Schulenburg Regency Nursing Center

Based on observations, interviews and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of two kitchens reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Assistant [NAME] A used proper hand hygiene during food preparation.2. The facility failed to ensure Dietary Assistant [NAME] A used appropriate oven mitt to remove food from the oven and prevent cross-contamination of the food. These failures could place residents who ate food from the kitchen at risk for foodborne illness.Findings included: 1. Observation on 11/01/2025 at 7:20 AM, reflected Dietary Assistant [NAME] A touched her shirt, the right side of her hair, and touched her face with her right hand. She did not wash or sanitize her hands prior to touching the cereal in bowls on a meal tray. She placed the meal tray full of bowls of cereal in the meal cart to be delivered to the 600-hall kitchenette. Interview on 11/01/2025 at 7:30 AM, Dietary Assistant [NAME] A stated she did not wash her hands, and she did touch her clothes and hair. She stated she did not recall if she touched her face. She stated her clothes, and hair was considered to be contaminated. Dietary Assistant [NAME] A stated she was required to wash her hands anytime she touched anything that was considered to have germs. She stated there was a possibility germs or bacteria may transfer from her hands onto the raisin bran cereal. Dietary Assistant [NAME] A stated if a resident ate the cereal the resident may have stomach issues such as being too sick to eat and have diarrhea. She stated she had been in-service on hand hygiene but did not recall the date of the in-service. 2. Observation on 11/01/2025 at 7:35 AM, Dietary Assistant [NAME] A obtained a dish rag with holes in the rag and brownish color stains laying on top of mop heads in a medium size white container. She held the dish rag and entered the kitchen area and used the dish rag to remove hot pan of bacon from the oven. When she removed the silver pan of bacon the dish rag touched over half of the bacon. The Dietary Assistant [NAME] A placed a lid on the bacon and placed it on the meal cart to be delivered to the kitchenette on 600 hall. She placed the dish rag on the food prep table and had very light scent of disinfectant. Interview on 11/01/2025 at 7:38 AM, the Dietary Assistant [NAME] A stated the dish rag was on the mop heads, and she did not know if the dish rag had been used to clean anything in the kitchen. She stated she was expected to use an oven mitt or potholder to remove food from the oven. She stated the dish rag did have holes in it and was stained. Dietary [NAME] Assistant A stated she did not smell anything on the dish rag when she first picked it up but she did smell something when she placed it on the food prep table. She stated the dish rag did touch the bacon, but it would be ok to serve the bacon. She stated she thought it would be ok to serve the bacon. Interview on 11/01/2025 at 7:42 AM Dietary [NAME] B stated the bacon, and cereal was considered contaminated and was expected to be thrown away and prepare more food for the residents. She stated anytime you touch clothes staff was expected to wash their hands. She stated only an oven mitt, or potholder was to be used to remove anything from the oven. Dietary [NAME] B stated all dietary staff had been in serviced on hand hygiene and preparing food. She did not recall the date of the in-services. Observation on 11/01/2025 7:40 AM Dietary [NAME] B instructed Dietary [NAME] Assistant A to prepare more bacon and cereal for the kitchenette on 600 hall. Dietary [NAME] Assistant A did remove the bacon and cereal from the 600-hall meal cart after Dietary [NAME] B asked her three times to remove the food and prepare more food. Interview with the Dietary Manager on 11/01/2025 at 1:40 PM, the Dietary Manager stated all staff was expected to wash their hands anytime the staff change tasks or touch their clothes or hair. She stated using a dish rag was not appropriate to remove food from the oven. The Dietary Manager stated dish rags was only to be used to clean food prep table and they were not to be stored on top of mop heads. She stated if the dish rag touched the bacon when the Dietary Assistant [NAME] A removed the bacon from the oven, the bacon was contaminated from the dish rag. She stated anytime dietary staff touched food after touching anything considered contaminated the food was expected to be discarded including cereal. She stated if a resident ate bacon or the cereal it was possible a resident may become physically ill with some type of food borne illness such as vomiting and other stomach issues. The Dietary Manager stated she was responsible for monitoring the kitchen policies and protocol. Interview with the Administrator on 11/01/2025 at 2:30 PM, The Administrator stated all dietary staff was required to wash or sanitize hands anytime they touched their clothes, hair, or change tasks. She stated if the dietary staff touched food and did not wash or sanitize their hand, she expected the food to be discarded and prepare the same food. The Administrator stated a dish rag was not appropriate to replace an oven mitt or potholder. She stated a dish rag with holes in it and stained may have been used to clean in the kitchen. The Administrator stated anytime a dish rag touched the food she required for the food to be discarded. She stated if the food was not discarded and a resident did eat the bacon or the cereal there was a potential a resident may become sick with stomach issues with vomiting or some type of food borne illness. The Administrator stated the Dietary Manager was responsible for monitoring the kitchen and she was responsible for monitoring the Dietary Manager. Record review of Dietary Inservice on hand hygiene, do not touch food with bare hands and all foods are required to be covered, dated 08/07/2025, Dietary Assistant [NAME] A and Dietary [NAME] B attended the in-service. Record review of the Facilities Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, revised on November 2022, reflected All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees must wash their hands before coming in contact with any food surfaces, during food preparation, as often as necessary to remove soil and contamination and to prevent cross-containment when changing tasks; and/or after engaging in other activities that contaminate the hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 12 residents (Resident #9, Resident #25 , Resident #102, ) observed for infection control.
1.
The facility failed to ensure all staff donned PPE when entering rooms of residents' rooms who were on droplet precautions.
2.
The facility failed to ensure PPE was adequately stocked for residents on droplet precautions.
These failures could place residents at risk of cross-contamination and development of infection.
Findings included:
Review of Resident #9 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of Dementia (a decline in mental ability that affects memory, thinking, and behavior), heart failure, and chronic fatigue (a long-term illness that causes severe fatigue and makes it difficult to perform daily activities).
Review of Resident #9 care plan revealed Resident #9 had increased potential to contract COVID 19 in facility. Interventions included to follow CDC and health department guidelines regarding COVID recommendations and precautions. Further review revealed of care plan with revision date of 12/11/2024 that resident had recent diagnoses of COVID 19 with position test. Interventions included to enforce strict isolation with proper donning and doffing of isolation equipment.
Observation on 12/12/24 at 10:03 AM revealed CNA Y walked into Resident #9's room without face shield or goggles on.
Review of Resident #25 face sheet revealed an [AGE] year-old male admitted on [DATE] with diagnoses of COVID-19 (an infectious disease caused by the SARS-CoV-2 virus), metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood that affects brain function) and anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress).
Review of Resident #25 care plan dated 04/09/2024 revealed resident with increased potential to contract COVID due to communal living, interventions included to follow CDC and health department guidelines regarding COVID recommendations and precautions. Further review revealed care plan dated 12/07/2024 Resident #25 had recent diagnoses of COVID 19 with interventions to enforce strict isolation with proper donning and doffing of isolation equipment.
Observation on 12/10/2024 at 2:19 PM revealed PPE observed outside of Resident #25's room. Resident had droplet precaution sign posted on door to room.
Observation on 12/11/24 at 11:47 AM revealed no face shields available for staff outside of Resident #25's room.
Review of Resident #102's face sheet revealed an [AGE] year-old female admitted on [DATE] with diagnoses of COVID-19 (respiratory virus), anxiety disorder (a mental health condition that causes excessive and uncontrollable feelings of fear or worry that can interfere with daily life), depression (a mental health condition that can affect how a person feels, thinks, and behaves), and essential hypertension (a condition where blood pressure is chronically elevated but there is no known cause).
Review of nursing progress notes for Resident #102 dated 12/09/2024 revealed Resident to begin strict covid isolation - contact & droplet precautions.
Review of Resident #102's care plan dated 12/09/2024 revealed resident with recent diagnoses of COVID 19 virus with interventions that included enforce strict isolation with proper donning and doffing of isolation equipment along with strict hand washing.
Observation on 12/10/2024 at 12:00 PM revealed CNA O entered Resident #102's room with gown, gloves, N-95 mask and a surgical mask under the N-95 mask. CNA O was not wearing a face shield or goggles.
Observation on 12/10/2024 at 2:13 PM revealed MA Q entered Resident #102's room with gown, gloves and surgical mask. MA Q was not wearing a face shield or goggles.
Observation on 12/10/2024 at 2:14 PM revealed a plastic bin with PPE in front of Resident #102's room and it included gowns, gloves, N-95 masks and surgical masks. There were no goggles or face shields in the cart.
Observation on 12/10/2024 at 2:19 PM revealed a sign on Resident #102's door that revealed droplet precautions were in place. Further observation revealed a sign titled sequence for putting on personal protective equipment (PPE) Instructions included to don gown, mask or respirator, goggles or face shield and gloves. Observation revealed an additional sign posted that everyone must make sure their eyes, nose and mouth are fully covered before room entry.
During an interview on 12/10/2024 at 2:17 PM MA Q stated that Resident #102 had COVID. MA Q did state why she did not have a face shield or goggles on entering Resident #102's room.
Observation on 12/11/2024 at 9:55 AM revealed a plastic bin with PPE in front of Resident #102's room and it included gowns, gloves, N-95 masks and surgical masks. There were no goggles or face shields in the cart.
Observation on 12/11/24 at 11:47 AM revealed no face shields available for staff outside of Resident #25's room.
Observation on 12/12/24 at 10:03 AM revealed CNA walked into Resident number #9's room without face shield or goggles on.
Observation on 12/12/2024 at 10:35 am revealed a large box in the housekeeping manager's office with face shields in it.
During an interview on 12/10/20245 at 2:17 PM MA Q stated that Resident #102 had COVID.
Interview with LVN Z on 12/11/24 at 10:35 am, she stated that if a resident had droplet precaution it should have been posted on the door. They were supposed to follow the sign on the door for putting on and taking off the PPE. They were supposed to wear a face mask, dispose of all the gear inside, and wash their hands. If there was not PPE available, she would have requested it from housekeeping.
Interview with CNA Y on 12/11/2024 at 10:03 am 12/11/2024, she stated that when she went into a room she put on gown, gloves and masks. When she exited a room, she took off gloves first, then gown, then mask, and then washed hands inside. She sanitized her hands outside the room. She stated that she did not like the face shield because it made her hot. She was not sure if she was supposed to wear the face shield. She stated if she did not have PPE, she would go to the nurse and ask her. She stated that housekeeping came to check and stock PPE. She thought she had an in-service from one of the nurses in November. She stated that if she does not have PPE, she could get other residents sick.
Interview with LVN AA on 12/12/2024 at 10:13 am, she stated that housekeeping came to check and stock up on PPE. She thought they needed face shields, and she stated she had an in-service in November for infection control. If they did not have PPE housekeeping or nurses would get PPE it out of the linen closet. She stated that she could get other residents sick if they do not wear PPE properly.
Interview with LA BB A on 12/12/2024 at 10:14 am she stated that another housekeeping staff was responsible for ensuring PPE was available. She stated that she did not check for PPE while she was cleaning the halls. She would occasionally check if the box were was obviously low from the outside. They had someone come this morning to fill up the PPE. If there was no PPE she would not go in the room. She thought her last in-service was 3 months ago.
Interview with LA CC B on 1112/12/2024 at 10:35 am, she stated it was her responsibility to stock PPE. PPE included gowns, gloves, blue bags, face shields, and masks. She was responsible for placing signs on the doors and checking PPE every morning. If there was not enough PPE available when she was in the facility she expected a verbal request, a text or a phone call from any staff that needed more PPE. She stated there were plenty of face shields available for staff. She stated the residents could be in danger if she did not stock the PPE for the direct care staff.
Attempted telephone interview with CNA O on 12/12/2024 at 12:19 PM.
Attempted telephone interview with MA Q on 12/12/2024 at 12:20 PM.
Interview with RN A, the infection preventionist, on 12/12/24 at 01:49 PM, she stated that employees were supposed to wear goggles or face shields when going in the rooms.
Interview with the DON on 12/12/2024 at 1:45 PM she said the facility did yearly PPE in-services or anytime there was a new COVID case. She stated that staffed needed to wear face shields or goggles. There was no reason staff should not have face shields on. The housekeeping was responsible for stocking the PPE. They had designated one person to stock it each morning. She stated that it would spread disease to other residents if staff did not wear proper PPE. DON stated staff were supposed to wear N95 masks and staff should not just wear surgical masks. DON stated staff should not wear an N95 mask over a surgical mask. She stated staff knew the order of PPE because they should look at the signs on the door. DON stated staff should just throw the face shield away and get a new one after they exited a room.
Review of facility in-services revealed an in-service was completed on 09/10/2024 with the topic of COVID-19. Informed review included how COVID-19 spreads, sequence for putting on PPE, and that staff must ensure their eyes, nose and mouth were fully covered.
Review of facility policy dated September 2022 titled Coronavirus Disease (COVID-19) - Using Personal Protective Equipment revealed Personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection adhere to standard precautions and use NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves and eye protection. Further review revealed an N95 respirator and eye protection (goggles or a face shield that covers the front and sides of the face) is applied upon entry to the resident room or care area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the residents rights to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 5 residents (Resident #26) reviewed for advanced directives.
The facility failed to ensure Resident #26's out of hospital do-not-resuscitate (OOH-DNR) order form was signed by a physician.
These failures could place residents at-risk of having their wishes dishonored or delay necessary medical treatment or intervention due to confusion.
Finding included:
Review of Resident #26 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, altered mental status, cognitive communication deficit, hypertensive heart disease with heart failure, and unspecified diastolic (congestive) heart failure.
Review of Resident #26 physician orders dated [DATE] reflected an order for do not resuscitate.
Review of Resident #26 care plan dated [DATE] revealed resident or family requested to be DNR. Interventions included chart to have proper documentation of DNR status and goals included resident decision to be honored through review date.
Review of Resident#26's out-of-hospital do-not-resuscitate (ooh-dnr) order form revealed no physician signature in the physician statement section. Further review revealed there was no physician signature in the section all persons who have signed above must sign below, acknowledging that this document has been properly completed.
During an interview on [DATE] at 3:17 PM, LVN C stated that she knew what a resident's code status was by a list provided by the ADON/DON. She stated that the list is updated often and that it was also in their chart. She stated that she verified an OOH-DNR was complete and valid because it was in the resident's chart and uploaded into the document section. LVN C stated that you had to make sure there were signatures on the OOH-DNR. LVN C stated an OOH-DNR is not considered valid if it did not have physician signature. LVN C reviewed Resident #26's OOH-DNR and stated that it did not have any physician signature. LVN C stated that because the OOH-DNR did not have a physician signature the resident would have to be a full code and it was not valid. She stated that unfortunately the resident's wishes may not be met if they had an OOH-DNR and are put as a full code.
During an interview on [DATE] at 3:22 PM, LVN D stated that she knew a resident's code status because it was in their chart on their face sheet and as an order. She stated she verified that an OOH-DNR is complete and valid by the physician signature. LVN D stated that if an OOH-DNR did not have a physician signature it was not considered valid. LVN D viewed Resident #26's DNR and stated that it did not have physician signatures and it should have them.
During an interview on [DATE] at 3:56 PM, SW stated that she knew a resident's code status was because she participated in getting signatures for OOH-DNRs. SW stated their code status is also in the system on their face sheet and there were copies of the OOH-DNRs. She stated that she verified that an OOH-DNR is valid by when she witnessed the resident or representative sign it and then it was sent to the doctor. SW stated it was incomplete until doctor signed it. SW stated she is unsure if there was an audit to see if OOH-DNRs were completed. She stated nurse handles scanning the OOH-DNR into the resident's chart. SW viewed Resident #26's OOH-DNR and stated it was not valid because it did not have physician signature. She stated that if a resident did not have a valid OOH-DNR a medical professional may assume it was valid and the resident may pass and later realize the resident was a full code. She stated that it was not valid, and staff performed CPR it would have also been a major concern.
During an interview on [DATE] at 2:54 PM, DON stated that staff knew a resident's code status because it was in PCC and binders were also available with the document. She stated that code status was also posted at the nurses stations. She stated that the SW was supposed to verify if an OOH-DNR was complete or valid. She stated that the SW should audit the document when they initially get the OOH-DNR. DON stated she expected that OOH-DNRs are audited quarterly. DON stated an OOH-DNR was not valid without a physician signature. She stated that the potential harm of an incomplete OOH-DNR was not following the wishes of the family or resident. DON stated that if an OOH-DNR was not valid the facility could potentially perform CPR, and if a resident did not want CPR it may lead to trauma.
