) was identified on [DATE] at 3:23 p.m. While the IJ was lowered on [DATE] at 11:22 p.m., the facility remained out of compliance at a severity level of no actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions.
These failures placed residents at risk of relapse of an ongoing infection and developing a secondary infection.
Findings include:
Resident #7
Record review of Resident #7's face sheet dated [DATE] revealed [AGE] year-old female originally admitted on [DATE] with most recent readmission on date [DATE]. Resident #7's diagnoses included: encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (surgery involving skin and below skin tissue), presence of left artificial knee joint (previous left knee surgery), encounter for removal of internal fixation device (surgery revision), methicillin resistant staphylococcus aureus infection (antibiotic resistant infection), and pain.
Record review of Resident #7's quarterly MDS assessment dated [DATE] revealed: BIMS score of 13 which indicated cognition was intact. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed resident received IV medication.
Record review of Resident #7's care plan dated [DATE] revealed resident had right chest central line and was at risk for infection, pain, infiltration, cardiac, and respiratory issues. The goal was for Resident #7 to be free from infections, infiltration, and adverse effects. The facility staff approach included for staff to assess IV site q shift and prn. Further review of care plan revealed Resident #7 had post-surgical history of infection. The goal was for Resident #7's infection to be cleared by the target date and for complications related to the infection. The facility staff approach included staff will administer medications as ordered, monitor lab work as ordered and report results to physician.
Record review of Resident #7's electronic physician orders dated [DATE] revealed: Midline catheter: change catheter site dressing / securement device every week on Monday and as needed with transparent dressing with start date of [DATE].
Record review of Resident #7's electronic MAR for the months of [DATE] and [DATE] revealed midline catheter dressing had been changed:
1.
[DATE] by LVN B
2.
[DATE] by LVN C
3.
[DATE] by LVN B
Resident #7's electronic physician orders dated [DATE] revealed: meropenem 1 gram to be administered IV every 8 hours for diagnosis of infection and inflammatory reaction due to internal left knee prosthesis (left artificial knee infection).
Record review of Resident #7's electronic MAR for the months of [DATE] and [DATE] revealed meropenem had been administered:
1.
[DATE] at 4:00 p.m. by LVN A
2.
[DATE] at 8:00 a.m. by LVN A
3.
[DATE] at 4:00 p.m. by LVN A
4.
[DATE] at 12:00 a.m. by LVN A
5.
[DATE] at 8:00 p.m. by LVN A
Review of Resident # 7's electronic physician orders dated [DATE] revealed: lab CBC w/Diff (a blood test that measures red blood cell count, white blood cell count and platelet count), CMP (a blood test that measures the body's fluid balance, electrolytes like sodium and potassium, and how well the kidneys and liver are working), ESR (a blood test that measures the level of inflammation in the body), CRP (a blood test that can measure a protein produced by the liver in response to inflammation or infection in the body) lab to be drawn once a day on Thursday with start date of [DATE].
Record review of Resident #7's electronic MAR for the months of [DATE] and [DATE] revealed lab CBC w/Diff, CMP, ESR, and CRP lab was performed:
1.
[DATE] by DON
2.
[DATE] by LVN C
3.
[DATE] by LVN A
4.
[DATE] by LVN C
Record review of Resident #7's lab results dated [DATE] revealed WBC was 7.97 (acceptable range between 4.0 - 11.0), ESR was 37 (acceptable range between 0 - 30), and CRP was 0.4 (acceptable range between 0.0 - 0.6).
Record review of Resident #7's lab results dated [DATE] revealed WBC was 11.42 (acceptable range between 4.0 - 11.0) indicated infection, ESR was 30 (acceptable range between 4.0 - 11.0), and CRP was 0.6 (acceptable range between 0.0 - 0.6).
Record review of Resident #7's hospital discharge paperwork dated [DATE] revealed a progress note from the IDP revealed she had original left total knee arthroplasty (surgical procedure in which parts of a damaged joint are removed and replaced) (in 2007, followed by revision in February 2020, then followed by two subsequent incision and drainage procedures in 2020. In [DATE], she underwent explant (removal of surgical hardware) of left knee arthroplasty and spacer placement. On [DATE] she underwent revision of left total knee arthroplasty. The plan was to continue meropenem (antibiotic medication), follow up on cultures, six weeks of antibiotic with end of treatment [DATE], monitor labs, supportive care, and placement of tunneled catheter ordered. Discharge planning included meropenem 1 gram every 8 hours with end date [DATE]. Patient to follow up in the ID (Infectious Disease) clinic in 3 weeks. Check lab CBC (a blood test that measures red blood cell count, white blood cell count and platelet count), CMP (a blood test that measures the body's fluid balance, electrolytes like sodium and potassium, and how well the kidneys and liver are working), ESR (a blood test that measures the level of inflammation in the body), CRP (a blood test that can measure a protein produced by the liver in response to inflammation or infection in the body) while on IV antibiotics. Provide central line dressing weekly and prn.
During an observation and interview on [DATE] at 10:49 a.m., Resident #7 had IV bag of 100 mL of NS infusing into right chest double lumen central line. On the medication bag there were instructions to *ACTIVATE VIAL PRIOR TO USE*. In the vial white powder (meropenem 1 gram) was observed and was dry. No date and time were written on IV tubing or on IV bag and it was being infused at 100 mL/hr using IV pump. There was approximately 25 mL left of NS in bag. The central line dressing loose, pulled away from skin toward bottom of the dressing, was not sealed to maintain sterile environment and moved when Resident #7 lifted shirt. Resident #7 stated she did not know when the dressing had been changed last. She stated she did not remember if facility staff had ever changed out the dressing. Date observed on central line dressing to be [DATE].
During an interview on [DATE] at 11:14 a.m., the DON stated she expected for central line dressings to be changed every 7 days or prn when dressing was compromised. She stated central line dressing should be assessed by every nurse that is performing IV medication administration and she did not know why the central line dressing had not been changed since [DATE]. She stated central line dressings should be intact and it should not be loose at the bottom. The DON stated not performing dressing changes when needed or every 7 days could cause resident to have infection at the insertion site. She stated that she expected IV tubing to be timed and dated when it was hung. She did not know why tubing was not timed and dated. She stated the powdered medication in vial should have been activated by popping the seal from IV bag to powdered vial, then mixing into the solution in IV bag prior to medication being administered. She stated she had personally checked off LVN A on IV medication administration and did not know why she failed to mix medication into the bag. She stated that sometimes the pharmacy would send already mixed medication in solution and LVN A may have thought it was already mixed. She stated not mixing medication meant that resident did not get antibiotic as ordered and she had instructed LVN A to call physician to notify of missed dose. The DON stated she monitored IV medication was given correctly.
During an interview on [DATE] at 11:21 a.m., LVN A stated she had administered IV medication that morning. She stated she hung medication with new tubing but did not label tubing with date or time. She stated the central line dressing should be intact and tight to skin. She stated she would change the central line dressing. LVN A stated loose central line dressing could cause resident to have infection and should be sealed. She stated she did not mix up the medication from vial into IV bag because it was coming premixed, and she thought medication was in the bag without her having to mix it. She stated not mixing the medication meant that resident did not get antibiotic dose.
During an interview on [DATE] at 12:28 p.m., the Pharmacy Director with contracted pharmacy the facility used stated the pharmacy record showed as long as the pharmacy had been filling meropenem (antibiotic) medication to Resident #7, the facility had received medication in a snap together vial. He stated typically it was an insurance issue on how the medication was filled. He stated the pharmacy had written instructions on the bag label to activate vial prior to use but no separate instructions were sent to the facility. He stated the effect of facility staff not activating vial would interfere with mixing the medication and no antibiotic would have been infused if it was not activated prior to infusion. He stated the effect on the resident would be she would have gotten hydration with a little bit of sodium, and it would not have harmed her. He stated whatever the medication in the vial was prescribed to treat, would not have been treated and could have interfered with wound healing if Resident #7 missed doses.
