Accel At Willow Bend

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Residents #1, #2 and #3) reviewed for infection control practices.1. MA A failed to disinfect the blood pressure cuff before checking Resident #1's blood pressure after she removed the cuff from her (MA A's) wrist.2. CNA B and CNA C failed to perform hand hygiene before contact, between care, and change of gloves while providing incontinence care to Resident #2 and Resident #3.These failures could place residents at risk of exposure to infectious agents and could lead to the development of infection. Findings included: 1. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. Resident #1 was cognitively intact with a BIMS score of 14. He had diagnoses which included hypertension (abnormally high arterial blood pressure) and anemia (a condition in which the blood is deficient in red blood cells, in hemoglobin, or in total volume).Observation on 02/03/26 at 10:54 AM revealed MA A removed a blood pressure cuff from her own wrist. Without disinfecting the blood pressure cuff, she entered Resident #1's room and she checked Resident #1's blood pressure.Interview/observation with MA A on 02/03/26 at 11:39 AM revealed she was still wrapping the blood pressure cuff on her wrist. She stated she did not disinfect the blood pressure cuff before checking Resident #1's blood pressure. She stated she was supposed to use the disinfectant wipes to clean the blood pressure cuff after unwrapping it from her wrist and before applying the cuff on Resident #1 to prevent the spread of infection, but she forgot. She stated she had received training on the care and disinfection of reusable equipment, but she could not recall when.2. Record review of Resident #2's Quarterly MDS Assessment, dated 12/16/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE] and readmitted [DATE]. The resident had severe cognitive impairment with a BIMS score of 7, and her diagnoses included hypertension and diabetes (a condition that happens when your blood sugar is too high). Record review of Resident #2's care plan, dated 07/18/25, reflected: Focus: [Resident #2] At risk for problems with eliminations bowel and bladder. Goal: [Resident #2] will have incontinent products available on daily basis over the next 90 days. Interventions: Provide peri care [the hygiene practice of cleaning and maintaining the genital and anal areas to prevent infection, discomfort, or skin breakdown] after each incontinent episode.Observation on 02/03/26 at 11:30 AM revealed CNA B went to Resident #2's room to provide the resident incontinence care. She first knocked on the resident's door and then entered the room. Without washing her hands, she put on gloves and put her supplies together. Next, CNA B used wet wipes to cleanse Resident #2's abdominal folds and perineal area (the anatomical region located between the thighs). Her technique was one wipe, one swipe. She wiped down the peri area from inner area towards the outer area. Resident #2 then turned on her right side, and CNA B wiped the resident's buttocks and thighs from inner area towards the outer area. Resident #2 was wet. CNA B then removed the soiled brief and discarded it. Without performing hand hygiene or changing her gloves, CNA B took a clean brief and put the clean brief on Resident #2. She then positioned the resident in bed with the call light in reach. Lastly, she removed her gloves, washed her hands, and left the resident's room. Interview with CNA B on 02/03/26 at 12:00 PM revealed she knew she was supposed to perform hand hygiene before contact with Resident #2, between the care, and with each removal of gloves. She stated she forgot. She stated failure to perform hand hygiene before contact, between care, and after removal of gloves could lead to contamination and spread of infection. She stated she had done training on hand washing, but she could not remember when.3. Record review of Resident #3's Comprehensive MDS Assessment, dated 12/26/25, reflected the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS score of 0, and his diagnoses included hypertension.Record review of Resident #3's care plan, dated 01/06/26, reflected: Focus: [Resident #3] Bowel and Bladder. Goal: [Resident #3] Improve or maintain current bladder and bowel continence. Interventions: Check and change, keep clean and dry.Observation on 02/03/26 at 3:40 PM revealed CNA C prepared incontinence care supplies and then entered Resident #3's room. Without washing his hands, CNA C put on gloves. He then positioned the resident and cleansed the resident's abdominal walls, penis, and Foley catheter starting from tip downwards. Resident #3 was observed to have had a bowel movement. CNA C then turned the resident, and he cleansed the resident's buttocks from the inner area towards the outer area. CNA C was observed changing gloves between care, but he did not perform hand hygiene. When the resident was clean, CNA C removed his gloves and put on new gloves, but he did not perform hand hygiene. CNA C then took a clean brief and put it on Resident #3. Next, CNA C applied cream on the resident. He then removed his gloves and put on new gloves without performing hand hygiene. CNA C positioned the resident in bed in a low position with his call light within reach. Lastly, CNA C removed his gloves, washed his hands, and left the resident's room. Interview with CNA C on 02/03/26 at 4:01 PM revealed he was supposed to perform hand hygiene before contact and with each change of gloves, but he forgot. He stated that failure to perform hand hygiene during incontinence care on Resident #3 could lead to cross contamination and infection. He stated he had received hand washing in-services in the facility.Interview with the DON on 02/03/26 at 5:10 PM revealed her expectation was for staff to perform hand hygiene before contact with residents, between care, and when they changed gloves. The DON stated she also expected staff to disinfect the reusable equipment before using it on a resident and after use. She stated failure to perform hand hygiene before contact, between care, and change of gloves could lead to cross contamination and spread of infection. She stated the failure to disinfect reusable equipment before contact with residents and after use could also lead to cross contamination. She stated she had been in the facility for four weeks, and she had not done training on infection control. She stated she had training on infection control that morning with staff. She stated the facility had offered training on hand washing and cleaning of equipment, and she was not sure whether the staff were in attendance. Record review of the facility's training records for the topic of Hand Washing Before and After Patient Care, dated 08/02/25, reflected CNA B and CNA C had not attended the training. Record review of the facility's training records for Focus on Infection Control-Cleansing of Designated Resident Devices, dated 08/20/25, reflected that MA A had not attended the training.Record review of the facility's current Cleaning, Disinfecting and Sterilizing Care Equipment policy, dated March 2025, reflected the following: .3. Noncritical items are those that either do not ordinarily touch the resident or touch only intact skin. Such items include.blood pressure cuffs, and other medical accessories. These items rarely transmit diseases. However, it is imperative that these items are clean. Depending on the piece of equipment or item, washing with a detergent or disinfectant detergent, rinsing and thorough drying may be sufficient.Record review of the facility's current Hand Hygiene for Staff and Residents policy, dated February 2025, reflected the following: Hand hygiene is the most important component for preventing the spread of infection.1 Hand Hygiene is done:Before A Resident contactAfter:A. Contact with soiled or contaminated articles such as articles that are contaminated with body fluids.B. Resident contact Note: Wash hands at end of procedures where glove changes are not required. For procedures in which change golfese's. clean gloves to sterile gloves, it is indicated follow the specific standard of practice. If gloves, hands become contaminated as gloves are changed hands can be washed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one of two residents (Resident #1) reviewed for accident hazards/supervision/devices The Facility failed to ensure CNA D used a gait belt correctly when transferring Resident #1 from his wheelchair to the bed and then from her bed back to the wheelchair on 01/06/26. These failures could affect the residents by placing the residents at risk for discomfort, pain, falls, injuries, and skin tears.Findings included: Record Review of Resident #1's Quarterly MDS assessment, dated 09/17/25, reflected an [AGE] year-old female admitted to the facility on [DATE]. She was severely cognitively impaired with a BIMs score of 3. She required moderate assistance with transfers, toileting, and personal hygiene and required the assistance of 1 person. She was occasionally incontinent of urine and frequently incontinent of bowels. She had sustained one fall without injury since the prior assessment. Diagnoses included dementia, diabetes and hypertension. Review of Resident #1's care plan revised on 06/09/25 reflected, Impaired Physical mobility related to .generalized weakness.left sided weakness.right lower extremity weakness.Goal.Resident will maintain or improve physical function in.Transfer.Interventions.Provide appropriate level of assistance to promote safety of resident.Requires assistance of one staff.Requires extensive assistance. In an interview and observation with Resident #1 on 01/06/26 at 9:15 a.m. resident was observed sitting in her wheelchair in her room. She stated she had fallen recently, and the staff and her family have told her she was not to get up by herself. She chuckled and stated she did not think she needed help to go to the bathroom but stated she was trying to keep her family happy and ask for help. In an observation on 01/06/2026 at 9:55 a.m. Resident #1 was observed being assisted from her wheelchair to the bed by CNA D. Resident #1 was able to hold to the side rail of the bed but required extensive assistance to stand up with CNA D holding on to her arm and pulling her up with the back of the resident's pants. Resident #1 was very unsteady and shaky. No gait belt was used during the transfer. CNA D provided incontinence care and then assisted the resident onto the side of the bed. Resident #1 attempted to hold the arm of the wheelchair while CNA D held her under her arm and once again grabbed the back of her pants to try and assist her to a standing position. Resident #1 was not able to completely stand, and CNA D struggled to get her from the bed to the wheelchair. CNA D then had the resident sit back down on the side of the bed and she placed both of her arms around the resident and lifted her from the bed to the wheelchair. In an interview with CNA D on 01/06/26 at 10:10 a.m. she stated they were not supposed to lift residents under their arms because it could cause injury to their shoulders. CNA D stated she tried not to put her hand directly under her arm pit to prevent injury. She stated she did not know she was supposed to grab the back of the resident's paints. She stated they were supposed to use a gait belt but stated she did not see one in the resident's room. She stated she had been trained on gait belt transfers. In an interview with the DOR on 01/06/26 at 12:15 p.m. she stated the facility does annual gait belt training with the staff and nursing does the training at the employee's time of hire. She stated Resident #1 was currently on therapy services due to a recent fall and her decline in transfers and standing ability. She stated she required extensive assistance with transfers. She stated it was not acceptable to lift someone under their arm pits due to the potential for injury not only to the resident but also to the caregiver. She stated it increased the risk of falls, fractures and nerve damage. In an interview with the DON on 01/06/26 at 02:00 p.m. she stated she had started with the facility about 3 weeks ago and was still learning the facility's procedures but stated no one should be lifting a resident under their arms or by their clothing. She stated she would expect staff to use a gait belt when transferring a resident. She stated the risk of staff not following the correct procedure for transfers were injury to a resident's shoulders and arm and or the risk of the resident falling. She stated she would be doing one on one training with the CNA and also begin Inservice with all of the staff to ensure staff were providing correct transfer techniques. Record review of CNA D's staff education/ orientation checklist reflected she had been skills checked for gait belt transfers on 06/25/25 and had met the criteria for proper technique. Record review of the facility's policy, ADL Care-Transfer Techniques dated June 2023, reflected, Staff will provide safe and effective transfer techniques for resident in accordance to standard practice guidelines.Transfer from, bed to chair.Use stand-and-pivot technique with one caregiver if appropriate.Apply gait/transfer belt snugly and low so it circles the resident's waist.Grasp transfer/gait belt keeping palms along resident's side.Rock resident to standing position.Maintain stability of the resident's weakened leg with knee.Pivot on foot farthest from chair.Instruct resident to use armrest on chair for support and ease into chair.

Based on observations, record reviews and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents and staff for 1 (Door #1) of 7 entry doors reviewed for environment. The facility failed to safely monitor individuals who gained access to the facility using the posted security code next to Door #1. This failure could affect the safety of all the residents and staff at the facility and diminish residents' quality of life.The findings include: During an observation of the facility's Door #1 on 1/6/26 at 8:35am surveyor saw a 4-digit code posted next to the door by the keypad. Surveyor entered the four-digit code that was posted, the door unlocked, and Surveyor entered the facility. Upon entry there was no one at the front desk and no one in the two halls that led to the nurses' stations to assist Surveyor. There was no alarm that notified staff that Surveyor had entered the building. Surveyor waited for approximately 7-10 minutes, then went to the 2nd office door behind the front desk to notify a staff member that the surveyors had entered the building. During an telephone interview with the Anonymous Staff Member on 1/9/25 at 2:26pm revealed she was very concerned about the safety of the residents, particularly after 4pm when there were no staff by Door #1. The Anonymous Staff Member stated she had had multiple complaints from relatives of the residents and stated one lady had entered the facility late and was concerned about the safety of her loved one because the code was visible to the public and could open Door #1 after hours, particularly closer to midnight. She stated the concern was brought to the Administrator's attention, but he had not provided a response to her complaint. She stated the risk to the residents of Door #1 not being monitored while the code to enter was posted, was someone could have come into the facility with a gun to harm staff or residents and the staff would not know the person was in the building. During an interview with the Social Worker on 1/6/26 at 3:30pm revealed over the summer she had a resident that complained about the safety of the building, related to unknown people in the hall at night talking. The Social Worker stated they talked to staff about allowing personal visitors to the building. She stated there were no staff in the evenings and at night at the front desk and it was the nurses' responsibility to monitor Door 1. The facility had a receptionist by Door #1 during the day throughout the week and weekend. The social worker stated they could stand at the nurses' stations and look down the hall to see if someone was coming down the halls. During an interview with the Director of Maintenance on 1/6/26 at 3:35pm revealed doors at the facility could not have been opened unless the individuals had a code to open the doors. He stated all the doors at the facility, including Door #1, had an alarm and the alarm would sound if someone attempted to enter the doors without the access code. He stated Door #1 had the code posted on the inside and outside so that staff and other individuals could enter the building without issues. He stated he was unsure how the facility monitored individuals who entered the building through Door #1 when the staff was not close to it. He stated once a person entered the code, they gained access to the building and there was no alarm or bell to notify the staff in the building that someone had entered the building. He stated the code had been posted 24 hours a day for several months. He could not recall the exact number of months the code was posted. He stated he was instructed to post the code by Door #1 because family members would come to the building and would jerk the door open causing the alarm to sound and would break the door. He was unwilling to state the risks to the residents of having the code posted outside without monitoring the door and stated, you need to talk to the Administrator. During an interview with LVN B on 1/6/26 at 4:15pm revealed it was the responsibility of all floor staff to keep an eye on who entered the building through Door #1 in the evenings. He stated he only knew when someone entered through Door #1 if they came to the nurse's station because he was usually providing care to patients. LVN B stated it would have been a safety concern that anyone could enter the building through Door #1 using the posted code, but it was not his decision to make. He stated he would not have his house unlocked at night and if he was the owner of the facility, he would have Door #1 locked or have a staff member at the front desk. He stated he always locked all his doors because anything can happen, however it was out of his pay grade to decide if the code was posted outside after hours and at night. He stated he would prefer visitors after hours to call the phone number to be allowed to enter the building. During an interview with LVN C on 1/6/26 at 4:35pm revealed no one monitored Door #1 after hours, as she usually worked until 10pm and there was no staff at Door #1. LVN C stated she knew the code was posted to enter Door #1 and anyone could come in, which was a risk for her and the residents. She personally had not felt safe because she did not know when someone came into the building during her shift. She stated she locked her door at her home at night to not allow anyone to come in and would expect the same from the facility. During an interview with ADON A on 1/7/26 at 8:33am revealed there was staff by Door #1 from about 8am to 3:30pm daily including the weekends. ADON A stated when there were no staff in front, by Door #1, and therefore it was everyone's responsibility to monitor Door #1. She stated although staff were busy in the units she was hopeful staff were walking around to ensure there were no random people in the building. ADON A believed it was a safety concern, no one was monitoring Door #1 after hours because bad things could happen. ADON A stated the safety concern crossed her mind when there was an irate spouse who was threatening staff because their loved one passed away. ADON A stated she believed the code had been posted for at least 6 months. During an interview with the Administrator on 1/7/26/ at 10:40am it was revealed the code to enter Door #1 had been posted for several months. The code was posted due to family members and staff forgetting the code. The Administrator stated he had not had any incidents in which having the code posted put people's lives in danger. He stated, In the world we live in anything is a safety concerns and we cannot prevent everything and therefore did not believe it was a true safety concern to the residents. He stated he did not believe there was risk of having the code posted to enter the building without monitoring individuals entering the building. During record review of the facility's policy Resident Rights revised August 14, 2022, reflected Policy: The staff will abide by and protect resident rights in accordance with state and federal guidelines. Procedure: Staff will abide by resident rights as outlined within CMS state Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities. Requested physical environment policy from the Administrator and was provided the Resident Rights policy.