During an interview on [DATE] at 3:04 PM, ADM stated that audits are completed monthly for advanced directives. She stated during the audit it was reviewed the accuracy of the OOH-DNR and match it to the order in the resident's chart. She stated the SW was responsible for completing OOH-DNR audits, but it has been a collaboration with nursing recently. She stated that an OOH-DNR should include physician signatures. ADM stated that the potential harm was that they may not resuscitate someone if an OOH-DNR was not valid.
Review of facility policy Advanced Directives dated [DATE] revealed the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.
Review of health and safety code 166.083(b)(4)(6) revealed an OOH-DNR order at minimum must contain statement that the physician signing the document is the attending physician of the person and that the physician is directing health care professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue certain life-sustaining treatment on behalf of the person and places for the printed names and signatures of the witnesses or the notary public's acknowledgment and for the printed name and signature of the attending physician of the person and the medical license number of the attending physician
Further review of health and safety code 166.089(3) revealed an OOH-DNR order form appears valid when it includes the signature or digital or electronic signature of the declarant or persons executing or issuing the order and the attending physician in the appropriate places designated on the form for indicating that the order form has been properly completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents had the right to be free from resident neglect for one
(Resident #12) out of three residents reviewed for neglect.
The facility failed to ensure FTA from ensuring the facility lift was located at the back facility door to transfer Resident #12 off the van onto the lift . Resident #12 fell from the van onto the lift located on the ground on 11/15/2024.
This noncompliance was identified as PNC. The deficient practice occurred on 11/15/2024 and in-service was completed on 11/15/2024. The facility had corrected the noncompliance before the survey began.
This failure could place residents at risk of neglect, injury, and psychosocial harm.
Findings included:
Record review of Resident # 12's face sheet, dated, 12/11/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #12 had diagnoses which included vascular dementia ( a condition that affects the brain's ability to think, remember, caused by lack of blood flow to the brain), type 2 diabetes with diabetic neuropathy, acute respiratory failure with hypoxia (a medical condition where the body's ability to take in oxygen is suddenly impaired, leading to a dangerously low level of oxygen in the blood. Hypoxia can be life-threatening), muscle weakness ( a lack of muscle strength that makes it difficult to move your body),glaucoma ( buildup fluid in the front of the eye, which increases pressure inside the eye. If left untreated can lead to vision loss and eventually blindness), and type 2 diabetes with diabetic neuropathy ( when nerve damage develops due to long-term high blood sugar levels).
Record review of Resident #12's Annual MDS Assessment, dated 10/07/2024, reflected the resident had a BIMS score of 4, which indicated her cognition was severely impaired. Resident #12 required assistance with transfers, dressing, hygiene, and showers.
Record review of Resident #12's Comprehensive Care Plan, completed on, 11/18/2024, reflected Resident #12 had Impaired physical mobility. Intervention: Assist resident in performing movements and tasks. Educate Resident and Representative on safety precautions. Educate resident and representative on safe transfer techniques. Resident #12 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to some cognitive deficits (related to mental process involved in knowing, learning, and understanding things) and safety concerns. Resident #12 required assistance with most aspects of ADL s. Intervention: Transfers: Resident #12 required one person assist with difficult transfers related to weakness. Resident #12 was at risk for falls. Resident #12 had a fall incident with transportation van on 11/15/2024 and was evaluated at emergency room with laceration and hematoma to back of head. Interventions: anti-roll back to wheelchair. Staff education on safe operation of van with loading and unloading residents. Van maintenance for proper function of the transportation van.
Record review of Resident #12's nurses note dated 11/15/2024 at 3:30 PM reflected called by transportation driver to the front awning. Seen resident laying on her left side. Resident was assisted into a sitting position. Resident stated she hit her head and it was hurting her. Small laceration and formation of hematoma was noted to the back of her head. Resident complained of pain to her bottom but denied pain anywhere else. Upon further assessment, no other injuries noted. Focused neuro assessment was completed, resident was alert and oriented , Vitals BP- 140/90, P-92, Respiration- 24, Temperature- 98.6, O2- 100 % RA. Assessed residents ROM, WNL of resident's baseline. EMS was called, R/P, MD, DON , and Administrator notified. Resident consented to transport. Signed by RN A.
Record review of the facility investigation report, dated 11/18/2024, reflected Transportation Aide T failed to raise the lift prior to rolling Resident #12 out of the van resulting in resident falling out of the rear exit of the van. The investigation was confirmed, and Transportation Aide T was terminated.
Record review of Resident #12's incident report, dated 11/15/2024, reflected called by transportation driver to the front awning. Seen resident laying on her left side. Resident stated she hit her head and it was hurting. Small laceration and formation of hematoma to the back of her head. Resident complained of pain to her bottom but denied pain elsewhere. No other injuries noted. Resident stated I fell out the back of the van. Resident noted to be anxious. Resident knew where she was and able to inform the nursing staff her name and date of birth . The following was documented on the incident report:
1. Immediate action taken: Resident sent to local hospital by EMS.
2. Injuries observed at the time of incident: laceration to the back of head.
3. Level of Pain: Resident #12's pain level was a 10 (on scale of 1 to 10 and 10 being the maximal level of pain). Resident #12 was alert.
4. Mental Status: Resident #12 was oriented to the following: person, situation, place and, time.
5. Injuries report post incident: Resident #12 did not have any observed post incident.
6. Witnessed fall: Resident #12 fell outside.
7. Predisposing situation and physiological factors: none.
8. Other information: Lift was not in raised position. Lift was lowered to the ground from previous resident that was unloaded from the van.
9. Statements: TA T statement was not printed in its entirety. ( The sentences were not complete due to printing error on the incident report) Requested on 12/10/2024 at 2:30 PM from the DON for a new incident report. It was not provided prior to exit. Resident #12 incident report was provided in the facility investigation, however, it did not have the statement by transportation aide T. Agencies/People notified: Physician, DON, and Family member.
Record review of Resident #12's first hospital visit on 11/15/2024 reflected findings of a fracture of the surgical neck of the right humerus, mild angulation, and impaction. Suspect second part fracture extending into the greater tubercle. No other evidence of injury. First hospital recommended Resident #12 sent to another hospital for further testing and assessment.
Record review of Resident #12's second hospital visit on,11/15/2024, reflected history of present illness. Resident #12 was presented to the ED as a transfer status post fall from wheelchair. Outside hospital imaging was concerning for subdural and right humerus fracture. However repeat trauma imaging did not show any signs of subdural hematoma or new humerus fracture aside from an old fracture. Trauma CT scan revealed an incidental finding of right lower lobe segmental Pulmonary Embolism ( a blood clot that blocks an artery in the lungs, preventing blood flow to part of the lung). Resident #12 had new O2 requirement and required 2 L on nasal cannula. Resident #12 at baseline and did not require any oxygen at facility. The hospital completed CT scans and x-rays of all areas of Resident #12. Resident #12 had an old fracture and did not have any new injuries.
Record review of Transportation Aide T personnel record reflected Transportation Aide T was hired on 04/15/2024 as a transportation aide. She received training by the former Transportation Coordinator U on 04/15/2024. Transportation Aide T and Transportation Coordinator U signed the facility form Steps for Operating the lift in the van. The facility followed protocol for any incident occurring in the facility van. Transportation Aide T results of the drug test was in the personnel file, and it was negative. Transportation Aide T was terminated on 11/15/2024.
Record review of Transportation Aide R's personnel record reflected her training and orientation to be a transportation aide was completed on 11/18/2024 and 11/21/2024.
Record review of Transportation Aides S personnel record reflected her training and orientation to be a transportation aide was begun on 12/2/2024 and was continued for 2 weeks.
Record review of demonstration in-services completed by Transportation Coordinator on 11/18/2024 after the incident on 11/15/2024 with Resident #1 in the white ford van reflected all staff on the facility van insurance was required to demonstrate how to load residents on the van and how to unload the residents off the van. The following was demonstrated :
Steps for operating the Lift in the [NAME] Ford Van
1. Ensure the van's engine is running.
2. Engage the emergency brake.
3. When a resident is positioned on the lift, lock the brakes on their chair.
4. Secure the strap behind the chair.
5. Gradually lower the resident and the ramp to the ground.
If there is a second resident awaiting unloading inside the van, ensure their chair remains secure with a harness until the staff is ready to assist.
1. Secure the yellow strap belt.
2. Return the lift to its raised position.
Please note: If the lift is left in the lowered position, an alarm will activate when the weight contacts the yellow-marked barrier on the lift mechanism.
Steps for Operating a [NAME] Dodge Caravan or the Green/ Gray [NAME]:
1. The ramp is operated manually
2. Ensure the vehicle is parked at least four feet from the curb and facing away from the traffic to prioritize safety.
3. Lower the ramp while employing proper body mechanics.
4. Secure all residents using a four-point harness system.
5. Fasten each resident with a seatbelt for additional safety.
6. When loading a resident , they should face inward towards the van.
7. During unloading, ensure the resident descends the ramp while facing the interior of the van.
Record review of Abuse and Neglect in-service dated 11/15/2024 reflected abuse and neglect was discussed during the in-service. Neglect- is the failure to care for properly. Cases of suspected abuse, neglect, or exploitation shall be reported immediately to the abuse coordinator, The Administrator or to The Director of Nurses.
Record review on 12/11/2024 of the signs steps for operating a white dodge caravan or the green/gray [NAME] placed in the facility vans after the incident on 11/15/2024. The signs reflected the following:
1. The ramp is operated manually.
2. Ensure the vehicle is parked at least four feet from the curb and facing away from traffic to prioritize safety.
3. Lower the ramp while employing proper body mechanics.
4. Secure all residents using a four-point harness system.
5. Fasten each resident with a seatbelt for additional safety.
6. When loading a resident, they should face inward towards the van.
7. During unloading, ensure the resident descends the ramp while facing the interior of the van.
Record review of QAPI for the upcoming meeting in January 2025 reflected the incident with the facility van would be addressed during the QAPI meeting and review the steps taken to prevent another incident on the van.
Record review, on 12/10/2024 of additional steps to be taken to ensure the staff was operating the van per protocol the Transportation Coordinator will complete monthly random checks with the transportation aides and the other staff on the insurance card to ensure they are operating the van per protocol. These random checks will be unannounced.
Record review, on 12/10/2024, of additional protocol was to perform drug testing on any new hires to drive the van and will do drug testing if suspect anyone is using illicit drugs.
Record review on 12/10/2024, of a statement from Transportation Aide T given to Transportation Coordinator, dated 11/15/2024, reflected, Transportation Aide T had both Resident #12 and Resident #48 in the transit van out from of the facility. Transportation Aide T Unstrapped Resident #48, pushed her on the ramp, lowered the ramp, and proceeded to wheel Resident #48 into the nursing home. Transportation Aide T then went through the right side of the transit van to unstrap Resident #12. Transportation Aide T stated they were talking and making jokes while Transportation Aide.
Unable to conduct observation of the facility van used to unload Resident #12 when she fell from the van onto the ground as it was not at the facility. The white dodge caravan was in the shop.
Record review of the invoice faxed from the mechanic shop where the facility white caravan was being repaired reflected the mechanics were working on the transmission torque converter and not the wheelchair lift.
In an interview on 12/10/2024 at 9:05 AM the Director of Nurses stated Resident #12 was returning from a doctor's appointment in the facility van. She stated Transportation Aide T had assisted Resident #48 off the facility van and into the facility. She stated when Transportation Aide T returned to the van she did not step onto the lift and maneuver the lift to the door instead she entered the van from the side door. She stated Transportation Aide T unhooked the belts and all the safety gear from Resident #12's wheelchair and began to assist her to the back of the van. The Director of Nurses stated Resident #12's back was toward the open door and Transportation Aide T was face to face to Resident #12. She stated Transportation Aide T pushed her off the van without the lift being at the door of the van. Resident #12 fell from the van onto the lift located on the ground. The Director of Nurses stated Resident #12 did not sustain any injuries. She was immediately transported to the emergency room by EMS and later transferred to another emergency room for further x-rays and CT scans. She stated the hospital report indicated no injury from the fall. The Director of Nurses stated Transportation Aide T was given a drug test per protocol of the facility's insurance and she was negative for any illicit drugs. She stated Transportation Aide T was terminated immediately for not following proper policies and procedures when transferring Resident #12 off the van. The DON stated during the investigation it was confirmed neglect. She stated the facility immediately began abuse and neglect in-services. The Transportation Coordinator on 11/18/2024 in-service everyone on the insurance card to demonstrate how to operate the vans. She stated this incident was on the next QAPI agenda. The Director of Nurses stated the facility will be doing random observation of staff operating the van and this would be unannounced. She also stated the facility has put in place to do drug screens on any staff will be operating the facility van and will do random drug screens if any suspicion of drug use when on duty.
In an interview on 12/10/2024 at 9:45 AM Transportation Coordinator stated Transportation Aide T came into the facility and asked for a nurse immediately. Transportation Coordinator stated few nurses went outside and she heard people talking and she immediately went outside. She stated when she arrived outside under the awning near the front door was the Van ( white dodge van). Transportation Coordinator stated she saw Resident #12 on the ground and there were two or three nurses assessing Resident #12. She stated she spoke with Transportation Aide T, and she was very upset. She stated Transportation Aide T explained what happened with Resident #12. Transportation Coordinator stated she wrote a statement of what Transportation Aide T stated what occurred and she did not think to get Transportation Aide T to sign the statement. ( The statement is listed above this interview). Transportation Coordinator stated she could understand how the statement could be confusing. She stated Transportation Aide T left the lift ( ramp) on the ground after unloading Resident #48. She stated after Transportation Aide T Escorted Resident #48 into the facility she returned to the van and entered from the side door. Transportation Coordinator stated Transportation Aide T unhooked all the belts and safety devices from Resident #12 wheelchair. She stated Transportation Aide T was facing Resident #12 and was pushing her backwards to the open door in the back of the van. Transportation Coordinator stated Transportation Aide T did not have the lift to the van door. She stated Resident #12 back was facing the open door and Transportation Aide To push resident off the van and Resident #12 fell from the van onto the lift located on the ground. She stated she was informed by the Administrator to escort Transportation Aide T to get a drug test. Transportation Coordinator stated after the drug test she escorted her into the Administrator's office and Transportation Aide T was terminated immediately. Transportation Coordinator stated she had been in this position after Transportation Aide T was hired. She stated the former Transportation Coordinator U Trained Transportation Aide T. She stated all staff hired as transportation aides are trained 2 weeks or more before they can drive the vans. She stated there were two facility vans one is a [NAME] Dodge Caravan and this was the one Resident #12 was in when she fell. She stated there was another van a Green/Gray [NAME]. Transportation Coordinator stated all staff on the insurance card had been re-trained on how to operate the vans uploading and unloading on 11/18/2024. She stated there was a new hire on 12/02/2024 as a full-time van driver. Transportation Coordinator stated the new van driver received training on how to operate the van on 12/02/2024 and for 2 weeks prior to Transportation Aide S drove the van. She stated Transportation Aide S and any new hires received training and would observe the current Transportation Aide R before she drove the van. Transportation Coordinator showed her list of staff on the insurance card, and it matched the administrations list. Transportation Coordinator stated everyone on that list had been in serviced verbally and given form of steps for operating the lift on the vans and the staff had to demonstrate how to operate the van on an individual basis. She stated this was the first time Transportation Aide T had an accident/ incident with unloading a resident off the van. Transportation Coordinator stated she was not aware of any transportation aides or anyone driving the vans having an incident.
Interview on 12/10/2024 at 1:00 PM Transportation Aide S stated she was hired on 12/02/2024 as a full-time transportation aide. She stated she did not work at this facility prior to being hired on 12/02/2024. Transportation Aide S stated she was given in-service and training over a week before she began driving the van. She stated she observed Transportation Aide R drive the van and observed residents being unloaded and uploaded on to the vans. She repeated how to upload a resident onto the van and unload a resident off the van. She stated she was in-serviced on resident neglect.
In an attempt to interview via phone Transportation Aide T on 12/10/2024 at 2:23 PM, 12/11/2024 at 10:20 AM and 12/12/2024 at 12:22 PM unable to leave voice message and sent 3 texts on the same dates and time to return phone call. Transportation Aide T did not return phone call or respond to three text messages.
