Calder Woods

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 10 (Resident #28) residents in 1 of 3 (DR #1) dining rooms.The facility failed to promote Resident #28's dignity during lunch on 01/28/2026 when staff did not serve Resident #28's lunch tray until twenty-two minutes after her tablemates were served.This failure could affect all residents who eat in the dining room, by contributing to poor self-esteem, and unmet needs.Findings included:Record review of Resident #28 Face Sheet dated 01/28/2026 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #28's diagnoses included vitamin B deficiency, pain in left knee, hyperthyroidism (excessive production of thyroid hormones), heart disease with heart failure, muscle weakness, limitation of activities due to disability, cognitive communication deficit (problems with communication), muscle weakness, anxiety (feeling of uneasiness or worry), and hypertension (high blood pressure). Record review of Resident #28's MDS dated [DATE] revealed Resident #28 had a BIMS score of 0 which indicated severe cognitive impairment.Record review of Resident #28's care plan dated 03/23/2025 revealed [Resident #28] has had an unplanned weight loss recently, started on Lasix (ordered for weight loss) on 12/2, possible fluid loss. Goal in place was Resident will receive adequate nutrition/fluid intake and weight will stabilize over the next 30 days. Interventions in place for Resident #28 were Serve diet as ordered and offer substitutions if <75% is eaten. Monitor and document intake on all meals. Dietary manager to discuss and monitor for food preferences. Offer snacks within dietary limits. Weigh once a week for 4 weeks. Report to MD and RP if 5% loss or gain. Registered Dietician to review residents medical record and make recommendations. Nursing to follow up on dietician recommendations. Administer supplements per MD orders. An Observation of lunch dining services on 01/28/2026 at 12:00 p.m., revealed seven residents were sitting at the dining room table in DR #1. The first resident at the table got her meal tray at 12:05 p.m. Five other residents got their meal tray within six minutes from the time the first tray was handed out. Resident #28 was the only resident who did not get her meal tray. An Observation of lunch dining services on 01/28/2026 at 12:13 p.m., revealed Resident #28 asked a staff member about her meal tray. The staff member was observed telling Resident #28 her food was coming and that the culinary staff had to go to the main building and get more bread. An Observation of lunch dining services on 01/28/2026 at 12:19 p.m., revealed Resident #28 asked a staff member about her meal tray. The staff member was observed telling Resident #28 her food was coming. An Observation of lunch dining services on 01/28/2026 at 12:27 p.m., revealed Resident #28 got her food. Resident #28 was observed telling the staff she was the last one and she did not want any of the food now. She said she had drunk all her drink and did not want the food. Observation revealed staff did offer Resident #28 something else to eat but Resident #28 did not want anything else. Interview with Resident #28 on 01/29/2026 at 12:11 p.m., revealed that she did not want to talk to surveyor about it. All she would say was yeah. Interview with CS A on 01/30/2026 at 10:56 a.m., revealed she had been trained on resident rights. She said that the kitchen staff were responsible for ensuring that enough food was sent to DR #1. She said the policy was to serve all residents at the same table at the same time before moving to the next table. She said since there was only one long table in DR #1 that a reasonable amount of time to serve the residents from start to finish was five minutes. She said the person serving the food was responsible for making sure all residents got their food at about the same time in DR #1. She said if a resident did not get their food with the other residents at the table the resident may feel like they are not a priority. She said the DM monitored to ensure that the cooks were sending enough food to the other dining rooms. She said he monitored the meal tickets from the residents as to what they wanted to eat that day. She also said once the meals were selected the portions were put on a board for the cook to know how much was needed. She said she felt like she was not given enough food for the residents in DR #1. She also said she thought someone else got Resident #28's food. Interview with the DM on 01/30/2026 at 11:05 a.m., revealed that he had been trained on resident rights. He said the policy was to get all residents at the same table their meal tray together. He also said that from the first tray to the last tray should only be five minutes in DR #1. He said the servers; the cook and the DM were responsible for ensuring enough food is sent to the other dining rooms. He said if all the residents at the same table did not get their meal together the resident may feel left out. He said the DM and the CK monitored to ensure that enough food was sent to the other dining rooms. He said the DM and the CK monitored by doing rounds. He said he did not know why DR #1 ran out of food and Resident #28 had to wait so long for her meal tray. He said sometimes the residents change their mind after the food is served and then they had to wait. He also said the DM and CK have adjusted and sent more of the popular food to the other dining rooms so they would not run out if residents changed their mind. Interview with CK A on 01/30/2026 at 11:05 a.m., revealed he had been trained on resident rights. He said the policy was the residents would pick what they wanted to eat for each meal. He said once the resident picks their meal they were up on a board and the CK would go by the menu and the exact amount next to the item on the menu. He said the CK was responsible for ensuring that enough food was sent to the other dining rooms. He said if a resident did not get their meal with the other residents in the dining room the resident may feel left out. He added the only time he had seen a resident not get their food with everyone else was when the resident changed their mind and wanted something different. He said a reasonable amount of time from the first tray to the last tray to be handed out in DR #1 was two to three minutes. He said the DM monitored to ensure enough food is sent to the other dining rooms. He said the DM would come to help portion the food out. He said he did not know why DR#1 ran out of food and Resident #28 had to wait twenty-two minutes for her meal tray. Interview with the ADM on 01/30/2026 at 11:30 a.m., revealed he had been trained on resident rights. He said his expectation was when staff took food to the other dining rooms, the staff were to take the temperature of the food and log the temperatures. He said staff were to serve everyone at the same table at the same time. He said the facility dietary staff would get the resident's meal choice and give the information to the kitchen. He said then the CK would send the choices plus two extra meals in case a resident changed their mind. He said a reasonable amount of time was five to seven minutes depending on if all the residents were at the table. He said the culinary department was responsible for ensuring there was enough food sent to the other dining rooms. He said a resident may get angry and feel left out of the dining experience. He said the ADM, nursing administration and DM monitored to ensure that enough food was sent to the other dining rooms. He also said that there was a group text for the nursing staff and culinary and if there was an issue the staff could let the DM know so it could be fixed. He said the ADM, nursing administration and DM monitor through observation and ensure staff were using the proper portion size. He said that the reason Resident #28 did not get her meal tray was because almost all the residents at the table changed their mind and wanted the teriyaki chicken on the hoagie roll. Record review of the facility's Food and Nutrition Services Policy dated 08/29/2023 revealed Optimal nutrition extends beyond providing adequate dietary intake and includes meeting an individual's social, cultural, and psychological needs where possible. Family involvement during meal service has a very positive impact on a resident's nutritional well-being. Record review of the Facility's Resident Rights Policy dated 01/23/2025 revealed Residents have the right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 medication and supply storage room [ROOM NUMBER] of 1 reviewed for pharmacy services.The facility failed to ensure expired medical supplies were removed from the singular medication and supply storage room.This failure could place residents at risk of contamination causing illness and decreased effectiveness or failure of medical supplies.Findings included:Observation on [DATE] at 11:30 AM of the singular medication room revealed the following:Three enteral feeding bags with attached gravity set 1200mL capacity with an expiration date of [DATE].One enteral feeding bag with attached gravity set 1200mL capacity with an expiration date of [DATE].Two Aspira drainage kits with use by date [DATE].In an interview on [DATE] at 11:30 AM MA D, stated she is in serviced on Infection control and medication/supply storage and labeling. She stated that the MAs are responsible for checking expiration dates of the medications in the medication and storage room. She stated the nurses are responsible for ensuring that all medical supplies stored in the medication and storage room and free of expired supplies. She stated that if expired supplies are used for resident care, they could be ineffective or cause infection.In an interview on [DATE] at 10:12 AM LVN I stated she was in serviced on Infection control and medication/supply storage and labeling. She stated that MAs are responsible for ensuring medication stored in the medication room and medication carts are within date. She stated that the nurses are responsible for ensuring the supplies are within date and removed once expired from supply. She stated if medical supplies are expired it could have potentially lost its sterility and if used it could cause infections.In an interview on [DATE] at 10:17 AM MA F stated she is frequently in serviced on Infection control and medication/supply storage and labeling. She stated that nurses are responsible for ensuring supplies remain in date. She stated that if expired supplies are used, they could potentially cause an infection.In an interview on [DATE] at 10:30 AM LVN J stated she was in-serviced on Infection control and medication/supply storage and labeling. She stated that it is the responsibility of each nurse on each shift to ensure all medications and supplies are stored within date and removed if expired. She stated that if medical supplies are used after the expiration date it could cause bacteria growth and infections. In an interview on [DATE] at 11:00 AM with DON she stated the staff are frequently in serviced on infection control, medication/supply storage and labeling. She stated that it is her expectation that expired medication, or supplies are removed to ensure they are not used for resident care. She stated that they have a pharmacy consultant that comes and ensures that the disposal of any expired medication. She stated it is ultimately her responsibility to ensure that there are no expired supplies in the supply room or in the treatment carts. She stated that if medical supplies are expired and utilized on the residents they could cause damage, not work properly, and could have bacteria from sitting so long.In an interview with ADM on [DATE] at 11:04 AM. He stated that the staff are frequently in serviced on infection control, medication/biological storage and labeling. He stated that he expected expired medication or supplies to be disposed of and not used on the residents. He stated that it is ultimately everyone who has access to supplies responsibility to ensure expired items are removed. He stated he was not sure what could happen if expired supplies were used but that he would expect that they could degrade over time and fluids would not flow well through tubing.Review of facility policy and procedure titled Storage of Medications, dated [DATE], revised on [DATE], reflected Service standard, [the facility] stores all drugs and biologicals in a safe, secure, and orderly manner. 2. The nursing staff is responsible for maintaining medication storage preparation areas in a clean, safe, and sanitary manner. 4. The facility may not use medication that has been discontinued, outdated, or has deteriorated.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen.1. The facility failed to ensure that dietary staff wore hair restraints to prevent hair from contacting food, on 1/28/2026. 2. The facility failed to ensure trash cans were properly covered on 1/28/2026.3. The facility failed to properly store, label, and date all food items located in the facility refrigerators, freezers and in the dry food pantry area on 01/28/2026 and 01/29/2026. 4. The facility failed to properly seal food product bags in the dry storage area to prevent exposure to air on 01/28/2026 and 01/29/2026. These failures could place residents who received meals from the kitchen at risk of foodborne illnesses.Observation during the initial tour of the kitchen on 01/28/2026 beginning at 8:50 AM revealed the following:Kitchen area:CK A with an approximate 2.5-inch beard was not wearing a beard restraint while he prepared food.4 large gray trash cans open, not covered with lids.Walk in refrigerator:5 one-gallon containers of different salad dressings, no open or discard dates1 one gallon container of tartar sauce, no open or discard dates1 silver container covered with foil, labeled tuna, no prepared date, no discard date.1 container covered with foil, labeled with letters (resembled slaw), no prepared date, no discard date.1 round silver container covered with foil, marked BBQ, no prepared date, no discard date.1 container of sliced red potatoes in water covered with foil, no prepared date, no discard date.1 package of thawing red meat, not labeled, not dated.1 opened package of cooked corn beef, not labeled, not dated.1 tray of 24 cups of mixed fruit, not covered, not labeled, not dated. Walk in freezer:1 opened to air bag of pork patties, no open, no discard date.1 opened bag of cooked Italian sausage, no open, no discard date.1 freezer storage bag of fish, no label, no open, no discard date. Dry storage:6 five-pound containers of opened seasonings, no open or discard date1 large box of cornmeal, opened to air, no open, no discard date.1 open container of chocolate frosting, open to air, no open, no discard date.1 large open box of chocolate chips open to air, no open, no discard date.Observation during lunch on 1/28/2026 on Cottage M beginning at 12:05 PM, revealed CS B serving lunch without hairnet.Observation during the follow-up tour of the kitchen on 01/29/2026 beginning at 11:20 AM, revealed the following:Walk in refrigerator:5 one-gallon containers of different salad dressings, no open or discard dates1 one gallon container of tartar sauce, no open or discard datesWalk in freezer:1 opened bag of cooked Italian sausage, no open, no discard date.1 freezer storage bag of fish, no label, no open, no discard date.Dry storage:6 five-pound containers of opened seasonings, no open or discard date1 large box of cornmeal, opened to air, no open, no discard date.1 large open box of chocolate chips open to air, no open, no discard date.Interview conducted with CK A on 01/28/2026, at 9:14 AM. CK A stated there was a policy on hair and beard restraints protocol for the kitchen, and he stated he has been trained on it. CK A stated that on this date wearing the beard restraint slipped his mind; however, he acknowledged the importance of wearing a beard restraint. CK A stated not wearing hair restraints could cause hair to get in resident's food, which could cause a negative outcome to residents getting sick.Interview conducted with CS C on 01/30/2026, at 10:05 AM. CS C stated she has worked at the facility for almost 2 years. CS C stated that hair and beard restraints must be put on before entering the kitchen, regardless of the kitchen entrance used. She stated that all trash cans are required to have lids. CS C stated when labeling food, staff should place the item name, open date, and use-by date. CS C stated failure to follow those kitchen protocols could lead to residents becoming ill. Interview conducted with DM on 01/30/2026, at 10:14 AM. DM stated that he, the Food Service Director, and the Executive Chef are responsible for training dietary staff on kitchen protocols. He stated that all trash cans are required to have lids and must be kept clean. He stated that all staff in the kitchen are required to always wear hairnets and beard nets. He stated that facility policy for labeling food items requires documenting the received date, open date, and expiration date. He stated that labeling food items is everyone's responsibility and that a label machine is available for this purpose. He stated that management conducts rounds to check whether food items are properly labeled. The Dietary Manager stated that leaving trash cans uncovered could result in cross-contamination and attract flies or bugs. He stated that failure to wear hair and beard restraints could result in hair contaminating food and posing a choking hazard to residents. He stated that failure to properly label foods could lead to items becoming spoiled, expired, or moldy, which could result in residents becoming ill.Interview conducted with EC on 01/30/2026, at 10:30 AM. EC stated that the management staff trains the dietary