Based on observations, interviews, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in:1. The facility failed to ensure food items in the facility walk-in refrigerator, walk-in freezer and dry storage were dated or labeled.2. The facility failed to ensure food stored in the freezer were properly closed and sealed to prevent exposure to the air. 3. The facility failed to ensure during lunch service kitchen staff used proper hand hygiene while serving residents' trays on 8/19/25.4. The facility failed to take temperatures of all food being served during lunch service on 8/19/25.5. The facility failed to place serving spoons on a sanitized surface during lunch services on 8/19/25.These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination.Observation of the walk-in refrigerator and an interview with the Dietary Manager on 08/19/2025 at 8:47 am revealed: -a clear plastic sealed gallon-sized bag with 3, 8-ounce globs of thick white substance with no label of contents. The Dietary Manager stated it was cream cheese.-a clear plastic sealed gallon-sized bag with about a 1/4 full of small black 1-centimeter circular items without a label of contents. The Dietary Manager stated they were chocolate chips. She stated everything should have been labeled with what the contents were and should have had a date received and date opened. Observation of the walk-in freezer and an interview with the Dietary Manager on 8/19/25 at 8:57 am revealed: - a 20-lb opened box of beef patties, with about 65 patties left, in plastic bags opened to the air and not sealed. The Dietary Manager stated all food must be sealed and closed appropriately when in the freezer to prevent freezer burn. Observation of the dry goods storage area on 8/19/25 at 9:00 am revealed: -3, 5-lb bags of manufacture sealed plastic bags, filled with about 1 cm beige objects with no label of what the item was.-17 small plastic 2oz cups with lids and a brown liquid substance, not labeled with contents. An interview with the Dietician on 8/19/25 at 10:45 am revealed she had been helping the Dietary Manager because she was new to the position. She stated all items in refrigerator, freezer, and dry storage should be labeled with date received, date opened, and list the name of the item. She stated all food that was opened should be sealed. She stated the box of patties should be sealed and not opened to the air. She stated the 3 bags of beige items were rice crispy cereal and should be labeled when they removed them from their original box. She stated the risk to the residents of not properly labeling the items would be wrong items could be served to residents. The risk to residents of the frozen patties not being sealed appropriately would be freezer burned and poor-quality food. Observation of lunch service on 8/19/25 at 11:54am revealed the Dietary Manager was cooking gravy on the stove. She then poured the gravy in the warming tray. [NAME] M nor Dietary Manager temped the food before serving the gravy to the first resident. Observation of lunch service on 8/19/25 at 12:15 pm revealed two metal serving spoons on the metal counter in front of the warming food. [NAME] M's clothing was rubbing back and forth on the counter where the spoons were placed. [NAME] M grabbed one of the metal spoons on the counter and put it in the pureed meat and proceeded to serve a meal tray. Observation of lunch service on 8/19/25 at 12:40 pm revealed [NAME] M left the serving area with her gloves on and went to the freezer to grab frozen fries. She returned to the serving area with the same gloves and poured the fries from the bag into the fryer. She left the fries frying and took the frozen fries back to the freezer with the same gloves on. When she returned to the serving area, she had removed the gloves, but had not washed her hands. She then put a new set of gloves on and continued to serve food. She removed the fries from the fryer, poured them on to a plate, and handed the plate to the Dietary Manager who served them immediately and did not temp them. Observation of lunch service on 8/19/25 at 12:45 pm revealed the Dietary Manager asked [NAME] M for the oatmeal. [NAME] M got the cooked oatmeal that was already served and being held in a warmer and handed it to the Dietary Manager. The Dietary Manager removed the plastic covering over the oatmeal container, did not temp it, and served it on a tray. Interview with the Dietician on 8/19/25 12:50 pm revealed all food, to include gravy, fries, and oatmeal should have been temped. The Dietician stated the only item that should not need temping was bread. The risk to the resident of not temping all food was food borne illness and potentially undercooked food. The serving spoons were all sanitized and the counter should have been sanitized as well, however, since [NAME] M's clothing was touching the counter and the spoons were on it then there would be a risk for cross contamination. Regarding the observation of [NAME] M not washing hands between glove changes, she stated she corrected her once during the observation and would in-service her again. [NAME] M stated the risk to the residents of in-proper hand hygiene during food service was cross contamination. Interview on 8/20/25 at 10:37 am with the Dietary Manager revealed the expectation for hand washing for kitchen staff was for them to wash their hands after every change of gloves or change of tasks. The risk to the resident of kitchen staff not washing their hands appropriately was residents could have gotten sick due to cross contamination. The Dietary Manager stated kitchen staff was in-serviced monthly on hand hygiene and they in-serviced them yesterday as well. The Dietary Manager stated the expectation for labeling was everything should be labeled and the risk to the resident of not labeling items was they may be served something they could not or should not be eating. The expectation for food temperatures was all food must be temped and there was no exception to that rule. The Dietary Manager stated it was the cook's responsibility to temp all food, but she temped foods at times. The risk to the resident of not temping food was they could be serving raw food and make residents sick. Interview with [NAME] M on 8/21/25 at 10:20 am revealed when an item was opened it needed to be put in a secured bag with a label of what it was, date opened, and the used- by date. [NAME] M stated kitchen staff needed to wash hands all the time. She stated their hands must be washed after gloves were taken off and before gloves were put on. The risk to the resident of improper hand hygiene and improper labeling was possible sickness or cross contamination. [NAME] M stated serving spoons should be taken off the wall and placed directly in the food and not on dirty surfaces. All food needed to be temped, both hot and cold. The risk of not temping the food was staff may not know if the food was fully cooked. [NAME] M stated she had been in-serviced already on hand hygiene. Interview with the Administrator on 8/21/25 at 4:49 pm revealed the expectations on food temperatures was all foods needed to be temped before serving. The Administrator stated the expectation for hand hygiene in the kitchen was once staff stepped away from the serving line to do something else, staff must wash your hands. The Administrator stated dietary staff needed to wash their hands before they put on new gloves and after they removed used gloves. The risk to the residents of not using proper hand hygiene was a break in infection control. The risk to the resident of not taking all temperatures on food before it was served was food might not be held at the right temperature and could be served to the resident. The expectation on labeling was all foods should be labelled with contents, date opened, and date use by. Review of the facility's policy Hot and Cold Food Temperatures revised 2/6/24 reflected: .Procedure: 1. Cooking temperatures must be achieved and maintaining according to recipes and regulations. 2. Hot temperatures will be taken and recorded prior to service to ensure foods are at or above 135.Review of the facility's policy Employee Infection Control revised 4/8/25 reflected .7. Employees will wash their hands before handling food in preparation. 8. Employees will clean and sanitize equipment and work areas after use and when changings tasks.Review of the facility's policy Food Storage revised 4/8/25 reflected .Storeroom.airtight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened.Refrigerator.all foods are covered, labeled and dated.Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (300 Hall Nurses Cart and 200 Hall Nurses Cart) of 4 medication carts reviewed for pharmacy services in that:The facility failed to ensure: 1- 300 Hall Nurses Cart did not have:o 1 insulin pen for Resident #64 without an open date on 08/19/25. o 1 insulin pen for Resident #58 without an open date on 8/19/25. o 1 insulin pen for Resident #7 without an open date on 08/19/25. o 1 insulin pen for Resident #51 without an open date on 08/19/25. 2- 200 Hall Nurses Cart did not have: o 1 insulin pen for Resident #44 without an open date on 08/19/25. These failures could affect residents resulting in diminished effectiveness and not receiving the therapeutic benefits of the medications.1- Record review and observation on 08/20/25 at 8:56 AM of the 300 Hall Nurses Cart, with RN A revealed: - The pen of insulin Lispro 100 unit/ml for Resident #64 with no open date. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use. - The pen of insulin Novolog 100 unit/ml for Resident #58 with no open date. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use.- The pen of insulin Lispro 100 unit/ml for Resident #7 with no open date. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use.- The pen of insulin Lantus 100 unit/ml for Resident #51 with no open date. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use Interview on 08/19/25 at 9:21 AM, RN A stated nurses were responsible to check the medication carts and the insulin pens for the open dates before giving insulin. He stated the nurse was supposed to label the pen with the open date when first opened. RN A stated the purpose of putting an open date was for expiration purposes because the insulin was only good for 28 days. He stated after 28 days the insulin would be ineffective. 2- Record review and observation on 08/19/25 at 9:27 AM of the 200 Hall Nurses Cart, with LVN I revealed: The pen of insulin Lantus 100 unit/ml for Resident #67 with no open date. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use. Interview on 08/19/25 at 9:45 AM, LVN I stated nurses were responsible to check the medication carts and the insulin pens for the open dates before giving insulin. She stated the insulin was good for 28 days only after opened, after 28 days the insulin should be discarded because its effectiveness decreased. Interview on 08/20/25 at 3:42 PM, the DON stated the insulin flex pens and vials, once opened, needed to be dated because each insulin pen and vial had a specific day's shelf life and if not thrown out by that time the insulin could lose its effectiveness. The DON stated the pharmacy consultant checked the carts monthly and he stated he would do random checks of the medication carts for monitoring.Record review of the facility's policy titled Medication Storage, dated January 2024, reflected . Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the attending physician documented in the resident's medical record that the identified drug irregularity had been reviewed and what, if any, action had been taken to address it. If there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record for 1 of 6 Residents (Resident #66) whose psychotropic medications were reviewed.Resident #66's attending physician failed to address the pharmacist's recommendation to consider a gradual dose reduction. Resident #66 had been receiving Citalopram (antidepressant) 20 mg and Risperidone once a day every day since October 2024 and Alprazolam .25 mg twice a day everyday since October 2024.This deficient practice could contribute to Residents receiving a higher medication dose than necessary and result in adverse side effects.The findings included: Record review of Resident #66 Quarterly MDS assessment, dated 07/20/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Alzheimer's Disease (loss of cognition), anxiety (feelings of intense worry), and depression (feelings of sadness/loss of interest). Review of Section N- Medications- N0415. High-Risk Drug Classes- reflected she was taking antipsychotic, antianxiety, and an antidepressant. N0450. Antipsychotic Medication Review reflected the resident received antipsychotic medications on a routine basis, a Gradual Dose Reduction (GDR) had not been attempted, and the physician had not documented the GDR as clinical contraindicated. Record review of Resident #66's care plan, printed 08/19/25, reflected she received anti-anxiety medication of Alprazolam .25 mg by mouth two times per day and interventions included administer medication as ordered, ask physician to review medication for possible dose reduction every 3 months, and monitor behaviors every shift and side effects, dated onset of 10/07/24 and reviewed and continued 05/06/25. She received an antidepressant medication of citalopram 20 mg tablet by mouth once per day and interventions of administer medications as ordered, monitor for worsening of depression, monitor duration-prior to discontinuation may need a gradual dose reduction or tapering to avoid a withdrawal syndrome, dated onset of 10/07/24 and reviewed and continued 05/06/25. She received the psychotropic medication risperidone .25 mg one tablet by mouth once per day and interventions included monitor for side effects and behavior every shift, and physician to review medication for possible dose reduction, dated onset of 10/07/24 and reviewed and continued 05/06/25.Record review of Resident #66's physician orders reflected an order for: Citalopram 20 mg, one tablet for by mouth, once daily for Major depressive disorder, recurrent severe without psychotic features with a start date of 07/29/25. Alprazolam 0.25 mg tablet for Unspecified dementia, unspecified severity, without behavioral disturbance with a start date of 07/01/25 and discontinue date of 08/01/2025 and new start date of 08/01/25. Risperdal 0.5 mg tablet for Unspecified dementia, unspecified severity, without behavioral disturbance, administer 1/2 tablet 0.25 mg by mouth daily, with a start date of 07/18/25Record review of Resident #66's Medication Administration Record for the month of August 2025 (08/01/25-08/19/25) reflected she was monitored for behaviors regarding depression and side effects for antianxiety, antidepressant, and antipsychotic medications every shift. Record review of the Pharmacist's Medication Regimen Review Recommendations with documented outcomes between 06/01/25 and 06/18/25 reflected Resident has been taking the anxiolytic ALPRAZOLAM .25 BID since 10/24 Please evaluate the current does and consider a dose reduction . With an outcome/response of declined without rationale. Review of Resident #66's progress notes from May 2025 to August 2025 did not reveal documentation which addressed the Consultant Pharmacist review, dated 05/11/25 or 06/18/25.In an interview on 08/21/25 at 12:38 PM with the DON, he stated he was responsible for reviewing the Medication Regimen Review (MRR) recommendations and ensuring the originals were signed by the physician with a response. He stated that he had recently starting working at the facility about 3 months ago, and had not noticed there was an issue with the MRR responses. He stated that usually the next step was a psychiatric assessment and then it was determined if a GDR should be attempted. He stated that Resident #66 had not received a GDR and was on the medications risperidone, alprazolam, and citalopram since she transferred from another facility in October of 2024. He stated that his expectation was that GDR trials were attempted unless it was contraindicated. He stated that GDRs were important because they could impact a resident's cognition and possibly could be on a medication that was not needed. He stated that moving forward, the facility would have interdisciplinary meetings with the Medical Director to review the residents on medications and GDR recommendations. In an interview on 08/21/25 at 1:24 PM with the Medical Director, he stated he was Resident #66's physician for many years before she admitted to the facility in October of 2024. He stated that he visited the facility multiple days per week and any GDR recommendations were reviewed and he submitted his response to the facility by signing the physician response form. He stated he could not recall the most recent MRR recommendations and was not in front of his computer to review the resident's chart. He stated when a GDR was recommended by the pharmacist, he typically reduced medications by 25% and monitored the resident for any indication that a GDR was contraindicated. He stated that Resident #66 was on a low dose of risperidone, alprazolam, and citalopram, and had been on the medications since she admitted to the facility, so there was a low risk to the resident and no impact on morbidity for not having a GDR attempt. In an interview on 08/21/25 at 2:57 PM with ADON L, she stated she was aware Resident #66 received psychotropic, antidepressant, and antianxiety medications and there were no concerns with over medication and stated Resident #66 had been stable since admitting to the facility. She stated she was responsible for reviewing the pharmacy consultant recommendations with the DON during plan of care meetings and was not aware there was a concern with the MRR recommendations not receiving a response. She stated she had only been ADON for the past 2 weeks and was going to be involved and address the issue. She stated gradual dose reductions were important to ensure residents were not on unnecessary medications. In an interview on 08/21/25 at 2:02 PM with the Pharmacy Consultant he stated that declined without rationale meant he never received a response from the physician regarding the MRR recommendations, and would have to look at his notes to refresh his memory. He stated that the facility had several changes of the DON and the ADON and had planned to discuss the non-response during his next visit to the facility.Record review of the facility's Medication Monitoring policy titled, Medication Regimen Review and Reporting, dated January of 2024, reflected .Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. In accordance with state regulations, the consultant pharmacist or clinical pharmacist at the provider pharmacy works with the nursing care center nursing staff to gather pertinent information related to the resident's status and/or request for consultation.Resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician.Medication Monitoring Medication Management.New Admissions: The attending physician in collaboration with the consultant pharmacist must re-evaluate the use of the psychotropic medication and consider whether or not the medication and be reduced or discontinued upon admission or soon after admission. Additionally, the facility is responsible for: . Obtaining physician orders for the resident's immediate care.Record review of the facility's psychotropic drugs policy titled, Psychotropic Drugs-Use, dated revised July 27, 2022 reflected: Purpose: 1. The community will use psychotropic drug therapy when appropriate to enhance the quality of life, while maximizing functional potential and well-being of the patient/resident. For drug therapy: Within the first year in which a resident is admitted on a psychotropic medication or after the facility has initiated a psychotropic medication: GDR attempts in two separate quarters with at least one month between the attempts. The GDR must be attempted annually thereafter unless clinically contraindicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (200 Hall Nurses Cart) of 4 medication carts reviewed for pharmacy services in that:The facility failed to ensure 200 Hall Nurses Cart did not have 1 insulin pen for Resident #67 with an expired open date on [DATE]. This failure could affect residents resulting in diminished effectiveness and not receiving the therapeutic benefits of the medications.Record review and observation on [DATE] at 9:27 AM of the 200 Hall Nurses Cart, with LVN I revealed: The pen of insulin Lantus 100 unit/ml for Resident #44 with an expired open date of [DATE]. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use. Interview on [DATE] at 9:45 AM, LVN I stated nurses were responsible to check the medication carts and the insulin pens for the open dates before giving insulin. She stated the insulin was good for 28 days only after opened, after 28 days the insulin should be discarded because its effectiveness decreased. Interview on [DATE] at 3:42 PM, the DON stated the insulin flex pens and vials, once opened, needed to be dated because each insulin pen and vial had a specific day's shelf life and if not thrown out by that time the insulin could lose its effectiveness. The DON stated the pharmacy consultant checked the carts monthly and he stated he would do random checks of the medication carts for monitoring.Record review of the facility's policy titled Medication Storage, dated [DATE], reflected . Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 (Resident #42) residents reviewed for respiratory care. The facility failed to ensure Resident #42's oxygen was administered at the correct setting of 2 liters per minute on 8/19/25 as ordered by the physician. The deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. Record review of Resident #42's admission record dated 8/21/25 reflected an [AGE] year-old male with an admission date of 7/6/23. Pertinent diagnoses included seasonal allergic rhinitis (inflammation of sinus) and chronic obstructive pulmonary disease (constriction of the airways and difficulty or discomfort in breathing. Record review of Resident #42's Quarterly MDS assessment, dated 7/18/25 reflected resident's cognition was moderately impaired with a BIMS score of 9. Record review of Resident #42's order dated 7/21/25, reflected O2 (oxygen) @ 2 liters per minute by Nasal Cannula every shift [Time: Shift1, Shift 2, Shift 3] via Nasal Cannula for J44.1 Chronic obstructive pulmonary disease with (acute) exacerbationRecord review of Resident #42's person-centered care plan, reviewed on 4/2/25 reflected .Breathing Patterns [4/28/25: Reviewed and continue] Related to: DX of COPD [1/26/24: Onset](jc142)[4/28/25:Reviewd and Continue](lw156) Evidence by:.Oxygen 2 liter per minute inhalation every shift [9/26/24:Onset](mt204)[4/28/25:Reviewed and Continue.Record review of Resident #42's Medication Record dated 8/1/25 - 8/31/205 reflected 7/21/25 O2 @ 2LPM by NC continuous every shift.Observation of Resident #42 in his room in his wheelchair on 08/19/2025 at 10:13 AM with oxygen on via nasal cannula. The concentrator rate was set at 4 liters per minute (LPM) . Observation of Resident #42 on 08/20/2025 at 8:48 AM revealed resident was in his wheelchair asleep. He had O2 on via nasal cannula. The O2 level on the concentrator was 4 liters per minute. Observation and interview with RN A in Resident #42's room on 8/20/25 at 9:09am revealed RN A was Resident #42's nurse. RN A was asked to read the concentrator and without looking at it he stated it should be at 2 liters per minute. He was asked to read the concentrator, and he read it out loud and stated it as at 4 liters per minute. He then stated they must have changed Resident #42's order for oxygen because he had pneumonia last week. RN A stated he would verify the orders. He verified the orders and stated he could not find an order for 4 liters per minute and would clarify the order with the doctor. RN A stated Resident #42 had been needing more than 2 liters per minute of oxygen but there should have been a new order entered. He stated the oxygen was already on when he arrived on shift, as the resident needed continuous oxygen. RN A stated he should have checked resident's concentrator at least once every shift. If a resident got too much oxygen, the risk would be hyperventilation and false saturation which could cause more breathing issues. Interview with LVN B on 8/20/25 at 1:53pm revealed when residents were on continuous oxygen, they should be checking the concentrator every shift to ensure the resident had gotten the correct amount of oxygen as ordered by the physician. LVN B stated the risk to residents of not giving the right amount of oxygen was the resident would not have gotten the proper amount of oxygen as ordered by the physician. Interview with ADON F on 8/20/25 at 2:50pm revealed when nurses administered oxygen, they needed to have an order and when the oxygen was administered, they needed to make sure it was as ordered. ADON F when a resident was on continuous oxygen the expectation was the concentrator be checked every shift. The risk to the resident of receiving too much oxygen was it could cause adverse reaction and put too much stress on the lungs. She stated she did not know when Resident #42's oxygen was moved from 2 liters per minute to 4 liters per minute, but ADON F believed his oxygen needs changed recently. Interview with the DON on 8/20/25 at 3:23 pm revealed if a resident had a need for oxygen, then the staff needed to follow the doctor's order. The DON stated the nurses were expected to complete rounds and check the concentrator to make sure resident were receiving oxygen as ordered. The DON stated if a resident had gotten too much oxygen, it could exacerbate any type of lung issues the resident already had. Interview with LVN C on 8/20/25 at 3:41 pm revealed she had been working at the facility for 2 weeks. She stated Resident #42 received oxygen and she checked his concentrator every shift. She stated Resident #42's oxygen had not been matching the physician order due him having problems breathing. LVN C to her knowledge nurses could titrate oxygen up to 5 liters per minute without an order. She stated she was unsure if this was the facility policy, but it was the law. LVN C stated Resident #42 had pneumonia and they were having issues keeping his oxygen levels up. LVN C stated she thought they notified his Hospice when the oxygen was titrated. LVN C stated from her experience a new order should have been requested when the resident needed more than 5 liters per minute. LVN C stated she didn't know who initially titrated his oxygen, but she checked his O2 levels each shift to make sure 4 liters per minute was sustainable for him. LVN C stated she had never changed his level as he had been at 4 liters per minute since she started. Interview with ADON G on 8/20/25 at 3:54pm revealed the expectation at the facility was the nurses needed an order to titrate oxygen, they could only titrate without an order if it was an emergency, and the physician would have to be notified immediately after. ADON G the risk to the resident of having more oxygen then ordered would be it could cause the resident more complications. ADON G stated the nurses needed to follow oxygen orders as written. Review of the facility's policy Oxygen Therapy, Concentrator - Initiation revised 1/12/2020 reflected Standard of Practice: The licensed staff will provide the prescribed amount of oxygen therapy to the residents as prescribed by physician and according to practice guidelines.Procedure: 1. Review physician's orders for oxygen.9. Turn liter flow to the prescribed amount.Review of the facility's policy Physician Orders - Electronic revised 1/12/2020 reflected .2. The licensed nursing staff will provide residents with medications and treatments as ordered by his/her physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 4 residents (Resident #12) reviewed for quality of care. The facility failed to ensure LVN I followed physician ordered water flushes between each medication administration given via the G-Tube (a feeding tube surgically inserted through a small opening in the abdomen directly into the stomach, used to deliver nutrition, fluids, and medications when a person cannot ingest enough by mouth) for Resident #12 on 08/20/25. This failure could place residents at risk of nausea, shortness of breath and a decrease potential fluid overload. Record review of Resident #12's Comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male with an admission date 11/13/23. Diagnoses included traumatic brain