Interview on 12/11/2024 at 10:30 AM RN A stated she heard staff calling for a nurse to go to the parking lot. She stated she was sitting in her office and immediately exit office and went to the parking lot. She stated she was first nurse to observe Resident #12. She stated Resident #12 was at an odd position on the lift and part of her side was on the ground. RN A stated Resident #12 was lying on the lift where a staff would push a resident onto the lift. RN A stated Resident #12 was lying on the arm of the wheelchair and Resident #12 was lying on the left side of wheelchair. RN A stated it was an unusual position and was difficult to describe. She stated Resident #12 buttocks was partially in the wheelchair. She stated Resident #12 was complaining of pain back of her head. RN A stated it appeared a small hematoma was forming, and she had a small laceration to back of the head. RN A stated there were two other nurses assisting with Resident #12. RN A stated the physician, EMR, Family, DON and the Administrator was contacted. She stated she wrote a nurses note, and another nurse completed incident report. RN A stated she did not speak with Transportation Aide A and was focusing on assessing Resident #12. She stated she knew Resident #12 fell from the bus on to the lift and ground and the lift was not at the door when she fell. She stated she knew this due to needing to know how she fell onto the ground. RN A stated there was a lot going on and she did not recall who gave this information. She stated she had been in serviced on Abuse and neglect. RN A stated she did not drive the vans.
In an interview on 12/12/2024 at 8:15 AM former Transportation Aide/ Receptionist stated she did work with Transportation Aide T when she was full time transportation aide. She stated she had ridden with Transportation Aide T when she drove the van and observed her unloading and loading residents. Former Transportation Aide/ Receptionist stated she never saw Transportation Aide To do anything wrong with the operation of any part of both vans. She stated training on how to operate every part of the van including the lifts was very important to the facility and the staff received hands on training. She stated she had was in-service on abuse and neglect. She stated she is currently receptionist and does not drive the van any longer, however she did go through the training on 12/18/2024 as a precaution if there was an emergency, she would be willing to drive the van. She stated she was in-service on abuse and neglect.
In an interview on 12/12/2024 at 10:55 AM Transportation Aide R stated she had been working at this facility as a MA and CNA since 11/7/2023. She stated she did drive the van as needed when Transportation Coordinator U was working at the facility, and he trained me how to use the vans. She stated Transportation Coordinator U would have me to demonstrate using a fake person in a wheelchair and observed me unloading, uploading , placing the straps secure and things like that in the van. She stated she was retrained on 11/18/2024 by the present Transportation Coordinator. She stated she is a full time Transportation Aide as of 12/02/2024 and was part time transportation aide prior to 12/02/2024. Transportation Aide R stated she did go through re orientation and in-service on abuse and neglect.
In an interview on 12/12/2024 at 1:35 PM the Administrator stated Transportation Aide T, had returned to the facility in the facility white van with 2 residents from doctor appointments. Transportation Aide T Unloaded Resident # 48 off the facility van with the lift. She stated when Transportation Aide T returned to the facility van, she did not enter the van per facility protocol. The Administrator stated Transportation Aide T did not stand on the lift and move the lift from the ground to the back open door. She stated Transportation Aide T was required per policy to stand on the lift and maneuver the lift from the ground to the back door to use to transfer Resident #12 from the facility van onto the ground. Transportation Aide T entered the facility van from the side door and proceeded to unhook the straps and belts from Resident #12's wheelchair. Transportation Aide T pushed Resident #12 wheelchair to the open door where the lift was not at the back door. Transportation Aide T was facing Resident #12 and Resident #12's back was to the open door. She stated Transportation Aide T did not notice she had not moved the lift from the ground to the open door. The Administrator stated Transportation Aide T pushed Resident #12 backwards where Resident #12's back was facing the door and pushed her off the van. The Administrator stated it was approximately 3 or 4 feet. She stated Resident #12 fell from the facility van onto the lift located on the ground. She stated the lift was not used to assist Resident #12 off the facility van. The Administrator stated the facility protocol for unloading residents onto the lift of the van was not followed. She stated the white van was used during the incident with Resident #12 was in the shop at a dealership for repair. She stated the repair was not the lift. The Administrator facility staff checked the lift after the incident, and it did not have any mechanical issues. The lift was in good condition. The Administrator did not specify what staff checked the lift.
In an interview on 12/12/2024 at 3:30 PM Resident #12 stated she did fall out of a van, and it was a long fall. She stated she was not hurt and was happy she did not break any bones. Resident #12 stated she was not afraid to ride on the van again. She stated accidents happens and she was lucky. Resident #12 stated she would ride the van anytime she was not afraid and was not nervous over the fall from the van.
In an interview on 12/12/2024 at 3:45 PM Transportation Coordinator stated the protocol listed below was the facility protocol for unloading a resident off the van.
Record review of the facility's protocol for Unloading Transportation Vans, not dated, reflected the following:
1. When unloading a resident, the resident is to be pushed onto the ramp, brakes engaged, and the driver is to ride down the ramp in front of the resident until the ramp is fully down and immobile on the ground.
2. Ensure that wheelchairs are always locked when not actively moving a resident .
3. Residents are required to have their wheelchairs secured in the van and the resident is to be wearing a seat belt.
4. Before unloading a resident, make sure the ramp is up all the way and ready for the resident to be pulled onto the ramp.
5. While unloading the van when transferring two residents, be sure to leave the resident not being unloaded at the same time secure in the van and have their wheelchair locked until ready to unload them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 5 residents (Resident #38) reviewed for misappropriation of property.
The facility failed to prevent the misappropriation of Resident #38's Hydrocodone-Acetaminophen, a medication to help with pain.
This failure could place residents at risk for not receiving prescribed medications.
Findings included:
Record review of Resident #38's admission record dated 12/12/24, reflected the resident was admitted [DATE]. Her diagnoses included dysphagia (difficulty swallowing), cerebral infarction (stroke), Rheumatoid arthritis (the immune system attacks the body's tissues, leading to swelling and joint deformity and pain), and pain.
Record review of Resident #38's quarterly MDS dated [DATE] reflected a BIMs score of 0 indicating severe cognitive impairment.
Record review of Resident #38's physician orders dated 11/3/24 reflected an active order for Hydrocodone-Acetaminophen 5-325mg 1 tablet oral every 24 hours as needed for pain.
Record review of Resident #38's Medication Administration Record (MAR) dated 11/1/23 through 11/30/24 reflected the Hydrocodone-acetaminophen had not been administered at all.
Record review of the facility's investigation of the missing hydrocodone-acetaminophen medication reflected on 11/03/24 during the shift change around 6AM the oncoming nurse noted a difference in color for 5 of the 60 tablets in the bottle. The charge nurse was notified. The charge nurse was not able to address the situation for some time but once she assessed the situation the on-call nurse and ADM were notified. The off going nurse that worked night shift had already left the facility and refused to return to perform a urine drug screen. The medications were found to be Imdur 60mg tab. No other resident in the facility had an order for Imdur.
Record review of the Pharmacy consultant's notes dated 11/11/24 revealed, DON reported a discrepancy in bottle of Norco 5/325 generic. Bottle contained 60 tablets, but 55 were identified by ID on bottle and Ephorates app as Hydrocodone/Appa 5/325 as dispensed and 5 of the 60 were noted to be Isosorbide Mononitrate 60mg tablets-per ID on the tablets, and per Drugs.com.
During an interview on 12/12/24 at 9:28 AM with LVN E, she stated she had worked at the facility for about a year. She stated that all controlled medications are to be counted when possession of responsibility for the cart changes. LVN E stated the first page in the count binder is a record of how many medications there are to be counted. Once the correct number of medications is verified then the quantity of each medication must match up to its paired sheet. LVN E stated if anything is off with the count or suspicion of anything not matching up correctly then it is to be reported to the DON immediately. She stated missing medications could mean that a resident does not get the medication when they are supposed to.
During an interview on 12/12/24 at 9:53 AM with LVN F, she stated she had worked at the facility for about 4 years. She stated that all medication carts are to be counted before changing shifts. She stated that if anything is off with the count, then the DON is to be notified immediately. She stated if there are medications missing then it could affect the resident by causing a missed dose.
A telephone message was left on 12/12/24 at 1:00 PM for Family member of Resident #38 requesting a return call. A return call was not received before close of business 12/13/24.
During an interview on 12/12/24 at 2:39 PM with the DON, she stated she was notified a few hours after shift change about the medication being a different color and possible different pill. She stated that her investigation revealed that during the shift change it was discovered that 5 pills in a bottle of 60 pills were with a different color and imprint than the other 55 pills. The DON stated that the off-going nurse (LVN W) on that day when this discrepancy was revealed refused to do a urine drug screen and has been terminated from employment with this facility. She stated that she contacted the physician, the consultant pharmacist, the resident's responsible party, the dispensing pharmacy and the sheriff's office to make a report. The DON stated the 5 other pills were identified as isosorbide mononitrate 60mg using drugs.com as a reference. She said that she looked and no one in the building at that time was prescribed that medication and dosage. She stated that she has since in serviced staff that she is to be notified immediately and no one is to leave the building until further instructed. The DON stated that her investigation into the missing medication was considered confirmed. She stated that this could have impacted the resident if she had received the wrong medication, it could have caused harm.
During an interview on 12/12/24 at 3:04 PM with the ADM, she stated Resident #38's family took her to the doctor in another city and returned with a bag from an outside pharmacy with a bottle of medication in the bag in October. The medication was counted and verified by staff. She stated, they asked their pharmacy to repackage it into a blister pack, but they would not do it because it was filled at a different pharmacy. After the incident, Resident #38's chart was reviewed, and it reflected no medication had been administered since the order was written. She stated the incident was reported to the police and the nurse that worked that night (LVN W) refused to do a urine drug screen and that nurse was terminated. The ADM stated it could have affected the resident if she had taken the medicine, but she looked back over Resident #38's medication administration record and the resident never received any medication from that bottle.
Record Review of Policy titled Storage of Medications dated 2001 and revised in November 2020 states,
Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner.
8.
Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan with resident rights, which included measurable objectives and time frames to meet the resident's mental and psychosocial needs for 3 of 10 residents (Residents #17, #41 and #98) reviewed for care plans.
1.
The facility failed to update Resident #17's care plan to reflect current needs for suprapubic catheter care.
2.
The facility failed to update Resident #17's care plan to reflect current needs with transfers.
3.
The facility failed to update Resident #41's care plan to reflect current diet consistency orders.
4.
The facility failed to update Resident #98's care plan to reflect current needs with transfers.
This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being.
Findings included:
Record Review of Resident #17's admission record dated 12/11/24 revealed an [AGE] year-old male admitted on [DATE]. Resident #17's diagnoses include benign neoplasm of prostate (an abnormal growth near the prostate), hematuria (blood in the urine), obstructive and reflux uropathy (urine cannot flow in through the urinary system due to an obstruction), need for assistance with personal care, and ankylosing spondylitis (an inflammatory disease that can cause back pain, stiffness, and hunched posture).
Record Review of Resident #17's quarterly MDS dated [DATE] revealed resident was unable to complete a BIMS assessment that indicated severe cognitive impairment. The MDS revealed Resident #17 required substantial/maximal assistance to complete dependence on staff for all the assessment under functional abilities. The quarterly MDS revealed an Indwelling catheter under the section labeled Bladder and Bowel.
Record review of Resident #17's physician order summary dated 12/11/2024 revealed Resident #17 had orders as follows:
1.
Catheter: Catheter care with Incontinent Wipes Every Shift with a start date of 7/11/2024
2.
Catheter: Change Foley Catheter or Supra-pubic Catheter [a tube inserted directly into the bladder through the abdominal wall to drain urine] as indicated for infection, obstruction, or when closed system is compromised as needed with a start date of 12/4/2024.
3.
Catheter: Change Foley Catheter or Supra-pubic Catheter as indicated for infection, obstruction or when closed system is compromised everyday shift on the 4th for 1 day with a start date of 12/4/2024
4.
Catheter: Change leg strap or stat lock with each foley change and prn as needed
5.
Catheter: Ensure Catheter is draining properly to bedside privacy bag and leg strap is in place every shift.
6.
Catheter: Monitor for signs/symptoms of infection with a start date of 7/11/2024
7.
Catheter: Monitor Output Every Shift
8.
Irrigate Foley with 500 ml's distilled water-push 100 ml's in and pull out and repeat until clear as needed for hematuria with a start date of 10/29/2024.
9.
May use [mechanical] lift and x 2 assist to transfer safely.
Record review of Resident #17's Care Plan dated 9/5/2023 and revised on 3/25/24 revealed The resident has an ADL self-care performance deficit. Interventions included Transfer: The resident requires assist x one staff member to move between surfaces. Further review revealed no mention of Suprapubic Catheter throughout the plan.
Review of Resident #41 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of heart failure, disturbances of salivary secretion, and dysphagia.
Review of Resident #41 care plan with revision date of 03/10/2022 revealed resident was at risk for weight loss and interventions included diet of mechanical soft texture with regular consistency liquids with date of 10/17/2022 with additional interventions listed on 04/20/2024 of mechanical soft texture and regular consistency liquids with date per resident request.
Review of Resident #41 nursing progress note dated 11/07/2024 revealed hospice nurse gave new order per hospice physician to change diet consistency to regular texture.
Review of physician's telephone orders for Resident #41 dated 11/07/2024, revealed change diet consistency to regular texture.
Review of Resident #41 physician order dated 11/07/2024 revealed reduced concentrated sweets diet, regular texture, regular consistency.
Record Review of Resident #98's admission record dated 12/10/24 revealed a [AGE] year-old female with an admission date 3/6/24. Resident #98's diagnoses included Chronic pain, fatigue, repeated falls, lack of coordination, muscle weakness, reduced mobility, need for assistance with personal care, and unspecified dementia (a disease that affects the short- and long-term memory).
Record Review of Resident #98's quarterly MDS dated [DATE] revealed a BIMS score could not be assessed due to severe cognitive impairment. The MDS revealed Resident #98 was substantial/maximal assistance to dependence on staff for all assessment under the self-care functional abilities section.
Record Review of Resident #98's Care Plan dated 3/15/2024 and revised on 7/9/2024 revealed The resident has an ADL self-care performance deficit. Interventions included Transfers: The resident requires assistance x one with transfers, providing weight bearing assistance, guidance as needed.
Record Review of Resident #98's Order Summary Report dated 10/10/24 revealed an order stated, May use [mechanical] lift and x 2 assist to transfer safely.
During an interview on 12/12/24 at 9:28 AM, LVN E stated she had worked at the facility about a year. She stated Resident #17 and Resident #98 require a [mechanical] lift and assistance x 2 staff for a safe transfer. She stated the DON and management are responsible for updating care plans for residents during the resident's care plan meeting or as changes occur. LVN E stated that the CNAs look at ADL sheets, which are provided when they sign in for the day, to determine care for each resident. She stated she was not sure who used the care plan.
During an interview on 12/12/24 at 9:53 AM, LVN F stated she had worked at the facility about 4 years. She stated MDSN, activities, therapy and ADM was responsible for updating all care plans. LVN F stated the care plans are updated every Wednesday during their meeting. She stated she was not sure who used the care plans for the residents.
During an interview on 12/12/24 at 2:18 PM, MDSN stated she was responsible for completing and updating care plans. She stated that care plans should be updated for falls, skin issues, changes in medications and any significant event. MDSN stated that care plans should be updated for new catheters and for changes in requirement for transfers. She stated that nursing staff, activities staff and dietary staff all utilized the care plan when they provide care to the resident and not updating the care plans could affect how they provide the care.
During an interview on 12/12/24 at 2:39 PM, the DON stated MDSN was responsible for updating the care plans and they should have been updated quarterly, with any significant change in care, and/or new preferences identified by staff. She stated that she expected care plans to be updated when a resident had a new order for a catheter or when the resident's need changes for how care is provided. She stated if diet orders were changed then the care plan should be updated too. The DON stated the care plans are reviewed by MDSN, DON and during the quarterly meetings. She stated that floor staff used the MAR and NMAR and ADL sheets for daily care instructions.
During an interview on 12/12/24 at 3:04 PM, the ADM stated MDSN was responsible for updating the care plans quarterly, annually and with any significant change, incident/accident, or new preference. She stated that care plans should have been updated when a diet order changes, when a resident's requirements for transfers and when a resident had a new order for a catheter. The ADM stated the care plans are used by the interdisciplinary team and if they were not updated correctly then it could cause the team to provide care incorrectly.