staff. He stated that all kitchen trash cans are required to be kept clean with lids. He stated that anyone who enters the kitchen area must always wear hairnets and beard nets if you have a beard. EC stated food items should be labeled with receive date, open date, and use-by date. EC stated that the kitchen used a new type of label machine that printed the three required categories: received date, open date, and use-by date. He stated that this machine has been a tremendous help in maintaining proper labeling practices. He stated that all cooks are trained to conduct rounds to ensure items are labeled and dated properly. The chef stated that if items are not labeled properly, it could lead to contamination, spoilage, and potential harm to residents. He stated that failure to properly wear beard or hair restraints could result in hair falling into food, which could lead to contamination and cause residents to become sick. He stated that if trash cans are left uncovered, they can produce unpleasant odors in the kitchen and contribute to cross-contamination. Interview conducted with CS B on 01/30/2026, at 10:41 AM. CS B stated she has worked at the facility for 2 years. She stated she was trained by management staff on kitchen policies. She stated that kitchen staff are required to always wear a hairnet. She stated that she recently began wearing a hat and on 1/28/2026 she had placed a hairnet on the back of the hat over her ponytail but did not realize it had fallen off. CS B stated that she now placed the hairnet over both her hat and hair to ensure proper coverage. She stated that if hair were to fall into food, it could result in cross-contamination and could cause a resident to become sick or choke.Interview conducted with ADM on 01/30/2026, at 11:39 AM. ADM stated that he did not know the facility's exact protocol for trash cans in food preparation areas. He stated that kitchen staff are required to wear hairnets and beard nets in the kitchen, food preparation, and service areas always. He stated his expectation is that dietary staff follow facility policies in accordance with standard operating procedures and the health code. He stated that failure to follow these protocols could result in cross-contamination, food spoilage, and bacterial growth, which could lead to gastrointestinal illness in residents.Record review of the facility's policy and procedure manual dated 2023, named Food Safety and Sanitation revealed: Policy: All local, state, and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department.Procedure:1. Employeesa. All staff will be in good health, will practice good personal hygiene, and will use safe food handling practices.c. Employees are required to have their hair styled so that it does not touch the collar, and to wear clean aprons, clothes, and closed toe shoes. Hair restraints are required and should cover all hair on the head. [NAME] nets are required when facial hair is visible. Record review of the facility's policy and procedure manual dated 2023, named Food Storage revealed: Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination.7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods.a. Old stock is always used first (first in - first out method). The person designated to manage stock should be trained to rotate it properly.b. Food should be dated as it is placed on the shelves if required by state regulation.c. Date marking should be visible on all high risk food to indicate the date by which a ready to-eat TCS food should be consumed, sold or discarded.d. Food will be stored and handled to maintain the integrity of the packaging until ready for use. Food stored in bins may be removed from its original packaging.8. Plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated.Record review of the facility's policy revised January 23, 2025, named Sanitation revealed: Procedure:1. Food is prepared, distributed, and served to residents under sanitary conditions.2. Food is obtained for resident consumption from sources approved or considered satisfactory by Federal, State, or Local Authorities; and3. Follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness.4. Safe food handling the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes.Record review of the FDA Food Code and Texas Administrative Code (26 TAC S554.1111), reflected the following must be met: Hands-Free Operation: Trash cans located near handwashing sinks or in food prep areas should ideally be hands-free (foot-pedal operated) to prevent cross-contamination. Material: Receptacles must be durable, cleanable, non-absorbent, and leak-proof. Plastic liners (trash bags) are required for wet waste. Covering: Trash cans must be covered when not in continuous use. If they contain food residue, they must have a tight-fitting lid to prevent pests and odors.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections for 3 out of 4 residents (R #18, R #32, R #21) reviewed for infection control. MA D failed to disinfect the blood pressure cuff between residents (R#5, R #18, R #32, R #21) while performing medication pass. The failure placed residents at risk for cross contamination and the development of infections.Findings include:In observation of medication administration on 1/29/2026 at 8:12 AM MA D utilized the blood pressure cuff on Resident #5, Resident #18, Resident #32, and Resident #21 and failed to disinfect the blood pressure cuff between the residents.In an interview on 1/29/2026 at 8:50AM with MA D, she stated that it is proper practice to cleanse the blood pressure cuff between residents with a Sani-wipe and wait 2 minutes for it to dry before using the equipment again. She stated that if the cuff is not cleaned between residents, it could take germs one patient has to another resident. She stated that the blood pressure cuff should be cleansed between residents to help prevent the spread of germs and infection. She stated she is frequently in serviced on infection control, hand hygiene, abuse, neglect, and cleaning reusable medical equipment. She stated she was nervous and forgot to clean the blood pressure cuff.In an interview on 1/29/2026 at 10:30 AM with LVN H, she stated they are frequently in serviced on infection control, hand hygiene, and how to clean reusable medical equipment. She stated that all equipment should be cleansed between each resident. She stated if the equipment is not cleaned between residents germs can be spread causing infections or illness.In an interview on 1/29/2026 at 10:50 AM with MA E, she stated they are frequently in serviced on infection control, hand hygiene, and how to clean reusable medical equipment. She stated that all equipment such as a blood pressure cuff should be cleansed between each resident.In an interview on 1/29/2026 at 11:11 AM with CNA G stated she has is frequently in serviced on infection control, hand hygiene, and the cleaning of reusable medical equipment. She stated that a blood pressure cuff should always be cleansed with a Sani-cloth and allowed to dry before using it on another resident. She stated that if reusable medical equipment is not cleaned between each resident germs can be spread from one resident to another, and they could get sick.In an interview on 1/30/2026 at 10:12 AM LVN I, stated she is In serviced on infection control and cleaning reusable medical equipment. She stated that all reusable equipment should be disinfected between residents. She stated that if reusable medical equipment is not cleaned between residents, it can spread infectious diseases from one resident to another one.In an interview on 1/30/2026 at 11:00 AM with DON, she stated the staff are frequently in serviced on infection control, disinfection of reusable medical equipment. She stated that she expected all staff to clean and disinfect all reusable medical equipment and allow them to dry before using on another resident. She stated that if the staff do not disinfect reusable equipment between residents they could be spreading germs and illness between patients.In an interview with ADM on 1/30/2026 at 11:04 AM. He stated that the staff are frequently in serviced on infection control, disinfection of reusable medical equipment. He stated he expects the staff to disinfect reusable equipment between residents following the manufacturer's instructions and that if the items are not disinfected they could spread skin infections from resident to resident.Review of facility policy and procedure titled Environmental Cleaning, dated April 6. 2020 and revised October 21, 2025, reflected: Service standard, Care and cleaning of the Community will perform in a way that is consistent with CMS requirements to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections. 7. Properly clean, disinfect and limit sharing of medical equipment between residents and areas of community.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide assistance devices and adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. The facility failed to ensure CNA A utilized a gait belt and had assistance from another staff member during a bed to wheelchair transfer on 11/19/24 which resulted in Resident #1 having a fall and complaints of pain. Resident #1 was sent to the local hospital emergency room where she was found to have fractured neck bones. She was care flighted to another hospital out of town for surgery to the neck. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 11/19/24 and ended on 12/05/24. The facility had corrected the noncompliance before the investigation began.This failure could place residents at risk for falls resulting in injury, pain, hospitalization, and possible death. Findings included:Record review of a face sheet dated 05/19/25 indicated Resident #1 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included kidney failure (condition where the kidney reaches advanced state of loss of function), gastrointestinal hemorrhage (bleeding from the small intestine or large intestine), gastroenteritis (inflammation that spreads from your stomach into your intestines), colitis (inflammation in the colon), pain, anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), osteoarthritis (a degenerative joint condition that causes pain, stiffness, and inflammation), depression (mental illness that negatively affects how you feel, the way you think and how you act), hypertension (a condition in which the force of the blood against the artery walls is too high), and chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe).Record review of a care plan initiated on 11/06/24 indicated Resident #1 required transfer assistance by 2 staff.Record review of the admission MDS dated [DATE] indicated Resident #1 cognitively intact with a BIMS of 15 out of 15. She was dependent ( Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) for chair/bed-to-chair transfers. She was 71 inches tall (5 foot 11 inches) and 229 pounds.Record review of Resident #1's progress notes indicated:* an entry dated 11/19/24 at 10:30 a.m. At 07:08 a.m. LVN B was notified of resident being on the floor by bedside by CNA A. Resident was noted on floor by the window on her left side. Resident said she fell face first (forward) laceration and redness noted on the bridge of her nose. Further assessment indicated a laceration to the left upper extremity. Resident was provided a pillow to rest head on to wait for EMS. EMS arrived around 07:15 a.m. Resident asked to get up complained of pain to the left upper extremity, right lower extremity, and crook in neck; and nausea. LVN B assist with board onto stretcher.* an entry dated 11/19/24 at 01:02 p.m. indicated LVN B was informed by Resident #1's RP resident was being transferred to another hospital due to neck fracture (C1-C2) from the fall this morning. LVN B also called the hospital emergency room and a diagnosis of neck fracture was given.Record review of the facility's investigation report dated 11/26/24 indicated on 11/19/24 Resident #1 had a fall and had initial signs of a laceration to her nose. Resident #1 was having significant pain and EMT's isolated her neck with a collar then transferred her by board to stretcher. The Administrator and DON interviewed CNA A. CNA A explained that she transferred Resident #1 from the bed to the chair, with one assist per plan of care. CNA A said Resident #1 leaned forward. CNA A was unable to stabilize the resident and she fell forward to floor. The investigation indicated that a gait belt was not in use at time of transfer. Resident #1 received a C-1 and C-2 fracture and will be required to wear a neck brace for a period of time. During an interview on 10/06/25 at 03:56 p.m. LVN B said she was coming on shift when the incident involving Resident #1 occurred. She said CNA A called and said she needed assistance to transfer Resident #1 so she and the night shift nurse went down to the room and Resident #1 was on the floor. She said CNA A said Resident #1 started falling and she tried to catch her. LVN B said Resident #1 had a cut on her nose. LVN B said Resident #1 complained of pain so EMS was contacted to send her to the hospital. LVN B said Resident #1 complained of pain to her neck when EMS arrived so they put a cervical collar on her. LVN B said she was contacted by Resident #1's family that she was being care flighted to another hospital due to a broken neck. She said Resident #1 usually was a 2-person transfer. She said a gait belt should always be used with 1 or 2 person transfers. During an interview on 10/06/25 at 04:32 p.m., the ED said CNA A was transferring Resident #1 without using the gait belt and a second staff on 11/19/24. She said Resident #1 fell forward hitting her face. She said the resident complained of pain and was sent to the local hospital emergency room. She said the family notified the facility the resident was being sent to another hospital because her neck was broken. She said CNA A was suspended from 11/19/24 through 11/26/24 and allowed to return to work after she received 1:1 training on gait belt use and transferring residents. She said all staff were trained on transfers with gait belt when hired. During an observation and interview on 10/07/25 at 02:25 p.m. Resident #1 was in her room sitting up in her chair. She was clean, neatly groomed, and had no offensive odors. She was not able to turn her head completely to the left to look at surveyor. She was not wearing a collar at the time. She said she was doing fine. She said the girl was helping her to go to the bathroom and she fell hurting her neck. She said she only had to wear the collar sometimes especially if she was riding in a vehicle. She said there are 2 staff that help her transfer and they put a belt on her. Record review of a Procedural Guideline #39-Assisting Resident to Transfer to Chair or Wheelchair revised 01/22 indicated 1. Purpose: To transfer resident to chair or wheelchair without trauma or avoidable pain. 2. Guidelines and Precautions for Moving an Lifting Residents:.C. Request assistance as needed prior to the move and use good body mechanics.4. Assisting Resident to Transfer to Chair or Wheelchair using Transfer Belt:.B. Show the resident the transfer belt and explain its use as a safety device. C. Apply the transfer belt over the resident's clothing around the waist and check the fit by inserting your fingers under it.E. Grasp the transfer belt with an under-hand grip and move the resident forward so his or her feet are flat on the floor.The surveyor attempted to contact CNA A for an interview on 10/07/25 10:45 a.m. There was a provider message saying the customer you are trying to reach was either restricted or unavailable. Surveyor was not able to leave a message for the CNA. On 10/07/25, the surveyor confirmed the facility implemented appropriate measures to ensure the safety of residents after the incident on 11/19/24 involving Resident #1 by: Record review of an Educational Summary Report dated 11/19/24 indicated staff were in-serviced regarding transfers and gait belt use.Record review of an In-Service Training Report dated 11/25/24 indicated staff were in-serviced regarding transfers and gait belt use.Record review of an In-Service Training Report dated 11/26/24 indicated CNA A had 1:1 training regarding transfers and gait belt use. Record review of an In-Service Training Report dated 12/05/24 indicated staff were in-serviced regarding transfers and gait belt use.Record review of Proficiency Trainings provided to staff upon hire and annually which included training on Transferring Residents, Use of Gait Belt with Transfers, and Abuse and Neglect.Record review of Proficiency Trainings provided to staff upon hire after the incident on 11/19/24 which included training for transfers and gait belt use received by MA E; CNA F and CNA G; and LVN C and LVN D. Record review of an In-Service on 11/19/24 after the incident on 11/19/24 included training for transfers and gait belt use received by LVN H, CNA J, CNA K, CNA L, CNA M, and CNA N.Record review of an In-Service on 11/25/24 after the incident on 11/19/24 included training for transfers and gait belt use received by CNA M, CNA N and CNA O.Record review of an In-Service on 12/05/24 after the incident on 11/19/24 included training for transfers and gait belt use received by LVN H, CNA J, CNA M, CNA N and CNA O.During an interview and record review on 10/06/25 at 02:16 p.m. indicated the Incident log from 11/19/24 through 10/07/25 there were 6 falls with injuries but only one of the falls with injury resulted in a fracture, Resident #1's fall. The DON said the other 5 injuries were bruises, abrasions, and skin tears. Observation of staff with transfer of Resident #2 on 10/06/25 at 02:34 p.m. indicated staff used 2 person for transfer and a gait belt was used. There were no observed concerns with transfer assistance. During an interview on 10/06/25 at 01:18 p.m. CNA J, CNA K, CNA L, CNA O, and CNA P said they worked the 06:00 a.m. to 06:00 p.m. shift. They said they were trained on gait belt use and transfers. They verbalized understanding of how to use the gait belt during a transfer. They said a manual transfer was 1 or 2 person depending on the residents' needs. During an interview on 10/06/25 at 01:35 p.m. LVN R said she was an agency nurse, She said she filled in 06:00 a.m. to 06:00 p.m. and 06:00 p.m. to 06:00 a.m. shifts at times. She said she received training on transfers and gait belt use with her staffing agency. She said all residents with manual transfers with 1 or 2 staff were to use a gait belt. She said she could find the information as to how many staff were needed to transfer a resident by looking in the resident chart or she could ask the staff working with the residents. During an interview on 10/06/25 at 01:45 p.m. MA E said she received training when hired on transfers and using a gait belt. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.During an interview on 10/06/25 at 03:56 p.m. LVN B said she received training on transfers and using a gait belt a couple of times after the incident on 11/29/24. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members. During a phone interview on 10/07/25 at 07:00 a.m. LVN D said she received training when hired on transfers and using a gait belt. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.During a phone interview on 10/07/25 at 07:06 a.m. CNA N said she received training on transfers and using a gait belt several times after the incident on 11/29/24. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.During a phone interview on 10/07/25 at 07:07 a.m. CNA M said she received training on transfers and using a gait belt several times after the incident on 11/29/24. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.During a phone interview on 10/07/25 at 07:13 a.m. LVN C said she received training when hired on transfers and using a gait belt. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.During a phone interview on 10/07/25 at 07:35 a.m. CNA F said she was trained when hired on transfers and using a gait belt. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.During a phone interview on 10/07/25 at 10:50 a.m. CNA Q said she received training on transfers and using a gait belt several times after the incident on 11/29/24. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.The noncompliance was identified as PNC. The Immediate Jeopardy began on 11/19/24 and ended on 12/05/24. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records maintained for each resident were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for resident records. The facility failed to ensure CNA Z documented that incontinent care was provided for Resident #1 from 6:27 p.m. on 08/09/25 through 6:00 a.m. on 08/10/25. The facility failed to ensure LVN V documented on a nurse progress note on 08/10/25 when Resident #1 was crying in pain, level of pain, and required pain medication. These failures could place residents at risk for delayed care and appropriate interventions. Findings included: Record review of Resident #1's face sheet dated 08/11/25 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included left femur (thigh bone) fracture, muscle weakness, unsteadiness on feet, cellulitis (bacterial infection) of buttocks, cognitive communication deficit, and anxiety (intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #1's admission assessment dated [DATE] indicated she was usually able to make herself understood and understood others, had moderately impaired cognition (BIMS-12), was dependent for toilet transfer, and was always incontinent of bladder and bowel. Record review of Resident #1's care plan dated 06/11/25 indicated she was always incontinent. Interventions included check and change if wet/soiled. Record review of Resident #1's care plan dated 06/11/25 indicated she was always incontinent of bowel movements. Interventions included check for incontinence and clean and dry if wet or soiled. Record review of Resident #1's incontinent care record dated 08/09/25 completed by CNA Z indicated Resident #1 was checked for incontinence of bladder and bowel on 08/09/25 at 6:27 p.m. The record indicated Resident #1 was incontinent. There was no documentation on Resident #1's incontinent care record after 6:27 p.m. Record review of Resident #1's MAR dated 08/10/25 at 1:14 a.m., completed by LVN V indicated she administered Tramadol (opioid used to treat pain) 25 mg tablet. Results were noted as effective at 2:14 a.m. Record review of a nurse progress note dated 08/10/25 at 8:23 a.m., completed by LVN Y indicated Resident #1 was sent out via 911 for evaluation and treatment for a fall at 7:10 a.m. Resident stable with no additional skin issues noted. There was no documentation of Resident #1 being incontinent, being in pain, or staff not being able to provide care. Record review of Resident #1's hospital records dated 08/10/25 indicated dried feces. During an interview on 08/11/25 at 9:43 a.m., RN X said Resident #1 arrived at the ER at approximately 8:07 a.m. on 08/10/25 with dried fecal matter contained to her brief. During an observation and interview on 08/11/25 at 10:57 a.m., Resident #1 was sitting in her wheelchair in the common area adjacent to the nurse's station. She was dressed in clean clothes. She said she was fine and had no complaints of her care. During an interview on 08/11/25 at 11:58 a.m., LVN Y said Resident #1 had feces in her brief when she was found on the floor on 08/10/25 at approximately 7:00 a.m. She said Resident #1 indicated she was in pain and not able to roll over for care. She said staff were not able to provide incontinent care prior to her transfer to the hospital. During an interview on 08/11/25 at 12:01 p.m., CNA W said she started her shift after 6:00 a.m. on 08/10/25. She said Resident #1 did not require incontinent care during her first round. She said she found Resident #1 on the floor at approximately 7:00 a.m. She said Resident #1 had a bowel movement but was in pain and was not able to roll for incontinent care prior to her transfer to the hospital. She said all care that was provided to residents should be documented in the electronic care record. During an interview on 08/11/25 at 12:46 p.m. the DON said there was no documentation of incontinent care for Resident #1 from 6:27 p.m. on 08/09/25 through 6:00 a.m. on 08/10/25. She said the CNAs and nurses were supposed to document the care because they did the hands-on care. She said it was her expectation staff would document care after the care was provided. She said residents were at risk for delayed care if the proper documentation was not completed. During an interview on 08/11/25 at 3:18 p.m., CNA Z said she completed rounds every two hours on 08/09/25 at 6:00 p.m. through 08/10/25. She said she completed incontinent care for Resident #1 at approximately 4:30 a.m. on 08/10/25. She said she did not document the care in Resident #1's care record. She said she was aware she should document care as it was completed. During an interview on 08/11/25 at 3:35 p.m., RN V said Resident #1 was crying and in pain after midnight on 08/10/25. She said she administered pain medication as ordered. She said she checked Resident #1 approximately 1.5 hours later and she was sleeping. She said she did not document Resident #1's status in the nurse progress notes. She said she was aware she should have documented in the nurse progress notes. She said not documenting resident status could delay care or treatment. Record review of the facility policy Incontinence briefs and pad handling dated 11/18/24 indicated .Documentation associated with handling incontinence briefs and pads includes: -date and time of care -name and title of any staff member who assisted with care . Record review of the facility policy Charting and Documentation dated 10/11/21 indicated All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record is primarily electronic; however, there may be some manual documents that are uploaded into the record. 1. The following information is to be documented in the resident's medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents, or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 2. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #3) residents reviewed for infection control. 1. CNA B failed to perform hand hygiene while performing incontinent care for Resident #3. These failures could place residents at risk for infection through cross contamination of pathogens. Findings included: 1. Record review of Resident #3's admission Record dated 08/11/25 reflected an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Major Depressive Disorder, hypertension (high blood pressure), and constipation. Record review of Resident #3's Comprehensive MDS assessment dated [DATE] reflected her BIMS score was 99 (unable to complete the interview). The other fields of the MDS assessment were not yet filled out except for her diagnoses which included depression, a hip fracture, and hypertension (high blood pressure). Record review of Resident #3's Care Plan reviewed on 8/11/25 reflected it had no information or interventions related to infection control. During an observation and interview on 08/11/25 at 9:49 AM, Resident #3 was awake and lying in bed. CNA B and CNA C entered the room and did hand hygiene, closed the door, and closed the blinds. CNA B and CNA C put on gloves. CNA B lowered the resident's brief and cleaned her perineal area appropriately. CNA B removed her gloves and placed new gloves on without completing hand hygiene. CNA B and CNA C assisted Resident #3 to turn onto her side and CNA B cleaned her buttocks. CNA B rolled the dirty brief inward and threw it away. CNA B removed her gloves and placed new gloves on without completing hand hygiene. CNA B placed a clean brief, adjusted the resident, and covered her. CNA B and CNA C cleaned up the supplies and completed hand hygiene. During an interview with CNA B on 08/11/25 at 9:57AM, she stated she completed hand hygiene first. She stated she would do hand hygiene before, between, and after incontinent care. She stated she realized she had not done hand hygiene after incontinent care and glove changes, and she should have. She stated she was trained to complete hand hygiene after glove changes and when going from a dirty to clean brief. She stated the risk of not performing hand hygiene was that infection could spread. During an interview with LVN A on 08/11/25 at 12:57 PM, she stated hand hygiene should be completed before care, after the change (brief change) itself, and before leaving the room. She stated staff were trained on hand hygiene for infection control purposes. During an interview with the Director of Nursing on 08/11/25 at 1:25PM, she stated the expectation was for the facility staff providing incontinent care to perform hand hygiene before starting care, when changing gloves (such as when the gloves were dirty), and after care. The DON stated the ADON and herself were responsible for training about hand hygiene. The Director of Nursing stated not completing proper hand hygiene could cause cross contamination. Record review of a facility In-service Training Report, dated 07/09/25, reflected: CNA B and CNA C's signatures on the first page. The second page included, .Incontinent Care.7. Remove old brief and place in bag. Remove gloves, wash hands and reapply gloves.10. Remove gloves and place in bag. 11. Wash hands and apply new gloves. 12. Apply new brief or pad 13. Remove gloves and wash hands. Record review of the facility policy titled, Incontinence briefs and pad handling, long-term care dated 11/18/24, reflected .perform hand hygiene, put on gloves.remove and discard your gloves, perform hand hygiene, put on clean gloves.discard soiled brief.remove and discard your gloves.perform hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 (Resident #2) residents who were reviewed for respiratory care. 1. The facility failed to ensure Resident #2 had orders for her oxygen therapy. 2. The facility failed to ensure Resident #2's oxygen humidifier was changed when emptied. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.The findings included: Record review of Resident #2's face sheet, dated 08/11/25, indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included anxiety disorder, hypertension (high blood pressure), and unsteadiness on feet. Record review of Resident #2's Comprehensive MDS assessment, dated 08/06/25, indicated Resident #2 had a BIMS score of 15 indicating she was cognitively intact. Resident #2's Special Treatment, Procedures, and Programs under Respiratory Treatments did not have oxygen therapy checked. Record review of Resident #2's care plan, dated 08/11/25, reflected it had no respiratory treatment or care included. Record review of Resident #2's physician orders reviewed on 08/11/25 prior to an interview with LVN A, did not indicate any orders for oxygen therapy or related care. Orders were added immediately after the interview with LVN A. During an observation and interview on 08/11/25 at 08:56 AM, Resident #2 was in her bed with her breakfast in front of her. Her nasal cannula was in her nostrils. The oxygen humidifier bottle was dated 08/02/25, was initialed, and was empty. She stated, They act like they don't even know I am on one (humidifier). She stated, they forget to check it. I have to remind them to change it. She stated, One night nurse has.something was buzzing when she came in. She stated, How would it affect me? when asked if it affected her to not have the humidifier changed timely. During an observation on 08/11/25 at 12:01 PM, the oxygen humidifier was still empty, and Resident #2 continued to wear her nasal cannula. During an observation and interview on 08/11/25 at 12:57 PM, Resident #2 asked LVN A if it (oxygen humidifier) was bubbling. LVN A stated, No, the water ran out. I have to get another one. LVN A stated the night shift changed the oxygen humidifier weekly or PRN if it was empty. LVN A stated the risk of not replacing the oxygen humidifier timely could be nose bleeds, shortness of breath, or dry sinuses. LVN A went to the computer to look up Resident #2's orders. She stated there were no orders for her oxygen therapy. She stated, I will put them in now. She stated the nurse that admitted her was responsible for ensuring the orders were in place. She stated the risk to the resident was that the respiratory equipment might not be changed out which could lead to infection. During an interview on 08/11/25 at 1:25 PM, the DON said nursing staff and nursing administration were responsible to ensure orders were in place. The DON stated the oxygen humidifier should be replaced when the water was out or weekly. The DON stated not changing the oxygen humidifier when it was empty could cause dry mucous membranes. The DON stated not having accurate orders in place could cause a change in condition for the resident. Requested Respiratory Care In-services from the DON on 08/11/25 at 1:25 PM, none were provided before exit. Record review of the facility policy titled, Respiratory Services dated 01/07/25 indicated, Service standard; healthcare personnel will provide respiratory care in compliance with current standards of practice.Respiratory services may include.oxygen administration.Respiratory equipment utilized will be maintained per the manufacturer's instructions or physician's orders.respiratory treatments will be administered per current standards.unless otherwise ordered by a physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for resident records.
The facility failed to document a physician ordered x-ray was completed, the results, or physician notification in Resident #1's medical record.
This failure could place residents at risk for delayed care and appropriate interventions.
Findings included:
Record review of Resident #1's face sheet dated 01/06/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included dementia (decline in cognitive function), pleural effusion (collection of fluid around the lungs), wheezing (high pitched whistle sound made when breathing), delirium due to know physiological condition, atrial fibrillation (abnormal heart rhythm), insomnia (sleep disorder), and anxiety (excessive, persistent, and uncontrollable worry and fear about everyday situations).
Record review of Resident #1's quarterly MDS dated [DATE] indicated she was able to make herself understood, usually understood others, and had moderate cognitive impairment (BIMS 9). She used a walker or wheelchair for mobility. She required assistance for all ADLS. She received oxygen therapy.
Record review of Resident #1's care plan dated 10/01/24 indicated she had potential for distressed respiratory effort due to SOB. Interventions included check O2 saturations and notify MD if outside parameters.
Record review of Resident #1's physician orders dated 10/16/24 indicated O2 at 2-4 L/min per nasal cannula PRN.
Record review of Resident #1's physician orders dated 12/31/24 indicated chest x-ray 2 views.
Record review of Resident #1's physician note dated 12/31/24 and completed by NP C indicated Resident #1 developed a wet cough this morning. Review of systems indicated breathing problems, cough, and shortness of breath with exertion. O2 SAT 97%. Assessments indicated cough and chronic congestive heart failure. Treatment included chest x-ray and continue Furosemide Tablet 40 MG 1 tablet orally once a day.
Record review of Resident #1's x-ray report dated 12/31/24 at 7:17 p.m. indicated right base infiltrate (white opacity(lacking transparency) in the lungs) and effusion (abnormal collection of fluid), worse than prior.