dysfunction (brain dysfunction caused by an outside force), respiratory failure (lungs can't properly exchange gases) and gastroesophageal reflux (condition where stomach contents back up into the esophagus. Nutritional status revealed Resident #12 had a G-Tube.Record review of Resident #12's care plan reviewed on 06/09/25 reflected, Care Area: Presence of G-Tube . Goal: Resident will have no signs or symptoms of aspiration over the next 90 days . Interventions: Keep the head of the resident's bed at 30 degree and 45 degree, . Provide water flush as ordered, . Provide water flush at med pass per nursing policy. Record review of Resident #12's August 2025 Physician's order sheet report reflected, .G-Tube Flush 30 cc water before and after medications . Use 15 cc water flush in between each medication administered . with a start date of 07/25/25. An observation on 08/20/25 at 9:31 AM of G-Tube medication administration revealed LVN I prepared medication for Resident #12. LVN I placed 1 tablet of Baclofen 10 mg (muscle relaxant), 1 tablet of folic acid 1mg (B vitamin), 1 tablet of furosemide 40 mg (water pill), 1 tablet of vitamin C 500 mg, 1 tablet of vitamin B1, and 1 tablet of multivitamin with minerals in an individual cup and crushed each tablet. LVN I placed the 6 medication cups and a cup filled with approximately 8 ounces of water on a tray and entered the resident's room. LVN I poured approximately 10 cc of water into each medication cup and then retrieved a 60-cc piston syringe (a medical device with a hollow barrel and a plunger that creates a seal to draw in or expel fluids for medical uses) and placed the piston syringe into the G-tube connector and checked for residual. LVN I then flushed the G-tube with 30 cc of water and then administered the first medication by gravity and she did not flush the tube feeding with water; she administered the second medication by gravity and she did not flush the tube feeding with water; she administered the third medication by gravity and she did not flush the tube feeding with water; she administered the fourth medication by gravity and she did not flush with water; and she administered the fifth medication and then the sixth by gravity. She then flushed with 10 cc of water and then 30 cc of water. LVN I then reconnected the feeding tube and turned the pump back on. In an interview with LVN I on 08/20/25 at 9:56 PM she stated she was not required to flush the G-tube with water before and after each med pass. When LVN I looked at the medication administration record, she stated Oh it was supposed to be 10 ml of water after each medication. She stated she overlooked the orders. She stated she was required to review with physicians' orders prior to giving any medication and clarify if it was not clear. She stated not flushing with the prescribed amount of water could result in possible tube clogging. In an interview with the DON on 08/20/25 at 3:42 PM, he stated staff were to always to follow the doctors' orders on the amount of fluid to flush before and after medications. He stated failing to follow the orders could result in complications with the G-tube and discomfort to the resident. He stated not flushing with water could cause tube to clog. He stated all nurses were skills checked prior to G-tube medications administration and were expected to follow the physician ordered flushes. He stated any time a nurse questioned an order it was their responsibility to clarify the order. He stated they would be doing follow up monitoring to ensure staff were following proper procedures. Record review of the facility's policy, Irrigating a Feeding Tube, revised 04/22/2020, reflected, .Flush medication completely through the tube. Irrigate routinely before, between, and after final medication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #41) of two residents reviewed for incontinence care. The facility failed to ensure CNA P provided appropriate perineal care for Resident #41 after an incontinent episode when she failed to clean the resident's labia on 08/19/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections. Record review of Resident #41's Quarterly MDS assessment dated [DATE] reflected Resident #41 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), and elevated blood pressure. Resident #41's BIMS score of 03, indicated Resident #41's cognition was severely impaired. The MDS assessment indicated Resident #41 was frequently incontinent of bowel and bladder. Record review of Resident #41's Care Plan reviewed 07/14/25, reflected the following: Problem: At risk for problems with elimination. Goal: Resident's elimination status will be maintained or improved over the next 90 days. Interventions: . provide incontinent care after each incontinent episode .In an observation on 08/19/25 at 2:56 PM revealed CNA P entered Resident #41's room to provide incontinence care. CNA C washed her hands and put on gloves and unfastened the brief to reveal the resident had been incontinent of urine. CNA P pushed the soiled brief down between the resident's legs, toward her buttocks and cleaned her peri area (the area of skin between the anus and the external genitalia) from the front to back but did not separate the labia and clean down the middle. CNA C rolled the resident onto her side revealing the resident had soaked through her brief. CNA C continued to provide incontinence care, wiping the resident's buttocks from back to front and reapplied a clean brief. She removed her gloves and washed her hands. An interview with CNA P on 08/19/25 at 3:02 PM revealed she failed to separate the resident's labia, and she wiped the resident's buttocks from back to front and by providing inappropriate incontinent care that could lead to an infection. She stated she had been in training and knew the importance of properly cleaning a resident. In an interview on 08/20/25 at 03:42 PM, the DON stated when providing incontinent care, staff were to clean the peri area including the labia for female residents, then moving toward the buttocks and always clean from the front to back. He stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. He stated he would monitor by doing skills check on all CNAs periodically. Record review of the facility's policy titled, Perineal Care/Incontinent Care, dated April 2012, reflected, .For female patient/resident: Separate the labia and wash downward (down the center of labia), then downward on each side of the labia using a different per wipe with each stroke.Clean outer hip of buttocks going upwards towards back .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 6 (Resident #66) reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #66's contracture to her left hand on 04/22/25. The facility failed to ensure physician orders were written for bilateral ( left and right) palm guards for Resident #66 on admission on [DATE].This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Record review of Resident #66 Quarterly MDS assessment, dated 07/20/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Alzheimer's Disease (loss of cognition), anxiety (feelings of intense worry), and depression (feelings of sadness/loss of interest). Review of Section O- Special Treatments, Procedures, and Programs reflected there were no days of restorative programs performed for a splint or brace assistance.Record review of Resident #66's care plan, printed 08/19/25, reflected she was a fall risk related to contractures and paralysis dated onset of 10/07/24, and reviewed and continued 05/06/25. Interventions included anticipate resident's needs, check frequently, low bed, and therapy referral. Record review of Resident #66's Kardex, printed 08/19/25, reflected blank spaces for what the resident enjoyed doing, what made life meaningful to the resident, and contracture devices. Record review of Resident #66's current physician orders did not indicate an order for a palm hand guard. Record review of Resident #66's Kardex, printed 08/19/25, reflected a section for contracture devices was blank. Record review of Resident #66's admission record, dated 10/07/24, active order summary reflected an order for palm protector to left hand with an order start date of 10/21/21. Further review revealed page noting the Resident Representative's notes for Resident #66's care that included Fussy Behavior: If she shouts out, she is usually in pain or anxiety.Nighttime: Blue brace on left arm comes off and is replaced with smaller white brace. This is so she doesn't cut her hands with her fingernails. [NAME] brace can stay on right hand. (can come off for a few hours if it bothers her). Morning: Put blue brace back on. [NAME] brace can stay on right hand.Record review of Resident #66's treatment administration record for the month of August 2025 did not reflect a palm guard. Record review of the facility's contracture log reflected Resident #66 had a contracture to her left and right elbows flexion (bent) and her left and right hands and was on staff management. Resident #66 was last treated on 10/31/25 for physical and occupational therapy and was previously screened on 07/18/25. Resident #66 had bilateral (left and right) palm guards. Record review of Resident #66's therapy screening, dated 07/18/25, reflected she had contractures to both elbows in flexion (bent) and both hands. Further review reflected palm guards for [bilateral] hand contractures are managed by nursing staff, pt has had no functional changes and no skilled PT/OT/ST services are warranted at this time. with recommendations to continue current interventions. In an interview on 08/21/25 at 12:38 PM with the DON, he stated that Resident #66 had been assessed by the therapy department upon admission and most recently on 07/18/25 where the recommendation was to continue bilateral palm guards for her hand contractures. An interview and observation on 08/21/25 at 9:09 AM with CNA H revealed Resident #66 had on a palm guard to her left hand and none on her right hand. Observation of Resident #66's right and left hands with CNA H revealed her nails were trimmed with no jagged areas and the skin of her palms had no injuries. CNA H stated that the CNAs only had access to the Kardex and if there were resident preferences, CNAs were informed by nursing management or during change of shift and could find information in the Kardex. She stated she was aware that music helped Resident #66 calm down because other staff told her and she followed the signs the representative had placed in Resident #66's room. In an interview on 08/21/25 at 9:16 AM with CNA K, she stated she was the restorative aide for the facility. She stated Resident #66 was not currently on restorative services and had a hand brace due to a contracture.In an interview on 08/21/25 at 9:28 AM with the Director of Rehabilitation Services revealed Resident #66 had been assessed upon admission and quarterly. She stated Resident #66 was not currently on therapy services. She stated that she did not see any orders for a palm guard and the resident was on their contracture log which noted she had bilateral palm guards. She stated with the facility transferring to a new electronic health record, she was not sure if Resident #66 had an order for the bilateral palm guards. In an interview on 08/21/25 at 9:35 AM with LVN I, she stated Resident #66 was typically in bed and she had a contracture to one hand and wore a palm guard. She reviewed the contracture log and stated she was not aware that the resident had bilateral contractures and palm guards to both hands and was only aware of one hand having the palm guard. She stated she would have expected there to be an order for the palm guards so it would show up in the treatment administration record. She stated she was not sure if there was a physician order for the palm guards and stated that it was important to ensure the resident wore the palm guards and if there was no order then no one would know that the resident wore palm guards. In an interview on 08/21/25 at 1:24 PM with the Medical Director revealed he was Resident #66's physician for many years before she admitted to the facility in October of 2024. The Medical Director stated he was not aware that there was no order for bilateral palm guards for Resident #66 and he was not sure why they did not transfer over from her admission in October, 2024. He stated there should be a physician order, and he visited the facility multiple days per week and signed orders in batches. He stated it was important to ensure there was a physician order for palm guards so the treatment was provided to the resident. In an interview on 08/21/2025 at 2:57 PM ADON L, she stated she wasn't aware until today about Resident #66's need for palm guards and did not know there was not an order for the palm guards. ADON L stated it there should be a physician order or physical therapy order was important to have for Resident #66 to ensure that palm guards had been evaluated by the physician or physical therapy and ensure it was followed by staff to prevent injuries of her palm from her nails.Record review of the facility's policy on admitting residents titled Admitting a Resident, dated reviewed April 23, 2024, reflected: Nursing staff will admit the resident to the community in accordance with applicable law and regulation, as well as helping the resident with adjustment to his/her new surroundings and initiating the appropriate assessments and the Plan of Care.The licensed nurse reviews transfer papers that accompany the resident.Record review of the facility's policy on rehabilitation services titled Clinical Policies and Procedures: Subject: Resident Screening Form, dated revised 01/01/2025, reflected: The screening process will provide a means of providing rehabilitation information into the care plan process for newly admitted patients, referrals, and established patients on a quarterly basis, as well as to indicate the need for an evaluation and aid in determining the patient's ability to participate in a skilled rehabilitation program. Review the following examples of the type of medication conditions and changes which should be monitored for appropriate therapy referrals (this list is not all inclusive). progressive joint contractures.review the following documentation during the screening process: . admission sheet, physician notes or history and physical.physician order sheet.patient care plan.Record review of the facility's policy on physician orders titled Physician Orders-Electronic, dated reviewed November 27, 2023, reflected: Policy:1. The licensed nurse will receive and transcribe the physician's orders according to the Practice Guidelines. 2. The licensed nursing staff will provide resident with medications and treatments as ordered by his/her physician.Procedure.2.The licensed nurse clarifies and reconciles all orders that may lead to an administration error. 3. The electronically entered order will be automatically transcribed onto the Medication admission Record (MAR) or Treatment Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #56) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #56 had his fingernails cleaned and trimmed on 8/19/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Record review of Resident #56's Quarterly MDS assessment dated [DATE] reflected Resident #56 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident (a condition that occurs when blood flow to the brain is blocked. The blockage can lead to brain tissue death.), and elevated blood pressure. Resident #56's BIMS score of 14, indicated Resident #56' cognition was intact. The MDS assessment indicated Resident #56 required maximal assistance with bathing. Record review of Resident #56's Care Plan revised 07/02/25, reflected the following: Care area: Self-care deficit . Goal: [Resident #56] will accept assistance with area of dressing, grooming hygiene and bathing over the next 90 days . Interventions: . provide assistance with self-care as needed. In an observation and interview on 08/19/25 at 10:24 AM revealed Resident #56 was lying in his bed. The nails on both his hands were approximately 0.3cm in length extending from the tip of his fingers. The nails were discolored tan and had brownish colored residue on the underside. Resident #56 stated he did not like his nails long and dirty and he did not tell staff because they were busy. In an interview on 08/19/25 at 2:08 PM, LVN I stated CNAs and nurses were responsible to clean and cut the residents' nails. LVN I stated she did not notice Resident #56's nails. She stated she would do it right then. She stated the risk would be infection control and injury. In an Interview on 08/20/25 at 3:42 PM, the DON stated nail care should be completed as needed and every time aides washed the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated he expected CNAs and nurses to offer to cut and clean nails if they were long and dirty. The DON stated the ADONs would do the routine rounds to monitor. The DON stated residents having long and dirty nails could be an infection control issue and skin break down if scratching. Record review of the facility's policy ADLs/Bathing revised February 2020, did not address the concern of fingernails care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 5 residents (Resident #3) reviewed for care plan development. The facility failed to complete Resident #3's comprehensive care plan in a timely manner after his comprehensive assessment was completed. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.Record review of Resident #3's admission MDS Assessment, dated 7/31/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] . Resident #3 had the following diagnoses: Anxiety Disorder, Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood circulation), Heart Failure, Diabetes and Asthma. Section M reflected resident was developing a pressure ulcer. Resident was admitted with the following medications: Antipsychotic, Anticoagulant (blood thinner), Antibiotic, Diuretic and Hypoglycemic (including insulin). Section O reflected resident needed continuous oxygen. Record review of Resident #3's Admit Baseline Care Plan reflected a completion date of 7/28/25.Record request for Resident #3's Comprehensive Care Plan on 8/21/25 at 2:04pm revealed he did not have one completed.Interview with the MDS Coordinator on 8/21/25 at 2:35pm revealed she was responsible for the completion of the Comprehensive Care Plan. The MDS Coordinator stated the expectation was she completed the MDS first and the Comprehensive Care plan would have been completed within 14 calendar days after the resident admitted to the facility. The MDS Coordinator stated she overlooked the care plan for Resident #3 and had not completed his comprehensive care plan yet. The MDS Coordinator stated she would used the CAA, notes from physician, nurses' notes and physician orders to complete the Comprehensive Care Plan. The MDS Coordinator stated psychotropic medications would be on the Comprehensive Care Plan, along with behavioral monitoring and monitoring of side effects. The risk to the resident of not having a comprehensive care plan in a timely manner was staff would not know how to provide accurate care and interventions. The MDS Coordinator completed the following trainings: RAI and Care Planning. The MDS Coordinator also referred to regional resources and trainings when she had questions on completion of the Care Plans. She stated the training for Care Planning was ongoing. Interview with LVN E on 8/21/25 at 3:25pm revealed the MDS Nurse or Unit Manager created and updated care plans. Nurses did not complete care plans. Interview with the DON on 8/21/25 at 4:09 pm revealed the comprehensive care plan was due 21 days from admission. The countdown started from the first day of admission and was calendar days. The nurses were responsible for acute comprehensive care plans, but the CAA triggers were completed by the MDS nurse. He stated Resident #3 should have had his comprehensive care plan completed already. The risk of not having had the care plan done would be it could impede the resident's treatment. He was unsure of the reason the care plan had not been completed. Interview with the Administrator on 8/21/25 at 4:49 pm revealed the expectation was the MDS nurse or nursing staff completed the care plans. The risk to the resident of not having a completed care plan was a lot of things could have gotten messed up and affected the resident negatively. Review of the facility's policy Person Centered Care Plans revised 6/25/22 reflected .Standard of Practice: Each resident will have a person-centered care plan developed and implemented to meet his or her other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.9. Comprehensive Care Plan - must be developed within seven (7) days after completion of the comprehensive assessment, quarterly, annually and with any change of condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 6 residents (Residents #66, #38) reviewed for care plans.1. The facility failed to develop the following comprehensive person-centered care plans for Resident #66: playing music calmed her her representative preferred her nightstand lamp to stay on at night the need for bilateral (left and right) palm guards due to hand contractures.2. The facility failed to develop a comprehensive person-center care plan that reflected Resident #38 preferred to have her medication placed in her hand, one at a time, during medication administration due to being legally blind. These deficient practices could place residents at risk of not receiving the necessary care or services.Findings included:1. Record review of Resident #66 Quarterly MDS assessment, dated 07/20/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Alzheimer's Disease (loss of cognition), anxiety (feelings of intense worry), and depression (feelings of sadness/loss of interest). Review of Section N- Medications- N0415. High-Risk Drug Classes- reflected she was taking antipsychotic, antianxiety, and an antidepressant. N0450. Antipsychotic Medication Review reflected the resident received antipsychotic medications on a routine basis and a gradual dose reduction (GDR) had not been attempted, the physician had not documented the GDR as clinical contraindicated. Review of Section O- Special Treatments, Procedures, and Programs reflected there were no days of restorative programs performed for a splint or brace assistance.Record review of Resident #66's care plan, printed 08/19/25, reflected she was a fall risk related to contractures and paralysis with an onset date of 10/07/24, and reviewed and continued 05/06/25. Interventions included anticipate resident's needs, check frequently, low bed, and therapy referral. Review of the care plan revealed no documentation that playing music calmed Resident #66. Review revealed no documentation that Resident #66's representative preferred Resident #66's nightstand lamp to stay on at night. Review of the care plan revealed no documentation that Resident #66 required bilateral (left and right) palm guards due to hand contractures.Record review of Resident #66's Kardex, printed 08/19/25, reflected blank spaces for what the resident enjoyed to do, what made life meaningful to the resident, and contracture devices. Record review of Resident #66's physician orders, printed 08/21/25, reflected no orders for palm guards or contracture devices.In an observation on 08/19/25 at 10:19 AM of Resident #66, she was asleep in bed on the lowest position with music playing from a music player on her nightstand next to her bed wearing a palm guard to her left hand. There was a sign on the wall that reflected: Music calms her-helps if she is yelling turn CD player on and a sign on the lamp on her nightstand that reflected: please leave light on at night, thank you. In an interview on 08/19/25 at 1:23 PM with Resident #66's representative, she stated she had put up the signs to ensure staff were aware of what helped Resident #66 to be calmer and the staff were good about following the interventions. She stated she participated in care plan meetings. She stated she was not sure if it was something they discussed during the care plan meetings. She stated she frequently visited Resident #66 and saw that staff were aware of the Resident's needs.An observation on 08/20/25 at 12:05 PM revealed Resident #66 was lying in bed and mumbling incoherently and was wearing a palm guard to her left hand. An interview on 08/20/25 at 12:10 PM with MA J revealed Resident #66 was not able to communicate coherently and sometimes yelled out in agitation. MA J stated Resident #66 was calmed when they played music that was on her nightstand, and she was aware because of the signs posted in Resident #66 room by the representative. She stated she was not sure if Resident #66's music and lamp light staying on at night, or palm guard were care planned. She stated she knew of Resident #66's interventions because of the signs in her room. She stated staff were informed during change of shift of residents needs and she was able to see the Kardex and Medication Administration Record (MAR).An interview on 08/21/25 at 9:09 AM with CNA H revealed Resident #66 had on a palm guard to her left hand and none on her right hand. Observation of Resident #66's right and left hands with CNA H revealed her nails were trimmed with no jagged areas and the skin of her palms had no injuries. CNA H stated that the CNAs only had access to the Kardex and if there were resident preferences, CNAs were informed by nursing management or during change of shift and could find information in the Kardex. She stated she was aware that music helped Resident #66 calm down because other staff told her and she followed the signs the representative had placed in Resident #66's room. In an interview on 08/21/25 at 9:16 AM with CNA K, she stated she was the restorative aide for the facility. She stated Resident #66 was not currently on restorative services and had a hand brace due to a contracture.In an interview on 08/21/25 at 9:28 AM with the Director of Rehabilitation Services revealed Resident #66 had been assessed upon admission and quarterly. She stated Resident #66 was not currently on therapy services. She stated that she did not see any orders for a palm guard and the resident was on their contracture log which noted she had bilateral palm guards. She stated with the facility transferring to a new electronic health record, she was not sure if Resident #66 had an order for the bilateral palm guards. In an interview on 08/21/25 at 9:35 AM with LVN I, she stated Resident #66 was typically in bed, and Resident #66's Representative had brought the music player and told staff that it helped to relax Resident #66 and it really helped Resident #66. She stated she was not sure if the intervention of playing music for Resident #66 was care planned and thought it would be helpful because if a new staff member came to care for Resident #66, they would know what helped the resident. In an interview on 08/21/2025 at 2:57 PM, ADON L stated Resident #66 was nonverbal, mumbled incoherently, and occasionally yelled out. She stated the signs that indicated music calmed Resident #66 and to leave the nightstand light on at night should be care planned. She stated the care plan informed staff of residents' needs and preferences. She stated she wasn't aware until today about Resident #66's need for palm guards and stated it was important to care plan her need so that everyone was aware for her to have it on to prevent injuries of her palm from her nails. In an interview on 08/21/25 at 12:38 PM with the DON, he stated that Resident #66's need for palm guards, keeping the bedside lamp light on a night, and music that calmed her, should be care planned and he was not aware that it was not care planned. He stated that the MDS Coordinator was responsible for updating care plans and they were reviewed in morning meetings, quarterly, or upon change of condition. He stated the facility had switched to a new electronic medical record system and they were going to continue to audit care plans. He stated it was important for care plans to reflect a resident's needs and preferences, so they were honored by staff. In an interview on 08/21/25 at 2:35 PM with the MDS Coordinator, she stated she was responsible for updating care plans during morning meetings, upon a change of condition, or quarterly. She stated she was not aware of the signs in Resident #66's room that stated music was calming or about the lamp light staying on at night. She stated it would be something that should be