Review of policy titled Resident Assessments and dated 2001 and revised in 2022 revealed.
Policy statement
A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements.
Policy Interpretation and Implementation
1)
The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessment and reviews according to the following requirements:
4. Significant Change in status assessment
3) A comprehensive assessment includes:
a. completion of the MDS.
b. completion of the care is assessment process and
c. development of the comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #109) of 4 residents reviewed for elopement on 10/27/24.
The facility failed to put interventions in place to prevent Resident #109 from eloping from the facility when she walked out of the memory care unit and exited the fire alarm gate on 10/27/24. Resident #109 was found by an exit door again on 12/01/24 . Resident has history of opening the doors after pushing on them for 15 seconds allowing the door to open.
An IJ was identified on 12/12/24. The IJ template was provided to the facility on [DATE] at 3:30 PM. While the IJ was removed on 12/13/24, the facility remained out of compliance at a scope of isolated and severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.
This deficient practice could place residents at risk for unsafe elopements, injuries, and hospitalization.
Findings included:
Review of Resident #109's admission record, dated 12/12/24, reflected she was an [AGE] year old female who initially admitted to the facility on [DATE], and had diagnoses including Alzheimer's disease (a brain disorder that causes a gradual decline in memory, thinking, and reasoning skills), Hypokalemia (a condition where the potassium levels in the blood are lower than normal), Hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), Hyperlipidemia (a condition where there are abnormally high levels of lipids (fats) in the blood), Essential primary hypertension (a type of high blood pressure that develops gradually over time and has no clear cause), Chronic atrial Fibrillation (a type of heart arrhythmia that causes the upper chambers of the heart to beat irregularly and quickly), unspecified atrial fibrillation (a heart condition where the upper chambers of the heart beat irregularly and out of sync with the lower chambers), seasonal allergic rhinitis (an inflammatory condition of the upper airways that occurs when the immune system overreacts to airborne allergens), constipation (a bowel dysfunction that makes it difficult or infrequent to have a bowel movement), primary osteoarthritis (is a type of arthritis that develops in joints over time and has no known cause), abnormalities of gait and mobility (any deviation from a normal walking pattern, which can manifest as difficulties with balance, coordination, or the rhythm of walking, often caused by underlying neurological, musculoskeletal, or sensory issues, leading to symptoms like limping, shuffling, dragging feet, or an unsteady gait), Altered mental status (a general term that describes a change in how well the brain is working) and cognitive communication deficit (a communication difficulty caused by a cognitive impairment).
Review of Resident #109's comprehensive MDS assessment, dated 10/16/24, reflected a BIMS of 2 indicated severe cognitive impairment. MDS review reflected wandering - Presence and Frequency: Resident score 1 indicating behavior of this type occurred 1 to 3 days.
Review of Resident #109's care plan, dated 10/11/24, reflected Resident #109 has impaired cognitive function with potential for worsening cognition related to progression of disease along with adjusting to new environment. Staff were instructed to keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Resident #109 is an elopement risk/wanderer related to disoriented to place, Impaired safety awareness. Staff were to maintain resident's safety will be maintained through the review date .
Review of Resident #109's progress notes, from 10/10/24 through 12/1/24 , reflected,
-A note by RN A on 10/10/24 at 5:09 AM, Late entry, which stated, behaviors: Wandering, Chronic. There have not been any recent medication reductions.
-A note by LVN I on 10/10/24 at 1:54 PM, stated admission details: Mental Status: Resident is confused. Resident is inattentive. Resident is experiencing signs of short-term memory loss. Resident is disorganized in thinking. Oriented to person. Confused: Chronic. Short term memory loss: Chronic. Safety: Utilizing wander elopement alarm.
-A note by LVN T, on 10/11/2024 at 10:54 AM, stated elopement evaluation: history of elopement while at home. Yes. Wandering behavior, a pattern or goal directed. Yes. Wanders aimlessly or non-goal-oriented: No. Wandering behavior likely to affect the safety or well-being of self/others: No. Wandering behavior likely to affect the privacy of others. No. Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 5.0 Score of 5.0 means: High risk of elopement.
-A note by LVN E, on 10/13/2024 at 11:10 AM stated, note text: Resident exit seeking currently. Resident pushed on doors until they came open. Resident walked through doors down hall. RN charge and I were able to redirect resident back onto secure unit, with no resistance. Directed resident to her room.
- A note by LVN E, on 10/13/2024 at 2:57 PM stated, note text: Resident in exit seeking, in search of her car to go home. Redirected resident to different activities with other residents. Redirection effective currently. Will continue with current plan of care.
- A note by LVN E, on 10/13/2024 at 3:52 PM stated, Mood and behavior: Resident is currently experiencing unwanted behaviors. Wandering: Chronic. Mood and behavior note exit seeking.
-A note by LVN U, on 10/13/2024 at 8:00 PM stated, note text: Noted with restlessness. Continuously pacing up and down hallway attempting to exit out of locked doors. Has held door long enough to release lock multiple times with staff able to redirect. Continues to state, I need to get to the parking lot and get my grey [NAME]. I am sorry but I am not staying here, especially when I do not belong here. Staff attempt to re-orient resident with no success. Staff continues to redirect currently. Plan of care to continue.
- A note by LVN I, on 10/15/2024 at 6:19 PM stated, Behavior notes: Noted with increased restlessness/agitation/exit-seeking - repeatedly ambulating to double doors while stating, I need to go home, I have work to do at home. Initially easily redirected though required x2 staff to redirect from exiting and to dining area for supper. Noted confusion increasing when interacting with peers- staff able to direct to dining area for supper. RP made aware of behaviors.
- A note by LVN V, on 10/27/2024 at 1:29 PM stated, note text: Resident was found around back of building approximately at 11:48 am. Resident was redirected back into the building by staff in which she was easily redirected without incidence. Resident assessed and noted no visible injuries, vitals taken 142/76/77, temperature 97.2, respiration rate 18. Skin warm, dry and intact. Resident states she had not been outside today. When question was asked resident stated she followed someone out of the gate and around the building, she also stated she goes out there numerous times. All parties are made aware including, MD, Representative, DON and administration. Resident eats her lunch and remains at table until family arrives.
-A note by DON, on 10/27/2024 at 2:55 PM , indicates note strike out reason from resident chart: Incorrect documentation. Note text: After review of camera footage; resident noted to be outside for approximately one hour. Weather noted to be 94 degrees. Notified Medical Director Received new orders for labs to be drawn when resident arrives back at facility for CBC, CMP. Diagnosis: Fatigue. Representative made aware of new orders.
-A note by DON on 10/27/2024 at 3:00 PM, stated Note text: after review of the camera footage and time stamp; resident noted to be out of sight for 14 minutes . Medical Director updated.
-A note by LVN E on 12/01/2024 at 03:46 PM, stated nurse note: Resident was observed at exit doors. Resident pushed on doors until they came open. Resident came through doors to other side. Nurse intervened and assisted in getting resident back on the other side.
Review of Resident #109's admission wandering evaluation, dated 10/11/24, reflected she had a history of wandering/elopement. There were no goals or interventions notated on the evaluation for Resident #109.
Review of Resident #1's plan of care, from 10/11/24 through 11/03/24, reflected Resident #109 exhibited Problem: The resident is an elopement risk/wanderer related to disoriented to place, impaired safety awareness. 10/27/2024: Resident found outside back of building with no injuries (resident states she followed someone out of gate). Interventions/Tasks: Resident to reside on secured unit. Staff education regarding elopement/wandering with new policy regarding elopement. Date initiated: 10/27/2024. Wander alert: resident may have wander guard applied to alert staff of attempts to exit to facility; check placement and functioning every shift. Problem: The resident has impaired cognitive function with potential for worsening cognition related to progression of disease along with adjusting to new environment. Interventions/tasks: Administer medications as ordered. Monitor/Document for side effects and effectiveness (Namenda and Aricept). Keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion.
Review of the facility's investigation file for Resident #109's incident on 10/27/24 reflected on 10/27/24, ADM investigation summary indicated review of camera footage. Resident observed exiting back door at 11:33 am. Resident noted exiting gate at 11:33 LVN V, observed walking out to the porch and to gate that is sounding at 11:35 am. Resident was escorted back to memory care wing at 11:49 am. Head to toe assessment performed, no injuries noted. Medical Director notified. Resident family member notified. Received new lab orders from doctor. Residents assessed and note no visible injuries, vitals taken 142/76/77, temperature 97.2, respirations 18. Skin was dry and intact. Resident states she had not been outside today. Resident eats her lunch and remains at table until family arrives as resident was scheduled to go out on pass this day to watch family member's theater performance. Action taken 10/27/24: Dementia training with appropriate interventions. Abuse and Neglect. Elopements. State reportable. 300 hall education: No propping open door, roller shades to be open. 10/28/24 Wander guard system placed for additional monitor placement on exit gate. Created new policy and procedure to follow for when exit alarms sound that include nursing staff conducting a roll call for all residents.
During an interview on 12/11/24 at 9:50 AM, LVN H stated Resident #109 was outside in the smoking area. LVN H noticed her outside and realized that she was a little confused and then realized she was a resident from the facility. She was standing outside the gate; the gate was propped open in the smoking rest area for residents. LVN H redirected the resident back inside. LVN H verbalized, I'm not sure how long she was outside, I didn't see her when I passed by the window but when I went outside to take a break, I noticed her outside, it could not have been that long voiced LVN H.
During an interview on 12/12/24 at 9:36 AM, LVN V stated she was the charge nurse for the memory unit on 10/27/24. She verbalized that staff were not very familiar with Resident #109 and the resident's family member had called that morning and asked that the staff get the resident ready for an outing. Staff got the resident ready and that morning staff had residents out in the outside area enjoying the weather. LVN V verbalized she is not sure if the resident was with the group but when the staff brought the residents back in shortly after the gate alarm went off outside. LVN V voiced she went out to check the gate and it was closed. She said she did not see anyone outside, so she closed the door that was left propped open during the process of bringing the residents back in that morning. LVN V verbalized she just thought someone pushed up on the gate and that is why the alarm went off. So, she turned the alarm off. LVN V, voiced another nurse came up to her at one point and told her he found one of her residents near the smoking area. LVN V provided a skin assessment on the resident and notified the doctor and family. LVN V, voiced she thinks the resident was gone for about 10 to 15 minutes. LVN V, verbalized that administration came in and re-checked everything to make sure staff complied and provided an in-service on elopements, abuse, and neglect. LVN V was sent home and informed that this was just part of the investigation process.
During an interview on 12/12/24 at 10:16 AM, LVN E verbalized Resident #109 can read so she knows that the instructions on the door say to hold for 15 seconds, and it will open. LVN E, verbalized after the 10/27/24 elopement staff have been instructed to see who is at the door if the alarm goes off and do a head count of all the residents.
During an interview on 12/12/24 at 10:28 AM, the DON verbalized she was not here the day Resident #109 eloped, but staff informed her of the elopement. DON voiced she is not sure if the resident walked through the grass around the back to reach the other end, or if she walked through the street that is located directly behind the building. DON acknowledged there was a potential for the resident to get hurt when she walked out of the memory care unit gate. DON verbalized that there were no other elopements since 10/27/24.
During an interview on 12/12/24 at 11:12 AM the ADM verbalized that the videos show the resident leaving the facility at 10:33 AM but that the video was behind the regular time by one hour. ADM verbalized that the back cameras behind the building were not working.
During an observation of the facility video footage on 12/12/2024, it reflected on 10/27/2024 resident exiting the alarm door outside the memory unit.
During a telephone interview with Resident #109's family member on 12/12/24 at 1:24pm, she stated they called her about the elopement that she was in their outdoor patio and waited long enough that she stated that they did not tell her about the incident. Resident daughter verbalized she does not have any concerns about her being able to get out she is very normal, and a lot of people do not realize that she belongs there. Daughter verbalized if the resident does get out, she is not going to get hurt and not going to get far and stated with the nature of her disease it will happen from time to time.
During an interview on 12/12/24 at 2:11 PM, maintenance employee W, stated that the alarms on the doors are checked monthly and records were provided and reviewed by survey team.
During an interview on 12/12/24 at 2:15 PM, ADM verbalized that the back door was propped open for about 15 minutes on 10/27/24 after the residents were brought back into the building that morning. ADM verbalized she is trying to provide video footage, but it keeps freezing on her end.
During an interview with DON on 12/12/24 at 3:02 PM, DON stated the nurse that was working on the 300-memory unit hall is was PRN nurse and 2 CNAs, along with an LVN and med aide. DON verbalized, I was not here that day, but I was told she walked outside the side door in front of the day room. The resident walked out the gate to the right, went out that door the blinds were closed in day room. Nurse went outside and she looked but the resident had closed the gate, so she just assumed that one of the residents pushed up on it. She was not gone that long at all. I will be honest less than 30 minutes. I will be honest the time stamp on the video footage is off. I believe when I calculated the time it was less than 30 minutes. Since then, we have done an in-service that includes staff need to make sure they are doing a roll count. Anytime alarms sound if it is not a planned exit, they need to make sure the residents are safe and all in the building. Make sure no doors are propped open. DON verbalized that all staff have been in-serviced and they were informed not to prop doors open, keep blinds open.
During an interview on 12/12/24 at 3:15 PM, ADM voiced new policies and procedures to do roll call will, new wander guard ordered to be installed by 12/16/24 . They have increased staffing levels. Staff have dementia training that they must update monthly.
During an interview on 12/12/24 at 3:48 PM with Alarm Representative X, the delayed egress should not be used for resident protection.
An observation of the outside of the back gate on 12/12/2024 at 11:00 AM where Resident #109 exited to the smoking gate where she was found by LVN H on 10/27/24 reflected approximately 200 - 225 feet of distance that the resident walked. There was a residential road directly behind the facility and a parking lot for employees to park.
This was determined to be an Immediate Jeopardy (IJ) on 12/12/24, The Administrator was notified. The Administrator was provided with the IJ template on 12/12/24 at 3:30 PM.
The following Plan of Removal submitted by the facility was accepted on 12/13/24 at 11:08 AM
Plan of Removal
Immediate Threat
On 12/12/2024 an abbreviated survey was initiated at facility. On 12/12/2024 the surveyor provided an Immediate Jeopardy that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety.
The notification of Immediate Jeopardy states as follows: state the issue you will find the info on the template you were provided.
Action: 1:1 Monitoring; assess staff is required to be always within arm's reach of resident.
Start Date: 12/12/2024 at 1:35 PM
Completion Date: In progress, will not complete until additional hardware (wander guard is installed on 12/16/2024)
Responsible: Facility's staffing nurse, the QM nurse, & Director of Nursing is responsible for ensuring the adequate 1:1 Monitoring of resident.
12-12-24 (Thursday): Staff #1 from 4 till left on bus.
Staff #2- while on the bus
12-12-24 (Thursday): staff # 3 from 8P-6A
12-13-24 (Friday): staff #4 from 6A-6P
12-13-24 (Friday): staff #3 from 6P-6A
12-14-24 (Saturday): staff #5 from 6A-6P
12-14-24 (Saturday): staff #6 from 6P-6A
12-15-24 (Sunday): staff #4 from 6A-6P
12-15-24 (Sunday): staff # 7 from 6P-6A
12-16-24 (Monday): staff # 4 from 6A-6P
12-16-24 (Monday): staff # 8 from 6P-6A
Action: Door Monitoring
Start Date: 12/12/2024 6:00 PM.
Completion Date: In progress until new locking mechanisms is installed, date pending.
Responsible: Facility's staffing nurse, the QM nurse, & Director of Nursing is responsible for ensuring the adequate 1:1 Monitoring of resident.
12/12/24 7P- 6A Staff member #9
12/13/23 6A-6P Staff member #10
12/13/24 6P- 6A Staff member #10
12./14/24 6A-6P Staff member #9
12/14/24 6P- 6A Staff member #11
12/15/24 6A-6P staff member #9
12/15/24 6P- 6A staff member # 11
12/16/24 6A-6P Staff member #12
12/16/24 6P- 6A Staff member # 13
Action: Training regarding: Abuse/Neglect, 1:1 Monitoring / Guarding of exit Doors, Elopement. A new policy and procedure , initiated on October 28, 2024, this procedure implements a roll call for all residents within the building. Medical Director, Director of Nursing, and Administrator created the policy and procedure 10/28/24. The CNAs receive training from charge nurses or administrative nurse, charge nurses are trained by the administrative nurses, who receive training from the DON, the DON receives training from Administrator; the Administrator receives training from Facility Consultant.