Record review of fax confirmation sheet dated 01/01/25 at 10:54 a.m. indicated LVN A faxed Resident #1's x-ray report to the MD B for review.
Record review of fax confirmation sheet dated 01/01/25 at 10:56 a.m. indicated LVN A faxed Resident #1's x-ray report to the MD B for review.
Record review of Resident #1's clinical notes dated 12/31/24 through 01/02/25 indicated no documentation of physician notification of change of condition and SOB, physician ordered chest x-ray, completion of chest x-ray, results of x-ray or sending results to the physician for review.
During an interview on 01/06/25 at 12:10 p.m., LVN A said Resident #1 had a change of condition on 12/31/24 with SOB and NP C ordered chest x-rays. She said the x-rays were completed on 12/31/24 but the results were not received in the facility before she left at 6:00 p.m. She said she returned to the facility on [DATE] and found the results in the portal. She said she faxed the results to the provider's two separate fax numbers and received confirmations the faxes were successful. She said she called the on-call NP and left a message regarding Resident #1's x-ray results. She said she could not recall the on-call NP's name. She said she put the fax confirmation and x-ray results in the binder at the nurse station for physician review. She said she spoke with the RP and showed her the x-ray results. She said the RP did not want Resident #1 sent out to hospital and was in process of considering hospice. She said on 01/02/25 Resident #1 was receiving her O2 via nasal cannula and also received her breathing TX as ordered. She said the x-ray results were still in the binder at the nurse station waiting for physician review. She said it was her error she did not document in Resident #1's chart for 12/31/24, 01/01/25 and 01/02/25. She said Resident #1 was at risk of not receiving care and services when there was missing information in the clinical records.
During an interview on 01/07/25 at 11:30 a.m., RD D said she was conducting a clinical chart audit and was not able to determine if Resident #1's physician ordered x-ray was completed. She said she was not able to determine if the x-ray results were received or if the physician was notified of the results because there was no documentation in Resident #1's chart. She said she called the facility on 01/03/25 and directed MDS LVN E to determine if the x-ray was completed, locate the results, and complete a focused assessment of Resident #1. She said MDS LVN E located the x-ray results by the fax machine, conducted a focused assessment of Resident #1 and notified NP C of the results. She said she was not aware the results of the x-ray were available to the facility as of 12/31/24. She said she was not aware LVN A obtained the results from the portal on 01/01/25 or faxed the results to MD B. She said there was no documentation in Resident #1's medical record. She said it was the facility's expectations the nurse on duty would document a physician ordered x-ray was completed, the results, and physician notification in Resident #1's medical record. She said residents were at risk of delayed care or untimely interventions if there was incomplete documentation in the medical record.
Record review of the facility's policy Charting and Documentation dated 10/11/21 indicated Documentation in the medical record is primarily electronic; however, there may be some manual documents that are uploaded into the record. 1. The following information is to be documented in the resident's medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents, or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 2. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. 3. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LVN, physicians, therapists, social workers, administrator, etc.) in accordance with state law and (named facility) service standards. 5. Per (named facility) expectations, the clinical record must contain per shift charting of resident's condition for a minimum of 3 days following incidents. 6. Per (named facility) expectations, the clinical record should include follow-up of resident's condition at least daily while a resident is on antibiotics or antiviral medication. 7. While long term care charting is by exception, it must include all assessments and unexpected outcomes to reflect thorough nursing care of the resident. 9. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician, or other staff, if indicated; and g. the signature and title of the individual documenting.

**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 1 of 13 residents (Resident #136) reviewed for infection control.
LVN C failed to wear a gown during wound care for Resident #136 who was on Enhanced Barrier Precautions (EBP).
This failure could place residents at risk of exposure to communicable diseases and infections.
Findings included:
Record review of Resident #136's face sheet dated 11/06/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included elevated white blood cell count (when the body produces more white blood cells than normal which could be caused by infection) and stage 3 (a deep wound that extends through the skin and into the subcutaneous tissue) pressure ulcer (a localized injury to the skin and soft tissue that occurs when an area of skin is under sustained pressure).
Record review of an admission MDS dated [DATE] indicated Resident #136 had moderately impaired cognition. The MDS had not been completed and had no further information.
Record review of a care plan dated 11/05/24 indicated Resident #136 had a stage 3 ulcer to her sacrum and staff were to utilize EBP which included wear gloves and gown during wound care of any skin opening requiring a dressing.
During an observation on 11/04/24 at 9:45 a.m., Resident #136's door had a sign instructing she was on EBP and a supply cart containing needed PPE (a type of clothing or equipment that protects people from injury or illness in the workplace).
During an observation on 11/05/24 at 3:25 p.m., LVN C prepped her supplies on a sterilized bedside table in Resident #136's room. She washed her hands and put on gloves. She then returned to the bedside and unfastened Resident #136's brief, rolled her to her right side and removed a dressing from her sacral wound. She washed her hands and put on clean gloves. She cleansed the wound using wound cleanser and gauzed, patted the area dry with gauze, applied collagen powder mixed with an antimicrobial skin wound gel, and covered with a border dressing. LVN removed her gloves, washed her hands and exited the room.
During an interview on 11/05/24 at 3:57 p.m., LVN C said she forgot to put on a gown while doing wound care for Resident #136. She said she realized she had not worn the gown when she finished the wound care. She said she had been in a hurry because she had so much that she needed to get done. LVN C said a gown and gloves were always required when doing wound care or having direct contact with a resident on EBP and Resident #136 was on EBP due to having an open wound. She said not wearing a gown when giving care to a resident on EBP could result in cross contamination to other residents. She said she was given training on EBP during her orientation a few months ago.
During an interview on 11/05/24 at 4:02 p.m., the interim DON said his expectation was for all nursing staff to glove and gown when giving care requiring direct contact with a resident on EBP. He said all nursing staff had been trained on the requirements of EBP. He said not wearing appropriate PPE during direct contact care to a resident on EBP could cause cross contamination to other residents and staff.
During an interview on 11/06/24 at 1:15 p.m., the interim Administrator said he expected all staff to follow CMS guidelines for EBP including donning and doffing appropriate PPE and hand hygiene. He said the interim DON was ultimately responsible for monitoring EBP, but all department heads made rounds daily and had been trained on EBP. He said a possible negative outcome of not following the guidelines for EBP could be the transfer of disease or illness to other residents and staff.
Record review of a facility policy titled Isolation Categories of Transmission-Based Precautions and Enhanced Barrier Precautions revised 10/23/24 indicated, . Enhanced barrier precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care areas that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. Examples of high contact resident care activities requiring gown and glove use for enhanced barrier precautions include: . Wound care: any skin opening requiring a dressing.

**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 and administering of all drugs to meet the needs of the residents for 1 (Resident #139) of 13 residents reviewed for controlled medications.
Resident #139's hydrocodone 5mg / acetaminophen 325 mg (narcotic pain medication for moderate or severe pain) 20 tablets were not accounted for at the time of discharge 09/11/24 and remained unaccounted for 55 days.
This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion.
Findings :
Record review of a face sheet dated 11/06/24 indicated Resident #139 admitted on [DATE] was [AGE] years old with diagnoses of fractured right hip and fractured right upper arm. The face sheet indicated discharged on 09/11/24 to another facility. The face sheet did not have contact information for the Resident #139. There was contact information for her family (her son) .
Record review of physician orders dated September 2024 indicated Resident #139 orders included hydrocodone 5 mg/ acetaminophen 325 mg as needed for pain with start date of 08/22/24.
Record review of the MAR dated September 2024 indicated Resident #139 received a hydrocodone 5 mg/ acetaminophen 325mg by mouth on 09/01/24, 09/04/24 and 09/07/24.
Record review of the annual MDS assessment dated [DATE] for Resident #139 was cognitively intact. She had fractures and received an opioid (pain medication) during the last 7 days.
Record review of the care plan dated 09/02/24 indicated Resident #139 had pain related to her fractured right leg and right arm. Intervention included she would receive medications per physician's orders.
Record review of physician orders dated September 2024 indicated Resident #139 orders included hydrocodone 5 mg/ acetaminophen 325 mg as needed for pain with start date of 08/22/24.
Record review of the MAR dated September 2024 indicated Resident #139 received a hydrocodone 5 mg/ acetaminophen 325mg by mouth on 09/01/24, 09/04/24 and 09/07/24.
During an observation and interview on 11/5/24 at 9:50 a.m., the interim DON A opened the cabinet and said the cabinet was in his office and was used to store narcotics for destruction. He said this was the first time he had opened this cabinet. The cabinet was secured with 2 locks and was empty. He pointed at the logbook and said when a narcotic was placed in the cabinet, staff logged in the medication. The logbook contained a stack of blank logs and there was an undated log form that had 2 narcotic medications listed on the form. The interim DON A said he had not seen that page before and said he would find out where the narcotics were atheld. He said there was another interim DON B before he was hired last week, and she might know where those narcotics were at.
Record review of the undated log record indicated there should have been 2 cards or bottles containing 20 narcotics each. The log indicated date dispensed on:
*08/22/24 RX#2028970, hydrocodone (norco) 20 tablets and
*09/06/24 RX # 2041187- 20 tablets of Xanax 0.5mg (antianxiety narcotic).
During an interview on 11/05/24 at 10:30 a.m., the interim DON B said she was a corporate regional RN, and she had been the acting interim DON after the last DON was terminated. She said she had not opened the narcotic cabinet while she was the interim DON at this facility. She said she had not been given any narcotics for destruction and had not destroyed any narcotics. She said any narcotics not released to residents or family upon discharge or narcotics which had been discontinued, would be given to the DON. The interim DON B said the narcotics would be logged in and placed in the double locked cabinet and would be destroyed with DON, a nurse or administrator and the pharmacist.
During an interview on 11/05/24 at 12:30 p.m., the interim Administrator said his expectation was for the narcotics to be kept in a secured manner per the facility policy and they were looking for the 2 narcotics prescriptions that were misplaced or missing. He said they had reached out to the pharmacy to identify who the residents were, and they were interviewing the staff who had discharged the residents who the narcotics was prescribed to.
Attempted an interview on 11/05/24 at 2:30 p.m., No answer Resident #139's family phone. A detailed message with the surveyor's contact information was left on the answering machine.
During an interview on 11/05/24 at 3:30 p.m. the interim DON A said they had located some narcotics which had been placed in a treatment cart and should not have been stored there. He said one of the missing medication was located. He said the 20 tablets of the prescription of hydrocodone 5mg/325 mg for Resident #139 had not been located. He said they were still investigating and had a call out to the family for Resident #139 who had been discharged on 09/11/24 to a local rehabilitation hospital.
During an interview on 11/06/24 at 9:30 a.m., the case manager of the rehabilitation hospital where Resident #139 was discharged said the facility had called yesterday evening about this medication and this hospital did not receive the hydrocodone for Resident #139. She said the physician here had ordered Resident #139 hydrocodone 7.5mg/325 mg during her stay here. The case manager said Resident #139 had not required any pain medication during her stay there and had since been discharged home. She said no narcotics were received. If they had been received the pharmacy would have logged the medication into our system.
During an interview on 11/06/24 at 10:00 a.m., LVN C said she was in orientation when Resident #139 discharged on 09/11/24. She said normally if the medications were sent with the resident, she would normally print a list of meds and write down how many were sent home. She said she did not remember the discharge for Resident #139. She said she might have sent a list with the resident and did not make a copy. She said she did not remember anything about the resident or the discharge. She said during her orientation the ADON was here.
During an interview on 11/06/24 at 10:15 a.m., the ADON said she did not remember a lot about the discharge for Resident #139 however she said the previous DON had told her not to send medications when residents went to the rehab hospital. She said she never saw Resident #139's medications during the discharge on [DATE] or after that day.
During an interview on 11/06/24 at 10:20 a.m. the interim Administrator said they could not locate the narcotic for Resident #139 and the facility reported the incident of the missing medication to the state and local police. He said the family of Resident #139 had never returned his call. He said, We must have an issue with the drugs being stored for destruction.
During an interview on 11/06/24 at 1:00 p.m., the interim DON A said his expectation for the narcotics were to be turned into the DON or interim DON and he was training all the nurses on the new policy. He said they did not have a policy and procedure prior to the DON receiving the narcotics for destruction.
Record review of the policy dated 11/05/24 titled Narcotics indicated . All active and discontinued Narcotic meds will be left on the cart and counted each shift until the DON is available to receive or take off the cart. When a resident is discharged with narcotics 2 nurses and the family or who is receiving the narcotics has to sign the narcotic count sheet and note the number given and the sheet placed in the scanning bin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for resident records.
The facility failed to ensure LVN C documented Resident #1's change of condition and physician notification on 12/17/2023.
This failure could place residents at risk for delayed care and appropriate interventions.
Findings included:
Record review of Resident #1's face sheet dated 10/15/24 indicated an [AGE] year-old female with an admission date of 10/18/23 with diagnoses of Alzheimer's disease unspecified, muscle weakness (Generalized), and other abnormalities of gait and mobility.
Record review of Resident #1's admission MDS dated [DATE] indicated she was understood and understood others and she had a moderate cognitive impairment (BIMS score of 6). She required supervision or moderate assistance for most ADLs. She had at least one fall in the last month prior to admission/entry or reentry to the facility. She was frequently incontinent of bladder and occasionally incontinent of bowel.
Record review of Resident #1's care plan, revised on 11/12/2023, indicated the resident had a history of falls since admission related to poor safety awareness due to Alzheimer's. The interventions included to engage resident in activities that improve strength, balance, and posture as tolerated and document results, keep nurse call bell within easy reach or instruct resident to use call bell or call out for assistance, instruct resident on safety measures to reduce the risk of falls, keep areas free of obstructions to reduce the risk of falls or injury, keep personal items within reach, and the bed was to be in low position with wheels locked.
Record review of the facility's Incident/Accident Log dated 12/01/2023 through 12/31/2023 indicated no history of falls for Resident #1. Incident log indicated an injury of unknown origin reported on 12/19/2023.
Record Review of Resident #1's incident report dated 12/19/2023 authored by LVN A indicated that the nurse noted resident to have bruising and swelling to the right eyebrow area while sitting in her wheelchair in the common area, resident said I'm fine and denied any pain or discomfort.