During a follow up interview on [DATE] at 02:49 p.m., the DON stated IV Certificate education should include management of the IV access site including central lines, and administration of IV medication including how to prepare medication. The DON stated IV Certification education was provided outside of the facility, but the curriculum matched what the contracted pharmacy had in their training. She stated no other residents in the facility had IV medication ordered currently that had to be activated prior to administration currently. The DON stated she talked to the nurse that was responsible for changing the central line dressing on [DATE]. She stated LVN B told her the central line dressing was not changed by LVN B due to there was a treatment nurse that day and LVN B assumed the treatment nurse would change the dressing. The DON stated she expected the nurses signing the MAR to verify that all treatments had been performed prior to leaving for the day and LVN B had been in-serviced on that. She stated Resident #7's wound had been healing and the surgeon had been pleased with the progress. She stated Resident #7 continued to have a wound vac in place and no impaired healing had been observed. The DON stated the facility reached out to Resident #7's attending physician that prescribed medication to notify her of the delayed meropenem dose and the facility was awaiting response. She stated the Medical Director of facility had been informed of delayed meropenem dose and new order obtained for medication dose to be rescheduled for 1300, 2100, and 0500 because of the medication error earlier.
During a follow up interview at [DATE] at 03:30 p.m., LVN A stated it had been over a year ago when she was certified on IV medication and that she would assume that the IV Certification went over mixing IV medication. LVN A stated in the last month and a half she had been floating and working in different areas and times. She stated she usually did not work on the hall Resident #7 resided on and she had filled in 2 nights shifts on that hall. She stated she did notice the central line dressing was loose prior to administering IV meropenem medication that morning but had not noticed the date on the dressing. She stated the central line dressing was not secured to the skin and she had planned to change the dressing after medication had been administered. She stated central line dressing being loose could cause site infection. She stated she had administered meropenem to Resident #7 previously and medication had been delivered premixed with no need to activate the vial. She stated she did not feel that any negative outcome occurred to the resident from central line dressing not being changed or medication error. She stated she had called the Medical Director when she could not get ahold of the ordering physician, and a new order was received to administer another dose at 1:00 pm so that Resident #7 did not miss a dose, and then retime medication every 8 hours after the 1:00 p.m. dose.
During a phone interview on [DATE] at 04:32 p.m., the Medical Director stated he expected staff to follow pharmacy instructions when administering medications. He stated that he was not familiar with the specifics of IV medication that had snap together vials but that he expected nurses to be trained on how to prepare medications that were being administered. The MD stated the effect of not getting meropenem as ordered for sepsis or infection may aggravate the infection and could have caused a flare up from the infection or relapse of an ongoing infection. He stated he assumed the nurses and the ADON, and the DON were who monitored medication was given as directed. He stated he was notified that medication was delayed and he did give directions to give medication and readjust every 8 hours with new time so that medication would not be missed. He expected IV tubing to be changed per protocol and not changing tubing could lead to secondary infection. He stated he expected tubing and medication bag to be labeled with a date because staff will get busy and may forget when bag / tubing was hung. He stated he expected central line dressings to be changed every 7 days per protocol and that it would be changed if dressing was compromised. He expected that dressing be secured to the skin and not changing could lead to secondary infection and insertion site infection risk.
During an attempted telephone interview on [DATE] at 10:25 a.m., the Attending Physician did not answer the phone. Left message with office staff to please have her return phone call. The Attending Physician did not return call.
During an attempted phone interview on [DATE] at 10:48 a.m., LVN D did not answer the phone and a message to return the call was left. The LVN D did not return call.
During an attempted phone interview on [DATE] at 10:51 a.m., LVN B did not answer the phone and there was no option to leave a voice message.
During a phone interview on [DATE] at 10:54 a.m., LVN C stated he had worked for the facility on and off for the last 3 years. He stated that if medication came with instructions to activate vial prior to use, there was a blue stem that needed to be snapped to break the seal. LVN C stated after seal broken then he would get NS into vial and mix with powdered medication. He stated the mixed liquid and medication in the vial would be drained back into IV bag prior to being administer. He stated he did not remember any of Resident #7's IV medication being delivered to facility pre-mixed, but the pharmacy had done that in the past for other residents. He stated when medication is pre-mixed, it is time sensitive so medication would only be delivered in lesser amounts. He stated he had not noticed medication not being prepared per instructions. He stated if medications were not mixed prior to administration, the effect on the resident would be that they only received hydration. He stated central line dressings should be changed once a week and as needed. He stated central line dressing would need to be changed if it was loose and could become looser with clothing changes. He stated the effect of not changing central line dressings every 7 days or as needed is hard to determine because if the dressings were still sealed, he believed the port of entry would not be exposed in some cases, but it could lead to skin breakdown from skin not being allowed to breath. He stated he had not changed the central line dressing and that if he had signed that he had performed it was signed in error. He stated he would sign off on task in MAR prior to performing task and would have made his best effort to perform the task. He stated the error may have been due to there are a lot of distractions in the facility and may have forgotten to perform. He felt that the facility had enough staff and was not shorthanded. He stated that distractions resulted from him trying to make himself available to all residents and would be approached routinely by residents even if they were not assigned to him and he would attempt to help them.
During an interview on [DATE] at 11:15 a.m., LVN F stated she had worked at the facility for a little over a year. LVN F stated she had IV medication training prior to working at the facility and had a refresher on [DATE]. She stated if the medication label stated activate vial prior to use that meant the nurse must break seal then mix with the saline prior to IV administration. She stated Resident #7's IV medication had never come from pharmacy pre-mixed. LVN F stated she had not had any concerns about other nursing staff related to administering IV medication administration. She stated that not activating vial prior to medication administration could cause Resident #7 to not get medication, her wound may not have healed quickly, or the infection to become worse. She stated the central line dressing should be replaced every 72 hours. She stated nurses should change the central line dressing if dressing was loose, and not changing as ordered or as needed could cause infection. She stated nurses should document treatment performed in MAR after the nurse had completed the treatment.
During a phone interview on [DATE] at 11:18 a.m., RN E stated that she was the nurse at the IDP's office. She stated her expectation would be for central line dressing changes to occur every 7 days or prn for any soiled, loose, wet dressings. She stated loose meant that insertion cite was exposed by clear part of dressing becoming compromised. She stated the central line dressing site should be monitored every shift. RN E stated the effect of not changing the central line dressing routinely and as needed would cause highly increased risk for central line infection in the blood stream. She stated IDP was using meropenem to treat an active infection and she expected IV antibiotics to be administered per physician's orders. She stated IDP should be notified when IV antibiotics were missed, or medication was delayed, and she had not received any notification from the facility of the medication error. She stated the effect of missing or delaying doses of meropenem could cause Resident #7's active diagnosis to be not treated properly, delayed healing, cause the infection to worsen, and risk hurting the resident. Could also cause prolonged antibiotic treatment, rehospitalization, and incision site failure. RN E stated she was unsure if missing antibiotic doses would cause any risk for surgery hardware failure. She stated the failure of not administering antibiotics as ordered could expose residents to extended treatments. RN E stated she had made two attempts to contact facility requesting lab results as IDP ordered lab CBC w/Diff (a blood test that measures red blood cell count, white blood cell count and platelet count), CMP (a blood test that measures the body's fluid balance, electrolytes like sodium and potassium, and how well the kidneys and liver are working), ESR (a blood test that measures the level of inflammation in the body), CRP (a blood test that can measure a protein produced by the liver in response to inflammation or infection in the body) labs to be drawn weekly on Monday while on IV therapy. At that time, she stated she had not received any lab results from the facility and as a result IDP planned on drawing labs in their office during post hospitalization visit.
During a follow up interview on [DATE] at 2:49 p.m., the DON stated the only labs that the facility had drawn from Resident #7 were done on [DATE]. She stated the facility had gotten a call from IDP office requesting labs on [DATE] and she did not know that labs had not been performed. She stated the facility should have drawn labs as ordered and the order would have been found on hospital discharge paperwork. She was unsure how often the order was for at that time. She stated the facility would be drawing labs when resident returned from physicians' visits in another town and would send results to IDP office. She stated it was her expectation that documentation in EMR be done after treatment had been performed. She stated she did not know why nurses had documented without performing the treatment. She stated nurses should not document something another nurse had stated they had performed. She stated the effect on the resident could be missed treatments. She stated that she monitors treatments are done by running EMR reports that would show when treatment had been missed and observing staff perform treatments.