care planned because it helped staff know what helped the resident. She stated the resident requiring palm guards should also be something that was care planned and she was not aware until now and if it was not care planned then staff might not know that the resident needed to wear a palm guard. She stated it was important that care plans reflected a resident's preferences to ensure their preferences were honored and was going to update Resident #66's care plan. 2. Record review of Resident # 38's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses of stroke, kidney failure, and hypertension (high blood pressure), severely impaired vision, and intact cognition. Record review of Resident #38's care plan, printed 08/21/25, reflected she had a visual impairment due to being legally blind and interventions included keep furniture in same place, keep most frequently used items in a consistent area within reach, dated 01/13/25. The interventions did not reference any preferences for medication administration. Further review reflected Resident #38 resisted care as manifested by: refusing medications after medication aide gives them to her and telling her which medication is which and it happens only during the morning med pass. with a goal to have less than 3 episodes per week, dated 08/14/25. Review revealed no documentation that Resident #38 preferred to have her medication placed in her hand, one at a time, during medication administration due to being legally blind. Interventions included administer medications as ordered, approach calmly, explain why procedures and care are needed before provided, and allow highest level of independence when making choices regarding care.In an interview on 08/19/25 at 11:00 AM with Resident #38, she stated that she was legally blind and during medication passes she preferred staff to tell her what the medication was and hand it to her in her hand so she could feel the pill because it reassured her. She stated she knew what her medications felt like and could make out some colors. She stated that she was not sure if it had been mentioned in care plan meetings and usually staff administered her medications to her by her preference except for a recent interaction with a new medication aide which the facility was responsive in addressing and informed her that the aide would no longer pass her medications, and the nurse was going to pass her medications. In an interview on 08/20/25 at 12:10 PM with MA J, she stated that she had passed medication to Resident #38 when she first started working at the facility and when she put them in a cup and handed them to Resident #38 she would not take them and requested to be informed of which pill she was being handed and it be placed in the palm of her hand so she could feel it. She stated she knew now that Resident #38 preferred medication administration a certain way because she was legally blind and knew the shape and color of the medications she took. She stated she was not aware if it was care planned and would typically look at the Kardex or was informed by nursing staff about resident preferences. In an interview on 08/21/25 at 9:35 AM with LVN I, she stated that Resident #38 was blind and during medication passes she wanted staff to tell her what the medication was and placed in the palm of her hand so she could feel the medication shape and sometimes could make out colors. LVN I stated she was not sure if that was care planned. She stated it would be important to care plan Resident #38's preference for medication pass to ensure her preferences were honored. In an interview on 08/21/25 at 9:18 AM with RN A, he stated Resident #38 was legally blind and during medication passes she wanted staff to tell her what each medication was, one at a time, then placed in her hand so she could feel the shape of the medication. He stated that if he was passing medications to her, he took her to wash her hands then proceeded to give her medications using her preferred method. He stated she requested medications be given in this way every time he passed medications to her. He stated he was not sure if it was care planned and stated it would be important to care plan to ensure all staff knew of the resident's preferences. In an interview on 08/21/25 at 12:38 PM with the DON he stated he was aware Resident #38 was legally blind and had heard the team speak about her preference for medication administration by placing the medications in the palm of her hand. He stated Resident #38's preference for medication administration should have been care planned to ensure her preferences were honored by staff and that staff were aware. In an interview on 08/21/25 at 2:35 PM with the MDS Coordinator, she stated she was aware that Resident #38 preferred the nurse to put the medications in the palm of her hand and she had updated the care plan after a medication aide had attempted to give Resident #38 her medication in a cup and Resident #38 refused her medications. She reviewed Resident #38's care plan and stated she could see how the updated care plan on 08/14/25 could've been made to seem more like a behavioral concern of refusing medications rather than a preference due to the resident being legally blind and wanting the medication in her palm so she could feel the medication. She stated person-centered care plans were important to ensure residents received their plan of care. In an interview on 08/21/2025 at 2:57 PM with ADON L, she stated Resident #38 was legally blind and during medication administration she liked to have the pills placed in the palm of her hand because it reassured Resident #38 because she knew what the pills felt like and could make out some colors. ADON L stated she was not sure if Resident #38's care plan was updated to reflect her preference and the MDS Coordinator was responsible for updating resident care plans. ADON L stated it was important to care plan Resident #38's medication administration preference so that other people were aware of her residents preferences and if a new staff member was going to work with the resident, they would be able to look at it and learn the resident too.In an interview on 08/21/25 at 4:43 PM with the Administrator, he stated that it was important to ensure a resident's care plan was as personalized as possible and would have expected Resident #66 and Resident #38's preferences to be care planned. He stated it was important for care plans to personalized so residents received the care they needed. The Administrator stated the MDS Coordinator was responsible for updating resident care plans and they were reviewed and updated upon change of condition, admission, and quarterly. Record review of the facility's care plan policy, titled Care Planning and dated revised 10/24/22 reflected: .To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs . Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section for 1 of 5 residents (Resident #3) reviewed for unnecessary medications.1.The facility failed to have an adequate indication for the use of the medication Quetiapine Fumarate (Seroquel - an antipsychotic) for Resident #3. 2. The facility failed to monitor behaviors and side effects of Quetiapine Fumarate (an antipsychotic) for Resident #3. The failures could place residents at risk of increased behaviors, negative outcomes, adverse reactions and even a decline in health.Record review of Resident #3's admission MDS Assessment, dated 7/31/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had a diagnoses of anxiety disorder. The resident's BIMS score was 11, indicating moderately impaired cognition. Section E reflected none of the above for potential indicators of psychosis and no behavioral symptoms. Section N reflected Resident #3 was admitted with Antipsychotic Medication with indication noted. Review of Resident #3's Admit Baseline Care Plan dated 7/28/25, reflected the resident had no psychotropic therapy. Record review of Resident #3 Physician's Orders dated 7/28/25 reflected Quetiapine Fumarate 50mg tablet (QUEtiapine Fumarate) for G47.00 Insomnia, unspecified ([Start 7/28/25 18:34] 1 tablet by mouth at Bedtime). No order for behavior monitoring or side effect monitoring was found. Record review of Resident #3's Medication Record for 8/1/25 - 8/31/25 reflected administration of Quetiapine Fumarate as ordered each day. The record did not include documented evidence the facility was monitoring for side-effects related to the use of the Quetiapine Fumarate or monitoring the resident's behaviors for signs of psychosis. Record review of progress notes for Resident #3 dated 7/28/25 to 8/21/25 did not reveal any documented behavioral or psychotic issues. Interview with LVN B on 8/20/25 at 1:53pm revealed Resident #3 had no significant behavioral issues and no major incidents since admittance to the facility. She stated Resident #3 was receiving psychiatric services for anxiety and was receiving Quetiapine Fumarate for depression. She stated there was no order to monitor his behaviors, but she monitored his behaviors due to his medications. She stated the nurses were supposed to chart how many episodes a resident had each shift, and it should have been documented in the MAR. She stated she was not currently charting any behaviors because she was learning the facility's new electronic record system. She stated the risk of not monitoring behaviors could lead to other problems such as over treatment and increased psychiatric symptoms. She stated if Resident #3 was having behaviors she would report to the ADON, DON and Administrator. She stated she could also reach out to the doctors immediately if residents had acute needs. She stated the last time she was in-serviced on monitoring behaviors was about 2 weeks ago. Interview with ADON F on 8/20/25 at 2:50pm revealed Resident #3 was being prescribed Seroquel (Quetiapine Fumarate) for mood and bipolar disorder. When questioned about the physician's order stating it was for Insomnia, she stated Resident #3 came from the hospital with that medication. ADON F stated insomnia was not an appropriate diagnosis for the use of Seroquel and stated the corrected diagnosis needed to be entered on the orders. ADON F stated there should have also been an order monitoring the resident's behaviors and side effects related to the psychotropic medications. Behaviors and side effects should have been monitored every shift and documented on the MAR. The risk of not documenting an adverse reaction to the medication would be the doctor would not have gotten a clear picture of how the resident was doing and therefore couldn't take the appropriate actions. Behavior monitoring was important to make sure patients were safe. If behaviors were not documented, then it puts the resident at risk of being over or under medicated . Interview with the DON on 8/20/25 at 3:12pm revealed antipsychotic medications were verified with the doctor upon a resident's admission. If a resident was admitted with psychotropic medication, they would ask the social worker to make a referral for psychiatric services. If the hospital discharged a resident with a psychotropic medication and the order stated it was for insomnia, they should have spoken to the doctor about it because insomnia was not an appropriate diagnosis for psychotropic medication. The facility should have an order for monitoring behaviors and monitoring side effects when the residents were taking anti-psychotic medications, regardless of the medical diagnosis used to prescribe it. The monitoring of behaviors would help to monitor the resident's medication and the need for it. The risk of not having an order to monitor the behaviors and side effects would be dependent on the skills set of the nurse, and whether they knew what behaviors and side effects to look for with residents on anti-psychotic medications . Interview with ADON G on 8/20/25 at 3:54pm revealed all psychotropic medications prescribed should have an appropriate diagnosis for the use of the medication. Insomnia would not be an appropriate diagnosis for an anti-psychotic medication like Seroquel. The facility should also have an order for behavior monitoring and monitoring of adverse reactions and it should be documented in the TARs and MARs. The risk to the resident of not having had an appropriate diagnosis for antipsychotic medication was the resident may have no longer needed the medication. The risk to the resident of not having an order for side effects or behaviors was the doctor wouldn't know if the medication was effective. Review of the facility's policy Psychotropic Drugs - Use reflected Purpose: 1. The community will use psychotropic drug therapy when appropriate to enhance the qualify of life, while maximizing functional potential and well being of the patient/resident. 2. Qualified staff will monitor the patient/resident for potential undesirable side effects that are associated with the use of psychotropic drugs according to CMS, State specific rules and regulation and Practice Guidelines.Standard of Practice:.B. Antipsychotics: Only appropriate for the following acceptable diagnosis(es):*Schizophrenia *Huntington's disease *Tourette's syndrome. Antipsychotic drugs are not used if one or more of the following is/are the ONLY indication:.7. Insomnia.Note: Careful evaluation of the residents' records should be reviewed for appropriate diagnosis for medication use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 3 (Resident #3, Resident #13, Resident #30) of 5 residents reviewed for care planning.1.The facility failed to accurately complete the Physician Orders section on the baseline care plan, to indicate Resident #3 was being admitted to the facility with psychotropic medications.2.The facility failed to have a baseline care plan for Resident # 13 and Resident #30 This failure could place newly admitted residents at risk of not having their needs met, not receiving appropriate medications, not receiving necessary treatments, resulting in poor quality of life. 1) Record review of Resident #3's admission MDS Assessment, dated 7/31/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnosis of anxiety disorder. The resident BIMS score was 11 indicating moderately impaired cognition. Section E reflected none of the above for potential indicators of psychosis and no behavioral symptoms. Section N reflected Resident #3 was admitted with Antipsychotic Medication and indication noted. Review of Resident #3's Admit Baseline Care Plan dated 7/28/25 under Physician Orders/Medications/Treatments reflected Resident had no psychotropic therapy. Record review of Resident #3 Physician's Orders dated 7/28/25 reflected Quetiapine Fumarate 50mg tablet (QUEtiapine Fumarate) for G47.00 Insomnia, unspecified ([Start 7/28/25 18:34] 1 tablet by mouth at Bedtime). Record review of Resident #3's Medication Record for 8/1/25 - 8/31/25 reflected administration of Quetiapine Fumarate as ordered each day. 2) Record review of Resident #13's face sheet dated 08/21/2025 reflected she was a [AGE] year-old female with an original admission date of 07/18/2025.Record review of Resident #13's care plan revealed she did not have a baseline care plan.3) Record review of Resident #30s MDS dated [DATE] reflected he was an [AGE] year-old male with an admission date of 07/30/2025, BIMS score of 09 indicated moderate cognitive impairment. His diagnoses included Chronic Obstructive Pulmonary Disease (breathing difficulty).Record review of Resident #30's care plan revealed he did not have a baseline care plan. Interview with the MDS Coordinator on 8/21/25 at 2:35pm revealed she did not complete baseline care plans; she stated the nurse who admitted the resident was responsible for completing the baseline care plan. The risk of not having completed the baseline care plan accurately would be the staff would not know how to provide accurate care and interventions to the resident when they are admitted . Interview with LVN E on 8/21/25 at 3:25pm revealed nurses are responsible for completion of the baseline care plan. LVN E stated the nurses had 24-72 hours to complete a resident's admission which included the baseline care plan. LVN E stated she answered questions on the baseline care plan using notes and residents' assessments. If a resident arrived at the facility with psychotropic medication they would mark psychotropic therapy on the baseline care plan. Seroquel would be considered psychotropic medication and therefore psychotropic therapy would be check marked on the baseline care plan. The risk of not identifying psychotropic medications on the baseline care plan would be all staff wouldn't know what the resident's needs were and wouldn't know to monitor the side effects and behaviors. Interview with the DON on 8/21/25 at 4:09pm revealed nurses were responsible for the completion of baseline care plans. The DON stated they got a new electronic record's system on 7/22/25 and the nurses had been struggling to complete the baseline care plan efficiently. The DON reported he was working with nurses' side by side to help teach them the new system. The facility also had super users in the building that helped with major issues with the system. Regarding Resident #3's baseline care plan, Psychotropic therapy should have been checked off for the resident due to him being prescribed Seroquel. The risk of not noting the psychotropic therapy on the baseline care plan was it could have impeded the resident's treatment plan. The DON stated he was unsure of the reason psychotropic medication was not marked on Resident #3's baseline care plan. Review of the facility's policy Person Centered Care Plans revised 6/25/22 reflected .1. The facility must develop and implement a baseline person-centered care plan that meets professional standards of quality care. The baseline care plan will consist of the following: 2. Be developed within 48 hours of a resident's admission. 3. Include the minimum healthcare information necessary to properly care for a resident including but not limited to:.b. physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 3 of 23 residents (Resident#13, Resident#30, Resident #4) reviewed for resident call system. 1) The facility failed on 08/19/2025 to ensure the call light system was adequately equipped, the call light string was lying on the floor in the shared resident toilets located inside the resident rooms.2) The facility failed to ensure the call light device was within the reach of Resident #4 on 08/19/2025 when the resident was lying in bed in his room. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for activities of daily living.1) Record review of Resident #13's face sheet dated 08/21/2025 reflected she was a [AGE] year-old female with an original admission date of 07/18/2025. Record review of Resident #30's MDS dated [DATE] reflected he was an [AGE] year-old male with an admission date of 07/30/2025, BIMS sore of 09 indicated moderate cognitive impairment. His diagnoses included Chronic Obstructive Pulmonary Disease (breathing difficulty). Review revealed Resident #30 required partial to moderate assistance with ADLs. Observation on 08/19/2025 at 10:01 AM inside Resident #13's shared bathroom revealed the call light device string was lying on the floor. Interview with Resident #13 revealed she needed assistance with ADLs. Observation on 08/19/2025 at 01:12 PM inside Resident #30's shared bathroom revealed the call light device string was lying on the floor. An interview and observation on 08/19/2025 at 02:23 PM with the Maintenance Director at both Resident #13 and #30's bathroom, he looked at the call light string and stated the call light string was expected to stay above the floor, and he was responsible to repair and maintain the call light system. He stated the call light string lying on the floor increased the risk for call light device malfunction and he expected all the employees to notify him when they saw the string was lying on the floor. He stated all the employees regularly received in-service trainings on call light device and he would right away repair the call light device on both rooms. An interview on 08/19/2025 at 02:05 PM with LVN Q revealed it was the Maintenance Director's responsibility to repair, maintain and ensure the call light system was adequately equipped, and all the employees were responsible to let the Maintenance Director know that the call light string was lying on the floor. He stated the call light string was expected to stay above the floor and lying on the floor could affect the proper functioning of the device. He stated he and his employees regularly received in-services on call light devices. An interview on 08/19/2025 at 01:47 PM with RN R revealed it was the maintenance director's responsibility to repair, maintain and ensure the call light system was adequately equipped. RN R stated all the employees were responsible to let the maintenance director know that the call light string was lying on the floor. He stated the call light string was expected to stay above the floor and lying on the floor could affect the proper functioning of the device. He stated he and his employees regularly received in-services on call light devices. An interview on 08/19/2025 at 02:22 PM with CNA S revealed the Maintenance Director was responsible to repair, maintain and ensure the call light system was adequately equipped. CNA S stated all the employees were responsible to let the maintenance director know that the call light string was lying on the floor. He stated the call light string was expected to stay above the floor and lying on the floor could affect the proper functioning of the device. He stated he received an in-service on call lights within the past month. An interview on 08/19/2025 at 03:35 PM with DON revealed he expected the Maintenance Director to repair, maintain and ensure the call light system was adequately equipped and working properly. The DON stated all the employees were responsible to let the Maintenance Director know that the call light string was lying on the floor. He stated the call light string was expected to stay above the floor and lying on the floor could affect the proper functioning of the device. Th DON stated all the employees received an in-service on call lights within the past month. 2) Record review of Resident #4 MDS assessment, dated 07/18/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of cancer, dementia (loss of cognition), quadriplegia, and had moderately intact cognition. Record review of Resident #4 care plan, printed 08/19/25, reflected he had impaired physical mobility and was a fall risk due to quadriplegia, dated 06/24/25. Interventions included keep call light within reach and provide appropriate level of assistance to promote safety of the resident. Observation on 08/19/25 at 9:32 AM revealed CNA H exited Resident #4's room with his breakfast tray. In an observation and interview on 08/19/25 at 9:34 AM revealed Resident #4 was laying in bed and his call light was on the floor next to his bed. Resident #4 stated that he needed his call light and was not sure where it was located. In an observation and interview on 08/19/25 at 9:43 AM with CNA H, she stated she had picked up Resident #4's tray and did not notice that the call light was on the floor before she left his room with his breakfast tray. CNA H picked up the call light and clipped it to Resident #4 blanket within reach. CNA H stated she should have checked before leaving Resident #4 room and ensured his call light was within reach. She stated that it was important to ensure a resident's call light was within reach because the resident may need to ask for help. In an interview on 08/19/25 at 1:04 PM with LVN I, she stated CNA H should have ensured Resident #4's call light was within reach before leaving his room. LVN I stated it was important to ensure resident call lights were always within reach so the residents could call for assistance. In an interview on 08/21/2025 at 2:57 PM with ADON L, she stated Resident #4's call light was supposed to always be within reach residents. She stated before staff left the resident's room, they should have ensured the call light was within reach. She stated it was important for resident call lights to be within reach because that was how they called for help; it was their life line.In an interview on 08/21/25 at 12:38 PM with the DON, he stated his expectation was for staff to ensure resident call lights were within reach before leaving the room. He stated having the call light within reach of the resident was important for residents to be able to call for assistance if there was an emergency.Record review of facility policy titled call lights answering with reviewed date of 01/19/2023 reflected: Purpose: Policy: .The staff will provide an environment that helps meet the resident's needs by answering call lights appropriately. when leaving the room, be sure the call light is placed within the resident's reach .

**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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Resident #10, Resident #56, and Resident #61) of 5 residents reviewed for infection control. The facility failed to ensure MA N disinfected the blood pressure cuff in between blood pressure checks for Residents #10, Resident #56, and Resident #61. This failure could place residents at-risk of cross contamination which could result in infections or illness. 1.Record review of Resident #10's Quarterly MDS assessment, dated 07/25/25, reflected Resident #10 was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included elevated blood pressure, multidrug-resistant organism (microorganisms that are resistant to at least one class of antimicrobial agents, including antibiotics, and wound infection). Resident #3 had a BIMS of 3 which indicated Resident #10's cognition was severely impaired. Record review of Resident #56's Quarterly MDS assessment dated [DATE] reflected Resident #56 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebrovascular accident (a condition that occurs when blood flow to the brain is blocked. The blockage can lead to brain tissue death.), and elevated blood pressure. Resident #56's BIMS score of 14, indicated Resident #56' cognition was intact. Record review of Resident #61's Quarterly MDS assessment, dated 06/16/25, reflected Resident #61 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included elevated blood pressure and type 2 diabetes mellitus. Resident #61's BIMS score of 11, indicated Resident #61's cognition was moderately impaired. Observation on 08/20/25 at 7:58 AM revealed MA N performing morning medication pass, during which time she checked the blood pressure on Resident #10. MA N did not sanitize the blood pressure cuff before and after using it on Resident #10 and continued to the next resident without sanitizing the blood pressure cuff. MA N then checked Resident #56's blood pressure. MA N did not sanitize the blood pressure cuff before using it on Resident #56. She continued to the next resident without sanitizing the blood pressure cuff. MA N then checked Resident #61's blood pressure. MA N did not sanitize the blood pressure cuff before using it on Resident #61. Interview on 08/20/25 at 8:40 AM, MA N stated reusable equipment, like blood pressure cuffs, should be sanitized before and after use on each resident in order to keep germs from spreading. She stated she forgot to sanitize the blood pressure cuff between residents' use.In an interview with the DON on 08/20/25 at 3/42 PM, he stated his expectation was for staff to sanitize the blood pressure cuff after each use. He stated to ensure staff were knowledgeable in the sanitation of the blood pressure cuff the facility would do skills competency checks and he stated he would make daily rounds and watched care and medication administration. Record review of the facility's policy titled Disinfecting and Sterilizing Resident Care Equipment, revised March 2025, reflected . Non-critical items are those that either do not ordinarily touch the residents or touch only intact skin. Such items include . blood pressure cuffs . it is imperative that these items are clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections that includes written standards, policies, and procedures for the program for 1 (Resident #1) of 4 residents reviewed for infection control.
1. RN (Registered Nurse) A failed to perform proper hygiene during a routine medication administration for Resident #1. RN (Registered Nurse) A knowingly used a syringe that had its plunger seal fall on the ground to administer medication to Resident #1.