Record review of Resident #1's progress notes reviewed from 12/01/2023 through 12/31/2023 found no progress notes or incident reports indicating Resident #1 was assessed by LVN C for injuries following a witnessed fall observed by CNA B on 12/15/2023 and/or documentation that the physician was notified of the witnessed fall.
During an interview on 10/16/2024 at 10:00 a.m., the Executive Director said she was the administrator at the time of the incident with Resident #1. During her investigation with the report of Resident #1 having an injury of unknown origin on 12/19/2023, she found that Resident #1 had a witnessed fall observed by CNA B on 12/17/2023.This was reported to LVN C, but she failed to complete an incident report and/or document in the resident's medical records regarding the fall. She said that the incident happened at shift change and due to poor communication (on coming shift thought out going shift was notified and aware of the incident) the incident was not documented. She said the staff were provided an in-service regarding completing incident reports and reporting incidents to physicians. She said not reporting changes to the physician could result in a delay in resident's treatment.
During an interview on 10/16/2024 at 4:52 p.m., LVN A said on 12/19/2023 she noticed bruising and swelling to Resident #1's right eye/eyebrow area. She said Resident #1 did not show grimace or signs of pain at that time. She said she completed an incident report for injury of unknown origin and incident was reported immediately to the DON, the AC, the MD, and the RP. LVN A said that Resident #1 had a history of falls, and that the MD did not give any new orders when the fall was reported on 12/19/2023. She said during interviews and conversations with other staff and the family it was later found that the resident had a witnessed fall observed by CNA B on 12/17/2023 which could have caused the bruise and swelling to Resident #1's right eye/eyebrow area. LVN A said she had received training on reporting incidents to the the NP/MD and completion of incident reports.
CNA B, no longer employed at the facility, was attempted to be reached via telephone on 10/16/2024 at 5:00 p.m. and 6:00 p.m., attempts were unsuccessful with no answered or returned phone calls.
Record review of a witness statement provided by CNA B indicated on 12/17/2023 at around 6:10 p.m., CNA B was arriving to work. Resident #1 requested CNA B take her to the restroom. CNA B assisted Resident #1 to the restroom, and when she was finished in the restroom, she assisted her to her wheelchair and started wheeling her back to the sitting area. Resident #1 said she had forgotten her purse in the restroom and asked CNA B to retrieve her purse for her. CNA B returned to the restroom to retrieve the purse, and when she was coming out of the restroom, she observed Resident #1 standing up from her wheelchair and falling. and CNA B ran to her and attempted to reach her to prevent a fall but was unsuccessful, and Resident #1 fell, hitting the side of her forehead. CNA B stated Resident #1 was getting herself up, saying nothing happened. Resident #1 was assisted back in her wheelchair, and LVN C was notified of the incident.
During an interview on 10/17/2024 at 10:45 a.m., LVN C said when she began her shift at 6:00 p.m. on 12/17/2023, CNA B reported to her that Resident #1 had a fall or near fall. LVN C said she conducted a head-to-toe assessment after CNA B reported the incident and she did not observe any injuries nor did the resident grimace or make sounds of pain when she was assessing her. LVN C said Resident #1's family and private sitter were present during the assessment and was aware of the fall/near fall incident and made light of the situation (no concerns). She said that she initially thought the incident had happened on the prior shift and the other shift had completed the incident report and documentation. She said she got busy during her shift and failed to review the chart for the incident report or document the head-to-toe assessment she completed. LVN C said she was later questioned about the incident, and it was found that Resident #1 fell at shift change and that she was responsible for completing the incident report and reporting the incident to the physician, which she failed to do. She said she received training on completing incident reports and notifying the physician of accidents/injuries. She said not reporting incidents to the physician could delay the resident's treatment.
During an interview on 10/17/2024 at 2:30 p.m., the interim DON said she had only been at the facility for a little over a week as interim DON, but her expectations were if a resident had a fall that the resident be assessed immediately by licensed facility staff and the fall and assessment findings be reported to the MD/NP, the ADON, herself, the Administrator, and the RP, if applicable. The DON said that the NP/MD would dictate what happened next with new orders (x-rays, to local ER for evaluation, medications). The DON said the facility staff should initiate the incident reporting process (incident report, neuro checks, changes, skin assessments, etc.) and document for 72 hours in the resident electronic medical records to identify any changes/concerns. The DON said staff should make sure all incident care and follow up care was documented in the resident's medical record. The DON said that not reporting the incident to MD/NP could delay the resident's treatment plan.
During an interview on 10/17/2024 at 3:00 p.m., the Administrator said that he had only been the interim Administrator for about one week, but his expectation was if a resident had a fall that the resident would be assessed immediately by licensed staff and the fall assessment would be reported to the physician/NP, the family, and the supervisor. The facility licensed staff should initiate the incident reporting process and document all findings in the resident's electronic medical record. The Administrator said that the electronic medical records should include an incident report, clinical documentation, who was notified of the incident, and complete documentation of the incident. The Administrator said that the resident involved in the incident should be assessed routinely until resolution and follow up from physician received. The Administrator said that not reporting the incident to MD/NP could delay the resident's treatment.
Record Review of Facility's In-Service Training Report Titled January Nursing Meeting dated 01/25/2024 indicated, Incident reports: All incident reports need to be done immediately when an incident occurs. This includes the entire incident process including risk assessments, neuro checks (if the fall is unwitnessed and the patient is unable to tell you if they hit their head or not neuro checks must be started.) Every shift is responsible for completing your section on the report.
Record review of the facility's Notification of Changes policy, revised July 16, 2024, indicated 1. The nurse will immediately notify the resident/resident responsible representative (consistent with his/her authority) and physician for the following changes (this list is not all inclusive) an accident involving residents, which result in injury and has the potential for requiring physician intervention . 2. The nurse will notify the resident/resident's representative and the resident's physician for non-immediate changes of condition in a timely manner 3. Document the notification and record any new orders in the resident's medical records .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to immediately notify the resident physician regarding a change in a resident's condition for one (Resident #1) of seven residents reviewed for changes in condition.
The facility failed to inform the physician immediately of Resident #1's witnessed fall on 12/15/2023.
This failure could place residents' physician at risk of not being aware of any changes in their conditions and could result in a delay in treatment and a decline in residents' health and well-being.
The findings included:
Record review of Resident #1's face sheet dated 10/15/24 indicated an [AGE] year-old female with an admission date of 10/18/23 with diagnoses of Alzheimer's disease unspecified, muscle weakness (Generalized), and other abnormalities of gait and mobility.
Record review of Resident #1's admission MDS dated [DATE] indicated she was understood and understood others and she had a moderate cognitive impairment (BIMS score of 6). She required supervision or moderate assistance for most ADLs. She had at least one fall in the last month prior to admission/entry or reentry to the facility. She was frequently incontinent of bladder and occasionally incontinent of bowel.
Record review of Resident #1's care plan, revised on 11/12/2023, indicated the resident had a history of falls since admission related to poor safety awareness due to Alzheimer's. The interventions included to engage resident in activities that improve strength, balance, and posture as tolerated and document results, keep nurse call bell within easy reach or instruct resident to use call bell or call out for assistance, instruct resident on safety measures to reduce the risk of falls, keep areas free of obstructions to reduce the risk of falls or injury, keep personal items within reach, and the bed was to be in low position with wheels locked.
Record review of the facility's Incident/Accident Log dated 12/01/2023 through 12/31/2023 indicated no history of falls for Resident #1. Incident log indicated an injury of unknown origin reported on 12/19/2023.
Record Review of Resident #1's incident report dated 12/19/2023 authored by LVN A indicated that the nurse noted resident to have bruising and swelling to the right eyebrow area while sitting in her wheelchair in the common area, resident said I'm fine and denied any pain or discomfort.
Record review of Resident #1's progress notes reviewed from 12/01/2023 through 12/31/2023 found no progress notes or incident reports indicating Resident #1 was assessed by LVN C for injuries following a witnessed fall observed by CNA B on 12/15/2023 and/or documentation that the physician was notified of the witnessed fall.
Resident #1, no longer resides at facility, attempted to call Resident #1 and/or FM via telephone on 10/16/2024 at 5:15 p.m. and 6:15 p.m., attempts were unsuccessful with no answered or returned phone calls.
During an interview on 10/16/2024 at 10:00 a.m., the Executive Director said she was the administrator at the time of the incident with Resident #1. During her investigation with the report of Resident #1 having an injury of unknown origin on 12/19/2023, she found that Resident #1 had a witnessed fall observed by CNA B on 12/17/2023.This was reported to LVN C, but she failed to complete an incident report and/or document in the resident's medical records regarding the fall. She said that the incident happened at shift change and due to poor communication (on coming shift thought out going shift was notified and aware of the incident) the incident was not documented. She said the staff were provided an in-service regarding completing incident reports and reporting incidents to physicians. She said not reporting changes to the physician could result in a delay in resident's treatment.
During an interview on 10/16/2024 at 4:52 p.m., LVN A said on 12/19/2023 she noticed bruising and swelling to Resident #1's right eye/eyebrow area. She said Resident #1 did not show grimace or signs of pain at that time. She said she completed an incident report for injury of unknown origin and incident was reported immediately to the DON, the AC, the MD, and the RP. LVN A said that Resident #1 had a history of falls, and that the MD did not give any new orders when the fall was reported on 12/19/2023. She said during interviews and conversations with other staff and the family it was later found that the resident had a witnessed fall observed by CNA B on 12/17/2023 which could have caused the bruise and swelling to Resident #1's right eye/eyebrow area. LVN A said she had received training on reporting incidents to the the NP/MD and completion of incident reports.
CNA B, no longer employed at the facility, was attempted to be reached via telephone on 10/16/2024 at 5:00 p.m. and 6:00 p.m., attempts were unsuccessful with no answered or returned phone calls.
Record review of a witness statement provided by CNA B indicated on 12/17/2023 at around 6:10 p.m., CNA B was arriving to work. Resident #1 requested CNA B take her to the restroom. CNA B assisted Resident #1 to the restroom, and when she was finished in the restroom, she assisted her to her wheelchair and started wheeling her back to the sitting area. Resident #1 said she had forgotten her purse in the restroom and asked CNA B to retrieve her purse for her. CNA B returned to the restroom to retrieve the purse, and when she was coming out of the restroom, she observed Resident #1 standing up from her wheelchair and falling. and CNA B ran to her and attempted to reach her to prevent a fall but was unsuccessful, and Resident #1 fell, hitting the side of her forehead. CNA B stated Resident #1 was getting herself up, saying nothing happened. Resident #1 was assisted back in her wheelchair, and LVN C was notified of the incident.
During an interview on 10/17/2024 at 10:45 a.m., LVN C said when she began her shift at 6:00 p.m. on 12/17/2023, CNA B reported to her that Resident #1 had a fall or near fall. LVN C said she conducted a head-to-toe assessment after CNA B reported the incident and she did not observe any injuries nor did the resident grimace or make sounds of pain when she was assessing her. LVN C said Resident #1's family and private sitter were present during the assessment and was aware of the fall/near fall incident and made light of the situation (no concerns). She said that she initially thought the incident had happened on the prior shift and the other shift had completed the incident report and documentation. She said she got busy during her shift and failed to review the chart for the incident report or document the head-to-toe assessment she completed. LVN C said she was later questioned about the incident, and it was found that Resident #1 fell at shift change and that she was responsible for completing the incident report and reporting the incident to the physician, which she failed to do. She said she received training on completing incident reports and notifying the physician of accidents/injuries. She said not reporting incidents to the physician could delay the resident's treatment.
During an interview on 10/17/2024 at 2:30 p.m., the interim DON said she had only been at the facility for a little over a week as interim DON, but her expectations were if a resident had a fall that the resident be assessed immediately by licensed facility staff and the fall and assessment findings be reported to the MD/NP, the ADON, herself, the Administrator, and the RP, if applicable. The DON said that the NP/MD would dictate what happened next with new orders (x-rays, to local ER for evaluation, medications). The DON said the facility staff should initiate the incident reporting process (incident report, neuro checks, changes, skin assessments, etc.) and document for 72 hours in the resident electronic medical records to identify any changes/concerns. The DON said staff should make sure all incident care and follow up care was documented in the resident's medical record. The DON said that not reporting the incident to MD/NP could delay the resident's treatment plan.
During an interview on 10/17/2024 at 3:00 p.m., the Administrator said that he had only been the interim Administrator for about one week, but his expectation was if a resident had a fall that the resident would be assessed immediately by licensed staff and the fall assessment would be reported to the physician/NP, the family, and the supervisor. The facility licensed staff should initiate the incident reporting process and document all findings in the resident's electronic medical record. The Administrator said that the electronic medical records should include an incident report, clinical documentation, who was notified of the incident, and complete documentation of the incident. The Administrator said that the resident involved in the incident should be assessed routinely until resolution and follow up from physician received. The Administrator said that not reporting the incident to MD/NP could delay the resident's treatment.
Record Review of Facility's In-Service Training Report Titled January Nursing Meeting dated 01/25/2024 indicated, Incident reports: All incident reports need to be done immediately when an incident occurs. This includes the entire incident process including risk assessments, neuro checks (if the fall is unwitnessed and the patient is unable to tell you if they hit their head or not neuro checks must be started.) Every shift is responsible for completing your section on the report.
Record review of the facility's Notification of Changes policy, revised July 16, 2024, indicated 1. The nurse will immediately notify the resident/resident responsible representative (consistent with his/her authority) and physician for the following changes (this list is not all inclusive) an accident involving residents, which result in injury and has the potential for requiring physician intervention . 2. The nurse will notify the resident/resident's representative and the resident's physician for non-immediate changes of condition in a timely manner 3. Document the notification and record any new orders in the resident's medical records .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #1) of 7 residents reviewed for accurate medical records.
The facility staff (RN B) failed to document on the admitting orders and MAR/TAR regarding Resident #1's indwelling Foley catheter care and maintenance, PICC line care and maintenance, and enteral feeding dosing upon admitting to the facility.
The facility staff (LVN A) failed to document an accurate assessment of a new wound identified on 02/05/2024.
The facility staff (RN B) failed to ensure physician's orders were written for removing a PICC line on 02/05/2024.