During an interview on [DATE] at 2:51 p.m., LVN B stated she had worked for the facility for 3 years in [DATE]. She stated she had received IV antibiotic medication administration training. LVN B stated when an IV was labeled activate prior to use and it was the antibiotic that Resident #7 used, the nurse should have snapped the connection from IV bag to vial, squeezed solution from IV bag into vial and mixed with powder, then with bag upside down squeezed bag to allow mixed solution into IV bag to prepare medication prior to it being infused. She stated she had not remembered seeing any premixed medication in the facility for Resident #7 after her most recent hospitalization. LVN B stated she had not had any concerns about other nursing staff not activating IV medication, but she would usually be the nurse who started medication dose in the morning with fresh tubing, so night nurse would not leave empty medication bag for her to observe. She stated tubing should be changed every 24 hours. She stated when new IV tubing was used then it should have a date, time, and nurses initial on it so that other staff know when it was first used. She stated missing IV antibiotic dose could cause Resident #7 to have longer healing time and would be considered a medication error. She was unsure what policy stated about central line dressing frequency but stated that it should be changed as ordered and prn when dressing was loose. LVN B stated not changing central line dressing when ordered or needed could cause another type of infection and significant problems by leaving area open for bacteria to get into insertion site. She stated she worked on [DATE] and she did sign that central line dressing had been changed since the facility had a RN performing treatments that day and she thought the RN changed the dressing. She stated usually the RN treatment nurse would let her know treatment had been performed and she would sign that it had been completed. She stated that she should have verified by observing central line dressing had been changed and did not remember why she did not verify it prior to signing that it was completed in MAR. She stated she had been in-serviced about central line dressings yesterday on changing dressing per orders and verifying treatment done prior to checking off it had been performed. She stated she should not check off treatments she had not performed.
During a follow up interview on [DATE] at 3:00 PM, the DON stated there were no labs drawn for Resident #7 since being discharged from the hospital and admitted into facility. She stated she expected the nurse to look at the EMAR to know when the lab was ordered and that if a nurse signed off the EMAR that lab was collected after procedure had been performed. She stated the nurse should send lab to the hospital if they signed off that lab was collected. She stated the order revealed labs were to be drawn by an RN as it was to be drawn from central line and should have been done weekly. The DON stated it was her as DON that did the lab trackers and with the nurses being flagged in the EMAR to alert them to draw the labs. She stated there would be potential harm to the resident based off of her labs not being drawn, which could have caused the resident to have become septic.
During a telephone interview on [DATE] at 3:26 p.m., LVN D stated she had worked for the facility for four or five years. She stated she had completed IV class but did not remember the date of original training, but the DON had a copy of certification. She stated she had received more training in IV administration on [DATE]. LVN D stated when an IV was labeled activate prior to use the seal needed to be broken and medication in vial mixed with solution from IV bag prior to administration. She stated the pharmacy had only delivered IV antibiotic medication that needed to be activated for Resident #7 since her most recent surgery. She stated she had no concerns about other nursing staff not mixing antibiotic medication prior to administering. She stated the effect of not mixing IV antibiotic could cause resident to not to get medication that she needed, and medication would not help whatever Resident #7 receiving medication for. She stated she believed the central line dressing needed to be changed every 7 days but would have to look at facility policy to verify that information. She stated the central line dressing would need to be changed if it had become loose, soiled, or damaged to prevent infection by bacteria getting under the dressing. She stated she assessed the dressing every time she administered IV medication and at least once a shift. LVN D stated she only documents completion of treatment in MAR when she completed the treatment that was ordered.
During an attempted telephone interview on [DATE] at 3:52 p.m., Resident #7's emergency family member could not be reached with directions. The phone number dialed was not a working number.
During a follow-up interview on [DATE] at 4:04 p.m., the DON stated Resident #7 was back from the ID physician's appointment and orthopedic surgeon's appointment. She provided paperwork the facility had received from ID physician's appointment but stated orthopedic surgeon did not send any additional paperwork from office visit. She stated that she was not sure why a new order from ID physician for PO antibiotic after IV antibiotic was completed. She stated Resident #7 was alert and more than likely would be able to answer basic questions about office visits. The DON stated she had started the afternoon dose of IV meropenem when the resident returned to facility after she had drawn blood from central line for lab work.
During a follow up observation and interview on [DATE] at 4:09 p.m., Resident #7 sat in wheelchair in her room with an immobilizing brace on her left leg. IV pump on and alarm beeped with IV tubing connected to her central line. A staff member entered the room and informed the resident that she had notified the nurse of the pump alarm, and she was not allowed to touch the pump. IV meropenem had been pre-mixed prior to infusion and tubing labeled with paper tape. Resident #7 stated that she had a plastic surgeon appointment scheduled for [DATE] and that appointment was made prior to her ID physician and orthopedic surgeon's appointments. She stated she did not know why ID had ordered oral antibiotic in addition to IV antibiotic. Resident #7 stated that the orthopedic surgeon did not think that the wound vac had been healing her left knee surgical wound and that was why she was scheduled to see plastic surgeon tomorrow to discuss surgical options. She stated she was nervous about having another surgery since she almost died during the last surgery. The call light was in reach.
Record review of summary of infectious disease physicians visit dated [DATE] revealed: Complete IV antibiotic on 6/20 as scheduled and we will send orders to remove PICC line. Start Levaquin 500mg PO daily on 6/21. Follow up with orthopedic surgeon in 6 weeks .next appointment [DATE].
During a follow up interview on [DATE] at 11:12 a.m., the DON stated she did not think that increased WBC lab value on [DATE] had anything due to IV antibiotic administration and stated there was no way of proving Resident #7 had any missed doses just the delayed dose on 6/10. She stated she thought the WBC lab could have been related to Resident #7's emotional distress on [DATE] or how the DON drew the lab. The DON stated that she may have drawn lab too quickly and she believed that may have affected lab value. She stated the facility faxed over lab results to IDP office and she would call and speak with RN E at the clinic to see how IDP interpreted the lab results. She stated at that time she had no information on how IDP had interpreted the lab value. She stated that she had spoken to the orthopedic surgeon's office who stated oral antibiotic daily after IV antibiotic would need to be administered for the remainder of resident's life. She stated she was told that the antibiotic may change to different antibiotic medication, but the resident would need treatment for the rest of her life.
During a follow up interview on [DATE] at 03:12 p.m., Resident #7 stated she was seen by plastic surgeon for her left knee wound. She stated during the plastic surgeon's appointment, she was told the surgeon recommended a skin graft and if the graft did not work then they wanted to amputate. She said that she did not want an amputation.
During an attempted telephone interview on [DATE] 11:23 a.m. with the MD, the MD did not answer and a message to return call was left.
During an attempted telephone interview on [DATE] 11:23 a.m. with the IDP nurse, RN E, RN E did not answer and a message to return call was left.
During an interview on [DATE] at 08:13 p.m., the ADMN stated he expected staff to not sign off on treatments unless they verified the treatment was done. He stated staff should not sign off on treatments prior to performing them. The ADMN stated that he expected dressings to be looked at to verify the date on the dressing and assess the site. He stated he felt the failure occurred due to staff becoming busy and had intention of performing but then forgot. The ADMN stated ADON monitors that treatments are performed, and DON was who monitored also. He stated the effect of not performing treatments could lead to infection.
Record review of LVN A's certificate titled Texas IV Therapy Certification dated[TRUNCATED]

Based on observations, interviews, and record review, the facility failed to store medications in a locked compartment for 2 of 3 (Hall 3 Medication Cart and Hall 5 Medication Cart) medication carts reviewed for medication storage.
The facility failed to keep each resident's drugs in their original containers/packaging.
These failures could place all residents at risk of harm or decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions.
Findings included:
During an observation on 04/02/2024 at 11:15 AM, the hall 3 medication cart had seven loose pills in the second drawer of the medication cart. The pills were loose under the blister packages of resident medications.
During an interview on 04/02/2024 at 11:20 AM, LVN B identified the loose pills as one Lisinopril, one Midodrine, one Furosemide, two Keppra pills, one Zoloft and one Buspirone. LVN B stated there should not have been pills loose in the medication cart. LVN B stated this was not normally her cart and she had not had a chance to look through the cart this morning. LVN B stated that staff sometimes get in a hurry. LVN B stated staff will accidentally drop pills and will just pop another pill out of the blister pack; and then forget to go back and dispose of the pill that was dropped in the bottom of the drawer. LVN B stated the effect on residents could have been resident be delayed on receiving their medications, or pharmacy might not want to refill because too early to refill a medication. LVN B stated that all staff were responsible for ensuring their medication carts were clean, organized and free from any loose pills.
During an observation on 04/02/2024 at 1:02PM, the hall 5 medication cart had 3 loose pills. The ADON stated the pills as one Atorvastatin, one Multi-vitamin and one Protonic.