2. RN (Registered Nurse) A failed to perform proper Syringe Protocol during routine medication and tube flushing for Resident #1. RN (Registered Nurse) A knowingly continued to use and/or did not change a syringe that he was aware of that had been used for 24 hours to administer a medication, flushing, and placement check to Resident #1.
3. The facility failed to provide evidence of a written Infection Control Policy.
These failures placed residents at risk for spread of infection through cross-contamination.
Findings included:
1. Review of Resident #1's Face Sheet dated 3/12/2025 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was not cognitively intact and had a Jejunostomy Tube (J-Tube, a plastic tube placed through the skin of the abdomen into the midsection of the small intestine). Diagnoses included Aphasia following cerebral infarction (Loss of the ability to understand following a stroke), Ileus (Digestive Disease), Pneumonia (infection that inflames the air sacs in one or both lungs), Sepsis (body's extreme response to an infection, potentially leading to organ damage and death if not treated promptly), Shortness of breath, Anxiety disorder (excessive and persistent fear, worry, and nervousness), Pain, Constipation (infrequent, hard, or difficult-to-pass bowel movements), Acute embolism and thrombosis (clot that travels and blocks a blood vessel).
Review of Resident #1's MDS assessment dated [DATE] revealed the resident did not have a BIMS score because the resident is rarely/never understood. The MDS assessment documented the resident's feeding tube.
Review of Resident #1's Care Plan dated 3/13/2025 revealed the resident received Peg-tube water flush and Peg-tube feeding every shift. Resident received Levofloxacin 500 mg tablet via G-tube every 24 hours on every morning 7 days. Resident received Morphine Concentrate 100 mg/5mL oral solution 0.25 ml/mL sublingually every 2 hours as needed for pain. Resident received Tramadol 50mg tablet via G-tube every 12 hours as needed for pain. Resident received Propranolol 10 mg tablet 2 times per day via J-Tube. Resident received Acetaminophen 325 mg tablet via G-tube every 6 hours. Resident received Finasteride 5 mg tablet via G-tube every evening. Resident received Apixaban 5 mg tablet via G-tube 2 times per day. Resident received Metformin 500 mg tablet via G-tube 2 times per day. Resident received Gabapentin 100 mg capsule via G-tube at bedtime.
Observation of video dated 3/11/2025 at 1:10 pm in Resident #1's room revealed Resident #1's family member dropped Resident #1's syringe's plunger seal on the ground. RN A entered Resident #1's room. RN A was told by Resident #1's family member that they had dropped the syringe's plunger seal on the ground. RN A attempted to clean the plunger seal by rinsing it with water before administering medication. At 1:10 p.m. RN A administered medication with the syringe.
An interview with DON C on 3/12/2025 at 10:00 a.m. revealed that all nursing staff received in-service training on infection control and j-tube policies. She stated that the staff have been trained how to use piston syringes (a device that is calibrated with a hollow barrel and a movable plunger that is used for feeding tubes and liquid medication).
An interview with ADON E on 3/12/2025 at 11:30 a.m. revealed that all nursing staff received in-service training on infection control policies.
An interview with RN A on 3/13/2025 at 9:30 a.m. revealed he knew that he should have performed better infection control standards by not using the syringe that had fallen to the ground. He stated that the reason that he used the syringe was because it was the only one available to him at that time. He stated that, although there were other syringes in the facility's central supply, he did not want to get another one from central supply because those syringes belonged to the facility. He stated that Resident #1's syringes were being supplied by Hospice. He stated there would be an infection control risk if using a syringe that had fallen to the ground. He stated that he is not the person who dropped the syringe. He stated that he was not in the room at the time that the syringe's plunger seal had been dropped on the floor. He stated that Resident #1's family member had been in the room prior to him and had been the one to drop the syringe's plunger seal on the ground. He stated that when he arrived to administer medication, Resident #1's family member told him that they had dropped the syringe on the ground. He stated that he attempted to rinse it with water and clean it the best that he could before he administered medication to Resident #1.
An interview with LVN F on 3/13/2025 at 10:00 a.m. revealed that all nursing staff received in-service training on infection control policies and j-tubes. She stated that the DON will train you on how to provide j-tube treatment and instruct you to demonstrate it back to her. She stated that anyone who is a nurse should know that you should never use a syringe that has been on the ground.
An interview with LVN G on 3/13/2025 at 10:15 a.m. revealed that all nursing staff received in-service training on infection control policies and j-tubes. He stated that nurses are trained to not use a contaminated syringe such as one that has fallen to the ground. He stated there is a big risk of infection if you use a contaminated syringe because it is connected to tubing that goes directly into the stomach.
An interview with Medication Aide H on 3/13/2025 at 10:45 a.m. revealed that she had been trained on infection control and in-serviced. She stated that her job is to strictly pass medications. She stated that if she were to drop anything containing medication on the ground that she would use to pass medication then she would have to dispose of the container and get a new one. She stated that she knew using something that had fallen to the ground would be an infection control risk.
An interview with Physician D on 3/13/2025 at 4:15 p.m. revealed that there was a risk of contamination or infection if using a syringe that had fallen to the ground. The risk would be small. It is not likely to happen if it is a one time or isolated incident. The risk would increase if it was happening more than one time. It is not best practice or acceptable standards to use medication equipment that had fallen to the ground.
On 3/13/2025, at 12:25 PM RN A was observed during a routine medication administration for Resident #3 with a syringe using good technique.
2. Observation of photograph dated 3/10/2025 of Resident #1's syringe bag revealed Resident #1's syringe bag had the date 3/8/2025 written on it. The facility J-Tube policies revealed all equipment used must be changed every 24 hours. The syringe is used in conjunction with the J-Tube to deliver medication, flush the tube, and check its placement.
An interview with ADON E on 3/12/2025 at 11:30 a.m. revealed the syringes are supposed to be placed in a bad and sealed. They should also have the date written and changed nightly.
An interview with LVN F on 3/13/2025 at 10:00 a.m. revealed nurses are responsible for supplying a new syringe and dated bag for the syringe every 24-hours.
An interview with RN A on 3/13/2025 at 9:30 a.m. revealed he knew that he should have performed better infection control standards by not using a syringe beyond the 24-hour timeframe from when it was last used. He stated that the reason that he used the syringe was because it was the only one available to him at that time. He stated that, although there were other syringes in the facility's central supply, he did not want to get another one from central supply because those syringes belonged to the facility. He stated that Resident #1's syringes were being supplied by Hospice. He stated there would be an infection control risk if using a syringe beyond the 24 hour allotted timeframe. He stated that there was a lot of confusion during the dates of 3/8/2025 - 3/11/2025 as to whether or not Resident #1 was still actively receiving hospice care. He stated that he was informed that Resident #1's family may have revoked hospice and he did not know which materials to use for Resident #1. He did not know if he should use the facility's central supplies or if Hospice was responsible for Resident #1's materials.
An interview with LVN G on 3/13/2025 at 10:15 a.m. revealed syringes should be changed every 24-hours or as needed.
An interview with Physician D on 3/13/2025 at 4:15 p.m. revealed that there was a risk of contamination or infection if using a syringe beyond the 24-hour window. The risk would be small. It is not likely to happen if it is a one time or isolated incident. The risk would increase if it was happening more than one time. It is not best practice or acceptable standards to reuse equipment beyond the 24-hour timeframe.
On 3/13/2025, at 12:25 p.m. RN A was observed during a routine medication administration for Resident #3 with a syringe. The syringe bag was properly dated.
3. Review of the facility's Infection Control policy could not be completed because it was not provided before or after exiting the facility. Attempts were made via email and face to face with the facility Administrator and Director of Nursing on 3/12/2025 and 3/13/2025.
In an interview on 3/12/2025 at 9:30 a.m. Administrator B stated that he would provide the facility's infection control policy as requested.
Review of an e-mail dated 3/12/2025 at 10:19 a.m. addressed to Administrator B reflected the request of the Infection Control Policy.
In an interview on 3/13/2025 at 11:00 a.m. Administrator B stated that he would provide the facility's infection control policy as requested.
In an interview on 3/13/2025 at 11:30 a.m. DON C stated that she would provide the facility's infection control policy as requested. She stated that the reason for the delay was because of the size of the infection control policy. She stated that the policy is very broad. She stated that the policy covered many topics and was very long.
In an interview on 3/13/2025 at 1:25 p.m. DON C stated that she would provide the facility's infection control policy as requested.
The infection control policy was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 5 residents (Residents #18, #25 and #323) reviewed for resident rights.
1. The facility failed to ensure Resident #323's call light was within reach.
2. The facility failed to ensure Resident #25's call light was within reach.
3. The facility failed to ensure Resident #18's call light was within reach.
These failures could put residents at risk of not being able to call for assistance, have their needs met, and increases their risk for falls.
Findings include:
1. Record review of Resident #323's Quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #323 had a BIMS score of 12, which indicated moderately impaired cognition.
Record review of Resident #323 face sheet, dated 07/22/2024, reflected diagnoses which included chronic kidney disease (kidney damage that interferes with blood filtering), peripheral vascular disease hydrocephalus (cerebral fluid in brain), muscle weakness, unsteadiness on feet, keratoconus (condition that thins and distorts the cornea leading to vision loss) and hearing loss.
Record review of Resident #323 care plan, dated reviewed 07/08/2024, reflected the resident was at risk for falls and interventions were to keep the call light and most frequently used personal items within reach and to remind the resident to call when needing assistance.
Observation on 07/22/24 at 8:15 AM of Resident #323 revealed he was sitting up in bed with a pillow underneath each arm bent at about a 45-degree angle, both of his hands were resting on top of the pillows and were contracted. Resident #323's call light and bed remote were not within reach and were wrapped around the bottom of the left bed rail. Observation revealed Resident #323 was not able to reach any items on his nightstand which were behind the head of his bed when he was sitting up which included his hearing aids and water.
Interview on 07/22/24 at 08:15 AM with Resident #323 revealed he had been at the facility for several months and had trouble reaching items on the nightstand if he were in a seated upright position, his hands were contracted, and his left arm was partially paralyzed so he was not able to reach around or through the bed rail to reach either the bed remote or call light. Resident #323 stated quite often he was not able to reach the remote for the bed and the call light and did not know why it became tangled often and was not able to get out of bed without assistance. Resident #323 stated he felt frustrated when he could not reach the call light. Resident #323 stated other times it had happened; staff were not sure why the call light was tangled up.
Observation and interview on 07/22/24 at 8:33 AM with the Staffing Coordinator revealed she observed Resident #323's call light tangled around the bottom of the left bed rail. The Staffing Coordinator untangled and unwound the call light and the bed remote and placed it next to resident on his bed and stated sometimes the call light got tangled up when the resident was placed upright for meals. The Staffing Coordinator stated the call light should always be within reach of the resident, so they were able to call for assistance.
2. Record review of Resident #25's face sheet, dated 07/22/2024, reflected he was an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25 had diagnoses which included hypertension (high blood pressure), hyperlipidemia (high level of fats in blood), and pain.
Record review of Resident #25's Comprehensive MDS, dated [DATE], reflected he had diagnoses which included dementia (loss of cognition), stroke (disruption of blood supply to brain), septicemia (blood poisoning), depression (persistent feelings of sadness and low energy), and osteomyelitis (inflammation in the bone).
Record review of Resident #25's care plan reflected he was at risk for falls and was to have his call light and most frequently used personal items within reach and be reminded to use the call light when in need of assistance, dated 06/29/2024.
Observation and interview on 07/22/2024 at 8:40 AM of Resident #25 revealed he was lying in bed in a slightly upright position with his call light not within reach, it was hanging from the bottom of the right bed rail. Resident #25 stated he did not know where his call light was and could not reach it.
Interview on 07/22/2024 at 8:51 AM with LVN O revealed he had worked at the facility for almost a month and Resident #25's call light should always be placed near him. LVN O stated the call light was important to have within reach so he could ask for help if needed and he placed the call light in the resident's lap. LVN O stated that he was not sure why Resident #323 call light would be wrapped around the bed rail out of reach.
3. Record review of Resident #18's face sheet, dated 07/22/2024, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #18's had diagnoses which included senile degeneration of brain (loss of cognition), pain and neuromuscular dysfunction of bladder (lack of bladder control).
Record review of Resident #18's Comprehensive MDS, dated [DATE], reflected she had a BIMS score of 3, which indicated severely impaired cognition.
Record review of Resident #18's care plan reflected she had a terminal diagnosis and was on hospice services through Hospice Q with an onset date of 11/09/2023 and reviewed date of 07/16/2024. Review reflected she was at risk for falls and was to have her call light and most frequently used items within reach with an onset date of 11/09/2023 and reviewed date of 07/16/2024.
Observation on 07/22/24 at 9:19 AM of Resident #18 revealed she was lying flat on her bed wearing pants with a long sleeve shirt and was non-interviewable. Observation revealed her call light was on floor beside the head of her bed with two wheelchair footrests on top of the cord and plastic bags with trash in them on top.
Observation and interview on 07/22/2024 at 9:23 AM with CNA P revealed she worked for Hospice Q and provided care to Resident #18. CNA P entered the room to pick up the trash bags. CNA P stated when she came in to provide care for Resident #18 the call light was already on the floor, and she had not gotten around to pick it up yet. CNA P stated she left the room and did not place the call light within the resident's reach because she planned to come back. CNA P stated the call light was important to be within reach of residents, so they were able to call for help.
Interview on 07/22/24 at 9:27 AM with LVN O revealed he was the charge nurse for the hall of Residents #18, #25, and #323. LVN O stated the call light should be placed next to each resident, within their reach, to ensure they were able to call for help if needed. LVN stated that Resident LVN O stated CNA P should have placed the call light next to the resident even if she planned to come back into the room.
Interview on 07/23/24 at 11:37 AM with CNA N revealed she worked at the facility for about one year and was the lead CNA for Residents #18, #25 and #323 hall since June of 2024. CNA N stated she noticed a pattern during her morning shifts where some call lights were wrapped around the bed rails or were out of reach of residents. CNA N stated that there had been discussion in morning meetings about the concern. CNA N stated that management are now rounding in the mornings and was not sure when that started. CNA N stated rounds were conducted by CNA's and nurses upon the start of their shifts, they checked on the residents and ensured call lights were in reach. CNA N stated the call light should always be within reach either in the resident lap or pinned to their bed next to their hand because that's how they knew they could call for assistance. CNA N stated it was concerning that Resident's #18, #25 and #323 did not have their call lights within reach and Resident #18 and that all staff are responsible for ensuring a resident's call light is within reach. CNA N stated that CNA's were expected to ensure the resident had their call light within reach before they left the room.
Interview on 07/23/24 at 3:44 PM with the DON revealed her expectation was the call light should always be within reach, not over the side of the bedrail outside of reach, on the floor, or wrapped around a bedrail, so a resident was able to get to it because it was a resident's only way of communication. The DON stated she expected resident call lights to be placed within reach of a every resident anytime a staff member left the room, even if they intended to come back shortly.
Record review of facility's call light policy titled Call Lights Answering dated effective January 12, 2018, and Reviewed January 19, 2023, reflected The staff will provide an environment that helps meet the resident's needs by answering call lights appropriately . Procedure .7. When leaving the room, be sure the call light is placed within the resident's reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for one of five (Resident #50) reviewed for comprehensive care plans.
The facility failed to ensure Resident #50's care plan was person centered and comprehensive and did not address the resident's resistance to care and resistance to eating and drinking.
This failure could place residents at risk of not having individual needs met, not to receive needed services, and negatively impact their psychosocial health and wellbeing.
Findings included:
Record review of Resident #50's Comprehensive MDS, dated [DATE], reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #50 had diagnoses which included hypertension (high blood pressure), hyperlipidemia (high level of fats in blood), Alzheimer's disease (loss of cognition), anxiety disorder (feelings of anxiety or panic), and cataracts (clouding of eye lens). Resident #50 had a BIMS score of 0, which indicated severely impaired cognition.
Record review of Resident #50's care plan reflected there was a care area problem of wandering due to the resident being a new admission, highly confused and demented with interventions which included assessment of fall risk, determine pattern of wandering, keep a picture at the nurses station, and to make sure staff were aware of elopement risk with an onset date of 07/03/0024 and reviewed on 07/19/2024. There was a care plan area problem of altered nutritional status-the resident had missing teeth and interventions included to provide a snack between meals as preferred, provide favorite foods and beverages, and monitor intake of meals. Review of the care plan revealed there were no problem areas that showed Resident #50 refused meals, resisted being fed by staff, resisted care by staff or was combative.
Observation on 07/22/24 at 9:26 AM of Resident #50 revealed she was lying in bed asleep with her call light within reach.
Interview on 07/22/24 at 11:34 AM with the Resident Representative (RR) for Resident #50's representative revealed when she was first admitted to the facility things were rocky, staff were waking her up in a way that startled the resident and after she spoke with the DON about her concerns it seemed to be better. RR stated that Resident #50 does not know how to eat by herself and she asked staff multiple times to place some food on her lip so she tasted it first and if she refused to eat then she should be provided an Ensure. RR stated that she buys and keeps the Ensures in the resident's room but when she comes to visit it seemed as if they were not used. RR stated that she felt like she had to reeducate staff often, it's like one shift person is not communicating to the other. RR stated she was not sure if the Ensure and strategy she asked staff to take when feeding Resident #50 were care planned.
Record review of Resident #50's care plan reflected no care area or problems related to resisting care or meals or the RR preference to provide the resident with an Ensure if the resident did not eat a meal.
Observation on 07/23/24 at 08:55 AM of Resident #50 revealed she was sitting in the wheelchair in her room next to the bed with a breakfast tray in front of her had oatmeal, toast with jam that was about 90% eaten and the oatmeal looked mixed but uneaten. The resident was not responsive to questions and stated she was doing well.
Observation on 07/23/2024 at 8:57 AM revealed MA L attempted to administer a nutrition boost to Resident #50 she walked into the resident's room with small transparent cup about a ¼ full of a pink liquid solution. MA L told resident Here, take your Ensure- it is good for you and Resident #50 shook her head, said no, and pushed the hand away of MA L when she tried to place the cup on the resident's lips. MA L attempted to lift the cup to the resident's mouth two other times and the resident pushed it back and frowned and shook her head. MA L repeated herself and stated here, take your Ensure, it is good for you and Resident #50 said is it good for me? MA said Yes, it is. Try it. and Resident #50 shook her head and said I don't think so. MA L told Resident #50 the drink was good for her and to try it and handed it to resident who took the cup and took a large drink but did not finish about a ¼ of the solution. MA L prompted Resident #50 to drink the rest of the solution and the resident refused then MA L left the room.
Interview on 07/23/24 at 9:00 AM with MA L revealed she started working at the facility about 5 months ago and was familiar with Resident #50. MA L stated Resident #50 was commonly confused in the mornings or any time after she woke up from sleeping. MA L stated Resident #50 commonly resisted taking medication. MA L stated when Resident #50 refused her medication then MA L tried a couple of more times and tried cuing and prompting the resident and if she still did not take her medicine then she would try to persuade a little later and sometimes that helped. MA L stated Resident #50 took a lot of cuing and prompting to eat and the resident became very resistant if you tried to feed her and gave her an Ensure if she did not eat all her food. MA L stated she attempted to have Resident #50 take the nutritional boost supplement but she would not drink all of it.
Interview on 07/23/24 at 11:00 AM with the Wellness Director revealed she was familiar with Resident #50 and she didn't stay still all the time and would like to care plan other independent activities such as one on one's and aroma therapy but had not had the opportunity to do so. The Wellness Director stated she did not create care plans, she provided input during a resident's quarterly and annual reviews.
Interview on 07/23/24 at 11:28 AM with LVN O revealed he was familiar with Resident #50 and was the charge nurse for her hall. LVN O stated Resident #50 was new to the facility, had dementia, was on hospice services, and her RR visited often. LVN O stated Resident #50 enjoyed drinking Ensure and sometimes she resisted care or taking medications. LVN O stated he knew to take his time when he administered medications or care for Resident #50.
Interview on 07/23/24 at 11:37 AM with CNA N revealed she had worked at the facility for about one year and was the lead CNA for Resident #50's hall since June 2024. CNA N stated she was familiar with Resident #50 and she was very combative when provided with care, did not like to eat, and needed to be a 3 person assist due to the behaviors during care. CNA N stated Resident #50 would kick and scratch and refused to be changed. CNA N stated she tried for 10-15 minutes yesterday to get the resident to eat some oatmeal but all she ate was toast with grape jelly. CNA N stated she saw the resident eat hush puppies and seasoned fish the RR brought in for the resident and offered Resident#50 grapes or bananas or gave her an Ensure. CNA N stated she noticed Resident #50 enjoyed the strawberry flavor more than chocolate. CNA N stated she was not sure if Resident #50's behaviors were care planned.