These failures could place resident at risk of having errors in care and treatment decisions being based on incomplete and inaccurate medical records.
Findings included:
Record review of face sheet dated 02/21/2024 indicated Resident #1 was admitted on [DATE], was a [AGE] year-old female with diagnoses that included nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), nontraumatic intracerebral hemorrhage, intraventricular (the eruption of blood in the cerebral ventricular system), myasthenia gravis (chronic neuromuscular disease that causes weakness in the voluntary muscles), dysphagia (difficulty or discomfort in swallowing), dementia (loss of cognitive functioning), and weakness to both legs.
Record review of Resident #1's hospital discharge instructions note dated 02/01/2024 indicated the resident's discharge diet was by tube feeding (G-tube - a tube inserted through the belly that brings nutrition directly to the stomach): Paptamen AF 95 ml/hr. Patient Discharge condition indicated the resident had a G-tube, indwelling Foley catheter (catheter inserted for continuous drainage of the bladder), and a double lumen (two ports) PICC line (thin flexible tubing inserted into a vein in the upper arm threaded into a large vein above the right side of the heart) to left arm upon discharge.
Record review of Resident #1's initial MDS assessment dated [DATE], indicated the resident had a memory problem and cognitive skills for decision making were severely impaired. The resident did not have any pressure injuries at the time of admission. The resident had an indwelling urinary catheter and received nutrition through parenteral or tube feedings.
Record review of Resident #1's chart reflected there was no comprehensive care plan developed. The initial care plan dated 02/02/2024 indicated the resident had an alteration/potential alteration in nutrition with goals to maintain weight and meet nutritional needs at highest practicable level. The interventions included for the resident to be NPO and a diet order for G-tube feedings of Isosource upon admission. The resident did not have any pressure injuries addressed on the initial care plan.
Record review of Resident #1's MAR (Medication Administration Record)/TAR (Treatment Administration Record) indicated no orders, treatments or interventions for Resident's # 1 indwelling foley catheter, PICC line and enteral feeding dosing was documented upon admission to the facility.
Record Review of Resident #1's Skilled Daily Nurse's Note dated 02/01/2024 at 7:30 pm, authored by RN B, the Nurse Summary indicated: Patient here from local hospital post fall/subarachnoid hemorrhage. The resident had a history of: dementia, Alzheimer's, subarachnoid hemorrhage, myasthenia gravis, stroke, and pulmonary embolism (a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs). The resident was NPO after failing a swallow study and had a G- tube. The tube was secured in place with an adhesive holder on the abdomen, abdominal binder covering G-tube site. The resident had an indwelling urinary Foley catheter and Podus boots (multi-purpose foot boot helps in the healing and prevention of hell and toe ulcers and safeguards against foot drop) on both feet to protect her heels. No breakdown was noted on her heels. Mild redness was noted on her buttocks. The resident had a left upper arm double lumen PICC line with the dressing in place.
Record review of Resident #1's Skilled Daily Nurses Note from 02/01/2024 to 02/08/2024 indicated there was not a Skilled Daily Nurse's Note assessment completed on 02/02/2024, 02/03/2024, or 02/04/2024. There was no documentation to address the resident's tube feeding and dosing, skin assessment, indwelling Foley catheter care or maintenance, or of the resident's medical or non-medical status with positive or negative changes.
Record review of Resident #1's Change in Condition clinical notes dated 02/05/2024 at 1:49 pm, indicated charge nurse, LVN A, was notified by the CNA that she found a wound on the resident's left buttock and some redness to bilateral (both) heels.
Record review of Resident #1's Skilled Daily Nurses Note indicated there was not a skilled daily nurses note assessment authored by LVN A, nor a wound assessment completed on 02/05/2024 at 1:49 pm when the resident had a change in condition of a new wound on her left buttock.
Record Review of Resident #1's Skilled Daily Nurse's Note dated 02/05/2024 at 7:55 pm, authored by RN B, Nurse Summary indicated: the resident received Isosource @ 95ml/hr with water flushes @ 60ml/hr every 3 hours. Moderate sized abdominal hernia visible. The abdominal binder covering the G-tube site was in place. The resident's indwelling urinary Foley catheter was in place. The resident had Podus boots on with no breakdown noted on heels. She had a large deep tissue injury with open skin noted to the top of her left buttock. She had a left upper arm double lumen PICC line the dressing secured. PICC line removed per physician's orders using aseptic technique.
Record review of Resident #1's physician's order summary dated 02/26/2024 of all orders, indicated there were orders dated 02/02/2024 for Resident #1 to admit to the facility with orders for NPO, HOB at 45 degrees at all times, and to check G-tube placement, and G-tube feedings, flushes, and residual checks.
Record review of Resident #1's physician orders from 02/01/2024 to 02/08/2024 indicated no orders in electronic medical records were found for eternal feeding type or dosing, indwelling Foley catheter care or maintenance, removal of the PICC line and/or new orders for treatment of a new wound identified on 02/5/2024.
During an interview on 2/26/2024 at 9:32 am, RN B said she provided care for Resident #1 during the 6 pm to 6 am shift on 02/01/2024 and 02/05/2024. She said she admitted Resident #1 to the facility on [DATE] and she did not recall the resident having any open wounds upon admission. RN B said on 02/05/2024 she received report during shift change that Resident #1 had a new wound on her left buttock. RN B said completed a head-to-toe assessment on Resident #1 and observed a new wound on left buttock, it was the size of a ½ dollar coin and was dark pink/purple area, with thin top layer of skin missing. RN B said she received approval from the physician to discontinue the PICC line on 02/05/2024, but she said she forgot to write the order. RN B said she did not recall if she flushed or maintained the resident's PICC line between 02/01/2024 to 02/05/2024. RN B said on 02/05/2024 she assisted the CNA with repositioning the resident, assisting with care and applying the barrier cream on the resident's buttocks. RN B said an order should have been obtained or written to provide treatment/care to the wound on Resident #1's left buttock.
During an interview on 02/26/2024 at 10:20 am, LVN A said she worked 6 am to 6 pm on 02/05/2024 and the aide came to her and told her Resident #1 had a wound on her left buttock. She said assessed the wound to be a reddish/purple area the size of ½ dollar piece. She said she applied barrier cream, notified the ADON for a referral for wound care, and completed an incident report for the new wound. She said she notified the family member who was present in the room about the new wound. She said that she should have completed a skilled assessment note which included a head-to-toe assessment. LVN A said she should have identified the wound and provided a better description and location of the wound, she should have completed a wound assessment sheet, and she should have obtained treatment/orders from the MD.
During an interview on 02/22/2024 at 10:20 am, LVN C said she worked 6 am to 6 pm on 02/03/2024 and 02/04/2024 providing care for Resident #1. She said the skilled assessment notes were done daily and during shift change while providing report, the off-going nurse would inform the oncoming nurse which residents needed daily skilled assessments. She said Resident #1's assessment was usually done on the late shift because she was admitted during the late shift. LVN C said therapists worked with the resident during the day shift and the resident required maximum assistance for all care. LVN C said Resident #1 had a DTI on her left buttock and staff were applying barrier cream to the area. LVN C said she recalled flushing the resident's G-tube, caring for the G-tube stoma (an artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut or trachea) site and check tube placement. LVN C said if any changes occurred during the shift, she would document it in the clinical notes section of the electronic medical records.
During an interview on 02/26/2024 at 2:45 pm, the DON said her expectation was when new residents were admitted to the facility for skilled therapy, staff should complete a head-to-toe assessment, document all findings in the electronic medical records, and generate orders for all medications and treatments required. The DON said all skilled residents should have a skilled nurse note/assessment completed at least daily. The DON said Resident #1 did not have a skilled nurse note completed on 02/02/2024, 02/03/2024, 02/04/2024, or 02/07/2024 and was transferred to hospital on [DATE]. DON said that the expectation now is that skilled residents have a skilled nurse note/assessment completed each shift, so there is no confusion of who is responsible to complete the assessment. She said Resident #1 was admitted late in the evening on 02/01/2024. She said the ADON should have done a chart review of the new admission and should have noticed there was no order for tube feeding, PICC line care and maintenance, indwelling urinary Foley catheter care and maintenance missing from orders and addressed the issues with RN B. The DON said she in-serviced staff on 02/15/2024 regarding newly admitted residents and the admitting nurse was to complete a head-to-toe assessment of the resident and document in a skilled nurse note and identify any skin abnormalities and document. The DON said inadequate or lacking documentation could put resident at risk for not receiving appropriate care.
Record Review of the facility Charting and Documentation policy and procedure, dated 10/11/2021, indicated: Service Standard: All services provided to the resident, progress toward care plan goals, or changes in the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the intradisciplinary team regarding the resident's condition and response to care.1.The following information is to be documented in the resident's medical record: a. objective observations; b. medication administrated c. treatment or services performed; changes in the resident condition; e. events, incidents or accidents involving the resident and f. progress toward or changes in the care plan goals and objectives, 2. Documentation in the medical record will be objective, complete and accurate.5. Per BRS expectations, the clinical record must contain per shift charting of resident's condition for a minimum of 3 days following incident.
Record Review of the facility Gastrotomy (G-tube) policy and procedure, revision date of 2/20/2018, indicated: Service Standard: G-tube orders will be written based on each resident's individual needs and will follow current standards for regulatory and best practice guidelines. Procedure: 1. Residents who are admitted to skilled nursing with a G-tube on admission or receive a G-tube after admission will receive physician orders specific to their individual needs. Physician orders should address any specific G-tube care the physician orders, irrigation, specifics about the enteral feeding including formula type method (i.e., pump, bolus), specific about medication administration flush orders including solution type and site care. Any additional needs specific to the G-tube will also be included in the resident's orders. This information should be documented in the residence care plan, and other areas of the clinical records as appropriate. Progress notes and updates will be documented accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment or no more than 21 days after admission for 1 of 7 residents reviewed for comprehensive plans of care. (Resident #3)
The facility did not develop a comprehensive care plan within 7 days of the completion of the comprehensive assessment or no more than 21 days after admission for Resident #3.
This failure could place residents at risk of not receiving appropriate care and services.
Findings included:
Record review of Resident #3's face sheet dated 02/26/2024 indicated she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease with (acute) exacerbation (a lung disease that blocks airflow making it difficult to breathe), pneumonia (an infection that inflames the air sacs in one or both lungs), gastro-esophageal reflux disease (stomach contents leak backward from the stomach into the esophagus (food pipe)), muscle weakness, limited activity due to disability, and cognitive communication deficit.
Record review of the clinical record from 01/24/2024 to 02/26/2024 for Resident #3 revealed no comprehensive care plan.
During an interview on 02/26/2024 at 1:11 pm, the MDS Coordinator said Resident #3's comprehensive care plan was not completed and said, must have missed it. The MDS Coordinator said she was in the process of completing overdo MDS and comprehensive care plans. She said the care plan was not completed and available to staff. She said the facility nursing staff (ADON, DON, or CN) usually reviewed and completed the care plans after they were initiated in the computer. The MDS Coordinator said not having a comprehensive care plan in the medical records could put the resident at risk for receiving appropriate and adequate care.
During an interview and record review 02/26/2024 at 3:20 pm, the DON was unable to locate a comprehensive care plan for Resident #3 in the electronic medical record. The DON said when a resident admitted to the facility there was a basic care plan in the computer. She said once the MDS/Comprehensive Assessment was completed then an IDT/care plan meeting was scheduled, and a comprehensive care plan was developed and should happen within 7 days of the compressive assessment completion. She said Resident #3's comprehensive care plan should have been completed by no later than 02/13/2024. The DON said not having a comprehensive care plan could put resident at risk for not receiving care, missing care, or appropriate/adequate care.
During an interview 02/26/2023 at 3:30 pm, requested a facility policy for comprehensive care plans and the Administrator said the facility does not have a policy for comprehensive care plans, they follow the RAI manual.
Record review of the mds-3.0-rai-manual-v1.18.11_October_2023 indicated The care plan completion date must be no later than 7 calendar days after the comprehensive assessment completion date (CAA(s) completion date = 7 calendar days).

Based on interview and record review, the facility failed conduct initially a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 calendar days of admission, excluding readmissions in which there was no significant change in the resident's physical or mental condition for 2 of 7 residents (Residents #1 and #2) reviewed for comprehensive assessments and timing.
The facility failed to ensure a MDS Assessment for Residents #1 and #2 was completed within 14 days after admission.
This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.
Findings included:
Record review of Resident #1's face sheet dated 02/21/2024 reflected an admission date of 02/01/2024 with diagnoses that included Nontraumatic Subarachnoid Hemorrhage (bleeding in the space that surrounds the brain), Nontraumatic intracerebral Hemorrhage, Intraventricular (the eruption of blood in the cerebral ventricular system), Myasthenia Gravis (chronic neuromuscular disease that causes weakness in the voluntary muscles), Dysphagia (difficulty or discomfort in swallowing), Dementia (loss of cognitive functioning), and weakness to both legs.
Record review of Resident #1's admission MDS indicated in Section A - A1600 Entry Date 02/01/2024 and Section Z Assessment Administration - Z0400 A. Signature of Persons Completing the assessment or entry/death report Signature: MDS Coordinator Title LVN, RAC-CT, Sections: A, C, D, B, E, F, J Date sections completed 02/05/2024 and Signature of Persons Completing the assessment or entry/death report Signature: MDS Coordinator Title LVN, RAC-CT, Sections: A,B , E, GG, H, I, J, K, L, M, N, O, P, Q, Z Date completed 02/20/2024. Z 0500 Signature of RN Assessment Coordinator Verifying Assessment Completion Signature as DON on 02/20/2024 (6 days late).
Record review of Resident #2's face sheet dated 02/26/2024 reflected an admission date of 02/10/2024 with diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in the tissues in your body), Atrial Fibrillation (a type of irregular heartbeat), Hypertension (A condition in which the force of the blood against the artery walls is too high), and Congestive Heart Failure (condition that happens when your heart can't pump blood well enough to give your body a normal supply).