During an interview on 04/02/2024 at 12:49 PM, the ADON stated there should not be loose pills in the medication carts. The ADON stated every night shift was responsible for cleaning the medication carts and that every shift nurse should be cleaning medication carts themselves. The ADON stated herself and the DON randomly checked medication carts at least once per week. The ADON stated the effect on residents was that they could have run out of medications too soon, insurance will not fill medication because it was too soon. The ADON state what led to failure was staff not paying attention, dropped and just did not pick it up.
During an interview on 04/03/2024 at 1:30 PM, the DON stated her expectation was that pills should not have been loose in the bottom of the medication cart. The DON stated the night shift were to check medication carts once per week and staff should be aware and be checking each shift. The DON stated herself and the ADON were responsible to monitor medication carts and check carts at least one time per week. The DON stated the effect on residents they could have run out of medication sooner than they should have and puts residents at the potential for having medication missed. The DON stated the reason for the failure was staff not aware of popping more than one pill and/or not realizing the cards had gotten nicked.
Record review of facility policy titled, Storage of medications dated April 2007 revealed: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received . The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs for 1 of 2 (Resident # 1) residents reviewed for care plan completion.
The facility failed to ensure Resident #1 had a comprehensive care plan with measurable objective and person-centered interventions specific to smoking safety and elopement.
This failure could place residents at risk for not receiving appropriate supervision.
Findings included:
Record review of Resident #1's face sheet dated 04/04/2024 revealed resident was a [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Age-related cognitive decline, Nicotine dependence, Unsteadiness of feet, high blood pressure, Major Depressive disorder, and anxiety.
Review of Resident #1's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns Resident #1 had a BIMS score of 5 (sever cognitive impairment).
Record review of Resident #1's Comprehensive Care Plan last revised on 02/23/2024 revealed:
Problem start date 02/23/2024: Resident #1 had an elopement 2/22/2024 at 4: 10 pm. He was found in the park adjacent to the facility with 7 minutes of report. Resident had been seen 10 minutes prior to report of resident being missing. When asked why he did it he stated I am a vet tech and a diesel mechanic. I am middle aged and do not belong in a nursing home. Created: 02/23/2024 Created By: DON.
Goal Resident #1 will have no further elopement attempts. Created: 02/23/2024 Created By: DON.
Approach: Full body RN assessment completed, Moved to the other side of the hall with a closed courtyard, Placed on A side of room by the door, Window audits and head count to be done BID x 7 days, QD x 14 days, 5x/week during IDT/friends with [NAME] rounds, 1: 1 with maintenance,
Elopement in-service, Abuse/Neglect in-service, Elopement drill with all shifts,
Questioned all staff for the unit if he has ever messed with the windows before: No Created: 02/23/2024 Created By: DON
Problem Start date 11/28/2023: Elopement attempt: Resident was on the smoking porch with other residents and a staff member. Staff turned around to talk to another resident and when she turned back around and saw resident jumping over the fence. Staff went to door and yelled for assistance and went back to the fence to look for resident. She saw the resident round the side of the building. 2 CNA's left out door 4 staff door and turned right running to the resident. When the 2 CNAs got between halls 2 and 3 they saw the resident in between our parking lot and the apartment buildings parking lot. Resident remained in the line of sight for the remainder of the event. Resident was out of sight while he was rounding the building for approximately 30 seconds. From start to finish the event was approximately 5 minutes before the resident was back in the building. Edited: 02/16/2024 Edited By: LVN A
Goal: Resident will not have the opportunity for another elopement attempt. Edited: 02/16/2024, Edited By: LVN A
Approach: Resident already resides on secure unit however did have smoking privileges previously. Smoking privileges revoked indefinitely. Edited: 02/16/2024 Edited By: LVN A
Record review of Resident #1's Safe Smoking Assessment with a completion date of 03/05/2024 revealed: Resident safe to smoke supervised.
During an interview on 04/03/2024 at 1:30 PM the DON stated the MDS Coordinator was responsible to complete care plans and the DON and ADON help to update the care plans. The DON stated care plans should have been person centered and measurable. The DON stated the goal should have been measurable and the approaches should guide staff on what the needs of residents were to be able to provide the needed care for resident and should have supported the goal. The DON stated the approaches should have incorporated different approaches and just not suspending Resident smoking, should have addressed that nicotine patches were given to the resident. The DON stated some of the approaches should not have been in the care plan because it was more about what the facility was going to do correct the issues facility wide. The DON stated Resident #1's care plan did not have measurable objectives and the interventions were not individualized. The DON stated Resident #1's care plan should have been person centered. The DON stated the effect on residents could have changed the was a resident was care for and could have prevented resident from receiving person centered care. The DON stated Affect care plans can change the way a resident cared for and may prevent a resident from receiving person centered care. The DON stated oversight led to failure of care plan not being person centered.
During an interview on 04/03/2024 at 3:15 PM the ADMN stated his expectation was that care plans should have been person centered interventions and measurable objectives. The ADMN stated the MDS coordinator and the DON were responsible to ensure care plans were completed and person centered with measurable objectives. The ADMN stated a resident not having a person-centered care plan could cause residents to not have all their needs fulfilled or met. The ADMN stated that the approaches listed for Resident #1 were not person centered and were all approaches that would help the resident. The ADMN stated what led to the failure was staff were in the heat of moment after resident had eloped and initial thoughts were on to protect Resident. The ADMN stated the approach listed for Resident #1 for the elopement attempt on 11/28/2024 were not appropriate.
During an interview on 04/04/2024 at 12:40 PM Resident #1 stated he would like to be able to smoke again.
Record review of facility policy titled Care Plans-Comprehensive, dated September 2010, revealed: Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain . Each resident's comprehensive care plan is designed to:
Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on the resident's strengths; Reflect the resident's expressed wishes regarding care and treatment goals; Reflect treatment goals, timetables and objectives in measurable outcomes; Identify the professional services that are responsible for each element of care; Aid in preventing or reducing declines in the resident's functional status and/or functional levels; Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and Reflect currently recognized standards of practice for problem areas and conditions .Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers.

**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, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 1 residents (Resident #1) reviewed for dignity.
The facility failed to ensure Resident #1 was allowed to smoke as according to his request and smoking assessment.
This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.
Findings included:
Record review of Resident #1's face sheet dated 04/04/2024 revealed resident was a [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Age-related cognitive decline, Nicotine dependence, Unsteadiness of feet, high blood pressure, Major Depressive disorder, and anxiety.
Review of Resident #1's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns Resident #1 had a BIMS score of 5 (sever cognitive impairment).
Record review of Resident #1's Comprehensive Care Plan last revised on 02/23/2024 revealed:
Problem start date 02/23/2024: Resident #1 had an elopement 2/22/2024 at 4: 10 pm. He was found in the park adjacent to the facility with 7 minutes of report. Resident had been seen 10 minutes prior to report of resident being missing. When asked why he did it he stated I am a vet tech and a diesel mechanic. I am middle aged and do not belong in a nursing home. Created: 02/23/2024 Created By: DON;
Goal Resident #1 will have no further elopement attempts. Created: 02/23/2024 Created By: DON;
Approach: Full body RN assessment completed, Moved to the other side of the hall with a closed courtyard, Placed on A side of room by the door, Window audits and head count to be done BID x 7 days, QD x 14 days, 5x/week during IDT/friends with [NAME] rounds, 1: 1 with maintenance,
Elopement in-service, Abuse/Neglect in-service, Elopement drill with all shifts,
Questioned all staff for the unit if he has ever messed with the windows before: No Created: 02/23/2024 Created By: DON
Problem Start date 11/28/2023: Elopement attempt: Resident was on the smoking porch with other residents and a staff member. Staff turned around to talk to another resident and when she turned back around and saw resident jumping over the fence. Staff went to door and yelled for assistance and went back to the fence to look for resident. She saw the resident round the side of the building. 2 CNA's left out door 4 staff door and turned right running to the resident. When the 2 CNA's got between halls 2 and 3 they saw the resident in between our parking lot and the apartment buildings parking lot. Resident remained in the line of sight for the remainder of the event . Resident was out of sight while he was rounding the building for approximately 30 seconds. From start to finish the event was approximately 5 minutes before the resident was back in the building. Edited: 02/16/2024 Edited By: LVN A
Goal: Resident will not have the opportunity for another elopement attempt. Edited: 02/16/2024, Edited By: LVN A
Approach: Resident already resides on secure unit however did have smoking privilege's previously. Smoking privileges revoked indefinitely. Edited: 02/16/2024 Edited By: LVN A
Record review of Resident #1's Safe Smoking Assessment with a completion date of 03/05/2024 revealed: Resident safe to smoke supervised.