Start Date: 12/12/2024.
Completion Date: 12/13/2024
Responsible: In-service was conducted by previous ADON on roll call 10/28/2024 & again 12/12/2024 by IP and QM . Agency staff will receive in-services prior to their shift begins by the charge nurse on shift. Staff members who are off shift or PRN will receive in-service training via portal.
Action: Door Signage posted as a reminder to staff not to prop the door open. In-service training provided by QM to re-iterate that doors are not to be propped open at any time. The CNAs receive training from charge nurses or administrative nurse, charge nurses are trained by the administrative nurses, who receive training from the DON, the DON receives training from Administrator; the Administrator receives training from Facility Consultant .
Start Date: 12/12/2024.
Completion Date: 12/12/2024 6:30 PM
Responsible: QM Admin Nurse
Action: Elopement Assessments Completed monthly and Care plans Updated as needed. Findings will be reported monthly to QA committee for review, with changes made to the plan as required.
Start Date: 12/12/2024 5:30 PM
Completion Date: 12/12/2024 09:30
Responsible: Assessments Charge Nurse #1, Care plans updated by designated MDS administrative nurse
Action: The facility will conduct monthly audits to ensure that all assess
Start Date: 12/12/2024 5:30 PM
Completion Date: 12/12/2024 09:30
Responsible: Assessments Charge Nurse #1, Care plans updated by designated MDS administrative nurse. QAPI attendees include Facility Consultant, Administrator, Medical Director, Director of Nursing, and all administrative nursing personnel. The Administrator receives training from facility consultant.
The Survey Team monitored the Plan of Removal on 12/13/24:
Observation on 12/13/2024 at 8:30 and 11:15am staff member sitting by the door .
Observation on 12/13/2024 at 11:15am revealed a staff member was in arm reach of Resident #1 . Further observation revealed that door signage was posted on both doors .
Observation on 12/13/2024 at 1:27pm revealed a staff member was sitting by the door .
Observation on 12/13/2024 at 1:28pm revealed a staff member was in arm reach of Resident #1 .
During an Interview on 12/13/2024 at 2:27 pm, LVN I stated and confirmed she took the training this month. LVN A stated that she was trained on one-on-one monitoring, Resident #109 is within arm's length and to always know the resident's location, and to keep the resident distracted. LVN, I stated she has been trained on monitoring the exit doors and she took all the training today. LVN, I stated when the alarm sounds, we must do a head count on all residents, monitor the doors, and keep them closed, do not leave them open. LVN, I stated she took the elopement training today, and to keep the door closed, perform head counts if the alarm goes off, and to always know the locations of all residents. LVN, I stated if a resident elopes, I must notify the ADM and DON, call 9-1-1, and to notify staff and attempt to locate the resident. LVN, I stated if the alarm goes off, I go to the location of the alarm, investigate what is going on, if I see a resident by the door I redirect the resident, I conduct a head count on the residents, and notify the ADM and DON. LVN I stated when completed the Charge nurse will ensure each resident is accounted for and after roll call, I keep a mental note of the findings and I then review our wander guard list and ADL list.
During an interview on 12/13/2024 at 2:37 pm, CNA M stated she took the in-service yesterday (12/12/2024), she has been educated on resident rights, she has been in-serviced on one-on-one monitoring. CNA M stated the training covered on how not to leave the resident's (Resident #109) side, and that a staff must be always at their side. CNA M stated he has been trained on monitoring exit doors, and that if the alarm goes off, we look at the surrounding area and ensure no resident got out, we do a head count and we can reset the alarm. CNA M stated that she has been trained on elopement procedures and that if a resident elopes or even steps on the other side of the door we must intervene and report to the charge nurse on duty, the charge nurse then reports the elopement up the chain of command, the goal is ensure no residents eloped. CNA M stated if a resident attempts to elope we must act, we redirect the resident and have them come back inside, we make sure there are no other residents out, we immediately notify the charge nurse on duty and we do a head count. CNA M added that we (staff) are all responsible that each resident is accounted for, one of us goes down the hall, another staff goes to the day area, and a third staff check the other doors, and that after the roll call we notify the nurses where all the residents were located, and we make a mental note on the residents and we communicate with all staff to assure all residents are accounted for.
During an interview on 12/13/2024 at 2:52 pm, CNA L stated she has been in-serviced on one-on-one monitoring on residents, and that we must keep residents safe, keep them from falling, assure residents are taken care of, and assure residents are within arm's reach. CNA L stated that she was trained on monitoring the exit doors and that she took the training today. CNA L stated the training covered the importance of watching and monitoring the doors, calling the ADM for all elopements, and the importance on all staff locating the residents. CNA L stated we immediately notify the charge nurse if a resident elopes, and if I hear an alarm I get up and check what set the alarm off; I see who went in our out, who is close to the door, I check outside to assure no residents are outside. CNA L stated that all staff are responsible for assuring each resident is accounted for, and that after roll call I confirm findings with nurse. CNA L stated that after our roll call we are checking all residents are accounted for, we are checking the number of residents locations and his or her ADL sheets.
During an interview on 12/13/2024 at 2:58 pm, CNA K stated she has taken the training, she has been trained on one-on-one monitoring. CNA K stated that she was in-serviced on having the resident stay within arm's reach, and if the resident (Resident #109) attempts to leave outside we must redirect the resident and have them come back inside, we were educated on redirecting the resident, keeping the resident busy by communicating with the resident. CNA K stated she was in-serviced on monitoring the exit doors, and we cannot leave doors cracked or propped open, we cannot let residents leave unsupervised. CNA K stated she was trained on elopement procedures, CNA K added if I see a resident g out , I intervene, I notify the nurse on duty, I tell the charge nurse, I start looking for the residents, and we notify the ADM and DON. CNA K stated if an alarm goes off, I will run and investigate who is going out of the door, I investigate if it was a resident or if a resident is outside the door. CNA K stated all staff, the charge nurse, everyone is responsible on assuring all residents are accounted for, and that after we complete our roll call for residents we communicated with the nurse on findings. CNA K stated that during the roll call, we confirm all residents, we count and make sure all residents are here and we review the ADL sheet for the residents.
During an interview on 12/13/2024 at 3:20 pm, LVN J she took trainings today, she has been trained on one-on-one monitoring and that we always have eyes on resident, within arm's reach, and if a staff member needs to go on break, we notify another staff to assure we are always doing these things. LVN J stated if an alarm goes off, we act, we do a head count, then a roll call to account all residents are here. LVN J confirmed she has taken the elopement trainings today, and added that if an alarm goes off, we act, the system will inform us what number band (wander guard) set off the alarm, and we follow the location of residents and roll call procedures. LVN J stated we must report all elopements to the DON, and if an alarm goes off, we find out if a resident went out of the building, we check outside the surrounding areas for any residents, and that we are all responsible that each and all residents are accounted for. After the roll call, I would take a mental note and recall each resident, if a resident is missing or not accounted for, I check our computer (records) and review who has been checked out (signed out on pass, appointment, et all) of the facility and reference that for all residents that should be present in the facility.
During an interview on 12/13/2024 at 3:22 pm, DON stated training was completed today, on the importance of one-on-one monitoring, how residents must be within arms always reach and for staff to communicate if they need a break, staff must assure another staff takes over the important duties until they return. DON stated we had education on guarding or monitoring the doors today and that staff should be at the door 24/7 and that the elopement training was done this morning. DON stated the training covered what to do if there is an elopement; there needs to be a roll call and if it is in the secured unit, we need to do an elopement assessment to determine who is at risk of an elopement, we always respond to alarms or if a resident elopes. DON also stated if nursing staff will assure the roll calls are completed for the whole facility, I (DON) will notify ADM and do a self-reported incident to HHSC . DON stated staff are to respond immediately, to get our residents to safety, staff need to communicate and get in touch with the charge nurses to do a roll call of the entire facility, charge nurses will use a printed midnight census to assure all residents are in the building and after the roll call staff are to huddle, assure all is clear on resident head counts and locations and to report all findings to myself and ADM.
During an interview on 12/13/2024 at 3:29 pm, ADM stated we must report all findings of abuse, we have trained staff on one-on-one monitoring, we educated staff that one-on-one is defined as you (staff) stay within arm's reach of the resident that needs the monitoring and to communicate and call if they (staff) need a break so one-on-one can continue. ADM stated I have been trained on monitoring exit doors, and that guarding or monitoring the exit doors mean to redirect or ask for additional staff to assist with residents who are trying to enter or exit. ADM confirmed the elopement training education conducted today, this morning, that in the elopement training we check for resident's safety, staff must notify us, administration, the residents RPs and Doctors. ADM added that we placed interventions to keep our residents safe and from further elopement. ADM added we have been trained in an elopement situation staff are to perform if an alarm goes off, even if it is just a fire alarm, all residents must be accounted for, we look around the premises, we locate the residents, we call local law enforcement advise of a silver alert, we notify doctors or nurse practitioners, we were trained on the importance of a roll call being completed and that we can just clear or turn off the alarm, all residents must be accounted for prior to resetting any alarm. ADM stated that the charge nurses for each hallway are responsible for assuring the residents are accounted for by matching face to name on the midnight census, after the roll call this will be submitted to the nursing office.
Record Review of In-Services for 1:1, door monitoring, door propping, elopement, abuse, and neglect, exit alarm sounding and Dementia revealed that 110 out of 129 staff have been in serviced. Staff [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication storage rooms reviewed for medications.
The facility failed to remove 2 expired suppositories and 1 bag of expired medication from the medication storage room when it was observed on 12/11/24 at 12:50 PM.
This failure could place residents at an increased risk of receiving expired and/or contaminated medications which could result in adverse health consequences.
Findings included:
Observation on 12/11/24 at 12:50 PM in the medication storage room revealed 2 suppositories of bisacodyl 10 mg with expiration date 09/24 and one bag of Gentamicin 60 mg in 100 ml 0.9% sodium chloride for intravenous use with expiration date 12/6/24, belonging to Resident #36.
Review of Resident #36's admission record dated 12/12/24 revealed an [AGE] year-old female, admitted on [DATE] with diagnoses that include urinary tract infection, traumatic brain injury, sick sinus syndrome (irregular heart rhythm), hyperlipidemia (high cholesterol), and Hypertension (high blood pressure).
Review or Resident #36's readmission MDS assessment dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment.
Review of Resident #36's physicians order summary dated 12/12/24 revealed an order for Gentamicin Sulfate Injection Solution 40 mg/ml. Use 60mg intravenously at bedtime related to bacteremia (an infection in the blood) for 5 days. Status on hold. Start date 12/2/24. End date 12/7/24.
Review of Resident #36's care plan dated 12/2/24 revealed Urinary tract infection; at risk for repeat urinary tract infections. Goal: Resident will show no signs/symptoms of infection. Interventions/Tasks: Administer antibiotic therapy as prescribed.
In an interview on 12/11/24 at 12:50 PM LVN F stated she had been working in the facility since January 2021. She stated nurses and medication aides are responsible for checking for expiration dates. LVN F stated that medications could lose effectiveness over time and may not work as well if administered to a resident.
In an interview on 12/12/24 at 9:27 AM LVN E stated she had been working in the facility since [DATE]. She stated that nurses, medication aides, and administration should check for expired medications at least once a month. LVN E stated the expired medications would not be as effective if given to a resident.
In an interview on 12/12/24 at 1:20 PM LVN G stated she had been working in the facility since August 2022. She stated that nurses should check for expired medications. LVN G stated the expired medications would not be as effective if given to a resident. She stated that the medication that was expired for Resident #36 was because the resident had a lab level drawn to check for the antibiotic in the resident's blood. She stated that the level was too high and so the medication was held and not used.
In an interview on 12/12/24 at 02:39 PM the DON stated she had been working at the facility since March 2021. She stated she expected the pharmacy consultant to check the medication room and carts monthly, and the nurses and medication aides to check at least weekly. The DON stated that using medications after they have expired could lead to decreased effectiveness or a possible adverse reaction.
In an interview on 12/12/24 at 3:04 PM the ADM stated her expectation was for the nurses and medication aides to check the medication carts and room weekly on Sunday nights and for administration to check the carts/room monthly for expired medication. The ADM stated using the medication after the expiration date could lead to decreased effectiveness.
Review of an undated facility policy and procedure titled Storage of Medications reflected The facility will store all drugs and biologicals in a safe, secure, and orderly manner.
4.
Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable state laws for 8 (Residents #1, #2, #3, #4, #5, #6, #7, and #8) of 9 residents reviewed for assessments.
The facility failed to ensure the ADON had a current and active license. The ADON provided assessments to Residents #1, #2, #3, #4, #5, #6, #7, and #8 while her RN license was expired from [DATE] through [DATE].
This could place residents at risk for inadequate care and/or services.
Findings included:
Review of Resident #1's admission record, dated [DATE], reflected an [AGE] year old female who was admitted to the facility on [DATE], discharged on [DATE], and had diagnoses including malignant neoplasm of bilateral ovaries (a cancerous tumor in both ovaries), unspecified anxiety disorder, restlessness and agitation, age-related osteoporosis without current pathological fracture (a condition that occurs when bones become less dense and more likely to break due to aging), cognitive communication deficit, other irritable bowel syndrome, overactive bladder, generalized muscle weakness, other abnormalities of gait and mobility, and need for assistance with personal care.
Review of Resident #1's assessments log, dated [DATE], reflected the ADON provided the following assessments to Resident #1:
-Quarterly ADL Only Evaluation on [DATE]
-Quarterly Elopement Evaluation on [DATE]
-Braden Scale for Predicting Pressure Ulcer on [DATE]
-Quarterly Fall Risk Evaluation on [DATE]
-Quarterly Lift/Transfer Evaluation [DATE]
-Dehydration Risk Evaluation on [DATE]
-Bowel and Bladder Program Screener on [DATE]
-Quarterly BIMS evaluation on [DATE]
-Quarterly PHQ9 on [DATE]
-Quarterly Mini nutritional assessment screening on [DATE]
-Quarterly social services quarterly note on [DATE]
Review of Resident #1's comprehensive care plan, closed [DATE], reflected charge nurses, which were RNs, were required to assess Resident #1's skin weekly for breaks in skin integrity and changes in usual appearance and follow up with physician with concerns. RNs were also required to monitor/document/report PRN any signs/symptoms of dehydration, UTI, any changes in cognitive function, changes in ADLs, and any possible causes of incontinence and malnutrition and perform risk evaluations and scheduled clinical evaluations per facility's protocol.
Review of Resident #2's admission record, dated [DATE], reflected an [AGE] year old female who was readmitted to the facility on [DATE] and had diagnoses including myopathy (diseases that affect skeletal muscles), major depressive disorder, primary osteoarthritis in the left shoulder (a type of arthritis that occurs in joints over time without a known cause), unspecified dementia, unspecified depression, unspecified anxiety disorder, memory deficit following cerebral infarction (a medical condition that occurs when blood flow to the brain is disrupted, leading to brain cell death), other speech and language deficits following unspecified cerebrovascular disease, generalized muscle weakness, overactive bladder, other abnormalities of gait and mobility, cognitive communication deficit, need for assistance with personal care, history of falling and other fatigue.
Review of Resident #2's assessments log, dated [DATE], reflected the ADON provided the following assessments to Resident #2:
-Quarterly social service quarterly note on [DATE]
-Quarterly bowel and bladder program screener on [DATE]
-Elopement evaluation on [DATE]
-Quarterly BIMS evaluation on [DATE]
-Quarterly social service quarterly note on [DATE]
-Quarterly PHQ9 on [DATE]
-ADL only evaluation on [DATE]
Review of Resident #2's comprehensive care plan, dated [DATE], reflected RNs were required to monitor/document for signs/symptoms of UTI, any possible causes of incontinence, changes in ADL status and abilities, change in mental status, changes in cognitive function, immobility, depression, and immobility, and perform scheduled clinical evaluations per facility's protocol.
Review of Resident #3's admission record, dated [DATE], reflected a [AGE] year old female who was readmitted to the facility on [DATE] and had diagnoses including urinary tract infection, unspecified protein-calorie malnutrition, dehydration, unspecified altered mental status, cognitive communication deficit, other lack of coordination, other abnormalities of gait and mobility, and generalized muscle weakness.