Record review of Resident #2's admission MDS indicated in Section A - A1600 Entry Date 02/10/2024 and Section Z Assessment Administration - Z0400 A. Signature of Persons Completing the assessment or entry/death report Signature: MDS Coordinator Title LVN, RAC-CT, Sections: A Date sections completed 02/16/2024, no additional signatures or sections identified as completed, no signature or date on Z 0500 Signature of RN Assessment Coordinator Verifying Assessment Completion. The admission MDS was not completed as of 2/26/2024.
During an interview on 02/26/2024 at 1:11 pm, the MDS Coordinator stated she was responsible for completing all MDS assessments. The MDS Coordinator stated the admission MDS assessment should be completed within 14 days of admission. The MDS Coordinator stated, she is behind on completing MDS, she has been out of the facility for training last week and she is the only staff member completing the MDS/comprehensive assessments, trying to get caught up. The MDS Coordinator said she was working on getting all the MDS/comprehensive assessments completed, the management staff and corporate staff would be helping with the completion of overdo MDS/comprehensive assessments. She said that the incomplete admission MDS could put the resident at risk for improper or incorrect care. She stated the facility followed RAI (resident assessment instrument).
During an interview on 02/26/2024 at 3:45 pm, the Administrator stated the facility followed the RAI manual guidelines for MDS assessments. The Administrator stated she expected the admission MDS to be completed within 14 days. The Administrator stated the MDS Coordinator was responsible for completing all MDS assessments but would get staff to help complete overdo MDS assessments. The Administrator stated it was important to complete the MDS assessment timely to ensure the regulations were followed and residents receive proper care.
Record Review of the facility's Minimum Data Set (MDS) policy and procedure, revision date of 01/23/2024, indicated Service Standard: facility retirement system communities will complete accurate resident assessments and submit assessments in accordance with current federal and state submission time frames. 1. All associates responsible for completion of the MDS will be educated on the proper assessment and date entry codes in accordance with the MDS RAI manual. 2. The MDS coordinator will ensure the appropriate edits are made prior to submitting the MDS data. 3. Timeframes for completion and submission of assessments is based on current requirements published in the Rai manual.
Record review of the mds-3.0-rai-manual-v1.18.11_October_2023 indicated The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: -this is the resident' s first time in this facility, OR -the resident has been admitted to this facility and was discharged return not anticipated, OR -the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of 10 residents reviewed for changes in condition.
The facility failed to notify the responsible party (FM F) for Resident #1 when she developed a deep tissue injury on her left buttock that required treatment.
The facility failed to notify the responsible party (FM F) for Resident #1 when she was transferred to the local hospital for a change in condition and respiratory distress.
The facility failed to notify the responsible party (FM F) for Resident #1 when she had abnormal lab results of RBC of 3.4 (Reference range 4,14-5.8), low Hemoglobin of 8.7 (Reference range 13.0-17.7), and a low Hematocrit of 27.3 (Reference range 37.5-51.0).
These failures could place residents at risk for a decline in health, and for family members not knowing the health status of the resident, being informed of and participating in care decisions.
Findings included:
Record review of face sheet dated 02/21/2024 indicated Resident #1 was admitted on [DATE], was a [AGE] year-old female with diagnoses that included non-traumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), non-traumatic intracerebral hemorrhage, intraventricular (the eruption of blood in the cerebral ventricular system), myasthenia gravis (chronic neuromuscular disease that causes weakness in the voluntary muscles), dysphagia (difficulty or discomfort in swallowing), dementia (loss of cognitive functioning), and weakness to both of her legs. Further review indicated the Emergency Contact #1 was FM F.
Record review of Resident #1's initial MDS assessment dated [DATE], revealed section Cognitive patterns - section C500 for BIMS (brief interview of cognitive status) summary score was blank. Review of section C for staff assessment of memory problems indicated the resident had a memory problem and the resident's cognitive skills for decision making were severely impaired. At the time of admission, Resident #1 did not have any pressure injuries.
Record Review of Resident #1's Skilled Daily Nurse's Note dated 02/01/2024 at 7:30 pm, authored by RN B, the Nurse Summary indicated: Patient here from local hospital post fall/subarachnoid hemorrhage. NPO after failing a swallow study. G-Tube (a tube inserted through the belly that brings nutrition directly to the stomach) in place. Mild redness was noted on buttocks. She had a left upper arm double lumen (two ports) PICC line (thin flexible tubing inserted into a vein in the upper arm threaded into a large vein above the right side of the heart).
Record review of Resident #1's Change in Condition clinical notes dated 02/05/2024 at 1:49 pm, indicated the charge nurse, LVN A, was notified by the CNA that she found a wound on the resident's left buttock and some redness to her bilateral (both) heels. The note did not indicate if FM F was notified of the new wound.
Record review of Resident #1's incident report dated 02/05/2024 indicated while the resident was getting her brief changed, the aide found a wound on the resident's left buttock. The incident report indicated the resident's Responsible Party was notified, listing FM G as the one notified. The incident report indicated the resident's doctor was notified. LVN A signed the note as the staff who notified the resident's Responsible Party.
During an interview on 02/22/2024 at 10:20 am, LVN C said she worked 6 am to 6 pm on 02/08/2024 and when she came on shift at 6 am during her initial rounds Resident #1 was breathing heavy, increased respiratory rate and oxygen saturation (test that measures the amount of oxygen being carried by red blood cells) was 91%, notified on-call doctor and he ordered for her to be sent to local ER for evaluation. LVN C said she notified family but did not recall which family she notified.
During an interview and record review on 02/26/2024 at 10:20 am, LVN A said she worked 6 am to 6 pm on 02/05/2024 when the aide told her Resident #1 had a wound on her left buttock. She said she went to resident's room to assess the wound and found an area the size of ½ dollar piece, that was reddish purple. She said she notified the ADON for a referral for wound care and completed an incident report for the new wound. LVN A said she notified FM G who was present in the room when she assessed the new area. She acknowledged she did not review the resident's chart to obtain the assigned representative, she said she assumed it was the FM G in the room. LVN A said she did not notify FM F, Resident #1's assigned representative, of the resident's change in condition. LVN A said that not notifying assigned representative of change in condition could put resident at risk for receiving care and representative aware of resident's condition.
Record Review of Resident #1's Skilled Daily Nurse's Note dated 02/05/2024 authored by RN B at 7:55 pm, the Nurse Summary indicated a large deep tissue injury with open skin on top of the left buttock. The note did not indicate if FM F was notified of the wound.
During an interview on 2/26/2024 at 9:32 am, RN B said she provided care for Resident #1 during the 6 pm to 6 am shift on 02/01/2024 and 02/05/2024. She said she admitted Resident #1 to the facility on [DATE] and she did not recall the resident having any open wounds upon admission. RN B said on 02/05/2024 she received report during shift change that during shower this AM, Resident #1 was found to have a new wound on her left buttock and was report to doctor. RN B said she completed a head-to-toe assessment of Resident #1 and observed the new wound on her left buttock, it was the size of a ½ dollar coin and was dark pink/purple area, with thin top layer of skin missing, and applied barrier cream.
Record review of Resident #1's lab results collected on 02/02/2024 indicated abnormal lab results of RBC (Red Blood Cell count - tells you how many red blood cells you have) 3.4 (Reference range 4,14-5.8), low Hemoglobin (measures the level hemoglobin (a protein in your red blood cells that carries oxygen from your lungs to the rest of your body) in your body) of 8.7 (Reference range 13.0-17.7), low Hematocrit (measures the proportion of red blood cells in the blood - red blood cells carry oxygen throughout the body) of 27.3 (Reference range 37.5-51.0).
Record review of Resident #1's clinical notes dated 02/05/2024 authored by the ADON indicated: Received lab results; RBC of 3.4 (Reference range 4,14-5.8), low Hemoglobin of 8.7 (Reference range 13.0-17.7), low Hematocrit of 27.3 (Reference range 37.5-51.0); will fax and call the physician about the above results. There was no indication that Resident #1's representative was notified of the results/findings.
Record review of Resident #1's Change in Condition clinical notes dated 02/08/2024 at 6:38 am, authored by LVN C, indicated the physician was notified of Resident #1 experiencing a change in condition with respiratory distress, the on-call physician ordered for Resident #1 to be sent to the ER. Notified Family. The note did not indicate if FM F was notified of the transfer.
Record review of Resident #1's hospital records dated 02/15/2024 indicated on 02/08/2024 Resident #1 was seen through the emergency room and later admitted and diagnosed with aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed), UTI (infection in part of urinary system), pulmonary embolism (a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs), myasthenia gravis (a rare chronic autoimmune disease causing abnormal weakness of certain muscles), and stroke (s loss of blood flow to part of brain, which damages brain tissue).
During an interview on 2/22/2024 at 11:59 am, Resident #1's FM F said Resident #1 went to the emergency room on [DATE] with respiratory issues where she was diagnosed with aspiration pneumonia and dehydration. She said the ER physician showed the family wounds and skin impairments. FM F said no one from the facility had called her (assigned representative) to let her know Resident #1 was having any skin issues on 02/05/2024. FM F said someone was typically at the facility every day for Resident #1, but it was usually FM G and he is older and had memory issues, hence why she was the assigned representative. FM F said she was not aware of the wounds or skin impairment until she was shown by the ER physician. FM F said the facility did not notify her of the resident being transferred the local ER on [DATE].
During an interview on 02/26/2024 at 3:20 pm, the DON indicated she did not know Resident #1's representative was not notified of the deep tissue injury on the resident's left buttocks and/or the abnormal lab results on 02/05/2024. The DON said LVN A notified her and the ADON about the deep tissue injury on the resident's left buttocks on 02/05/2024, but she did not realize FM G who was present during the assessment and findings of the wound, was not Resident #1's representative. The DON said facility staff should have verified the resident's representative and the resident representative should have been notified of the wound at the time of the assessment and review of lab results so they would know what was going on and the assigned representative should have been notified of Resident #1's transfer to local ER.
Record Review of the facility policy titled Notification of Changes revised date 2/23/2024 indicated: Service Standard: Facility communities - will notify the resident/resident responsible representatives and attending physician of change in the resident's condition or status to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choice about treatment and care preferences. 1. The nurse will immediately notify the resident/resident's responsible representative (consistent with his/her authority) and physician for the following changes (this list is not all inclusive). An accident involving the resident, which results in injury and has the potential for required physician intervention. a significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health mental or psychosocial status in their life-threatening condition or clinical complication. A need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences) or to commence a new form of treatment. Any lab results that fall out of clinical references range into a panic level. Radiology and other diagnostic reports that are significantly outside the clinical reference range and have the potential of needing an immediate alteration to the resident's current treatment plan. A decision to transfer or discharge the resident from the facility. 2. the nurse will notify the resident/resident representative and the resident's physician for non-immediate change of condition in a timely manner. 3. document the notification and record any new orders in the resident's medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident, residents who use psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 13 residents (Resident #24) reviewed for unnecessary medications.
The facility failed to monitor Resident #24 for behaviors or side effects for the antidepressant medication, Lexapro.
This failure could place residents at risk for adverse consequences such as dizziness, drowsiness, oversedation, agitation, restlessness, and suicidal thoughts related to the use of psychotropic medications.
Findings include:
Record review of Resident #24's face sheet, dated 10/09/23, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis which included major depressive disorder (also known as depression is a serious mood disorder that effects how a person thinks feels and handles daily activities)
Record review of a care plan, initiated 09/13/23 , indicated Resident #24 received the antidepressant medication Lexapro with interventions which included monitoring for side effects of the medication and record behaviors on the behavior tracking record and observe for changes in mood or behaviors and notify the physician.
Record review of an admission MDS, dated [DATE], indicated Resident #24 had a BIMS score of 15, which indicated intact cognition. Resident #24 had a diagnosis of major depressive disorder and received an antidepressant medication 6 of 7 days during the look back period.
Record review of the physician orders, dated October 2023, indicated Resident #24 was prescribed Lexapro 20 mg every day for major depressive disorder with a start date of 09/09/2023.
Record review of a MAR, dated 10/11/23, indicated Resident #24 received Lexapro 20 mg every day for major depressive disorder from 10/1/23 to 10/11/23 with a start date of 09/08/23, with no monitoring for behaviors or side effects noted.
Record review of the electronic medical record for Resident #24 contained no documentation of monitoring for behaviors or side effects of Lexapro from 10/1/23 to 10/11/23.
During an interview and record review on 10/11/23 at 12:37 p.m., LVN F said Resident #24 was her patient. She said Resident #24's Lexapro should have been monitored for side effects and behaviors and was not. LVN F said the nurses providing care for a resident were responsible for adding medication monitoring into the computer system. She said the ADONs double checked to ensure antidepressant medication were monitored. LVN F said it was just overlooked. She said she was educated on monitoring antidepressant medication. LVN F said the risk of an anticoagulant not monitored was bleeding.
During an interview on 10/11/23 at 12:47 p.m., ADON E said Resident #24 should have been monitored for the side effects of Lexapro but was overlooked. She said the admission nurse was responsible for the addition of medication monitoring into the system. ADON E said the nurses worked as a team and were all responsible for double checking for medication monitoring. She said it was just overlooked. ADON E said the nurses were educated on monitoring of antidepressant medication. She said the risk of Lexapro not monitored was behavior issues if not strong enough and the physician would be unaware if there was a therapeutic range.
During an interview on 10/11/23 at 12:50 p.m., the DON said Resident #24 should have been monitored for side effects of the antidepressant medication, Lexapro and was not. She said it was overlooked. The DON said the nurses were in-serviced on monitoring antidepressant medication. She said the admission nurse was responsible for putting the monitoring in the computer system when they received the order for the medication. The DON said the ADONs were responsible for double checking within 24 to 72 hours after the order of an antidepressant medication was placed for monitoring. The DON said she did random checks but had not checked Resident #24's chart. She said the risk of Lexapro not being monitored was a potential of the medication not at a therapeutic dose. The DON said her expectation was all residents on antidepressant medication be monitored.
During an interview on 10/11/23 at 1:10 p.m., LVN G said she was the admission nurse for Resident #24 and completed the admission paperwork. She said she was unaware Resident #24's antidepressant medication was not being monitored. LVN G said she received education and was aware antidepressant medication had to be monitored for side effects and behaviors. She said she had problems putting the monitoring in the computer system before and had to get another nurse to help her. LVN G said she should have had another nurse check and make sure the monitoring was put in the system correctly. She said she must have put the monitoring in the system incorrectly or overlooked it. LVN G said the risk of not monitoring the antidepressant was a risk of behavior issues and the medication not being effective.