During an interview on 04/03/2024 at 1:10 PM CNA C stated they took Resident #1's smoking privileges away because the facility was afraid Resident #1 would try to run off again.
During an interview on 04/03/2024 at 1:30 PM, the DON stated after thinking more about suspending Resident #1's smoking privileges she could see where it could possibly a violation of resident rights. The DON stated the care plan did read punitive but that was not the intentions. The DON stated the idea was not to punish Resident #1, but for the safety of resident #1 . The DON stated she was fearful that Resident #1 could have been harmed by trying to run off or climbing the fence. The DON stated the facility had not attempted any other measures, they just stopped the smoking. The DON stated the resident did not have any safety concerns related to smoking, she did not know if they would be able to prevent him running off. The DON stated they did not try to have one on one while smoking, or allowing him to smoke in the secure courtyard.
During an interview on 04/04/2024 at 10:30 AM, Resident #1's family member stated her only concern with the facility was that they took Resident #1's smoking privileges away and that was the only thing that he still enjoyed. Resident # 1's family member stated she understood they had to punish him for trying to run off but even without smoking he still ran away from the facility. Resident #1's family member stated Resident #1 was able to smoke safely, the facility was concerned he would try to run off. Resident #1's family member did not understand why they did not allow him to smoke in the secure courtyard, because he was able to smoke there when she visited. Resident # 1's family member stated she did not have a problem sending Resident #1 cigarettes.
During an interview on 04/04/2024 at 12:40 PM Resident #1 stated he would like to be able to smoke again.
Record review of facility policy titled, Resident Rights dated August 2009 revealed: Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable
environment for residents, staff, and the public for 3 of 6 (room [ROOM NUMBER], #204 and #206) rooms in the secure unit observed for
environment.
The window blind blades (white 2-inch vinyl blades) were broken or missing in residents' rooms #202, #204 and #206.
This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment
.
Findings include:
Observation on 12/12 23 at 3:40 pm, revealed that Resident #6's room [ROOM NUMBER], Resident #8 room [ROOM NUMBER], and Resident #9 room [ROOM NUMBER]'s
windows blinds (white 2-inch vinyl blades) were broken or missing blades.
Resident's #6, #8 and #9's cognition was severely impaired and were not interview able.
Record review of the Maintenance repair log for October 2023 through December 13, 2023, revealed no repair request was found for
the damaged blinds in rooms #202, #204 and #206.
Interview on 12/14/23 at 9:45 am, the Administrator stated he knew about damaged blinds in rooms #202, #204 and #206.
Administrator stated the maintenance man had been home ill for several weeks and Administrator was trying to fill-in as he could.
Interview on 12/14/23 at 11:00 am, The Administrator stated that new blinds were purchased, and Administrator replaced damaged
blinds in rooms #202, #204, and #206.
Observation on 12/14/23 at 11:34 am revealed the damaged blinds were replaced with new blinds in rooms #202, #204 and #206.
Record review of 2001 MED-PASS, Inc, dated December 2009 revealed.
Maintenance Service Policy Statement:
Maintenance services shall be provided to all areas of the building, grounds, and equipment.
Policy Interpretation and Implementation.
1.
The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable
manner at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an ongoing program of activities designed to meet
the interests and the physical, mental, and psychosocial well-being for 4 of 13 residents (#6, #7, #8, #9) on the Secure Unit reviewed
for activities, in that
1. Resident #6, #7, #8, #9 did not have an ongoing activity program designed to meet her interests.
This deficient practice placed residents on the Secure unit at risk for isolation, low self-esteem, and decline in mental status.
Finding Include:
1. Review Resident #6 face sheet dated 12/15/23 revealed an [AGE] year-old female, admitted to facility on 1/7/21 with diagnoses that
included Gastrointestinal hemorrhage (bleeding in the gastrointestinal tract), Alzheimer's disease (neurodegenerative disease).
Review of Resident #6's MDS assessment dated [DATE], BIMS score 4 (severe cognitive impairment) revealed under preferences
for activities was not coded.
Review of Resident 6's Care Plan dated 10/14/23 for Psychosocial Well-Being Provide opportunity for me to build relationships with
others residing in the facility through activity programming. For Behavioral Symptoms Offer in-room activities such as favorite
TV, music, reading, and provide a program of activities that is of interest and accommodates residents' status.
Observation on 12/12/23 at 3:00 pm, revealed 3 residents were sitting in the tv room watching old black/white western shows. 5
residents were sitting at dining tables doing nothing. 2 residents were in their rooms sleeping in bed. 3 residents were sitting in their
rooms in wheelchairs; 1 was watching tv and 2 were doing nothing. No Activity calendar was found in any resident's rooms or in the
Secure unit common areas.
Observation on 12/12/23 at 3:08 pm, revealed Resident #6 was sitting at a dining table staring out the window.
Interview on 12/12/23 at 3:20 pm, CNA A stated that residents in the Secure unit does not have many activities. CNA A stated that
sometimes she will hand out coloring books or play music, but nothing is scheduled. CNA A stated the Activity Director will
sometimes supply them with puzzles or coloring books. CNA A stated there has never been any Activity calendar posted for
residents and residents do not leave the hall to participate in activities in the main unit. CNA A stated the residents only get
activities if staff has enough time.
Interview on 12/12/23 at 3:40 pm, CNA B stated that the Activity Director sometimes brings supplies for activities, but nothing is
scheduled or planned for the residents in the Secure unit. Sometimes if residents get bored, staff will play music. CNA B stated the
Activity Director does not lead any activities for Secure unit, aides initiate activities when possible. CNA B stated she never seen
any calendars for the residents in the Secure unit.
2. Review of Resident #7's face sheet dated 12/15/23 revealed [AGE] year-old female, admitted to the facility on [DATE] with diagnosis
that included Pulmonary embolism (blockage of an artery in the lungs).
Review of Resident #7's annual MDS dated [DATE] revealed a BIMS score 3 (severely cognitive impaired), under preferences for
activities that were somewhat important to her was music, groups of people, pets, keeping up with the news.
Review of Resident #7's Care Plan dated 10/14/23 for Behavioral Symptoms revealed Provide activity calendar and encourage
participation in the unit, provide a program of activities that is of interest and accommodates residents' status.
Observation and interview on 12/12/23 at 3:00 pm revealed Resident #7 was sitting in her wheelchair in her room doing nothing.
Resident #7 stated she did nothing all day. Resident #7 stated she likes reading and doing crosswords. Observed some reading
materials in her room but found no crossword puzzle books.
3. Review of Resident #8's face sheet dated 12/12/23 revealed [AGE] year-old female, admitted to the facility on [DATE], with diagnosis
that included Schizophrenia (mental disorder characterized by continuous or relapsing episodes of psychosis).
Review of Resident #8's MDS dated [DATE], BIMS score 10(moderate cognitive impairment) under preferences for activities
somewhat important to resident.
Review of Resident #8's Care Plan dated 11/17/23 for Activities, Provide activity program that is satisfying for resident.
Observation on 12/13/23 at 10:15 am, no activities being conducted, 2 residents were sitting in common area watching tv, 3 residents
were sitting at dining table. Resident #8 was sleeping in bed, lights out, call light within reach. Found no activity calendar in room.
4. Review of Resident #9's face sheet dated 12/13/23 revealed [AGE] year-old male admitted to the facility on [DATE] with diagnosis
that included Major depressive disorder (clinical depression), insomnia (sleeplessness)
Review of Resident #9's MDS dated [DATE], BIMS score 8 (cognitive impaired) under preferences for activities no response.
Review of Resident #9's Care Plan dated 11/10/23 for Psychosocial Well-Being stated, Provide opportunity for me to build
relationships with others residing in the facility through activity programming and provide activity program that is satisfying for
resident.
Observation and interview on 12/13/23 at 10:22 am, revealed Resident #9 was sitting in her room in her wheelchair. Resident #9
stated she was bored. When asking what her interests were, Resident #9 could not stay on topic.
Activity Director had turned in (his/her) notice of termination and was not available for an interview during the time of survey.
Attempts to contact (him/her) by phone failed.
Interview on 12/14/23 at 10:40 am with Assistant Activity Director C revealed she tries to get supplies, coloring books, puzzles for
the activities in the Secure unit. Assistant Activity Director C stated she usually supplies aides with activities to do. Assistant
Activity Director C stated they did not supply the Secure unit with activity calendars or setting up more structured activities for
residents in the secure unit.
Interview on 12/14/23 10:48 am, The Administrator stated the Activity Director is responsible for providing activities for the whole
facility, not providing activities for the residents in the secure unit could cause emotional harm.