Review of Resident #3's assessments log, dated [DATE], reflected the ADON provided the following assessments to Resident #3:
-Quarterly social services note on [DATE]
-Quarterly PHQ9 on [DATE]
-Quarterly BIMS evaluation on [DATE]
Review of Resident #3's comprehensive care plan, dated [DATE], reflected RNs were required to perform clinical evaluations per facility's protocol and monitor/document/report PRN any changes in status, any potential for improvement, reasons
for self-care deficit, expected course, and declines in function, confounding communication problems, and UTI.
Review of Resident #4's admission record, dated [DATE], reflected an [AGE] year old female who was readmitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy (a brain disorder that occurs when an underlying condition causes a chemical imbalance in the blood that affects the brain), unspecified anxiety disorder, dehydration, unspecified depression, unspecified altered mental status, restlessness and agitation, unspecified dementia, other recurrent depressive disorders, unspecified Alzheimer's disease, other chronic pain, unspecified low back pain, repeated falls, need for assistance with personal care, and history of falling.
Review of Resident #4's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #4:
-Quarterly social services note on [DATE]
-Quarterly BIMS evaluation on [DATE]
-Quarterly PHQ9 on [DATE]
-Bowel and bladder program screener on [DATE]
-ADL only evaluation on [DATE]
Review of Resident #4's comprehensive care plan, dated [DATE], reflected RNs were required to monitor/document/report to MD PRN signs and symptoms of UTI, any changes, any potential for improvement, reasons for self-care deficit, expected course and declines in ADL function, any possible causes of incontinence, change in mental status, agitation, complications related to constipation, changes in cognitive function, abnormalities for urinary output, dehydration, and perform scheduled clinical evaluations per facility's protocol.
Review of Resident #5's admission record, dated [DATE], reflected an [AGE] year old female who was readmitted to the facility on [DATE] and had diagnoses including unspecified ataxia (a neurological sign that indicates a loss of muscle coordination and control), cognitive communication deficit, need for assistance with personal care, unspecified depression, generalized muscle weakness, other specified disorders of muscle, other abnormalities of gait and mobility, and other lack of coordination.
Review of Resident #5's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #5:
-admission social services history and initial assessment on [DATE]
Review of Resident #5's comprehensive care plan, dated [DATE], reflected RNs were required to evaluate Resident #5's desire to return to the community and perform clinical admission evaluation.
Review of Resident #6's admission record, dated [DATE], reflected a [AGE] year old female who was admitted to the facility on [DATE] and had diagnoses including unspecified candidiasis (a fungal infection caused by an overgrowth of the Candida yeast), other abnormalities of gait and mobility, history of falling, unspecified chronic fatigue, cognitive communication deficit, generalized muscle weakness, and need for assistance with personal care.
Review of Resident #6's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #6:
-Quarterly social services note on [DATE]
Review of Resident #6's comprehensive care plan, dated [DATE], reflected RNs were required to perform scheduled clinical evaluations per facility's protocol and monitor/document/report PRN any changes in ability to communicate, potential contributing factors for communication problems and potential for improvement, physical/ nonverbal indicators of discomfort or distress and confounding communication problems such as decline in cognitive status and mood.
Review of Resident #7's admission record, dated [DATE], reflected an [AGE] year old male who was readmitted to the facility on [DATE] and had diagnoses including unspecified anxiety disorder, major depressive disorder that was recurrently severe without psychotic features, cognitive communication deficit, vascular dementia (a condition that occurs when blood flow to the brain is disrupted, causing changes in memory, thinking, and behavior), generalized muscle weakness, unspecified abnormalities of gait and mobility, and unspecified lack of coordination.
Review of Resident #7's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #7:
-Quarterly social services note on [DATE] and [DATE]
Review of Resident #7's comprehensive care plan, dated [DATE], reflected RNs were required to perform clinical evaluations per facility's protocol and monitor/document/report PRN any changes any potential for improvement, reasons for self-care deficit, expected course and declines in function, changes in cognitive function, confounding communication problems such as decline in cognitive status and mood, ability to communicate, potential contributing factors for communication problems, potential for improvement, ability to express and comprehend language, memory, reasoning ability, and problem solving ability and ability to attend.
Review of Resident #8's admission record, dated [DATE], reflected an [AGE] year old female who was readmitted to the facility on [DATE], admitted on [DATE], and had diagnoses including unspecified fracture of shaft of right arm, insomnia, need for assistance with personal care, unspecified altered mental status, history of falling, restlessness and agitation, age-related cognitive decline, generalized muscle weakness, other abnormalities of gait and mobility, cognitive communication deficit, unspecified depression, unspecified anxiety disorder, and unspecified Alzheimer's disease.
Review of Resident #8's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #8:
-Quarterly social services note on [DATE] and [DATE]
-Preadmission memory screening form on [DATE]
Review of Resident #8's comprehensive care plan, dated [DATE], reflected RNs were required to monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course and declines in function, any changes in cognitive function, signs/symptoms of non-verbal pain, confounding problems such as decline in cognitive status, mood and decline
in ADL, physical/ nonverbal indicators of discomfort or distress, ability to express and comprehend language, memory, reasoning ability and problem solving ability and ability to attend, changes in ability to communicate, potential contributing factors for communication problems and potential for improvement, change in mental status, and signs/symptoms of UTI.
Review of the Texas Board of Nursing Primary Source License Verification Database, dated [DATE], reflected the ADON's license was originally issued on [DATE] and currently issued on [DATE].
Review of the ADON's personnel file, dated [DATE], reflected the ADON was hired as the ADON position on [DATE].
Review of the ADON's personnel change form information change, undated, reflected the ADON changed from the ADON to the DON effective [DATE].
During an interview on [DATE] at 10:35 AM, CNA A stated she worked at the facility from February 2024 through [DATE]. CNA A stated she observed the ADON provide direct care to residents. CNA A stated she recalled the ADON performing perineal care on a resident two months ago . CNA A couldn't recall who the resident was that the ADON performed perineal care on.
During an interview on [DATE] at 12:02 PM, the WCN stated the current DON used to be the ADON.
During an interview on [DATE] at 12:07 PM, the Wound Care MD stated the DON used to be the ADON and rounded with him. The Wound Care MD stated he couldn't recall when the ADON last rounded with him.
During a confidential interview on [DATE] at 12:15 PM, the CE stated they were working at the facility when the DON used to be the ADON. The CE stated the ADON worked the floor and provided direct care to residents, performed resident COVID-19 tests and signed off and charted resident assessments and medication administrations during the day shift and night shift . The CE stated the ADON also signed the staff schedules stored at the nursing station as RN daily and presented herself as an RN during the time her license was delinquent from [DATE] through [DATE] . The CE stated the ADON promoted to DON on [DATE] according to a social media post in which the facility presented the ADON as having a BSN RN on [DATE]. The CE stated there were nursing staff who observed the ADON working the floor and providing direct care to residents .
During an interview on [DATE] at 12:52 PM, the MD stated he visited the facility once a week. The MD stated the ADON rounded with him. The MD stated he observed the ADON reposition residents and unwrap residents' bandages with him in the past . The MD stated he couldn't recall the last time that the ADON repositioned residents and unwrapped residents' bandages with him.
During an interview on [DATE] at 3:41 PM, the ADM stated she was the DON for 4 years until [DATE] when she got her administrator license. The ADM stated LVNs and RNs were responsible for completing residents' assessments, such as elopement and fall risk evaluations. The ADM stated LVNs and RNs must have a current license in order to do those residents' assessments. The ADM stated the current DON used to be the ADON and had a delinquent license for several months . The ADM stated on [DATE], it was discovered that the ADON's license was delinquent . The ADM stated the Texas Board of Nursing reinstated the ADON's license on [DATE]. The ADM stated the ADON didn't perform any nursing duties during the delinquent period. The ADM stated the ADON didn't know her license was delinquent. The ADM stated she knew RNs' licenses renew during RNs' birthday months. The ADM stated the former ADON didn't get the notification when her license was required to renew. The ADM stated in 2024, the Texas Board of Nursing stopped mail notification. The ADM stated she knew that the ADON didn't have a nursing license on [DATE] during the facility's state readiness process. The ADM stated the HR must check annually at minimum to ensure nursing licenses were current. The ADM stated the facility had a payroll system transition period that started in 2023 and messed up the HR's automatic notifications. The ADM stated the HR's backup process during the payroll system transition period was that the HR checked nursing licenses manually. The ADM stated the HR was unaware that the ADON didn't have an active RN license.
During an interview on [DATE] at 3:54 PM, the HR stated she couldn't recall when the ADON was hired as the DON, but she believed it was [DATE] or [DATE]. The HR stated she was required to check LVNs and RNs licenses upon hire. The HR stated that six months ago, she was told to start reviewing LVNs and RNs licenses every quarter. The HR stated she couldn't recall when she was told to start reviewing licenses quarterly. The HR stated she forgot to check the LVNs and RNs licenses last quarter. The HR stated she started reviewing licenses again a month ago ([DATE]). The HR stated she was trained to print out all LVNs and RNs licenses and place them in a binder. The HR stated she was under the impression that she was to check only new hire LVNs and RNs licenses. The HR stated the BOM previously worked as the HR until she was hired in [DATE]. The HR stated the BOM trained her to check new hire LVNs and RNs licenses using the EMR/CNA/CMA/Nursing license sites. The HR stated the BOM trained her to input information to ensure LVNs and RNs had their license and to ensure licenses were not expired. The HR stated she misunderstood the BOM's training and thought she was to check LVNs and RNs licenses who were in the process of being hired and when first hired. The HR stated she misunderstood the training that the BOM gave her two months ago. The HR stated she believed she misunderstood the training on [DATE] or [DATE].
During an interview on [DATE] at 4:04 PM, the BOM stated she was trained to check LVNs and RNs licenses to ensure they were current at the time of hire. The BOM stated she would print the LVNs and RNs license status results and place them in the LVNs and RNs files. The BOM stated she didn't know how often she was required to check LVNs and RNs licenses at the time of interview because she wasn't familiar with the facility's current process. The BOM stated she trained the HR how to check LVNs and RNs licenses and to check licenses at time of hire. The BOM stated the nursing administration taught the HR more on that process than she did. The BOM stated she didn't know who from the nursing administration taught the HR more on the process.
During an interview on [DATE] at 5:35 PM, LVN B stated LVNs and RNs perform assessments on residents. LVN B stated LVNs and RNs must have current licenses to perform assessments on residents. LVN B stated he was not sure if residents were at risk if LVNs and RNs performed assessments on them without current licenses. LVN B stated he was not sure if he was notified of his license requiring renewal or expiring soon.
During an interview on [DATE] at 5:42 PM, RN C stated she was notified by mail and email from the Texas Board of Nursing as to when her license was due for renewal. RN C stated LVNs and RNs complete assessments on residents. RN C stated LVNs and RNs licenses must be current to perform evaluations on residents. RN C stated LVNs and RNs were not supposed to perform assessments on residents without a current license. RN C stated LVNs and RNs shouldn't even be in the building if they didn't have a current license.
During an interview on [DATE] at 6:02 PM, LVN D stated a staff member had to be an LVN or RN to perform assessments on residents. LVN D stated LVNs and RNs must have a current license to perform assessments on residents. LVN D stated she was notified by mail when her license was due for renewal.
During an interview on [DATE] at 6:13 PM, the ADON stated she started her DON position on [DATE]. The ADON stated she was previously the ADON and Infection Control Preventionist. The ADON stated her license lapsed. The ADON stated she couldn't recall when her license lapsed . The ADON stated no one would knowingly let their license lapse because it's more expensive to reapply for a license than to renew. The ADON stated she didn't check the status of her RN license. The ADON stated she wasn't monitoring her own license status. The ADON stated she relied on the notification by mail as to when she needed to renew her license. The ADON stated when her RN license lapsed, she found out she no longer received a mail notification. The ADON stated her RN license expired on her birthday month . The ADON stated she knew her license expired on her birthday month because this was the second time she was renewing her license. The ADON stated she didn't think to check her license status and didn't get a notification. The ADON stated her license expired in February 2024 . The ADON stated she used to be notified by mail when her license was due for a renewal. The ADON stated the HR didn't realize she was supposed to be running LVNs and RNs nursing licenses quarterly. The ADON stated she wasn't sure that licenses were supposed to be checked quarterly to verify status. The ADON stated the HR didn't have any oversight to ensure the process of checking license statuses was completed prior to her license incident. The ADON stated the HR notified her that her license was expired. The ADON stated she couldn't recall when the HR notified her that her license was expired. The ADON stated the facility wasn't responsible for notifying her to keep up to date with her license. The ADON stated she expected RNs and LVNs to keep their licenses up to date. The ADON stated the importance of staying up to date with an LVN or RN license was to ensure that education and certification was current. The ADON stated she didn't give direct care a lot to residents. The ADON stated she also couldn't recall if she performed any evaluations or nurse duties during her delinquency license period. The ADON stated she didn't know she performed assessments on residents during her license delinquency period. The ADON stated she didn't know if LVNs and RNs needed a current license to perform evaluations on residents, such as fall risk evaluation. The ADON stated anyone who was more than capable of asking a question and answering questions in a residents' electronic health record evaluation, especially for evaluations related to social service didn't need a current license to do so. The ADON stated if a staff member could be trained, they could evaluate residents without a LVN and RN license. The ADON stated having anyone complete the evaluation without a current license also depended on questions in the evaluation unless the questions were nursing related. The ADON stated a person just needed to know how to answer yes or no questions in residents' evaluations that ask for a yes or no answer.
Review of the facility's job description for charge nurse, undated, reflected,
Qualifications: Must have successfully completed state board of registration or licensure and carry a current state license as a registered or licensed vocational nurse.
Responsibilities:
6. Make meaningful rounds of all patients utilizing Resident Assessment and Comprehensive Care Plan
7. Insures that the individual Resident Assessment and Comprehensive Care Plan is followed to meet the resident's needs according to generally accepted nursing practices in the State of Texas
8. Assist in writing and updating the Resident Assessment and Comprehensive Care Plan as resident's condition changes, with the help of the Director of Nursing, Activities Director, Dietary Manager, and designated nurse
19. Directs charting on his/her shift and makes regular detailed evaluation of all resident charting at least monthly so chart reflects progress and condition of resident at all times. Is responsible for approving and signing each chart when observations are made
20. Be aware of legal implication if physician's orders are not carried out correctly
22. Know when situation cannot be handled and be willing to ask for help and to know who to ask
23. Abide by policies of facility and ascertain that employees under his/her supervision do the same
25. Insure that all medications and treatments are charted after the fact: by the person administering the medication or completing the treatment on his/her assigned shift.
29. Detect and correct situations that have a high probability of causing accidents or injuries to residents
30. Ensures continuing promotion of the resident's physical and emotional health by assisting him regarding their medical care.
Review of the facility's job description for assistant director of nursing, undated, reflected,
Qualifications Needed: Must be a graduate of an accredited school of vocational or professional nursing and have a current nursing licensure in the state of Texas.
Responsibilities and Duties: Provide nursing care on shift when needed
Review of the facility's resident assessments policy and procedure, revised [DATE], reflected,
7. All members of the care team, including licensed and unlicensed staff members, are asked to participate in the resident assessment process.
9. The results of the assessments are used to develop, review, and revise the resident's comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of four residents reviewed for catheter care (Resident #6 and Resident #30).
A) The facility failed to ensure Resident #6's catheter was secured to her body with a catheter secure device per the care plan and physician's orders.
B) The facility failed to ensure Resident 30's catheter was secured to his body with a catheter secure device per the care plan and physician's orders.
This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections.
Findings included:
Review of Resident #6's Face Sheet dated 10/26/2023 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses Extended Spectrum Beta Lactamase (ESBL) (A type of enzyme or chemical produced by some bacteria that can break down the active ingredients in many common antibiotics), Personal History of Urinary Tract Infections, Retention of urine and Down Syndrome (A genetic disorder associated with physical growth delays, characteristic facial features and mild to moderate developmental and intellectual disability. It is caused by the presence of full or partial extra copy of chromosome 21.)
Review of Resident #6's Quarterly MDS dated [DATE] reflected Resident #6 was assessed to have a BIMS score of 6 indicating moderate cognitive impairment. Resident #6 was assessed to require dependent assist for ADLs. Resident #6 was further assessed to have an indwelling urinary catheter.