During an interview on 10/11/23 at 1:20 p.m., the Administrator said the nurses were responsible for monitoring antidepressant medication. She said the ADONs were responsible for double checking medication for monitoring during the admission process meeting. The Administrator said the interdisciplinary team went over every admission the morning after or the Monday morning after a weekend. She said her expectation was all antidepressant medication be monitored.
Record review of the facility's policy, revised 04/18/23, titled, Psychotropic Drugs indicated: .Psychotropic drugs are those drugs that affect brain activities associated with mental processes and behavior. These drugs include but are not limited to the following categories of drugs: . 2. Anti-depressant; .The facility is expected to attempt a gradual dose reduction in two separate quarters . the first year . attempted annually. A gradual dose reduction is clinically contradicted if: A. Target symptoms returned or worsened after the most recent attempt at a gradual dose reduction and the physician documents the clinical rationale.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs when used without adequate monitoring for 1 of 13 residents (Resident #24) reviewed for unnecessary medication.
The facility failed to monitor Resident #24 for side effects of the anticoagulant medication Eliquis (a blood thinning medication).
This failure could place residents at risk for adverse consequences such as bleeding, bruising, and black colored stools related to the use of the anticoagulant medication.
Findings include:
Record review of Resident #24's face sheet, dated 10/09/23, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis which included atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots in the heart and increases the risk of a stroke).
Record review of a care plan, initiated 09/13/23, indicated Resident #24 received an anticoagulant medication, Eliquis with interventions which included monitor for bleeding in the urine, nose and stool.
Record review of an admission MDS, dated [DATE], indicated Resident #24 had a BIMS score of 15, which indicated intact cognition. Resident #24 had a diagnosis of atrial fibrillation and received an anticoagulant medication 6 of 7 days during the look back period.
Record review of the physician orders dated October 2023, indicated Resident #24 was prescribed Eliquis (a blood thinning medication) 2.5 mg two times a day for atrial fibrillation with a start date of 09/09/23. The orders did not address monitoring the anticoagulant medication.
Record review of a MAR, dated 10/11/23, indicated Resident #24 received Eliquis 2.5 mg two times a day from 10/01/23 to 10/11/23 with a start date of 09/08/23.
Record review of the electronic record for Resident #24 indicated the nurses did not document monitoring of side effects of anticoagulant daily with medication administration.
During an interview and record review on 10/11/23 at 12:37 p.m., LVN F said Resident #24 was her patient. She said Resident #24's Eliquis should have been monitored for side effects and was not , it was overlooked. LVN F said the nurses caring for a resident were responsible for adding monitoring to the computer system. She said the ADONs double checked to ensure anticoagulants were monitored. LVN F said it was just overlooked. She said she was educated on monitoring anticoagulants. LVN F said the risk of an anticoagulant not monitored was bleeding.
During an interview on 10/11/23 at 12:47 p.m., ADON E said Resident #24 should have been monitored for the side effects of Eliquis. She said the admission nurse was responsible for the addition of monitoring into the system. ADON E said the nurses worked as a team and were all responsible for double checking for medication monitoring. She said it was just overlooked. ADON E said the nurses were educated on monitoring of anticoagulant medication. She said the risk of Eliquis not monitored was a possible bleeding risk.
During an interview on 10/11/23 at 12:50 p.m., the DON said Resident #24 should have been monitored for side effects of the anticoagulant medication Eliquis and was not. She said it was overlooked. The DON said the nurses were in-serviced on monitoring anticoagulant medication. She said the admission nurse was responsible for putting the medication monitoring in the computer system when they received the order for the medication. The DON said the ADONs were responsible for double checking within 24 to 72 hours after an order of an anticoagulant medication was placed for monitoring. The DON said she did random checks but had not checked Resident #24's chart. She said the risk of Eliquis not monitored was bleeding. The DON said her expectation was all residents on anticoagulants be monitored .
During an interview on 10/11/23 at 1:10 p.m., LVN G said she was the nurse that admitted Resident #24 and completed the admission paperwork. She said she was unaware Resident #24's anticoagulant medication was not being monitored. LVN G said she received education and was aware anticoagulant medication had to be monitored for side effects. She said she had problems putting the medication monitoring in the computer system before and had to get another nurse to help her. LVN G said she should have had another nurse check and make sure the monitoring was put in the system correctly. She said she must have put the medication monitoring in the system incorrectly or overlooked it. LVN G said the risk of not monitoring the anticoagulant/ Eliquis was possible bleeding, bruising and staff being unaware to monitor for bleeding.
During an interview on 10/11/23 at 1:20 p.m., the Administrator said the nurses were responsible for monitoring anticoagulants medication. She said the ADONs were responsible for double checking medication for monitoring during the admission process meeting. The Administrator said the interdisciplinary team went over every admission record the morning after or the Monday morning after a weekend. She said her expectation was all anticoagulant medication be monitored.
During an interview on 10/11/23 at 3:00 p.m., the Administrator said the facility did not have a specific policy for monitoring anticoagulant medication.
Record review of the Reference obtained from the internet on 10/12/23 from, How Rx ELIQUIS® (apixaban) Can Help | Safety Info (bmscustomerconnect.com) indicated, . ELIQUIS can cause bleeding, which can be serious, and rarely may lead to death. This is because ELIQUIS is a blood thinner medicine that reduces blood clotting. While taking ELIQUIS, you may bruise more easily and it may take longer than usual for any bleeding to stop.
Call your doctor or get medical help right away if you have any of these signs or symptoms of
bleeding when taking ELIQUIS:
*
unexpected bleeding or bleeding that lasts a long time, such as unusual bleeding from the
gums, nosebleeds that happen often, or menstrual or vaginal bleeding that is heavier
than normal
*
bleeding that is severe or you cannot control
*
red, pink, or brown urine; red or black stools (looks like tar)
*
coughing up or vomiting blood or vomit that looks like coffee grounds
*
unexpected pain, swelling, or joint pain
*
headaches, or feeling dizzy or weak

**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 entered the facility with an indwelling catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated that catheterization was necessary for 1 of 3 residents (Resident #23) and a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #133) reviewed for indwelling catheters.
1. The facility failed to have an appropriate diagnosis for Resident #23's Foley catheter.
2. The facility failed to prevent Resident #133's urinary catheter drainage bag from touching the floor.
These failures could place residents at risk for inappropriate placement of indwelling catheters, discomfort or injury, and urinary tract infections.
Findings include:
1. Record review of Resident #23's face sheet, dated 10/11/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hypertensive chronic kidney disease (a long-standing kidney condition that develops over time due to persistent or uncontrolled high blood pressure), anxiety disorder (persistent and excessive worry that interferes with daily activities), diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), stage 4 pressure ulcer to the right foot (a sore) , and stage 2 pressure ulcer of sacral region (a sore has broken through the top layer of the skin and part of the layer below in the tailbone area).
Record review of Wound Assessments, dated 09/18/23, for Resident #23 indicated:
* Wound #1-was present on admission, located on right upper arm, and was a 2cm x 1.5cm x 0cm fluid filled intact blister.
* Wound #2-was present on admission, pressure wound, located on the pelvic region-sacral area, vascular classification, and was a 1.10cm x 0.8cm stage 2 partial thickness.
* Wound #3-was present on admission, pressure wound, located in the pelvic region-coccyx area, vascular classification, and was a 1cm x 1cm x 0cm stage 2 partial thickness.
* Wound #4-was present on admission, located on the plantar foot-left heel area, vascular classification, and was a 2cm x 0.3cm x 0.3cm stage 2 partial thickness; and
* Wound #5-was present on admission, located on plantar foot-left heel area, vascular classification, 1.5cm x 1.5cm fluid filled blister.
Record review of the care plan, dated 09/20/23, indicated Resident #23 was at risk for infection related to indwelling catheter due to multiple wounds.
Record review of an admission MDS, dated [DATE], indicated Resident #23 had moderately impaired cognition with a BIMS score of 08 out of 15. She required extensive assistance of 1 person for toileting; she had an indwelling catheter; she had not had a trial of a toileting program; she was not rated for urinary incontinence because she had a catheter; she was at risk of developing pressure ulcers; she had an unhealed pressure ulcers; she had 2 stage 2 pressure ulcer on admission; and she had 1 stage 4 pressure ulcer on admission.
Record review of physician orders for October 2023 indicated Resident #23 had an order, dated 10/03/23, for a Foley catheter with related diagnosis of hypertensive chronic kidney disease.
Record review of the Wound Evaluation and Management Summary indicated Resident #23 had the following:
* 09/20/23-a non-pressure wound to upper arm, a non-pressure wound to the right buttock, a stage 2 pressure ulcer to the sacrum, a stage 2 pressure ulcer to the left foot, and a stage 4 pressure ulcer to the right heel. There was no indication of a stage 3 or 4 to the sacrum.
* 09/27/23-a non-pressure wound to the right buttock, a stage 2 pressure ulcer to the sacrum, a stage 2 pressure ulcer to the left foot, and a stage 4 pressure ulcer to the right heel. The non-pressure wound to the right buttock was healed. There was no indication of a stage 3 or 4 to the sacrum.
* 10/04/23-all wounds were healed.
During an observation on 10/09/23 at 09:37 a.m. revealed Resident #23 was in her bed. She had a Foley catheter.
During an observation and interview on 10/09/23 at 11:42 a.m. revealed Resident #23 was in her bed. She had a Foley catheter. Her family member was at the bedside and said the catheter was in place because she had wounds on her bottom. She said the wounds were healed.
During an observation on 10/10/23 at 10:41 a.m. revealed Resident #23 was in her bed. She had a Foley catheter.
During an observation on 10/11/23 at 11:15 a.m. revealed Resident #23 was in her bed. She had a Foley catheter with yellow sediment in the tubing.
During an interview on 10/11/23 at 11:20 a.m., LVN F said Resident #23 had Foley catheter because she had wounds on her bottom. She said the physician was keeping the Foley catheter in place to prevent the wounds on the bottom from getting bad again. She said the wounds that healed were stage 2 pressure wounds. She said she did not realize Resident #23's catheter should have been removed after the 14-day assessment period because it did not meet the criteria for a catheter to be used.
During an interview on 10/11/23 11:25 p.m., ADON E said Foley catheters could be retained for stage 3 or 4 pressure wounds to the bottom. She said they should be removed when the wounds healed. She said the indwelling catheters could be used for certain diagnoses and conditions such as urinary retention and neurogenic bladder. She said she did not realize Resident #23 should have had the catheter removed. She said the resident could have discomfort or acquire a urinary tract infection if the catheter were to remain.
During an interview on 10/11/23 at 12:14 p.m., the Administrator said the facility did not have a policy, but they followed the federal guideline requirements for Foley catheters.
Record review of an email attachment received on 10/11/23 from the MDS Nurse indicated CMS's RAI Version 3.0 Manual, dated 10/2019, 6. Urinary Incontinence and Indwelling Catheter: Use of indwelling catheter (H0100 is checked): (Presence of situation in which catheter use may be appropriate intervention after consideration of risks/benefits and after efforts to avoid catheter use have been unsuccessful with coma, terminal illness, stage 3 or 4 pressure ulcer in area affected by incontinence, need for exact measurement of urine output, and history of inability to void after catheter removal were listed.
Surveyor: [NAME], [NAME]
2 . Record review of Resident #133's face sheet, dated 10/11/23, indicated a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Benign Prostatic Hyperplasia (an age-related prostate gland enlargement that can cause urination difficulty). Due to this diagnosis, Resident
#133 had an indwelling urinary catheter (a catheter which is inserted into the bladder to drain urine).
Record review of a Baseline Care Plan, dated 10/03/23, indicated Resident #133 had an alteration in bladder elimination and had an indwelling urinary catheter.
Record review indicated an admission MDS had not been completed for Resident #133 at the time due to being in process.
Record review of physician orders for October 2023 indicated Resident #133 had an order, dated 10/05/23, for an indwelling urinary catheter with related diagnosis of Benign Prostatic Hyperplasia.
Record review of a Competency Assessment Catheter Care, Urinary form, dated September 2014, indicated the following. 2b. Be sure the catheter tubing and drainage bag are kept off the floor.
During an observation on 10/09/23 at 12:00 p.m., Resident #133 was transported via wheelchair to the dining room for the noon meal by COTA H. The urinary catheter was in a privacy bag below Resident #133's wheelchair with the bag touching the floor as he was wheeled into the room.
During a joint interview on 10/09/23 at 12:30 p.m., CNA B and CNA C both said Resident
#133â Euro's urinary catheter drainage bag was sitting on the floor. They said they received training on urinary catheter care and the drainage bag should never touch the floor due to risk of infection.
During an interview on 10/09/23 at 12:44 p.m., LVN A said Resident #133's urinary drainage bag was on the floor. She said the drainage bag should not be touching the floor. She said in-service and training had been provided in facility in the past. LVN A said potential issues could be infections from contamination of an unclean floor, the urinary drainage bag could potentially be caught on any objects and/or catheter could be pulled out causing harm to residents. LVN A said she monitors the CNAs correct positioning of urinary drainage bags.
During an interview on 10/09/23 at 12:45 p.m., ADON D said Resident #133's urinary drainage bag should not touch floor due to risk of infection.
During an interview on 10/09/23 at 12:57 p.m., COTA H said she transported Resident #133 from the therapy department to the dining room for the noon meal. She said she was unaware Resident #133's urinary catheter drainage bag had been dragged during transport. She said she had received training in the past regarding urinary catheter care and placement of tubing and drainage bags.
During an interview on 10/09/23 at 2:19 p.m., Resident #133 said he wasn't sure why he had a urinary catheter and it was inserted pre-admission while at the hospital. Resident #133 said facility staff positioned the catheter bag below his wheelchair when he was out of bed and in the chair.
During an interview on 10/11/23 at 2:00 p.m., the DON/Infection Preventionist said her expectation was for staff to be aware of urinary catheter bag placement to prevent contamination on floors. She said staff were educated on urinary catheter bag placement in the past.