Interview on 12/14/23 10:50 am, The DON stated not having structured activities for residents in the secure unit could cause
emotional harm.
Record review of Activity Policy: Med-Pass, revised dated April 2009 revealed,
Group Programs and Activities Calendar
Policy Statement
Group activities are available in this facility and an activities calendar is completed to inform residents, families, and staff of the
activity opportunities available.
Policy Interpretation and Implementation
I. Both large and small group activities are part of our activity programs.
2.
The activities calendar states all activities available for the entire month, which may also include scheduled room visitation.
3.
Residents are encouraged to participate in all group activities, especially those that are best suited for their interests and
physical, mental, and emotional needs.
4.
Activities professionals plan scheduled activities for the month and post the activities on a large bulletin board in a
prominent location in the facility.
5.
Activities calendars are posted in high-visibility and high-traffic areas in the facility at a height that is readable from a
wheelchair. The number of posted calendars is determined by the size and physical layout of the overall facility.
6.
Smaller monthly activity calendars are placed in each resident room at a height and location that is acces [NAME] to the
resident.
7.
Activities are also advertised through announcements over the public address system and [NAME] invitations to join an
activity on an individual basis. If public address announcements are appropriate for the facility the following format is
recommended: Orientation (i.e., Today is Monday, April 27, 2009); brief description of the activity; location of the activity; time
activity will begin.
8.
Modifications, time changes, cancellations or substitutions are reflected on all large posted calendars. It is recommended
that final versions of the monthly calendar be kept on file for three years.
9.
Calendar development and changes are discussed with the Resident Council to keep them informed. The Activity
Director/Coordinator periodically reviews the current types of activity programs in terms of the current facility population and
changes are made based on this analysis with input from the Resident Council.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the residents who need respiratory care, is
provided such care, consistent with professional standards of practice, the comprehensive person-center care plan, the residents'
goals, and preferences for 2 of 4 residents (Resident #11, Resident #13) reviewed for quality of care.
The facility failed to ensure Resident #11 and Resident #13's nebulizer cup and tubing was kept in bag while not in use.
This failure could place residents at risk for respiratory infections.
The findings include:
1.
Record review of Resident #11's MDS, [AGE] year-old male, admission assessment, dated 10/5/23 revealed Resident #11 was admitted to the facility on [DATE]. Cognitive patterns revealed a BIMS score of 10 (moderate cognitive impairment). Medical diagnosis revealed Cerebral infarction (stroke).
Record review of Resident #11's Care Plan dated 11/7/23 revealed it did not include the use of nebulizer.
Record review of Resident #11's Order summary report accessed 12/13/23 revealed an order on 10/2/23 for Albuterol sulfate solution
for nebulization: 2.5mg/3ml (0.083%) amount 1 UD via nebulizer inhalation.
In an observation and interview on 12/13/23 at 10:30 am, Resident #11 was sitting in wheelchair in room watching tv. Resident #11's nebulizer cup and tubing was sitting on the nightstand not stored in bag while not in use. Resident #11 stated he had treatment last night. Resident #11 stated sometimes he will have several treatments per day if needed. Resident #11 did not recall if or when nebulizer cup and tubing have been cleaned or replaced.
2.
Record review of Resident #13, [AGE] year-old female admitted [DATE], MDS dated [DATE], revealed Cognitive patterns indicated a BIMS score of 15 (cognitively intact). Section I: Medical diagnosis revealed Acute respiratory failure.
In an observation and interview on 12/13/23 at 11:02 am, Resident #13 was lying in bed. Nebulizer cup and tubing was laying on nightstand not stored in bag while not in use. Resident #13 stated she had her last breathing treatment at 9:00 am.
Record review of Resident #13's Care Plan dated 10/13/23 revealed it did not include the use of nebulizer.
Record review of Resident #13 Order summary report accessed 12/13/23 revealed an order on 7/24/23.
Albuterol-Ipratropium 0.5mg-3mg (2.5mg base)/3ml suspension; 0.5mg-3mg (2.5mg base)/3ml; amt: ONE inhalation.
In an interview with DON on 12/13/23 at 2:05 pm, The DON stated she expected the nebulizer cup and tubing to be bagged by the nurse when not in use and changed each Sunday as per policy. DON stated the failure to store nebulizer equipment properly could
result in infection.
Record review Respiratory Policies and Procedures Dated 6/2012
Subject: Handheld Nebulizer
Procedure-23; Disassemble device and rinse the mouthpiece and nebulizer cup with water and dry. Place entire unit in a bag to be
maintained in the patient's/resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the menu was followed, for 3 (Resident # 11, Resident #14 and Resident #53) of 13 residents observed during lunch meal on 04/25/2023.
The facility failed to ensure Resident # 11, Resident #14 and Resident #53 received a garlic bread stick or an approved alternative during the lunch meal.
This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss.
The findings include:
Review of Resident #11's Quarterly MDS assessment dated [DATE] revealed, Section A- Identification Section revealed a [AGE] year-old female. C- Cognitive Behavior revealed a BIMS score of 5 (severely impaired cognitive); Section I - Active Diagnoses revealed Anemia, Diabetes, Dementia, and Malnutrition.
Review of Resident #14's Annual MDS assessment dated [DATE] revealed, Section A- Identification Section revealed a [AGE] year-old female. C- Cognitive Behavior revealed a BIMS score of 2 (severely impaired cognitive); Section I - Active Diagnoses revealed Dementia, and Malnutrition.
Review of Resident #53's Quarterly MDS assessment dated [DATE] revealed, Section A- Identification Section revealed a [AGE] year-old female. C- Cognitive Behavior revealed a BIMS score of 3 (severely impaired cognitive); Section I - Active Diagnoses revealed Renal Insufficiency and Malnutrition.
Observation and review of posted daily facility menu for Tuesday 04/25/2023 revealed, Lasagna w/meat sauce, Winter Mixed Vegetables, and Garlic Bread Stick
Observation of the meal on 04/25/2023 at 11:30 AM revealed Resident # 11, Resident #14 and Resident #53 were served Lasagna w/meat sauce, and Winter Mixed Vegetables. Residents' trays were served without a garlic bread stick or an approved alternative.
During an interview on 04/28/23 at 10:52 AM, the DM stated her expectation was the menu was followed and residents received all items on menu or given a substitution. The DM stated the effect on residents not receiving all their food was residents would not have gotten all nutritional value they were supposed to have received in their daily calorie intake. The DM stated the cook, and the DM were responsible to ensure residents' meal trays were correct . The DM stated the cook and DM were supposed to ensure the food on the tray matched the resident's meal ticket. The DM stated staff were nervous, because state surveyors were in the building, and that was what led to failure of items being missed.
During an interview on 04/28/23 at 12:19 PM, the ADMN stated his expectation was that residents received a meal that was hot, balanced, appealing and residents enjoyed eating. The ADMN stated residents not receiving an item on the menu could have caused residents to have had weight loss or had not received a balanced meal they needed. The ADMN stated the cook, cook aide, DM, and nurses were responsible to look at each tray and ensure residents received all items on menu. The ADMN stated staff were nervous which led to failure of items being missed on tray.
Review of facility policy titled, Menus dated October 2008 revealed: Menus shall a) meet the nutritional needs of residents; b) be prepared in advance; and c) be followed. Menus will be planned that meet the nutritional needs of residents in accordance with the recommended dietary allowanced of the Food and Nutrition Board

Based on interview and record review the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week in that:
The facility had no RN coverage on 03/20/2022, 06/18/2022, 06/19/2022, 08/21/2022, 01/01/2023, 01/29/2023, and 03/25/2023. The facility had less than 8 consecutive hours of RN coverage on 04/30/2022, 05/22/2022, 08/28/2022, 10/30/2022, 04/14/2023, and 04/22/2023.
This failure could affect residents at the facility by placing them at risk for not having their nursing and medical needs met.
Findings Included:
Record review of nursing staff schedules, daily staffing sheets, and RN time records between 03/10/2022 and 04/28/2023 revealed that the facility did not provide 8 hours of RN coverage on 7 days (03/20/22, 06/18/22, 06/19/22, 08/26/22, 01/01/23, 01/29/23, and 03/25/23) of the 118 days reviewed and did not provide RN services for a full 8 hours on 6 (04/30/22, 05/22/22, 08/28/22, 10/30/22, 01/14/23, and 04/22/23) of the 118 days reviewed. There was no scheduled RN coverage on January 1, 2023, and January 29, 2023.