Interview on 07/23/24 at 1:07 PM with the Dietician revealed she was not very familiar with Resident #50 and she last saw her on 07/08/2024. The Dietician stated Resident #50's refusal of the nutrition boost solution should have been documented and her preference for Ensure, which included preferred flavor, should have been care planned. The Dietician stated she was not aware the RR had Ensure in the Resident's refrigerator and asked staff to give Resident #50 an ensure if she did not eat much or refused her meal.
Interview on 07/23/2024 at 4:05 PM with LVN U revealed she was familiar with Resident #50 and worked at the facility since November of 2023. LVN U stated Resident #50 had dementia and resisted taking medications and care. LVN U stated Resident #50 had scratched her when resisting care. LVN U stated sometimes the RR was able to get Resident #50 to cooperate with staff and sometimes the RR needed help from staff.
Interview on 07/24/24 at 2:42 PM with the MDS Nurse revealed she had a care plan meeting on 07/01/2024 with Resident #50's RR, the Rehabilitation Manager, and the Social Services Director was present. The MDS Nurse stated typically nursing was included in the care plan meeting and did not remember if nursing was in the meeting. The MDS Nurse stated she was responsible for creating the care plans and she depended on the rest of the interdisciplinary team to inform her of changes that required care planning. The MDS Nurse stated she remembered they discussed Resident #50 had wandering behaviors and did not like to eat and did not remember anyone mentioning other behaviors. The MDS Nurse stated she thought she heard Resident #50 was resistant to care and was not sure when or how she knew of it and did not know if it was care planned or not. The MDS Nurse reviewed Resident #50's care plan and stated the only behaviors that were care planned were the wandering behaviors she had when she was living with the RR. The MDS Nurse stated the care plan notes she had the care area or problem of anti-anxiety based not having a prescription for lorazepam 1 mg as needed for anxiety and did not know what she had anxiety about. The MDS Nurse stated the care plan was comprehensive because the resident had not been given any doses of lorazepam and did not require personalized interventions for a medication she had not yet received. The MDS Nurse stated she did not care plan any interventions for Resident #50 resisting care or specific food preferences because she was not aware of them. She stated that care plans were important because they show what a residents needs and problem areas were.
Interview on 07/24/24 at 3:20 PM with the DON revealed her expectation was care plans should be personalized to the resident and if a resident had a diagnosis or problem with anxiety there should be personalized interventions that showed what situations the anxiety was displayed or what prevented anxiety for that resident. The DON stated she would expect the MDS nurse to speak with nursing to obtain their input of what they were seeing if they were not present in a care plan meeting.
Record review of the facility's care plan policy titled Comprehensive Care Plans, dated effective 01/12/2018 and reviewed 04/17/2023, reflected:
Policy: It is the policy of this facility to develop and implementation a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .
Record review of the facility's psychotropic drug use policy titled Psychotropic Drugs-Use, dated effective 02/12/2020 and revised 07/27/2022 reflected:
.5. Address the documented behaviors in the patient/resident care plan, including:
A. Problem (s)
B. Patient/Resident specific goals
C. Outcomes
D. Interventions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for one of six residents (Resident #57) reviewed for ADL care.
The facility failed to ensure Resident #57 had her fingernails trimmed.
This failure could place residents at risk for loss of dignity, risk for infections and a decreased quality of life.
Findings include:
Record review of Resident #57's Quarterly MDS assessment, dated 07/10/2024, reflected Resident #57 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension ( high blood pressure) , bipolar disorder (mental illness associated with episodes of mood swings from depressive lows to manic highs), viral pneumonia (infection of the lungs caused by a virus) , chronic pulmonary embolism ( a blockage of pulmonary arteries that happens when a blood clot does not dissolve over time despite treatment) , and depression (a low mood or loss of interest in activities, causing an impairment in daily life). Resident #57 had a BIMS score of 14, which indicated Resident #57's cognition was intact. Resident #57 required supervision with personal hygiene.
Record review of Resident #57's Comprehensive Care Plan, revised 7/14/2024, reflected the following: Care Area: Self Care Deficit. Goal: Bathing: [Resident#57] will assist with bathing and hygiene on a daily basis. Interventions: Encourage [Resident #57] to participate in ADLs and praise accomplishments.
An observation and interview on 07/22/24 at 10:33 AM revealed Resident #57 was lying down in the bed in her room. The nails on both hands were approximately 0.5 centimeter in length extending from the tip of his fingers and some of them were chipped. Resident #57 stated she did not like her long nails; she wanted them short and was unable to cut them by herself. She stated she did not ask the staff to trim her nails because she did not want to be in trouble .
In an interview on 07/22/24 at 01:33 PM with CNA B, he stated both CNAs and LVNs were responsible for nail care during shower days and as needed. He stated if a resident had diabetes, only nurses were allowed to provide nailcare. He stated the risk for not performing nailcare was increased risk of infection.
In an interview on 07/22/24 at 01:53 PM with RN C revealed both CNAs and RN/LVN could provide nailcare to the resident. She stated Resident #57 had very long nails and she did not remember if she had any refusals. She stated she would ask if podiatry would want to cut her fingernails. She stated the risk for not performing nailcare was increased risk of infection and skin break down. She stated she would ask the incoming nurse for 2-10 shift on 7/22/24 to trim Resident #57's fingernail .
In an interview on 07/22/24 at 03:06 PM with the DON revealed her expectation was nail care should be provided every shower day and as needed. She stated both CNAs and Nurses were responsible for doing nail care on all residents; except Nurses were responsible for nailcare if resident had diagnosis of diabetes. She also stated the Podiatrist was only called for toenails on as needed basis. She stated as the DON she rounded residents frequently and checked if ADLs were performed. The DON stated residents who had dirty fingernails could be an infection control issue.
In an interview on 07/23/24 at 10:07 AM with the ADON E revealed her expectation was nail care should be provided every shower day and as needed. She stated both CNAs and Nurses were responsible for doing nail care on all residents; except Nurses were responsible for nailcare if resident had a diagnosis of diabetes. She also stated Podiatry only did toenails, and they were not called for fingernails. She stated as the ADON she conducted spot checks and daily rounds for monitoring. The ADON stated residents who had long, chipped fingernails could be an infection control issue.
In an interview on 07/24/24 at 10:09 AM with LVN D revealed CNAs were responsible for cleaning and clipping fingernails on shower days for all residents, except resident with a diagnosis of diabetes. She stated CNAs were to notify the Nurse should resident refused nailcare. She stated she had taken care of Resident #57 several times in the past and had not heard of any refusals with ADL care. She stated she offered nailcare to Resident #57 and clipped her nails on 7/22/24 after RN C notified her. She stated resident with long, chipped, dirty fingernails could be at high risk of infection.
Record review of the facility's policy titled Bathing, revised February 12, 2020, reflected, . Perform hand hygiene and perform nail care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for three of four residents (Resident #5, Resident #44 and Resident #176) reviewed for catheter and incontinence care.
1. The facility failed to ensure the Staffing Coordinator and CNA F maintained the foley catheter drainage bag below Resident #5's bladder during a mechanical lift transfer.
2. The facility failed to ensure CNA G provided appropriate and timely incontinence care for Resident #44 on 07/23/24.
3. The facility failed to ensure the Therapist did not place the urine catheter bag on the floor during the transfer of Resident #176 from his bed to the wheelchair.
These failures could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections.
Findings included:
1. Record review of Resident #5's quarterly MDS assessment, dated 06/06/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS of 3, which indicted he was severely cognitively impaired. Resident #5 required substantial/maximum assist with toileting and transfers, had an indwelling catheter and was always incontinent of bowel. Resident #5 had diagnoses which included neurogenic bladder (loss of bladder control due to brain, spinal cord, or nerve problems) and hemiplegia (paralysis that affects one side of the body).
Record review of Resident #5's care plan, with an onset date of 06/16/24, reflected, Suprapubic catheter (catheter that in inserted through the abdomen into the bladder) .Goal-Resident will be free of complications of indwelling catheter over the next 90 days .Interventions .Keep catheter tubing placed below level of bladder .use leg strap to avoid pulling catheter
Record review of Resident #5's Consolidated order, dated 07/24/24, reflected .Foley catheter 16 FR every shift to continuous gravity drainage and catheter care .with a start date of 05/30/24.
Observation on 07/22/24/24 at 10:45 a.m. revealed the Staffing Coordinator and CNA F entered Resident #5's room to get the resident up for the day. The Staffing Coordinator placed the catheter drainage bag, which had approximately 200 cc of urine, on the bed while preparing to place the mechanical lift sling under the resident. Both staff positioned the resident on the sling. The Staffing Coordinator picked up the catheter drainage bag and placed it top of Resident #5's abdomen. The staff raised the resident from the bed with the catheter drainage bag remained on the resident's abdomen, above the resident's bladder. Urine was observed flowing back toward the resident's bladder. The staff then positioned him over his wheelchair and lowered him into his chair and then placed the catheter bag onto the side of his wheelchair.
In an interview with the Staffing Coordinator on 07/22/24 at 10:50 a.m., she stated she was trained to always keep the catheter drainage bag below the bladder. She stated she was just not thinking. She stated having it above the bladder could possibility cause the urine to run backwards, which could cause an infection. She stated placing the bag on the bed could cause a risk of cross contamination. She stated she was the one who performed the skills checks on the CNA staff and could not recall if it included how to handle the catheter drainage bag during a transfer but stated it would always need to be below the bladder.
In an interview with CNA F on 07/22/24 at 10:55 a.m., she stated they should not have placed the catheter bag in Resident #5's lap. She stated she should have said something when the Staffing Coordinator placed it on Resident #5's lap. when the resident held out his hand for the bag, they just handed it to him without thinking. She stated she knew the catheter bag and tubing were to be kept below the bladder to prevent urine from backing up and might cause an infection.
Record review of the Staffing Coordinator skill checks, dated 04/16/24, reflected she was competent in Indwelling catheter care and hand hygiene.
2. Record review of Resident #44's significant change in status MDS assessment, dated 05/25/24, reflected a [AGE] year-old male with an admission date of 11/03/21 and readmission date of 11/13/23. Resident #44 was unable to participate in the interview for cognition and was assessed by the staff to be severely impaired. He was dependent for ADL care and was always incontinent of urine and bowel. His active diagnoses included respiratory failure with hypoxia (not enough oxygen in the blood). In Section O-Special Treatments, Procedures, and Programs it reflected he required tracheostomy care and oxygen therapy during the 14 days look back period.
Record review of Resident #44's care plan, reviewed on 06/12/24, reflected, .At risk for problems with elimination .Requires extensive assistance for toileting .Skin Breakdown: at risk for/actual related to history of rash/dermatitis .Interventions. Check resident every two hours and assist with toileting as needed .Provide peri care after each incontinent episode .Keep skin clean, dry, and free of irritants
An observation on 07/23/24 at 03:09 p.m. revealed CNA F and CNA H entered Resident #44's room to provide incontinence care. Both staff performed hand hygiene and put on gloves. LVN J entered the room and placed the G-tube pump on hold. CNA F opened the resident's brief to reveal another brief wadded up into a ball and placed over the resident's penis. CNA F stated this was not normal and no resident should be double briefed. CNA F removed the wadded-up brief, which revealed the resident's scrotum was red. CNA F provided peri care and with assistance from CNA H turned the resident over on his side to reveal he had saturated through the brief and the draw sheet down to the bed. Resident #44's buttocks was red with creases noted in skin, but no skin breakdown. CNA F provided peri-care and applied barrier cream to the resident's buttocks.
In an interview with CNA F on 07/23/24 at 03:10 p.m., she stated she worked the 6-2 p.m. shift today as well but had not assisted with his care. She stated CNA G was assigned to Resident #44 and asked her once to help with his care, but she stated she was giving a shower and was not sure who assisted her. She stated resident #44 was a heavy wetter so they had to check him frequently.
In an interview with the 6-2 p.m. Charge nurse, LVN I on 07/23/24 at 03:35 p.m., she stated CNA G had not requested assistance from her with incontinent care for Resident #44 on her shift.
In an interview with CNA G on 07/23/24 at 03:40 p.m., she stated she was assigned to Resident #44 today (07/23/24) and provided incontinence care to him around noon. She stated she had given him a bed bath and shaved him. She stated, I did it and I know it was wrong, she stated she placed the wadded-up the brief on him because she did not want him to be soaked when she came back for her final check, but stated she forgot to go back and check him and remove the brief before her shift and ended at 02:00 p.m. She stated she knew she was not supposed to do what she did. She stated she provided the care to him by herself because there was no one available when she needed the assistance. She stated she knew better and should not have done what she had done.
Record review of CNA G's skill checks, dated 07/02/24, reflected she was competent in perineal care.
3. Record review of Resident #176's Comprehensive MDS assessment, dated 07/22/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS of 13, which indicted he was cognitively intact. Resident #176 required substantial/maximum assist with toileting and transfers, had an indwelling catheter. Resident #176 had diagnoses included metabolic encephalopathy (a neurological disorder that occurs when a chemical imbalance in the blood caused by an illness or organ dysfunction affects the brain) and kidney failure.
Record review of Resident #176's care plan, with an onset date of 07/20/24, reflected, Urinary catheter (catheter that in inserted into the bladder through the urethra to allow urine to drain from the bladder for collection) .Goal-Resident will be free of complications of indwelling catheter over the next 90 days
Observation on 07/23/24/24 at 11:16 AM revealed the Therapist and CNA K entered Resident #176's room to provide incontinent care and get the resident up for therapy. The Therapist assisted CNA K to provide incontinent care to Resident #176. After completion of the continent care the Therapist proceeded to transfer Resident #176 from bed to wheelchair. The Therapist placed the catheter drainage bag, which had approximately 200 cc of urine, on the floor while assisting Resident #176 to sit on the bed. She instructed the resident to sit closer to the edge of the bed, she helped him to do so. While the catheter drainage bag was still on the floor, the Therapist assisted Resident #176 to the standing position using the walker to support Resident #176 in the standing position. The Therapist positioned the resident on the wheelchair. She picked up the catheter drainage bag from the floor and put in the dignity bag and hanged it onto the sides of his wheelchair. The Therapist removed her gloves, washed her hands and Resident #176 in his wheelchair to therapy room.
In an interview with the Therapist on 07/23/24 at 11:30 AM, she stated she was trained to always keep the catheter drainage bag out of the floor. She stated she just overlooked it. She stated placing the bag on the floor would cause a risk of cross contamination. She stated she was supposed to hang the urine bag on the side of the bed or the side of the wheelchair.
In an interview with the DON on 07/24/24 at 10:00 a.m., she stated any resident with a foley catheter should always have the bag and tubing below the bladder and should never be placed on the bed or in the resident's lap. She stated placing the bag on the floor would place residents at risk of a urinary tract infection and cross contamination. She stated not keeping the foley catheter bag below the resident's bladder, placed them at risk of a urinary tract infection and cross contamination. She stated all the staff had been trained numerous times on the expectation of performing hand hygiene after completion of care, after removing gloves and before they leave the resident's room. She stated at no time was the staff to ever brief a resident double she stated this placed at resident at risk of skin breakdown and increased risk of urinary tract infections. She stated the expectation was staff were to check and change if needed every 2 hours, or if the resident was a heavy wetter, then it needed to be more frequent. She stated to ensure staff were knowledgeable in the care of indwelling catheter and hand hygiene and peri-care the facility did skills competency checks and she stated she and the ADONs made daily rounds and watched care. She stated she did spot checks on residents to ensure they were receiving timely care.
Record review of the facility's policy titled, Urinary Catheter Infection Prevention, dated January 2022, reflected, All personnel involved in the handling and maintenance of catheters are periodically trained on the methods and techniques utilizing current recommendations and the facility policies .Whenever handling catheters or urinary drainage systems hands are washed both before and after .Gravity drainage bags are positioned below the level of the patient's bladder .Gravity drainage bags are kept off the floor. If these inadvertently touch the floor, clean the outside of the bag using soap and water or appropriate disinfectant
Record review of the facility's policy titled, Perineal Care, dated, April 2024, reflected, Staff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, including tracheostomy care and tracheal suctioning, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for one of one resident (Resident #44) reviewed for tracheostomy care.
The facility failed to ensure LVN I maintained a sterile/clean field for supplies necessary for tracheostomy care.
The facility failed to ensure LVN I kept her dominant (right) hand sterile while providing trach care and tracheal suctioning for Resident #44.
These failures could place residents at risk for respiratory infections.
Findings include:
Record review of Resident #44's significant change in status MDS assessment, dated 05/25/24, reflected a [AGE] year-old male with an admission date of 11/03/21 and readmission date of 11/13/23. Resident #44 was unable to participate in the interview for cognition and was assessed by the staff to be severely impaired. He was dependent for ADL care and was always incontinent of urine and bowel. His active diagnoses included respiratory failure with hypoxia (not enough oxygen in the blood). In Section O-Special Treatments, Procedures, and Programs it reflected he required tracheostomy care and oxygen therapy during the 14 days look back period.
Record review of Resident #44's Physician consolidated orders, dated 07/24/24, reflected, .Trach Care 2 times per day Bivona size 7. Cleanse outer trach stoma with NS, Pat Dry Apply dressing. Change ties when soiled ., with a start date of 06/13/24.Suction Trach as needed . with a start date of 02/22/24.
Record review of Resident #44's care plan, reviewed on 06/12/24, reflected, .Tracheostomy .Trach Care 2 times per day .Suction trach as needed .Goal .Effective airway will be maintained and monitored over the next 90 days .Interventions .Change dressings and ties every day or when they become soiled .Clean tracheostomy tube, inner cannula per physician's order .Observe stoma for redness, swelling, bleeding and signs of infection
In an observation on 07/22/24 at 10:05 a.m. revealed LVN I entered Resident #44's room to change out the oxygen tubing, the suction machine tubing and performed the resident's daily trach care. LVN I connected the oxygen tubing and removed the old tubing from the suction machine and replaced it with new tubing and then opened a package of sterile trach suction kit and attached the suction catheter to the suction machine tubing and placed it in a plastic bag handing on the chest of drawers next to the residents bed. She then placed 2 paper containers on top of the chest of drawers and filled them with normal saline. She then sanitized her hands, put on gloves, and cleaned the bedside table with a germicidal wipe and allowed to dry. She removed her gloves and performed hand hygiene. She then placed a piece of wax paper on top of the bedside table and sat out her supplies which included 4 x 4 gauze (unsterile), trach care kit, extra trach ties. LVN I then washed her hands put on a gown and gloves and removed the old stoma dressing from around the trach. She removed her gloves and washed her hands. She then opened the trach care kit and pulled out the sterile drape and placed it to the side as well as the brush, q tips and neck ties and removed sterile gloves and placed them on the wax paper. She put on the sterile gloves and then reached around and picked up the paper container on top of the chest of drawers containing the normal saline and poured it into the trach care tray, thus contaminating her gloves. LVN I then placed some gauze in the saline and wiped around the stoma site, which caused the resident to cough up phlegm. She then wiped away the phlegm with more gauze and then took the brush, dipped it into saline, cleaned the outside to the trach and then entered the end of trach with the brush, which then caused the resident to cough again. LVN I then reached into the bag with the same gloves used to clean the stoma and wipe away the phlegm and removed the tracheal suctioning catheter and inserted it into the trach and suctioned the resident. She then placed the suctions catheter back into the plastic bag hanging on the chest of drawers. LVN I then opened a package with a stoma dressing and placed the clean stoma dressing around the trach. LVN I then removed her gloves and put on a new pair of utility gloves without performing hand hygiene and replaced the trach ties.
In an interview with LVN I on 07/22/24 at 10:40 a.m., she stated she used the trach brush when he coughed up the phlegm. She stated she was not aware she should not use the brush on the trach. She stated she knew she messed up with the sterile gloves. She stated she was trained on trach care but she just forgot some of the steps. She stated she knew trach care and suctioning was supposed to be sterile. She stated she should not have placed the tracheal suction tubing in the plastic bag.
In an interview on 07/24/24 at 11:35 a.m., the DON stated trach care was considered a sterile procedure. She stated when LVN I contaminated her gloves and did not follow the proper steps of trach care she posed the risk of respiratory infections to the resident. She stated all the staff assigned to Resident #44 had been skills checked by their contracted RT just a few months ago.
In an interview on 07/23/24 at 10:52 a.m., with the facility's RT Consultant, she stated she was contracted with the facility to provide Respiratory evaluations and provided training to the staff on trach care and was available by phone for any questions. She stated they did a class in May with the staff that needed tracheostomy care training. She stated LVN I was in the class. She stated LVN I did not pass the first competency test and had to review the procedure again but did pass the second time. She stated she told the ADON she would need some monitoring until she built up her confidence in her skill level. She stated she was teaching trach care as a clean technique, but stated the staff needed to have all their supplies opened and set up prior to putting on the sterile gloves to prevent the risk of cross contamination and infection. She stated the staff needed to change gloves and perform hand hygiene when going from dirty to clean and had never been taught to place the suction catheter into a plastic bag.