Review of Resident #6's Comprehensive Care Plan reflected a problem area dated 03/07/2023 and revised on 04/10/2023 The Resident has a indwelling Foley Catheter related to neuromuscular dysfunction of bladder with potential for complications related to long term use of Foley catheter . Interventions included Catheter: Change Foley catheter as indicated for infection, obstruction or when closed system is compromised .check tubing for kinks every shift and ensure that catheter is draining properly to bedside privacy bag and leg strap in place
Review of Resident #6's Consolidated Physician's Orders reflected an order dated 03/07/2023 Catheter: ensure catheter is draining properly to bedside, privacy bag in place and leg strap in place.
Review of Resident #6's Nurse Medication Administration Record dated October 2023 reflected an entry Catheter: ensure catheter is draining properly to bedside, privacy bag in place and leg strap in place. Entry was signed every shift as Yes.
Observation on 10/26/23 at 9:54 AM revealed Resident #6 lying in bed while CNA B, CNA C, and CNA D performed catheter care. Resident #6 was observed with an indwelling urinary catheter draining to a bag on the side of the bed. There was no leg strap or other stabilizing device in place. When CNA C and CNA D turned Resident #6 to her left side, it caused tension on the catheter tubing. They stopped turning the resident and adjusted the position of the drain bag then continued with the procedure.
Review of Resident #30's Face Sheet dated 10/26/203 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Cystitis (Infection or inflammation of the urinary bladder or any part of the urinary system caused by a type of bacteria called Escherichia coli (E. coli). This results in urge to urinate, blood in urine and burning while urinating.), Obstructive and reflux uropathy (Is a term that refers to conditions that affects the urinary tract due to blockage or backward flow of urine) and Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.).
Review of Resident #30's Annual MDS dated [DATE] reflected Resident #30 was assessed to have a BIMS assessment not conducted indicating Resident #30 had severe cognitive impairment. Resident #30 was assessed to require extensive to dependent assist for ADLs. Resident #30 was further assessed to have an indwelling catheter.
Review of Resident #30's Comprehensive Care Plan reflected a problem with the start date of 08/30/2022 and revised on 09/13/2023 The resident has indwelling catheter related to diagnoses of neuromuscular dysfunction of bladder with increased risk of urinary tract infections . Interventions included .ensure catheter is draining properly to bedside with privacy bag and leg strap in place.
Review of Resident #30's Consolidated Physician's Orders reflected an order dated 09/12/2022 CATHETER: Ensure Catheter is draining property to Prescriber bedside privacy bag and leg strap is in place.
Review of Resident #30's TAR and MARs dated October 2023 reflected no entry for checking Resident #30's leg strap for his catheter.
Observation on 10/25/23 at 2:49 PM revealed Resident #30 lying in bed while CNA A and CNA B performed catheter care and incontinent care. Resident #30 was observed with an indwelling urinary catheter but no leg strap or other stabilizing device in place.
During an interview on 10/26/23 at 9:56 AM with CNA B, she stated they used catheter stabilization devices on some people adding, It all depends. She stated sometimes the devices got wet so she would let the nurse know.
During an interview on 10/26/23 at 10:41 with LVN E, she stated they had two types of stabilization devices; one has adhesive on the back and the other was a leg strap. LVN E reached into the nurses' cart and retrieved a stabilization device with the adhesive on the back and stated she preferred that type as is stayed in place better. She stated the CNAs let her know if a device needs to be replaced. She stated if a resident with a catheter did not have a stabilization device in place, the catheter could get pulled out which could be painful.
In an interview on 10/26/23 at 10:49 AM with RN F, she stated they do use stabilizing devices for residents with indwelling catheters. She stated there was a device that sticks on the leg, kind of like a bandage that has a clamp where you would put the tubing. RN F stated, Lots of times we just use the clamp that comes on the catheter bag. She described the clamp on the drain bag tubing that is usually attached to the sheet or bed. She stated without a stabilization device, residents were at risk of having the catheter pulled on, pulled out, and pain.
In an interview on 10/26/23 with the DON, she stated they used a couple different stabilizing devices including the ones that stick to the leg. She stated it is her expectation that all resident with a catheter will have a stabilizing device. She stated without the device, the catheter could get caught on something or pulled out. She stated it did not meet her expectations that two residents with catheters had been observed without a stabilization device. A policy for indwelling catheters was requested.
Review of the facility's policy Catheter care, Urinary dated August 2022 reflected The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Steps in the Procedure . 16. Secure catheter with catheter securement device

Based on interview and record review, the facility failed to follow guidelines for mandatory electronic submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 3 quarters reviewed for payroll data information (Quarter 3 2023).
The facility failed to submit PBJ staffing information to CMS for the 3rd quarter (April 1 - June 30) of fiscal year 2023.
This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.
Findings included:
Review of the facility's undated Civil Rights Survey Report (Form 3761) indicated the following:
7 RNs
24 LVNs
42 Direct Care Staff
14 Dietary
22 Housekeeping & Laundry
12 All Others
Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report) 1705 D FY Quarter 3 2023 (April 1 - June 30), dated 10/18/2023, indicated the following entry: Metric Failed to Submit Data for the Quarter, Result Triggered Definition Triggered = No Data Submitted for Quarter.
In an interview on 10/26/2023 at 9:54 AM, the DON was asked who in the facility was responsible for quarterly PBJ reporting. The DON stated that the BOM was responsible for reporting to CMS. The DON stated that she knew they also had a payroll consultant that assisted with preparation. The DON stated that she knew that the PBJ information is provided to CMS to ensure adequate staffing and is very specific to RN coverage requirements.
In an interview on 10/26/2023 at 10:00 AM, the BOM stated that PBJ reporting was the responsibility of her office during the 3rd quarter of fiscal year 2023. The BOM stated that she had an ABOM that was responsible for the quarterly submission of the report but stated that assurance of submission was her responsibility. The BOM stated that the PBJ report was to be submitted to CMS quarterly and was due within 45 days of the final day in the quarter. The BOM stated that the PBJ report contains staffing hours for nurses, agency, dietary consult, and pharmacy. The BOM stated that the PBJ reporting was important because it goes towards their star rating and CMS uses the report to ensure staffing ratios. The BOM was questioned about how failure to submit the PBJ report could affect residents and she stated she could only think of the star rating. The BOM stated that they utilized a consultant who puts together the information and provides it back to the facility, which then is provided electronically to CMS. The BOM was notified that they failed to electronically file their 3rd quarter PBJ. The BOM stated that she knew the ABOM had been working on it. The BOM was asked if the ABOM still worked for the facility, and she stated she did not. The BOM stated that the ABOM was a part time employee who they terminated for not coming into work and mistakes with payroll. The BOM was requested to provide employment dates for the ABOM, which were later provided as December 6, 2022, through July 11, 2023. The BOM was asked if she would be able to provide email correspondence from the consultant for the 3rd quarter or the PBJ report that may have been prepared by the ABOM but not submitted. The BOM stated that she did not have an email from the consultant and that it likely would have been sent to the ABOM. The BOM stated that she would check to see if she could locate information the ABOM completed but stated that she would likely be unable to do so.
In an interview on 10/26/2023 at 10:44 AM, the Administrator stated the PBJ reporting was important because it helps to determine and ensure that necessary staffing ratios were met by the facility. The Administrator stated that he knew it was a requirement of CMS to report their PBJ information quarterly and knew that their failure to do so lowered their star rating. The Administrator stated that while it was not his direct responsibility, he failed to ensure that the PBJ was reported for the 3rd quarter.
In an interview on 10/26/2023 at 12:20 AM, the BOM stated that she was not able to retrieve any email information from the ABOM's account due to it being inaccessible. The BOM further stated that she was not able to recover or locate a prepared 3rd quarter PBJ report.
Review of facility Reporting Direct Care Staffing Information (Payroll-Based Journal) policy with a revised date of August 2022 indicated:
Policy Statement: Direct care staffing information is reported electronically to CMS through the Payroll-Based Journal system.
Policy Interpretation and Implementation:
1. Complete and accurate direct care staffing information is reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS.
8. Technical specifications for uploading data directly from a payroll or time and attendance system will be accessed through: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html.
9. Direct care staffing information is submitted on the schedule specified by CMS, but no less frequently than quarterly. 10. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows:
Fiscal Quarter
Date Range
Submission Deadline
1
October 1 - December 31
February 14
2
January 1 - March 31
May 15
3
April 1 - June 30
August 14
4
July 1 - September 30
November 14
References:
OBRA Regulatory Reference Numbers - 483.70(q) Mandatory submission of staffing information based on payroll data in a uniform format.
Survey Tag Number - F851

Based on interview and record review, the facility failed to develop and implement written policies and procedure that prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property for one (OT) of five employees reviewed for file.
The facility failed to complete criminal history checks prior to or upon hire for the occupational therapist.
This failure could place residents at risk for abuse, neglect, and exploitation.
Findings included:
Record review of OT employee file revealed hire date of 09/07/2004. The personnel records did not include criminal history check.
During an interview on 08/24/22 at 11:44 AM with the DOR, he stated OT was still employed with the company and has valid license. The DOR stated for OT to renew the license the background check has to be completed. OT has active license. The DOR stated he was not employed with the company at the time OT was hired. The DOR stated job description was conducted for OT on 12/20/2004 by the current DOR. The DOR stated he cannot speak for what had happened prior to his employment.
During an interview on 08/24/22 at 1:10 PM with the Admin, he stated he has been with the company for a month and cannot speak for what happened prior to his start date. The Admin stated HR/pay roll personnel was responsible to ensure all new hire employee screening were done and ultimately, he himself was responsible. Admin stated employee background check should be conducted prior to hire and they were not allowed to work inside the facility until it has been completed. The Admin stated his expectation was to make sure everything was completed as it should be if it was required.
During a phone interview on 08/24/22 at 1:23 PM with the CEO, he stated the therapy employees were contracted to the nursing facility. The CEO stated he thought OT's background check and all other documents were in the personal file and to give time to check the office.
During an interview on 08/24/22 1:42 PM with the CEO, he stated he could not find any documents and stated, We will fix it moving forward and we will correct it.
Review of facility's background screening investigation policy dated March 2019 states: Our facility conducts employment background screening checks; reference checks and criminal conviction investigation checks on all applicants for positions with direct access to resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to develop and implement comprehensive care plan to meet the medical and nursing needs for 2 of 10 residents reviewed for care plans (Resident # 66 and Resident #75).
- The facility failed to ensure Resident #75's Comprehensive Care Plan was developed in a personalized manner to address refusal of diet recommendation.
- The facility failed to ensure Resident # 66's Comprehensive Care Plan was developed to address physical needs for devices to prevent wounds or other skin concerns.
-The facility failed to ensure Resident #66 was provided bunny boot to left foot at all times as tolerated as ordered by his physician.
This failure could place residents at risk for not having their individualized needs met in a timely manner and communicated with providers and could result in an injury, pressure ulcer and a decline in physical well-being and in quality of life.
Findings included:
Review of Resident #75's face sheet dated 08/24/2022 revealed Resident #75 was an [AGE] year-old female admitted to the facility 08/17/2017 with a diagnoses of pneumonia, dysphagia (trouble swallowing), urinary tract infection and vascular dementia (loss of cognitive functioning that interferes with a person's daily life and activities).
Review of Resident #75's MDS Significant Change assessment dated [DATE] revealed Resident #75 was admitted to hospice care which resulted in the significant change assessment . Resident #75 had a BIMS score of zero to indicate severely impaired cognition.
Resident #75 received a mechanically altered diet and did not receive a therapeutic diet.
Review of Resident #75's Care Plan dated 08/01/2022 revealed Resident #75's care plan was not updated to include an Informed Refusal of Diet Recommendation for Resident #75 to have a mechanical soft diet order instead of the recommended pureed diet order.
Review of Resident #75's Physician orders dated 08/09/2022 revealed Resident #75 was ordered a regular diet, pureed texture with nectar thick liquids.
Review of Resident #75's Nursing Progress Note dated 08/03/2022 revealed Change of condition care plan meeting held with social services, activities, dietary manager, MDS nurse, DON and administrator in attendance; resident and Family Member A on conference phone call; no participation by resident or hospice this date; resident w/ recent admission to hospice; requires extensive to total assistance with all aspects of ADL's; resident admitted hospice related to diagnosis of cerebrovascular disease, vascular dementia, dysphagia, aspiration pneumonia; comfort medications in place; resident with recent diet change as per family wishes as resident disliked pureed diet; FamilyMember A signed waiver understanding potential risks to change of diet to mechanical soft; Family member A and Family member B both stated they hoped resident would eat better but understand possible risk of aspiration w/diet change; resident current weight is 133.4 pounds and stable at present.
In an interview on 08/23/2022 at 2:00 PM, the DON stated Resident #75 had aspiration pneumonia at the end of June 2022 and was hospitalized . She said when Resident #75 returned to the facility the physician ordered a pureed diet to decrease the risk of further aspiration pneumonia or other complications from dysphagia. She said Resident #75 did not like the pureed foods and Resident #75's RP brought it to their attention. She said Resident #75's RP said that for Resident #75's quality of life they wanted Resident #75 to have a regular diet or mechanical soft diet. She said she spoke with them regarding a waiver to allow the upgraded diet and that they were aware of the risks for Resident #75. She said Resident #75's RP agreed to signing the Informed Refusal of Diet Recommendation and they held a care plan meeting to discuss the diet changes and Resident #75 going on hospice care. She said after the waiver was signed on 08/09/2022 and the diet order was changed, Resident #75's care plan was not updated. She said Resident #75's care plan was updated with the hospice care information, but not the diet order information.
In an interview on 08/23/2022 at 11:20 AM, MDS LVN G stated Resident #75's care plan should have been updated with the new diet order of mechanical soft and that the Informed Refusal of Diet Recommendations Waiver was in place with the risks noted on her care plan. She said it could result in Resident #75 not receiving appropriate and safe care if her care plan was inaccurate.
Review of Resident # 66's face sheet dated 08/24/2022 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] and 07/19/2022 with a diagnoses type 2 diabetes mellitus with diabetic neuropathy, unspecified (high blood sugar can injure nerves throughout the body. Most often damages nerves in the legs and feet), type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene (a blood vessel disease caused by high blood sugar levels), cutaneous abscess of left lower limb ( a localized collection of pus in the skin and may occur on any skin surface), cellulitis of right and left lower limb ( potentially serious bacterial skin infection. The affected skin is swollen and inflamed and is typically painful and warm to the touch), local infection of the skin and subcutaneous tissue , unspecified ( bacterial or fungal that enters any break in the skin and can invade the subcutaneous tissue) and localized edema ( your small blood vessels leak fluid into nearby tissues).
Review of Resident #66's MDS admission assessment dated [DATE] reflected resident had a BIMS score of 11 which indicated resident cognition was mildly impaired. Resident #66 was assessed to require extensive assistance with one-person physical assist with bed mobility, transfers, dressing and personal hygiene. He required extensive assistance with two persons assist with toileting. Resident #66 was also assessed to have limited range of motion in lower extremity on both sides. Resident was at risk for developing pressure ulcers/injuries. Resident required a pressure reducing device for chair.
Review of Resident #66's MDS Significant Change assessment dated [DATE] reflected resident had a BIMS score of 13 indicated his cognition was intact. Resident #66 required assistance with ADL's. Resident was also assessed at risk of developing ulcers/injuries and had an unhealed pressure ulcer/injury which was unstageable. He was assessed to require a pressure ulcer reducing device for bed.
Review of Resident #66's Comprehensive Care Plan dated 8/11/2022 reflected Resident #66's bunny boot to left foot at all times as tolerated every day and night shift and offloading cushion to float bilateral heels while in bed every day and night shift related to pressure-induced deep tissue damage of left heel was not care planned.
Review of Resident #66's Physician Orders dated 07/19/2022 reflected bunny boot to left foot at all times as tolerated every day and night shift related to pressure-induced deep tissue damage to left heel. Offloading cushion to float bilateral heels while in bed every day and night shift related to pressure induced deep tissue damage to left heel.
Review of Resident #66's Wound- Weekly Observation Tool dated 07/08/2022, 7/15/2022 and 7/22/2022 reflected special equipment offloading cushion and bunny boot to left heel at all times as tolerated. The physician was notified of skin status by Treatment Nurse-LVN on each wound-weekly observation tool. The wound to resident's left heel was acquired on 07/05/2022 and resolved on 07/22/2022.