During an interview with the Director of Nurses on 04/28/23 at 11:24 AM, she stated could only speak to why the failure occurred since she was hired in August 2022. The DON explained the missing RN hours were due to call ins and no one would cover the shift. As for no RN scheduled for 2 weekend days in January 2023, she stated making sure the days were covered was overlooked on the schedule. The DON stated the ADON was responsible for developing schedules for nursing staff and the DON looks over the schedule before it was posted. She stated she was much more involved in scheduling now. The DON explained the ADON was already doing the scheduling when she was hired so she could not comment on training the ADON received on scheduling. The DON stated she was responsible for monitoring schedules. She stated the consequences to residents of not having an RN available every day was related to the scope of practice differences between LVN and RN. The DON explained that an RN could assess a resident whereas an LVN could only evaluate. She stated an RN may notice things an LVN may not, due to an RN's larger knowledge base.
During an interview with the ADON on 04/28/23 at 11:40 AM, the ADON stated she did not receive training when she accepted the ADON position and responsibilities of an ADON. The ADON explained not having an RN in the facility every day could affect the residents because if something goes wrong, having a nurse with the extra training RNs receive was beneficial. She stated having an RN to utilize as a resource to ask questions or verify findings was a benefit for the nursing staff.
During an interview on 04/28/23 at 11:55 AM, the ADMN explained the reason for the failure of having an RN in the facility for 8 consecutive hours every day was he had a night RN who refuses to change her schedule or fill in shifts. He explained in several situations on the time sheets, an RN was in the building for 12 hours, but the hours were not consecutive. He stated he had hired an RN to work weekends but due to personal circumstances she has not been able to start working yet. The ADMN stated the new DON had made improvements by hiring RN's that were willing to help fill the schedule. The ADMN verified the ADON was responsible for scheduling and coordinated with the DON. The ADMN stated he did not feel missing RN coverage would have much of an impact on the residents.
During an interview on 04/28/23 at 11:55 AM, the ADMN was not able to provide a policy on RN coverage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 2 (Resident # 57 and Resident # 35) of 18 residents reviewed for abuse.
The facility failed to complete a thorough investigation and maintain documentation that an allegation of abuse for Resident #57 and Resident #35 were thoroughly investigated.
This failure could place residents who report allegations of abuse at risk of not being thoroughly investigated.
Findings include:
Review of Resident #35's face sheet dated 04/28/2023 revealed a [AGE] year-old female admitted on [DATE], with the following diagnosis Dementia, Alzheimer's disease, and need for assistance with personal care.
Review of Resident # 35's Quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 0 (Severe cognitive impairment
Review of Resident #35's progress notes, written by LVN B , written on 11/20/2022 at 12:18 AM revealed nurse was called to unit by CNA. CNA said she heard grunting and went to where it was coming from and found this resident on her back on the bed another resident was on top of her in a sexually aggressive manner, both residents were fully clothed. CNA asked the other resident to get off this resident and that resident replied no. CNA rolled the other resident off this resident and removed her from the room and came and got this nurse.
Review of Resident #35's progress notes, written by LVN A, written on 11/25/2022 at 6:30 PM revealed this resident was located in room [ROOM NUMBER] lying at the foot of the bed underneath the male resident that resides in that room . Male resident was on top of this resident with his brief and pants down to his ankles. This resident's shirt was pulled up exposing her breast. Her pants were pulled down mid-thigh and her brief was partially down but still covering vaginal area. Male resident was immediately redirected and moved off the resident. The resident was immediately taken out of the room and to her room for assessment. Resident is not displaying any emotional distress at this time. Resident noted with slight red area to top of right breast and slight small red area to top of left breast. Skin intact. Resident is not able to recall incident poor cognitive ability.
Review of Resident #57's face sheet dated 04/27/2023 revealed a [AGE] year-old male admitted on [DATE], with the following diagnoses: Dementia with behavioral disturbance, Alzheimer's disease, antisocial personality disorder, , and conduct disorder.
Review of Resident # 57's Annual MDS assessment dated [DATE] revealed, Section C - Cognitive Behavior revealed a BIMS score of 5 (Severe cognitive impairment) and Section E- Behavior Resident revealed Resident #57 exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing other sexually).
Review of Resident #57's physician orders dated 11/19/2023 revealed Provera tablet 5mg: amount one tablet; oral once a day 9:00 AM.
Review of Resident #57's physician orders dated 11/26/2023 revealed Provera tablet 10mg: amount one tablet; oral once a day 9:00 AM.
Review of The Sexual Abuse Clinic accessed https://www.sacpd.com on 04/28/2023 revealed: depo-Provera is the trade name for a medication whose chemical name is medroyxprogesterone acetate. It is a female hormone which, when given to a man, inhibits the production of testosterone, thus reducing sexual drive. When taking depo-Provera, men are still able to engage in sexual relations, but they do not think about sex as often and their sexual thoughts are not as strong as before. Hence there is less risk that a man will act out sexual impulses in ways that might get him into trouble.
Review of Resident #57's progress notes, written by LVN B, on 11/19/2022 at 8:30 PM revealed; this nurse was called back to unit by CNA. CNA stated she had just separated this resident and other resident. CNA stated she had heard grunting noises and went to this residence room to find him on top of female resident and stated this resident had other resident in a sexual vulnerable position. CNA stated that both residents were fully clothed. CNA stated she told this resident to get off the other resident and this resident replied no. CNA at this time rolled this resident off the resident and removed female resident from the room. The female resident had been urinated on by this resident.
Review of Resident #57's progress notes, written by LVN A, on 11/25/2023 at 6:30 PM revealed, Resident was discovered on top of a female resident at the foot of his bed. Upon discovery of resident, it was noted that residents brief and pants were pulled down to his ankles. Female resident's shirt was pulled up exposing her breast. Female resident's pants were pulled down mid-thigh and brief was partially pulled down but still covering vaginal area. This resident was immediately redirected and removed off the female resident. Female resident immediately removed from the room and taken to her room. Residents brief and pants were pulled back up to proper placement.
During an observation on 04/25/023 at 11:10 AM Resident # 35 was on secure unit (Hall 2).
During Observation on 04/26/2023 at 10:00 AM Resident #57 was in his room on Hall 3 laying in his bed sleeping.
Review of the facility incident report, completed by LVN A, dated 11/19/2022 revealed Resident #57 had aggressive sexual behavior toward another resident .
Review of the facility incident report, completed by LVN A, dated 11/20/2022 revealed Resident #35 was found in sexually vulnerable position under other resident.
Review of the facility incident report, completed by LVN B, dated 11/26/2022 revealed Resident #35 was discovered in room [ROOM NUMBER] laying at the foot of the bed underneath the male resident that resides in that room. Male resident was on top of this resident with his brief and pants down to his ankles. This resident shirt was pulled up exposing her breast, her Pants were pulled down mid-thigh and her brief was partially down but still covering vaginal area. Male resident was immediately redirected and removed off this resident. The resident was immediately taken out the room and to her room for assessment.
Review of the facility incident report, completed by LVN B, dated 11/26/2022 revealed Resident #57 was on top of the female resident at the foot of his bed in room [ROOM NUMBER]. Upon discovering a resident., it was noted that residents brief and pants were pulled down to his ankles. Female resident shirt was pulled up exposing her breast. Female resident's pants were pulled down mid-thigh and brief was partially pulled down but still covering vaginal area. This resident was immediately redirected and moved off of the female resident. Female resident immediately removed from the room and taken to her room.
During an interview on 04/27/23 at 3:04 PM Resident #35's family member stated he had been notified of the incidents with Resident #35 on 11/ 19/2022 and 11/25/2022. Resident #35's family member stated the male resident was moved off Hall 2(secure unit) on to another hall. Resident #35's family member stated he did not think Resident #35 suffered physical or psychological injury. Resident #35's family member stated he feels that the facility is taking good care of Resident #35.