In a follow up interview with the DON on 07/24/24 at 10:05 a.m., she stated going forward she was going to be the one ensuring the nurses assigned to specialty care were trained and qualified and she and her ADONs would be doing more frequent skills checks and monitoring of the staff and provided more frequent refresher classes. She stated LVN I had been re-educated and skills checked on 07/22/24.
Record review of LVN I skills Respiratory competency evaluation reflected she had been skills checked on Tracheal Suctioning and Tracheostomy care on 05/24/24 and again on 06/13/24.
Record review of the facility's policy, Tracheostomy Care' dated March 2023, reflected, Staff will provide care for residents with a tracheostomy in accordance with standard practice Guidelines
Record review of the facility's skills check titled, The Nursing Services-Respiratory Competency Evaluation for Tracheostomy care, dated March 2023, reflected .Verify orders for type and size of tracheostomy tube and inner cannula.
.Gather trach care kit and suctions supplies, ensure emergency supplies are kept at bed side . Wash hands and apply PPE appropriate for risk of contact with secretions .Suction and clear airway if needed .Open and prepare trach care kit .Wash hands and apply gloves .Grasp the flange with dominant hand .Cleanse outer cannula surfaces and skin around the stoma using a circulation motion from stoma site outward .While securing trach tube, remove old tracheostomy tie .replace trach ties ensuring one or two finger widths between neck and tie .Ensure tube is midline and replace dressing under faceplate
Record review of the facility's skills check titled, Tracheal Suctioning, dated March 2023, reflected, .Test suction machine with thumb applied to tubing .Wash hands and apply PPE appropriate to risk of exposure to secretions .Open sterile water or normal saline. Open sterile catheter and place on sterile filed .Fill basin with about 100 ml of sterile normal saline .then don sterile gloves without contamination .Pick up suction catheter with dominant hand without touching non-sterile surface, pick up connection tubing with non-dominant hand and connect to catheter .Place tip o catheter in sterile basin and suction small amount of solution .Insert catheter gently but quickly through tracheostomy without suctioning .Apply suction during removal of catheter for no more than 10-15 seconds .Allow resident to time between suctioning .dispose of supplies .perform hand hygiene

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 4 carts (Med Aide cart hall 500) reviewed for pharmacy services.
The facility failed to ensure LVN S and LVN R, responsible for Med Aide cart hall 500, counted controlled drugs every shift change and signed the narcotic sheet form after the count.
This failure could place residents at risk of not having the medication available due to possible drug diversion.
Findings include:
Record review and observation on 07/22/24 at 8:40 AM of Med Aide Cart halls 500, revealed missing signatures for Off duty and On duty for 07/02/24, 07/03/24, 07/04/24, 07/05/24, 07/06/24, 07/11/24, 07/12/24, 07/15/24, 07/16/24, and 07/18/24 of the narcotic count sheet.
Interview on 07/24/24 at 03:06 PM, LVN S stated she should have signed the narcotic sheet after counting the narcotics on 07/11/24, 07/12/24, 07/15/24, 07/16/24, and 07/18/24 because it was the proof that she counted with the other nurse . LVN S stated the risk of not signing the narcotic sheets would be a potential for drug diversion. She stated she did not remember why she did not sign the narcotic sheet for all those days .
Interview on 07/24/24 at 03:45 PM, LVN R stated he should have signed the narcotic sheet before and after counting the narcotics on 07/02/24, 07/03/24, 07/04/24, 07/05/24, and 07/06/24 . LVN D stated, I counted the narcotics but forgot to sign. LVN R stated it was very important to count before he took the keys. He stated he might get busy after he counted with the other nurse and he forgot to go back and sign the count sheet. He stated this failure could potentially cause a drug diversion.
Interview on 07/24/24 at 10:00 AM, the DON stated she expected nurses to sign the narcotic count sheet at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated if the staff were not signing the narcotic count sheets, she was unable to prove they were counting. The DON stated it was important to ensure a drug diversion did not occur. The DON stated the ADON, and the DON were supposed to check the cart randomly for monitoring . Medication count was done and no drug diversion was noticed.
Record review of the facility's policy Controlled Medication Storage, dated September 2007, reflected the following: . 6. At each shift change or when keys are surrendered, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report. The nursing care center may elect to count all controlled medications at shift change

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen reviewed for food safety.
1.
The facility failed to discard food stored in the refrigerator that should no longer be consumed.
2.
The facility failed to ensure food item in the walk-in refrigerator had use-by date and labeled .
3.
The facility failed to ensure a bin of hard-boiled eggs in the walk-in refrigerator was appropriately covered .
These failures could place residents at risk for food-borne illness and food contamination.
Findings include:
Observation on 07/22/24 at 08:13 AM in facility's walk-in refrigerator revealed a half-used container of chopped garlic in water with an expiration date of 7/3/24.
Observation on 07/22/24 at 08:14 AM in facility's walk-in refrigerator revealed a white, cream-like food in one-gallon Ziplock bag that was unlabeled and undated. The zip-lock bag was placed in a medium-size brown corrugated box that had packaged cheese blocks.
Observation on 07/22/24 at 08:15 AM in facility's walk-in refrigerator revealed hard-boiled eggs in a large plastic bin that were not securely covered and left exposed.
In an interview on 07/23/24 at 12:53 PM with [NAME] A revealed everyone in the kitchen was responsible for covering, dating, and labeling food items, she stated she was serving breakfast on the morning of 7/22/24 and forgot to securely close the lid of the hard-boiled egg bin after using the eggs for breakfast. She also stated she did not identify the white unlabeled, undated items in the facility refrigerator since she did not place it there. She stated the cooks were usually responsible for checking expiry dates on food items before using them and the expired food items should be promptly thrown away after notifying the dietary manager. She stated they were in serviced in the past about labeling each food item if it was out of its original container and writing the use-by date on it. She stated the risk of using expired food products for cooking or not appropriately dating, labeling, covering food items could lead to residents being sick and possible food contamination.
In an interview on 07/23/24 at 12:58 PM with Dietary Manager revealed her expectation was all kitchen staff were responsible for dating, labeling, and covering food items. She stated the unlabeled and undated food item in the refrigerator was left over yogurt that was poured into the zip-lock bag and should have been labeled with yogurt as well as had a use-by date on it. She also stated it should not be placed in the cheese box and would re-educate the kitchen staff on appropriate dating and labeling of food items. She stated cooks were responsible for overseeing expired food items in the kitchen and needed to follow First-In-First-Out protocol for all food items. She stated there were low in staffing on the morning of 7/22/24 and the cook who was serving breakfast may have left the egg bin exposed and forgot to close the lid tightly. She stated as the Dietary Manager, she made rounds in the kitchen every morning to ensure all foods were appropriately date, labeled and covered each day; however, was unable to do so on 7/22/24 since she was busy with helping for Breakfast service. She stated the risk to residents for using expired food products or not dating, labeling, covering food was lapses in infection control in the kitchen and food contamination .
In an interview on 07/23/24 at 1:12 PM with the Dietitian revealed her expectation was all food items in the kitchen were labeled, dated with a use-by date, and covered appropriately by all kitchen staff. She stated her expectation was all foods should be checked for expiry dates and expired foods should be promptly thrown away and the Dietary Manager should be notified. She also stated unlabeled, undated, food items could not be identified and needed to be thrown away. She stated there was a risk for residents to get sick with possible food borne illness/infection if expired, undated, unlabeled, uncovered food items were used in the facility's only kitchen .
Record review of the facility's policy titled Food Storage, revised February 6, 2024, reflected.2. Refrigerator: .All foods are covered, labeled, and dated .Facility policy for Expired food items was not available for review
Record review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 16 residents (Resident #7, Resident #18, Resident #13, Resident#16, Resident#176, and Resident#5) reviewed for infection control.
1. The facility failed to ensure MA L disinfected the blood pressure cuff in between blood pressure checks for Residents #7 and #18.
2. The facility failed to ensure MA M disinfected the blood pressure cuff in between blood pressure checks for Residents #13 and #16.
3. The facility failed to ensure CNA K performed hand hygiene while providing incontinence care to Resident # 176.
4. The facility failed to ensure the Staffing Coordinator performed hand hygiene after completion of a mechanical lift transfer for Resident #5 and prevented cross contamination when the catheter drainage bag was placed on the resident's bed
These failures could place residents at risk of cross contamination which could result in infections or illness.
Findings include:
1.Record review of Resident #7's Quarterly MDS assessment, dated 04/26/24, reflected Resident #7 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included type 2 diabetes mellitus, elevated blood pressure, and stroke (damage to the brain from interruption of its blood supply). Resident #7 had a BIMS of 12, which indicated Resident #7's cognition was moderately impaired.
Record review of Resident #18's Quarterly MDS assessment, dated 02/12/24, reflected Resident #18 was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included senile degeneration of brain (cognitive decline in older people, especially memory loss), and neuromuscular dysfunction of the bladder (a urinary tract condition that occurs when the nerves and muscles of the urinary system don't work together properly.) Resident #18 had a BIMS of 99, which indicated Resident #18 was unable to complete the interview (impaired cognition.)
Observation on 07/22/24 at 7:25 AM revealed MA L performed morning medication pass, during which time she checked the blood pressure on Resident #7. MA L did not sanitize the blood pressure cuff before and after using it on Resident #7, continued to the next resident without sanitizing the blood pressure cuff. MA L then checked Resident #18's blood pressure. MA L did not sanitize the blood pressure cuff before using it on Resident #18.
Interview on 07/22/24 at 7:50 AM, MA L stated reusable equipment, like blood pressure cuffs, should be sanitized before and after use on each resident in order to keep germs from spreading. She stated she forgot to sanitize the blood pressure cuff between residents use because she was nervous.
2. Record review of Resident #13's Quarterly MDS assessment, dated 07/09/24, reflected Resident #13 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included elevated blood pressure, and cerebrovascular accident (damage to the brain from interruption of its blood supply). Resident #13 had a BIMS of 00, which indicated Resident #13's cognition was severely impaired.
Record review of Resident #16's Comprehensive MDS assessment, dated 06/19/24, reflected Resident #16 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included fracture of left lower leg and elevated blood pressure. Resident #16 had a BIMS of 15 which indicated Resident #16's cognition was unable intact.
Observation on 07/22/24 at 8:10 AM revealed MA M performed morning medication pass, during which time she checked the blood pressure on Resident #13. MA M did not sanitize the blood pressure cuff before and after use on Resident #13 and continued to the next resident without sanitizing the blood pressure cuff. MA M then checked Resident #16's blood pressure. MA M did not sanitize the blood pressure cuff before using it on Resident #16.
Interview on 07/22/24 at 8:15 AM, MA M stated reusable blood pressure cuffs, should be sanitized before and after use on each resident. She stated the risk of not sanitizing the blood pressure cuff between use would be cross contamination and spread of infections. She stated she forgot to sanitize the blood pressure cuff between use on Resident #13 and Resident #16.
3. Record review of Resident #176's Comprehensive MDS assessment, dated 07/22/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS of 13 which indicted he was cognitively intact, required substantial/maximum assist with toileting and transfers, had an indwelling catheter. Resident #176 had diagnoses which included metabolic encephalopathy (a neurological disorder that occurs when a chemical imbalance in the blood caused by an illness or organ dysfunction affects the brain) and kidney failure.
Record review of Resident #176's care plan, with an onset date of 07/20/24, reflected Urinary catheter (catheter that in inserted into the bladder through the urethra to allow urine to drain from the bladder for collection) .Goal-Resident will be free of complications of indwelling catheter over the next 90 days .Problem: at risk for problems with elimination. Goal: Decrease in number of incontinent episodes
Observation on 07/23/24 at 11:01 AM revealed CNA K and Therapist entered Resident #176's room to provide incontinence care. Both staff washed hands and donned gloves and gowns CNA K unfastened the brief and cleaned the front pubic area using incontinent wipes. The resident was assisted onto his side. CNA K discarded the dirty gloves, without hand hygiene she donned clean gloves. The Therapist held the resident and CNA K cleaned the resident's buttocks area using several wipes which revealed a smear of bowel movement. CNA K discarded the dirty gloves, without hand hygiene, she donned clean gloves, she placed a clean brief under the resident. Both staff repositioned the resident back on his back. CNA K gathered the dirty clothes and trash, removed her gloves and washed her hands.
In an interview on 07/23/24 at 11:35 AM, CNA K stated she was to wash hands before and after care. CNA K also stated she was supposed to complete hand hygiene after removing the dirty gloves. CNA K stated she did not complete hand hygiene between change of gloves because she was rushing. CNA K stated she was supposed to complete hand hygiene to prevent the spread of infection.
4. Record review of Resident #5's quarterly MDS assessment, dated 06/06/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS of 3, which indicted he was severely cognitively impaired, required substantial/maximum assist with toileting and transfers, had an indwelling catheter and always incontinent of bowel. Resident #5 had diagnoses which included neurogenic bladder (loss of bladder control due to brain, spinal cord, or nerve problems) and hemiplegia (paralysis that affects one side of the body).
Record review of Resident #5's care plan, with an onset date of 06/16/24, reflected Suprapubic catheter (catheter that in inserted through the abdomen into the bladder) .Goal-Resident will be free of complications of indwelling catheter over the next 90 days .Interventions .Keep catheter tubing placed below level of bladder .use leg strap to avoid pulling catheter
Observation on 07/22/24/24 at 10:45 a.m. revealed the Staffing Coordinator and CNA F entered Resident #5's room to get the resident up for the day. The Staffing Coordinator placed the catheter drainage bag, which had approximately 200 cc of urine, on the bed while preparing to place the mechanical lift sling under the resident. Both staff positioned the resident on the sling. The Staffing Coordinator picked up the catheter drainage bag and placed it on top of Resident #5's abdomen. The staff then positioned him over his wheelchair and lowered him into his chair and then placed the catheter bag onto the side of his wheelchair. The Staffing Coordinator removed her gloves and left the room with the mechanical lift without performing hand hygiene.
In an interview with the Staffing Coordinator on 07/22/24 at 10:50 a.m., she stated she was trained to always keep the catheter drainage bag below the bladder. She stated she was just not thinking. She stated placing the bag on the bed could cause a risk of cross contamination. She stated she was supposed to perform hand hygiene after completion of care and before she left the room and she had not done that. She stated she received numerous trainings on hand hygiene.
In an interview with the DON on 07/24/24 at 10:00 a.m., she stated any resident with a foley catheter should always have the bag and tubing below the bladder and should never be placed on the bed or in the resident's lap. She stated not keeping the foley catheter bag below the resident's bladder, placed them at risk of a urinary tract infection and cross contamination. She stated all the staff were trained numerous times on the expectation of performing hand hygiene after completion of care, after removing gloves and before they left the resident's room. She stated staff were trained on the expectation of sanitizing blood pressure cuffs after each use. She stated to ensure staff were knowledgeable in the care of indwelling catheter, hand hygiene, and sanitation of blood pressure cuff the facility did skills competency checks and she stated she and the ADONs made daily rounds and watched care.
Record review of the Staffing Coordinator skill checks, dated 04/16/24, reflected she was competent in Indwelling catheter care and hand hygiene.
Record review of the facility's policy titled, Hand Hygiene for Staff and Residents, dated January 2022, reflected, Purpose-To reduce the spread of infection with proper hand hygiene .Hand hygiene is done before resident contact .after contact with soiled or contaminated articles, such as articles that are contaminate with body fluids .Resident Contact .toileting or assisting other with toileting, or after personal grooming .removal of medical/surgical or utility gloves .Note: Wash hands at end of procedures where glove changes are not required .Contact with a resident's intact skin .Contact with environmental surface int eh immediate vicinity of resident
Record review of the facility's policy titled, Disinfecting and Sterilizing Resident Care Equipment dated January 2022, reflected, . non-critical items are those that either do not ordinarily touch the resident or touch only intact skin. Such items include crutches, bed boards, blood pressure cuffs and other medical accessories. These items rarely transmit disease. However, it is imperative that these items are clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures to prevent abuse to ensure residents were free from abuse for one (Resident #1) of 10 residents reviewed for abuse.
1) The facility deprived goods abuse for Resident #1.
2) CNA B, LVN C, LVN D, and Staffing Coordinator reported an allegation of abuse and neglect on 01/01/24 to the Administrator, who is the Abuse Coordinator immediately when they found Resident #1 soaked in urine and bowel movement.
These failures could affect the residents by placing them at risk for a delay in intervention and Providing ADL care including incontinent care and life-saving treatments that could lead to psychosocial harm.
Findings included:
Review of facility's policy Abuse, Neglect and Exploitation and Misappropriation of Resident Property dated 06/23/17 reflected, The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (Unit) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property .
3.2 All facility staff members have a duty to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the Administrator of the facility, who serves as the Abuse Coordinator . In the Administrator's absence, the Director of Nursing (DON) or another designee will be appointed to function as the interim Abuse Coordinator . Upon learning of a suspected incident of resident abuse, neglect, exploitation, and/or misappropriation of resident property, the Charge Nurse or other Department Manager or Supervisor must immediately notify the Abuse Coordinator or the DON of the incident. The person receiving the report or designee must document all incidents of alleged abuse/neglect on incident reports, which are to forwarded directly to the Abuse Coordinator .
Review of Resident #1's admission MDS assessment dated [DATE] revealed he was [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Critical illness myopathy (significant slowing of the muscle fiber) , hypertension, pneumonia, Diabetes mellitus, aphasia (loss of ability to understand or express speech, caused by brain damage) , Cerebrovascular Attack , Respiratory Failure, Dysphagia (difficult swallowing) , tube feeding dependent (Tube feeding is a therapy where a feeding tube in inserted into the abdomen ans supplied nutrients to people who cannot get enough nutrition through eating). Resident #1 required extensive assistance of at least two people with Activities of Daily Living. He was totally dependent with transfers and bathing. It revealed that resident#1 was always incontinent of urine and bowel. MDS assessment revealed BIMS of 99 indicating resident had sever cognitive impairment.
Review of Resident #1 admission Care plan dated 12/9/2023 revealed Resident #1 at risk for problems with Elimination (updated 1/6/24) . Administer stool softeners, laxatives, suppositories or enemas as ordered; Monitor for signs and symptoms of urinary tract infection; Requires two-person assistance with bowel, bladder, and ADL; Uses brief.
Review of Resident #1's physician order dated 12/20/23 revealed Resident #1 was on Furosemide 20 mg tablet 1 tablet by mouth per day which was prescribed for DX of primary hypertension (high blood pressure). ( Furosemide is a diuretic will make a resident urinate more often to remove the body of excess fluid/fluid retention).
Review of Resident #1's physician order dated 12/23023 revealed Resident #1 was on Nystatin 100,000 unit/gram topical cream 2 times per day for rash on the perineal area.
Review of Resident # 1 ADL Documentation on EHR for 12/31/23- 1/1/24 revealed incontinent care documented at 9 pm on 12/31/23 and 10 am on 1/1/24. There was no documentation of incontinent care on the ADL in the electronic health record or paper documentation.
Observation on 1/3/24 at 2:18 PM of Resident #1 room revealed resident had Blink camera in the room that detects any motion close to the resident in the room. Observed Resident #1 was lying in the bed and covered with sheets. Resident #1 looked groomed, and no odors noted. Also observed tube feeding pump next to the bed and infusing tube feed formula. Observed call light within reach.
Interview with Resident #1 attempted on 1/3/24 at 2:20 PM revealed resident is not verbal and cannot respond as stated by the resident's #1 Family Member A that was present in the room.
Interview with Resident#1's Family Member A and Family Member B on 1/3/24 at 2:18 PM revealed that she was very concerned that Resident#1 was not changed during the night shift of 12/31/23. Resident# 1 admitted to the facility on [DATE]. She stated when she came to the facility around 11am on 1/1/24, she noted that resident#1's side support pillow and other pillow was placed on the chair in the room and was soaking wet and smelled of urine. She picked up the pillow from the chair and saw the chair was wet from the pillow. Shen then called Resident#1 Family Member B to check if she could review the camera to see when Resident#1 was last changed.