Review of Resident #66's Nurses Notes from 07/23/2022 thru 08/24/2022 reflected a fluid filled blister to his left heel. Resident #66 frequently had edema to his left lower leg. Nurse's notes did not reflect documentation about an offloading cushion or a bunny boot to left heel.
Observation and interview on 08/22/2022 at 3:46 PM revealed Resident #66 was in his room sitting in his recliner with his feet propped on the footrest of the recliner. Resident #66 stated he had pain in his knees and legs. He stated he was wearing house socks due to his feet were swollen and he was unable to wear his shoes. He stated he did have a sore on his left heel, but it was no longer there. He stated he currently had a blister on his left heel and pulled his sock down to show surveyor the fluid filled blister . He stated he was supposed to be wearing some type of boot, but he didn't know if the doctor had taken it away from him. He also stated the boot helped when he was sitting in his recliner.
Observation on 08/22/2022 at 4:15 PM, Resident #66 was sitting in his recliner asleep. He was not wearing his bunny boot to his left foot and his left foot had edema.
Observation on 08/23/2022 at 8:17 AM, Resident #66 was sitting in his room eating breakfast. His left foot had edema. He was not wearing bunny boot to his left foot.
Observation and Interview on 08/23/2022 at 12:33 PM revealed Resident #66 was sitting in his room in the recliner. He did not have his shoes on or his bunny boot to left foot. He had nonskid house socks. Resident stated his legs and feet was hurting and he needed to prop his feet up to help with the swelling. He stated his shoes fit perfect except when his feet swell. He stated he must be careful about his heel because he had a blister. (he pointed to the left heel and showed the blister). Resident stated he didn't want to get any wounds to his legs, feet or anywhere if he could prevent it.
Observation and Interview on 08/24/2022 at 11:45 AM revealed Resident #66 was sitting in wheelchair in his room. Resident had his shoes on, and he stated he had been to therapy. He also stated his legs and feet was hurting him and he was waiting on staff to assist him to his recliner. He stated he was going to take his shoes off and put on some socks. He stated no one had placed a bunny boot on his left foot in a very long time. He stated he wore it a few times when he had a wound on his left heel but did not wear it all the time. He also stated he was taking medication for his swollen feet. He stated he did not know the exact days staff looked at his heel.
In an interview on 08/25/2022 at 9:30 AM, LVN A stated the offloading cushion and the bunny boot to Resident #66's left foot was required to be care planned. She stated the staff would not know if a resident needed a device if it wasn't on the care plan. She stated the interventions on the care plan was transferred to electronic medical records for the staff to know what type of personalized care each resident needed. She stated any type of device most definitely needed to be care planned. She stated the cushion and the bunny boot was to prevent skin breakdown or any other skin issues. She also stated it was the Treatment Nurse, DON and MDS nurses' responsibility to monitor the care plans.
In an interview on 08/25/2022 at 10:00 AM, MDS LVN B stated if there was a physician order for a bunny boot to left heel and an offloading cushion for a resident to use daily, these devices were required to be care planned. She stated any type of interventions related to skin concerns/ wounds were the Treatment Nurses responsibility to document those concerns on the care plan. She also stated care plans were developed for the staff to know what type of care and interventions each resident needed. She stated the CNA's had access to electronic medical record and these devices would be in the ADL section for the CNA's to know what type of intervention each resident would need to help with their physical condition. She also stated it was the Treatment Nurse responsibility to monitor any care plans related to skin concerns. She also stated the nurses was documenting in the nurses notes of new fluid filled blister on his left heel.
In an interview on 08/25/2022 at 11:45 AM, CNA C stated Resident # 66 had not been wearing a heel boot to his left heel. She stated she didn't know he needed to be wearing a heel boot. She stated she was not aware of a cushion he needed in bed. She stated Resident #66 wasn't in bed during the day. She also stated if a resident needed any type of devices such as: alarms for bed/wheelchair, cushions, or heel boots, it would be in the electronic medical record under ADL. She stated no staff informed her verbally or in writing that Resident #66 required a heel boot. She stated the charge nurse would inform the staff if there were any changes with residents' care. She stated if any resident refused a device, she would report it to the nurse working on that hall. She stated she did not see any type of devices located under the ADL tab for Resident #66. She also stated if Resident #66's feet became swollen, he preferred to sit in his recliner with his feet propped up. She stated he preferred to wear non-skid socks when his feet were swollen.
In an interview on 08/24/2022 at 12:00 PM, CNA D stated she was assigned to care for Resident #66 sometimes. She stated if anyone had heel protectors, alarms, cushions, or any type of device it would be located under the ADL tab in the electronic medical record. She stated she had not noticed Resident #66 wearing a heel boot. She also stated Resident #66 feet did swell sometimes. She stated she didn't give care to Resident #66 very often and didn't know his routine. She further stated if a resident refused to wear a device staff would inform the nurse on the 400 hall. She stated any devices or any type of care a Resident needed would be under the ADL tab in the electronic medical record. She stated she didn't know he was to have a bunny boot.
In an interview on 08/24/2022 at 12:45 PM, LVN E stated if any resident required any type of special device it would be in the electronic medical record for the CNA's to know what type of device / care to give each Resident. She stated she would need to review the electronic medical record to determine if Resident #66 needed bunny boot or cushion. She also stated Resident #66 did have a wound on his left heel approximately 3 weeks, but it was healed. She stated a bunny heel protector could possibly prevent further skin breakdown. She stated Resident #66 did have a blister on his left heel at this time and the bunny heel protector could benefit him from having another wound. She also stated he was high risk for skin breakdown on his legs and feet. She stated the CNA's never reported to her of Resident #66 refusing to wear the bunny heel protector. She also stated the Treatment Nurse F did not verbally inform her or give her any information in writing concerning Resident #66 needing a heel protector or offloading cushion
In an interview and record review on 08/24/2022 at 1:05 PM, the DON stated the bunny boot and uploading cushion for Resident #66 was a preventive measure to prevent any wounds or skin breakdowns. She reviewed the physician order and care plan during the interview and stated the cushion and heel protector was expected to be care planned. She also stated the care plan was implemented for the staff to know what type of care to give each resident. She stated if it wasn't on the care plan the information would not be on the electronic medical record for the staff to know what type of devices,/ care Resident #66 needed. She also stated if Resident #66 was not wearing left heel bunny boot or using the cushion there was a potential the wound could reopen or develop other skin concerns. She stated it was Treatment Nurse F's responsibility to care plan interventions for wounds, skin concerns or any devices needed to prevent skin breakdown She also stated it was the Tx Nurse F responsibility to monitor these type of care plans.
In an interview on 08/25/2022 at 1:15 PM, Treatment Nurse F stated Resident #66's offloading cushion and bunny boot documented on the physician order most definitely needed to be care planned. She stated the care plan was where the staff received information of what type of care/ interventions the residents needed to prevent skin breakdown or to help hear any type of skin concerns. She also stated Resident #66 needed to be wearing the bunny boot as tolerated. She stated his feet had edema sometimes and this was when resident preferred to sit in his recliner with his feet elevated. She stated Resident #66 did have a blister to his left heel. She also stated a bunny boot would be more beneficial to Resident #66 than him wearing his shoes especially when his feet had edema. She stated if Resident #66 did refuse the bunny boot the staff would report it to her, or the nurse would document it in the nurse's notes. She also stated any type of interventions on the care plan would be transferred over to the ADL in the electronic medical record for the staff to know what type of devices Resident #66 required. She stated if these were not on the care plan it wouldn't be in the ADL electronic medical record for the staff to know to use these devices. She stated she would print a copy of the ADL's in the electronic medical record and bring it to the conference room to review with surveyor.
Records of CNA's ADL and the MARS was requested from the treatment nurse on 08/24/2022 and these records were not provided at time of the exit.
Review of Facility's Policy on Care Plans, Comprehensive Person -Centered revised March 2022 reflected
A. The interdisciplinary team in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.
1. The comprehensive, person-centered care plan:
a. includes measurable objectives and timeframes.
b. Describes the services that are to be furnished attain or maintain the resident's highest
practicable physical, mental, and psychosocial well-being.
c. Reflects currently recognized standards of practice for problem areas and conditions.
2. Care plan interventions are chosen only after data gathering, proper sequencing of events,
Careful consideration of the relationship between the resident's problem areas and their
causes, and relevant clinical decision making.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 of 3 residents (Resident #19) reviewed for discharge planning.
The facility failed to provide discharge planning for Resident #19 that focused on the resident's discharge goals and notify Resident #19 of the discharge goal.
This failure could place residents at risk of not receiving care and services to meet their needs upon discharge.
Findings included:
Review of Resident #19's dated 08/24/2022 revealed Resident #19 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included a history of a stroke causing partial paralysis, Type II Diabetes, major depressive disorder, anxiety disorder and high blood pressure.
Review of Resident #19's quarterly MDS assessment dated [DATE] revealed Resident #19 had a BIMS score of eight to indicate moderately impaired cognition. For questions regarding Resident #19's discharge plan the question of overall goal established during assessment process was not answered. For the question, is active discharge planning already occurring for the resident to return to the community? the answer was no.
Review of Resident #19's admission MDS assessment dated [DATE] revealed Resident #19's overall goal established during assessment process was unknown or uncertain for discharge plans. For the question, is active discharge planning already occurring for the resident to return to the community? the answer was no. For the question, does the resident want to be asked about return to the community on all assessments the answer was yes.
Review of Resident #19's Care Plan dated 06/17/2022 revealed Resident #19 did not have a discharge plan in his care plan with goals and interventions defined.
In an interview on 08/22/2022 at 11:00 AM, Resident #19 stated he wanted to go home, and his doctor said he could go home, but he did not know if he was going to be allowed to go home. He stated his family member and family lived with him prior to his admission to the facility and it was his family member's decision as his POA if he was able to go home . He asked the facility in the past when he would get to go home, and they did not have an answer for him. He said nothing was wrong with the facility, he just wanted to go home.
In an interview on 08/23/2022 at 2:41 PM, the SW stated she had spoken with Resident #19's RP and the discharge plan for Resident #19 was for him to remain in the facility . She said Resident #19's family member had not had the conversation with Resident #19 about remaining in the facility permanently at this time. She said they did not want to upset Resident #19. She stated the plan had been back and forth for a while about whether Resident #19 would be able to return home. She said Resident #19's RP did not feel he could provide the needed care and supervision Resident #19 required due to multiple falls. She said Resident #19 did ask frequently about going home, but in the past month had not asked as much. She said the plan when he was admitted was for him to go home, but the plan changed. She said she thought the discharge plan was in his care plan and she also specified it in her last quarterly note. She said she was responsible for discharge planning at the facility and for establishing discharge goals with residents and responsible parties. She said the MDS Nurses would add the plans to the care plan based on what was decided.
In an interview on 08/24/2022 at 10:45 AM, CNA H said Resident #19 would ask about his discharge plans frequently and they would direct him to the social worker or the DON. She said in the last few weeks he had not asked as much. She said Resident #19's RP told them they could not care for him at home. She said Resident #19's RP did not want to have to tell Resident #19 that he was not coming home.
In an interview on 08/24/2022 at 11:20 AM, MDS LVN G stated Resident #19's care plan should be updated with his established discharge plan, but because the plan had not been confirmed for so long it was not added to the care plan. She said when Resident #19 was first admitted Resident #19's plan was to return home. She said Resident #19's RP made the decision that Resident #19 required more care than he could provide, and Resident #19 was safest at the facility. She stated she was not sure if anyone had the conversation with Resident #19 about the permanent plan.
In an interview on 08/24/2022 at 11:30 AM, MDS LVN B stated the social worker was in charge of discharge planning and the MDS nurses would update the care plan. She said the original plan for Resident #19 was to return home, but Resident #19's RP did not feel he could take care of Resident #19 and the permanent plan became for Resident #19 to remain in the facility. She said Resident #19 required increased supervision due to multiple falls. She said Resident #19's care plan should have been updated with the permanent plan and Resident #19 should have been notified of the permanent plan.
In an interview on 08/24/2022 at 11:55 AM, the DON stated the long-term plan for Resident #19 was for him to remain at the facility as decided by Resident #19's RP. She stated Resident #19's care plan should have been updated with the care plan and Resident #19 should have had a care plan meeting to discuss the decision. She stated the social worker was in charge of the discharge planning process.
Review of Resident #19's Social Services Quarterly Note dated 06/14/2022 revealed Resident #19 was noted to have no plans on discharge.
Review of Resident #19 admission Social Services Quarterly Note dated 03/14/2022 revealed Resident #19's discharge plan was uncertain.
Review of Discharge Summary and Plan Policy dated December 2016 revealed Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services. If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents medical record included documentation that indicates the resident either received the influenza and pneumococcal immunizations or did not receive the immunizations due to medical contraindications or refusal for 1 of 5 residents (Resident #76) reviewed for immunizations.
Resident #76's medical record contained no evidence of the influenza or pneumococcal immunizations being administered.
This failure could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes.
Findings included:
Review of Resident #76's admission Record printed 08/24/2022 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, cerebral infarction (stroke), communication deficit, anemia (lack of healthy red blood cells), major depressive disorder, and anxiety.
Review of Resident #76's admission MDS assessment dated [DATE] reflected the influenza vaccine was not given in the facility. The MDS also reflected the pneumococcal vaccination was not up to date. The reason the pneumococcal vaccine was not received was marked as not offered. The MDS reflected a BIMS assessment was not completed because the resident is rarely or never understood. The MDS reflected the resident had impaired long- and short-term memory impairment.
Review of Resident #76's Pneumococcal Vaccination and Influenza Vaccination Consent forms revealed both forms had been signed by the responsible party on 01/19/2022 and gave the facility permission to administer both vaccines.
Review of Resident #76's immunization record in the electronic medical record revealed no evidence of influenza or pneumococcal vaccine administration.
During an interview on 08/24/2022 at 9:06 AM with the IP, she stated she could not find any documentation or other paperwork regarding Resident #76's immunizations. The IP stated, I think we missed it.
During an interview on 08/24/2022 at 10:27 AM with the IP and DON, the DON stated the immunizations may not have been given at the time because the resident was having some behaviors and the responsible party wanted the behaviors to resolve first. The DON stated the facility had not documented any reason for not giving the immunizations.
During and attempted interview on 08/24/2022 at 11:35 AM with Resident #76, she mumbled something unintelligible when asked if she had ever had a pneumococcal vaccine. When asked if she had taken flu shots every year she responded, probably then did not engage in any other interactions.
During an interview on 08/24/22 at 11:55 AM with Resident #76's Responsible Party, she stated she remembered giving consent for both the influenza and pneumococcal vaccines. She stated she was a registered nurse, and she was familiar with the immunizations. She could not recall if the resident had received the immunizations. She stated there was no reason she could recall that she would not have wanted the vaccines given.
During an interview on 08/24/2022 at 12:56 PM with Resident #76's Responsible Party, she stated she thought about it some more and had to call back. She stated the resident had recently been in acute care and inpatient rehabilitation and she must have had the immunizations at one of those facilities and that would be why this facility did not give the immunizations. She denied having any paperwork regarding immunization status from the previous facilities.
During an interview on 08/24/2022 at 1:20 PM with the DON, she stated the IP was responsible for monitoring and tracking immunizations. She stated the immunizations were not given to Resident #76 because she had the immunizations before. When asked why earlier she said the immunizations were not given because of behaviors, she stated the behavior should not stop a resident form getting immunizations. She stated she had not looked at prior facility documents nor called the previous facility for immunization records for Resident #76. She stated she thought the Responsible Party had reached out to the previous facility for the immunization records. She stated it did not meet her expectations that facility had not documented whether the immunizations had been administered. She stated and adverse outcome of not documenting resident immunization status could be an outbreak of infections.
During an interview on 08/24/2022 at 1:34 PM with the ADMIN, he stated it does not meet his expectations the immunization status of a resident is not documented. He stated not administering immunizations could lead to people getting sick and spreading infection.
Review of the Pneumococcal Vaccine policy revised March 2022, reflected in part, 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) day of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission in not conducted prior to admission.
Review of the Influenza Vaccine policy revised March 2022, reflected in part, 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to resident and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. 5. For those who receive the vaccine, the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the resident's/employee's medical record. 6. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record.