During an interview on 04/27/2023 at 3:32 PM, the DON stated Resident #57 had been placed on the secure unit (Hall2) due to his exit seeking behaviors. The DON stated prior to the incident on 11/19/2023 Resident #57 had not had any inappropriate sexual behaviors. The DON stated physician was contacted after the incident on 11/19/2023 and he ordered Provera to reduce sexually inappropriate behaviors and was put on 15-minute checks and referred to psych services. The DON stated Resident remained on secure unit, and staff were told to maintain close supervision of Resident #57. The DON stated after the incident on 11/25/2022 the physician increased Resident #57's Provera, MHMR was contacted, and he was placed on 15-minute checks until they were able to move him from the secure unit, back to Hall 3. The DON stated Resident #57 primarily stays to himself and did not leave his room and there has not been any other incidents with this resident
During an interview on 04/28/23 at 11:35 AM, LVN B stated she was the nurse who worked the night of 11/25/2022. LVN B stated she was under the assumption the incident between Resident #35 and Resident #57 had been reported. LVN B stated she completed a head-to-toe assessment of Resident #35 and that she had red area to both of her breasts and did not note any other red marks or bruising. LVN B stated the red marks faded within 24 hours. LVN B stated she had not seen or heard of Resident #57 having any other inappropriate sexual behaviors besides the incident on 11/19/2022 and 11/25/2022, and that he rarely left his room. LVN B stated neither resident had the mental capacity to consent. LVN B stated that Resident #35 wandered around the unit, and that Resident #57 resided in Resident #35's old room. LVN B stated she contacted Resident #57's physician who increased Resident # 57's Provera, which had been prescribed to prevent inappropriate sexual behavior.
During an interview on 04/28/23 at 11:53 AM, the ADMN stated he was the Abuse Coordinator and was responsible for completing investigations of Abuse and Neglect. The ADMN stated his expectation was that allegations of abuse and neglect be investigated thoroughly. The ADMN stated the determination for not investigating was due to neither resident was able to consent, and there was no physical harm . The ADMN stated 15-minute checks were conducted on Resident #57 to assess for behaviors. The ADMN stated after the incident on 11/19/2022 the physician was notified and Resdient #57 was restarted on Provera 5mg. The ADMN stated the Physician was notified on 11/25/2022 and Provera was increased from 5mg to 10 mg. The ADMN stated Resident #35 was monitored closely and she did not have any signs of pain, discomfort, or emotional distress. The ADMN stated he talked with staff but did not document any interviews with staff and he did not conduct any resident or resident family safe interviews . The ADMN stated he did not have any documentation to support a thorough investigation. a reportable incident . The ADMN stated a thorough investigation should have included documentation of interviews with staff, residents, families, and other related documentation to the incident. The ADMN stated the effect on residents for not completing a thorough investigation would have been residents could have felt unsafe. The ADMN stated LVN A no longer worked for the facility.
During an interview on 05/01/2023 at 10:30 AM with CNA D she stated she had worked the night of 11/19/2022. CNA D stated she was shocked to find Resident #57 and Resident #35 together. CNA D stated she was not aware of Resident #57 previously having any issues of inappropriate sexual behaviors, and has not had any incidents since the 11/25/22 incident.
Review of facility policy titled, Abuse, Neglect, and Misappropriation of Property dated April 26, 2012, revealed: The facility maintains that all allegations of abuse, neglect, and misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken . The facility conducts an internal investigation to the legal department, if applicable, and reports the results to enforcement agencies within five working days . Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusion Written summaries of interviews with individuals having firsthand knowledge of the incidents. NOTE: employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer Unless otherwise directed by the legal department, all Ms. situations are to be in writing and kept on file in the Administrator's office. The facility collects, retains and safeguards all information and evidentiary material pertinent to the investigation of the alleged abuse or neglect.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 8 staff reviewed for infection control procedures.
Facility staff failed to wear facemasks that covered the nose and mouth at all times when in the presence of residents.
These failures could place residents at risk for the transmission of communicable diseases.
Findings included:
During an observation and interview on 04/25/23 at 09:25 AM, there was a nurse sitting at a central nurses' station with her mask hanging off her ear. ADM came to greet surveyors, and said the transmission was medium and they preferred for staff to wear masks if doing direct patient care or within 6 ft of residents.
During an observation on 04/25/23 at 09:56 AM, a housekeeping staff on hall 4 was wearing a mask that was not covering the nose. A shower aide was wearing a mask that did not cover her nose. Residents were ambulating in the hallway near both staff.
During an observation on 04/25/23 at 09:59 AM, 2 staff came from outside and walked into dining room with their mask below their chin while residents were sitting at tables throughout the dining room. Another housekeeper was observed cleaning rooms on hall 4 with her mask below her nose. Staff took medicine to a resident in the dining room with her mask below nose.
During an observation on 04/25/23 at 10:08 AM, a nurse aide gave resident a hug at nurses' station and began talking with resident, while her mask was below her nose. DON was talking with a resident at nurses' station and her mask had gone below her nose. Staff walked from hall 4 to nurses' station, then down hall 3 with mask barely covering mouth, not covering nose at all. Shower aide walked down hall 4 with mask below chin. Dietary staff came out of dining room to the nurses' station, passing residents with her mask below her chin.
During an observation on 04/25/23 at 10:15 AM, again noted that DON mask has fallen below nose while talking with a resident. Nurse aide on hall 1 was pushing a resident in a Geri chair from their room with her face leaned over the resident and the aide's mask was not covering her nose.
During an interview on 04/25/23 at 10:17 AM with DON, she said the facility was in the yellow, meaning transmission rates for the county were medium. She said that meant that staff were to wear masks throughout the facility in resident care areas working with residents. She said those areas included the dining room, nurses' station or hallways. She said the masks were expected to be pulled up to cover the nose and the mouth when staff were in those areas.
During an interview on 04/27/23 at 5:45PM, ADM provided facility policy for Masks in the facility. He said the facility was in the yellow range meaning medium level transmissibility for Covid-19 in the county. He said with the facility being yellow, that meant that staff was to wear a mask covering the nose and the mouth in all areas that were frequented by residents. ADM said the hallways, resident rooms, and dining room were areas that were frequented by residents and masks should be worn properly in those locations. He said that talking to a resident, hugging a resident, and pushing a resident in a Geri chair would constitute being within 6 feet of a resident and providing some type of direct care. ADM said that would require that the staff wear their facemask properly and ensure that the mask covered the nose and the mouth.
Record review of facility policy labeled Coronavirus Source Control Requirements and Policy undated revealed: When community transmission rate is high or substantial the facility staff will be required to wear surgical masks. For the week of 4/21/2023 the facilities transmissibility rate was medium (substantial).
Record review of CDC website accessed on 05/01/23 at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html#masks last updated 01/26/23, revealed: When wearing a mask or respirator (for example, N95), it is most important to choose one that you can wear correctly, that fits closely to your face over your mouth and nose, that provides good protection, and that is comfortable for you.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.
The facility failed to ensure foods were sealed and/or labeled properly in refrigerator.
The facility failed to ensure foods were sealed and/or labeled properly in dry storage.
The facility failed to ensure all food was not past expiration date.
These failures could place residents that eat from the kitchen at risk for food borne illnesses.
Findings included:
Observation of the kitchen on 04/25/23 between 9:35AM and 10:00 AM revealed the following:
Refrigerator
1.
Container of Beef Soup with a use by date of 4/19.
2.
One container of cottage cheese with a use by date of 4/15.
3.
One bag of shredded lettuce frozen.
4.
One plastic bag with a seal of grated cheese with no use by date.
Dry Storage
1.
One plastic bag with a seal of tortilla chips with no use by date or label of food item.
2.
One plastic bag with a seal of potato chips with no use by date or label of food item.
3.
One container of open pickles with a manufacturer label stating, refrigerate after opening.
During an interview on 04/28/23 at 10:52 AM, the DM stated her expectation was that food items were labeled with an open date, use by date and an item description. The DM stated food items were supposed to be discarded after 72 hours. The DM stated the facility policy does not give a time frame, but she was trained that food should be discarded after 72 hours and that was her expectation. The DM stated cooks, aides and herself were responsible to ensure items were labeled and discarded. The DM stated staff were given verbal training on storage, labeling, and discarding items by herself when hired. The DM stated the effect on residents could have been food lost flavor, lost nutritional value, or could have made residents sick. The DM stated what led to failure of items not being discarded or labeled was due to the weekend person was brand new.
During an interview on 04/28/23 at 12:19 PM, the ADMN stated his expectation was that residents received fresh and good food. The ADMN stated what led to failure of items not being labeled or discarded was the large fridge was broken and staff were having to use the small fridge and things were unorganized. The ADMN stated this failure could have affect residents by causing them to get sick.
Review of CMS Form 672 titled, Resident Census & Conditions of Resident dated 04/25/2023 revealed 69 of 69 resident eat out of the kitchen.
Review of facility policy titled, Food Receiving and Storage dated December 2008 revealed: Dry foods that are stored in bins will be roved from original packaging labeled and dated (use by date). All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).