Family Member A also stated that per camera placed in the room revealed Resident#1 was not changed or repositioned from 12/31/23 at 9:05 PM until 1/4/24 at 10:20 AM. She also stated that she had requested LVN D to reposition Resident#1 around 7 AM on 1/1/24 through the camera. She then stated that she went to LVN D who told her he started his shift at 6 AM on 1/1/24 and did not know which nursing staff was assigned for Resident #1 that worked on night shift of 10am - 6AM on 12/31/23. Family Member A asked LVN D if he received shift report in the morning for Resident# 1's care and which nursing staff provided the report. Per Family Member A , LVN D refused to talk to the Family Member A and directed her to the front office. She stated that she was not able to find any Admin nursing staff and was told ADON B had left for the day. Family Member A also revealed that she had complained to the DON regarding her concerns with Resident# 1 ADL care earlier on 12/18/23 and approached the DON that Resident#1 needed two people assist on all ADL's including incontinent care. She also stated that on the night shift on 12/17-12/18/23 CNA A was changing and repositioning the resident by herself incorrectly when Resident #1's Family Member B intervened from the camera and had to come to the facility at midnight to make sure that Resident #1 was okay. She stated that resident's Family Member B spoke with Charge Nurse LVN I on 12/18/23 who stated that she will have another CNA care for the resident for that night. She also stated that Resident#1's Family Member B spoke with the DON on 12/21/23 regarding needing two people assist on all ADL care including incontinent care and repositioning. She stated DON reported it was not the facility policy to turn the resident every 2 hours, but the DON and wife agreed on checking on the resident every four hours.
Interview with LVN D on 1/4/24 at 2:36 PM revealed that he had started working in the facility around November 2023, he reported he was the LVN who was taking care of Resident #1 on 1/1/24 morning shift from 6am-2 pm. He reported that he checked on Resident #1 around 7am on 1/1/24 and administered his G-tube (meds and checked Resident#1's blood glucose. He also reported that he briefly lifted Resident#1 sheets and it appeared that Resident #1's brief was dry. He stated that he did not physically check on Resident#1 for incontinence. He also stated that Family Member A talked to him from the camera around 7 am on 1/1/24 when he was providing G-tube care to the resident and asked him to reposition Resident#1. He reported that since Resident#1 was a 2-person assist, LVN D went to look for CNA and could not find the CNA, so he continued with his med pass and blood glucose checks to other residents in the hall. LVN D reported he did not reposition Resident #1. LVN D also stated that the Staffing Coordinator and CNA B provided incontinent care and repositioning around 10 am on 1/1/24.
He also reported that Resident #1 Family Member A came to him at the nurse's station around 11am on 1/1/24 stating that Resident #1 was not changed on the night shift of 12/31/23 and asked for nursing staff that took care of the resident the previous night. LVN D redirected the Family Member A to the front office. He reported that Family Member A came to him again after some time (around noon) asking to put nystatin ointment on resident's peri-area by herself. LVN D informed Family Member A that since the ointment is a prescribed medication, it will need to be applied by a nursing staff. LVN D stated he did not feel comfortable entering the resident's room by himself and hence he, along with Staffing Coordinator entered the Resident's room and applied Nystatin ointment for resident#1. LVN D reported that nystatin was applied to resident's peri care area between 12:15 PM - 12:30 PM on 1/1/24.
LVN D reported that Nystatin was started on Resident #1 on 12/30/23 for diaper rash and it was usually used for fungal infection or skin irritation and can be caused if area was wet for a long time. LVN D stated that he did not report the allegation from the Family Member A that the resident was not changed over several hours of night shift to anyone. LVN D reported when he started at the facility about a month ago, he was provided with several in services that included abuse and neglect as well. He defined neglect as resident not being provided the needed care and services by the facility. He stated he knew to report any allegation of abuse and neglect to the Abuse Coordinator immediately. He stated that if the allegation from the Family Member A was true that the resident indeed did not receive incontinent or ADL care during the night shift, it looked like neglect to him, and he should have reported it then.
Interview with CNA E on 1/3/24 at 2:42 PM revealed that she worked in the facility for last 8-9 months. She usually worked the 2PM -10 PM shift. She had taken care of Resident #1 in the past and was aware with Resident #1 care needs. She reported that Resident #1 needed two-person assist with all ADL care and she always takes help from the Nurse or CNA from other halls for changing or repositioning the resident. She reported that she was not aware of rounding policy for the facility, but she rounded on her residents at least every two hours. She also reported that Resident#1 has Nystatin cream for diaper rash that was always applied by Nursing staff when they change the resident.
She also reported that he was provided abuse and neglect in services in the past and defined neglect as resident not getting the needed goods or services. She also stated that if a resident had not been provided ADL care may result in neglect and should be reported to the administration team immediately.
Interview with LVN C on 1/3/24 at 2:50 PM revealed that he worked at the facility for about 2 years. He reported that he worked the night shift 10PM - 6AM on 12/31/23. He reported that he hung a new tube feeding bag and reprogrammed the feeding pump around 10:30-11 PM on 12/31/23, but he did not check resident for incontinent care at that time nor did he repositioned Resident #1 at that time. LVN C also stated that he did not repositioned or provided incontinent care to Resident #1 at all during his shift because he thought the CNA would have provided that care. He also reported that he was the Charge Nurse for the unit on the night of 12/31/23. He reported as a Charge Nurse, he assigned residents to CNA's that they need to take care of during their shift. He reported that Resident #1 was assigned to CNA A along with all other residents on 500, 600, 700 Hall. He reported he became aware of the incident that family alleged that resident was not provided ADL care including incontinent care on the night shift of 12/31/23 when Resident #1's Family Member A approached him during his afternoon shift 2PM- 10 PM on 1/1/24. LVN C also stated that CNA A did not tell him that she will not be caring for Resident#1 anytime during the night shift of 12/31/23 when they worked the halls together. He stated that when he spoke with CNA A around 10 PM on 1/1/24 she told him she assumed he knew that she will not take care of Resident#1 because of some prior concerns that CNA A had with resident#1's family. He further added that he asked CNA A if she communicated this with him beforehand OR ask for swapping residents so other CNA could take care of the resident OR made nursing administration aware of her dispute or displeasure to work with Resident #1, CNA A replied NO to all his questions. He also stated that since CNA's usually take care of all ADL's, he did not check whether Resident #1 was provided ADL care including incontinent care. He also stated that Resident #1 was two persons assist and that most CNA's will ask for help from Nurses on the floor or CNAs from other halls. LVN C reported that he had received in-services on abuse and neglect and defined neglect as not providing good and services to the resident. He also said that CNA A not providing care was an example of neglect. He also stated that he was going to report the alleged Neglect to the Abuse Coordinator soon but waited to speak with CNA A about the incident.
Interview with ADON B on 1/3/24 at 3:05 PM revealed that she was familiar with Resident#1's care. She stated she spoke with Resident#1's Family Member B during the admission care conference. She had not spoken with the Family Member regarding family's concern for two persons assist for ADL's; however, she was aware of family requesting two-person assist with ADL care from the DON. She stated that she was not aware if DON had filed any grievance report regarding family concern of resident care. She also reported that family approached her about 30 minutes before this interview regarding their allegation of Resident#1 not being provided ADL care included incontinent care during the night shift of 12/31/23. She also stated that no other staff member including Charge nurses, CNA or floor Nurses reported the allegation to her before the Family Member . She reported she will file a grievance report and investigate the incident soon. She also reported that she was the on-call Nurse Manager for night shifts of 12/30/23, 12/31/23 and 1/1/24. She also stated that she had not reported the allegation of potential neglect for not providing care to the resident at the time of this interview and was preparing to send the email to the Abuse Coordinator . ADON B stated that if Family Member A 's allegation of not providing resident with ADL care throughout the night shift was true, that would be an example of neglect since the resident was not provided with service he needed. She also reported that any resident can have rash in peri area if the area was wet for long time. She also stated that resident#1 cannot reposition himself and her expectation was staff checked on resident every two hours for ADL care. She stated that if ADL care including incontinent care was not provided in a timely manner it can lead to rash, skin breakdown and Resident's dignity and comfort can be compromised.
Attempted phone interview with CNA A on 1/3/24 3:16 PM, left Voicemail to call back.
In a phone interview with CNA A on 1/4/24 9:03 AM she revealed she was aware of Resident#1's care. She stated she worked the night shift 10PM -6AM on 12/31/23 and was assigned to the Resident#1's care per assignments provided to her by the Charge Nurse, LVN C. She also stated that she did not provide any ADL care including incontinent care or repositioning to Resident #1 on the night shift from 10PM-6AM on 12/31/23. She did not know if any other CNA or LVN provided care to the resident that night. She reported that she had a situation with the Family Member s of Resident#1 roughly 2 weeks ago, she did not remember the exact date - but thought it was around 18/19th of December. CNA A stated that the family was rude to her and was not happy with the ADL care she provided to the resident the night of December 18th. She stated the incident was reported to LVN I who was charge Nurse that shift since the family came to the facility at midnight. She reported she failed to communicate with LVN C about her decision to not provide care to Resident#1 on the night shift and further stated that she assumed LVN C was aware of her previous incident with the family and her decision to not care for Resident #1. She also stated that it was her fault for assuming and not communicating with the Charge Nurse regarding her decision to not provide care. She reported that the risk to dependent resident for not providing ADL care including incontinent care over a period of 8-hour shift could lead to skin breakdown and diaper rash. She also revealed she has been provided Inservice regarding abuse and neglect. She defined neglect as not providing service to the resident. She acknowledged that her decision of not providing ADL care to Resident #1 and not communicating her decision to the Charge Nurse on the night of 12/31/23 was a form of neglect. She reported that when she worked on the night shift of 1/1/24 at the facility, she had a conversation with LVN C about care not being provided on 12/31/23. She also stated that she continued to work in the facility on 1/1/24 on a different hall and was not assigned to care for Resident #1.
In an interview with CNA B on 1/4/24 9:28 AM revealed that she worked the morning shift 6 AM-2PM on 1/1/24 and was assigned to care for residents on three halls that included Resident#1. She reported that when she came to work in the morning, call lights for most residents were on and she was trying her best to take care of the resident needs one by one. It took her some time, after breakfast, around 10 AM to go and check on Resident #1. She reported since Resident #1 was a two person assist for ADL's including incontinent care, she called for help from Staffing Coordinator , who was also an LVN to change the resident. She reported that as soon as she moved the support pillow it was soaking wet in urine. Then they removed the covers, Resident #1 was covered with urine from head to toe, brief was saturated with urine, and had a small bowel movement as well. They proceeded to clean, change and repositioned Resident #1. She reported that Resident #1 was not verbal but had a distressed look on his face She also stated that the support pillow was left on the chair in the resident's room to dry and sheets were taken to laundry since they were saturated in urine. She also reported that when she came back to the resident's hall, she saw that the call light for Resident #1 was on, and the Family Member A was coming out of Resident #1 room to the nurse's station. The Family Member A looked very upset and stated to CNA B that Resident# 1 was not changed through the entire night shift and showed CNA B the video recording of last time the resident was changed, which was around 9 pm on 12/31/23. She also asked for Nystatin cream to apply on Resident#1. CNA B reported that she would inform LVN D and left the room. She then communicated with LVN D regarding Family Member
A 's request for Nystatin cream. CNA B left to pass out Lunch trays after that. CNA B reported that she has been trained on abuse and neglect and defined neglect as not providing care to the resident. She also stated that she was aware any allegation of abuse and neglect needed to be reported to Abuse Coordinator immediately. She also stated that Family Member A alleged of resident#1 not been provided care during the night shift was an example of neglect. She stated that she told the Staffing Coordinator to bring it up in the morning meeting for the next day but did not report it to the Abuse Coordinator immediately per policy since she was very busy on her shift.
In an interview with Staffing Coordinator on 1/4/24 9:45 AM, she revealed she worked on 1/1/24 from around 8:30 am to 7PM and was providing care on the floor. She reported that she was called by CNA A to assist with ADL care for Resident#1. Around 10 am, when CNA A and Staffing Coordinator went to Resident#1, they found that Resident #1's sheet and pillows, support pillows were soaked in urine and had some feces in his brief. They cleaned, changed, and repositioned Resident #1. She was then called around noon by LVN D to help apply Nystatin cream to Resident#1. She reported Resident#1's Family Member A was present in the room, was visibly upset and complained that resident#1 was not changed or repositioned for the entire night shift of 12/31/23. Staffing Coordinator reported she had been provided several in services about abuse and neglect and defined neglect as resident not being provided goods and services. She revealed that Family Member A 's allegation of not providing care to the resident was an example of neglect and failed to report it to the Abuse Coordinator immediately per facility policy. She also reported that most residents should be checked or provided care every 2-3 hours but stated it also depended on staffing ratios. She was not sure if there was a facility policy on how often resident should be provided ADL care by the Nursing staff. She reported that if a resident is not provided ADL care including incontinent care, it can lead to skin breakdown and possible infections. She also reported that she was responsible for scheduling and was not aware of CNA A's concern with providing care to Resident #1. She stated that if she was made aware she would have not had CNA A work in the unit; Resident #1 was present.
In an interview with DON interview on 1/4/24 2:30 PM revealed that her expectation for dependent resident with incontinence was that there was no facility policy on how often residents should be checked for continence or nursing rounds. She expected that dependent resident who need incontinent care be changed when they were visibly spoiled or as needed and Nursing to round throughout the shift. DON also stated that as a Registered Nurse, she would check on resident at least three times per shift. DON stated that CNA and Nurses were responsible for providing ADL care, including incontinent care. She also reported that if CNA did not provide care to a resident, it was her expectation that she would notify Charge Nurse or Nursing administration immediately. She also stated that Staffing Coordinator was responsible for scheduling and assigning CNAs to the residents for all the shifts.
The DON also stated there she was not aware of any restrictions for any CNA's that cannot go to resident room and if there were any restrictions Staffing Coordinator should have been aware. If there were any changes to be made, Charge Nurses can reassign CNAs on duty as needed. DON reported that she was not aware if CNA A had any restrictions on caring for Resident#1 and hence there was no communication to Nurses on the floor. She also stated that CNAs cannot make a decision about not caring for Resident that they were assigned to. If CNA had any reservation regarding resident's care, she should be communicating it with charge nurses or nursing administration.
DON stated that she was aware Resident#1's family had some concerns with care provided by CNA A since the family spoke to the DON about it on the 12/18/23 and 12/21/23. DON reported that resident#1 family was speaking to CNA A over the camera that Resident #1 was a two person assist and that she was providing care by herself. She also reported that family came to the facility midnight and verbal threats that were made by family and CNA A. DON reported she was not sure if any grievances were filed regarding the incident, but she was still investigating the incident at the time of this interview. DON reported that management had not provided any direction to CNA to not enter Resident #1's room or provide care to Resident #1. DON also stated Resident #1 is on therapy and needed maximum assistance for transfers, however not for all ADL care. DON reported that maximum assistance was defined as resident needing 2 people to provide care. She stated that Resident#1's family requested two persons assist on all ADL cares. DON reported the risk to resident for not providing ADL care that included incontinent care for dependent resident may lead to skin breakdown and infections.
DON defined Abuse and Neglect as follows : Abuse is willfully doing something wrong to the resident that may result in harm. Neglect defined as not providing service or goods to resident. DON also stated that if CNA does not provide care to the resident assigned to her is an example of neglect. She sated she expected staff to report any allegation of abuse and neglect immediately to the Abuse Coordinator , who is the Facility Administrator and DON was the backup for Abuse Coordinator .
In an interview with Facility Administrator on 1/4/24 at 3:03 PM revealed that he was made aware of the incident regarding allegation that CNA A did not provide ADL care including incontinent care to Resident #1 on 1/3/24 at 3:45 PM. He reported that he was in the process of investigating the incident and was talking to Nursing Staff from Night shift of 12/32/23 and Morning shift of 1/1/24. He also reported that CNA A was suspended yesterday (1/03/24) pending outcome of the investigation. Administrator stated that he had provided numerous in-services to all staff for abuse and neglect, and it was his expectation to report any allegation of abuse and neglect to him immediately. He defined abuse willfully, regardless of intent, harming the resident and Neglect was when good or services are not provided to the resident. He added that he explained that his simple explanation to staff regarding abuse and neglect was To abuse to occur - I must be facing you.
To neglect - I actively turn my back on you. He stated that as an Abuse Coordinator , his role was to investigate the allegation thoroughly and report to TX HHS within 2 hours of the incident . He also reported that he was not aware of any grievance filed by resident # 1 family. He stated that about a week after Resident #1 admission, around 17th or 18th of December , family had concerns with care provided by CNA A and requested two persons assist for all ADL care. DON spoke with the family and provided Inservice that Resident #1 will need two persons assist for all ADL care. He also stated that Management had not tell CNA A that she could not go to Resident #1 room or take care of the resident. He continued I think it's her (CNA A )impression that she could not go to the room.
Administrator also reported that risk to a dependent resident for not providing ADL care including incontinent care is potential skin breakdown and infections.
Review of CNA A's timesheet from 12/30/23-01/01/24 revealed CNA A worked on the 10pm-6 am shift. CNA was scheduled to work on 01/03/24 but was suspended after surveyor intervention on 1/3/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of seven residents (Resident #1 and Resident #3) observed for infection control.
The facility failed to ensure:
1-MA BB donned the face mask correctly when she entered Resident#3' isolation room.
2-ADON B and CNA O performed hand hygiene during incontinence care for Resident # 1.
These failures could place the residents at risk for infection.
Findings include:
1- Review of Resident #3's significant change MDS dated [DATE] reflected Resident #3 was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of cancer, heart failure, hypertension, diabetes. Resident #3 required partial/moderate assistance with ADLs except for eating, oral hygiene and upper body dressing.
Review of Resident #3's physician order dated 12/28/23 for Resident #3 on droplet precaution for 10 days.
Observation on 01/03/24 at 10:57 AM revealed MA BB had PPE gown with gloves and had surgical face mask under her N95 mask with the N95 mask lower strap hanging down. She did not have any goggles or face shield when entering Resident #3's room to give Resident #3 her medications.
Interview on 01/03/24 at 11:04 AM with RN V revealed facility staff should be wearing full PPE when entering resident room on droplet precautions and positive for COVID. He stated full PPE included gown, gloves, N95 and face shield or goggles.
Interview on 01/03/24 at 11:06 AM with MA BB revealed she should have worn the N95 mask properly without the surgical mask underneath along with face shield or goggles when giving Resident #3 her medications and taking her blood pressure. She stated Resident #3 was on droplet precautions due to covid positive status. She stated it was important to wear proper PPE when going into resident room on droplet precautions so not to contaminate.
Review of facility's staff Inservice for Isolation for droplet infection and days on isolation dated 12/24/23 reflected MA BB was in-serviced by DON along with other facility staff.
2- Review of Resident #1's admission MDS assessment dated [DATE] revealed he was [AGE] year-old male admitted to the facility on [DATE] with diagnoses included critical illness myopathy (significant slowing of the muscle fiber), diabetes mellitus, aphasia (loss of ability to understand or express speech, caused by brain damage), tube feeding dependent (a feeding tube supplies nutrients to people who cannot get enough nutrition through eating). Resident #1 required extensive assistance of at least two people with Activities of Daily Living. He was totally dependent, 2 persons assist with transfers and bathing, Toileting hygiene, and dressing. Resident#1 was always incontinent of bowel and bladder. assessment revealed BIMS of 99 indicating resident had severe cognitive impairment.
Observation on 01/04/23 at 9:15 AM revealed CNA O providing incontinent care to Resident #1. CNA O was observed cleaning Resident #1's front area with wipes. CNA O with the help of ADON B positioned the resident on the side and cleaned the resident's bottom area. Observation revealed small bowel movement. After cleaning the resident CNA O took off and discarded the dirty brief and without any form of change of gloves or hand hygiene, CNA O applied the clean brief. ADON B applies skin cream to the resident bottom area. ADON B changed gloves without any form of hand hygiene. CNA O and ADON B positioned resident on his back; ADON B applied skin cream to the resident's front pubic area. ADON B changed gloves without any form of hand hygiene. CNA O and ADON B positioned resident in bed, they changed his gown. ADON B changed gloves without any form of hand hygiene, she turned on the feeding pump. She removed and discarded dirty gloves and completed hand hygiene. CNA O without any change of gloves and without any form of hand hygiene she positioned pillows to support resident's position. CNA O removed and discarded gloves and completed hand hygiene.
In an interview on 01/04/24 at 9:30 AM, CNA O stated she was to wash hands before and after care. CNA O also stated she was supposed to change gloves and complete hand hygiene after taking the resident's dirty brief off. CNA O stated she did not complete hand hygiene or change gloves after cleaning the resident because she forgot. CNA O stated she was supposed to change gloves and complete hand hygiene to prevent the spread of infection. CNA O stated she had an in-service on infection control about two weeks ago.
In an interview on 01/04/24 at 10:00 AM, the ADON B stated she supposed to perform hand hygiene between gloves change. She stated she did not sanitize her hand between change of gloves because she forgot to bring the sanitizer with her in the room. She stated failing to do these steps risk cross contamination and increased the risk of infections.
In an interview on 01/04/23 at 02:04 PM with the DON she stated during incontinent care the staff were to complete hand hygiene before and after care. DON also stated in between care staff were to complete hand hygiene and change gloves because the hands were considered dirty after cleaning the resident. The DON stated the staff were to complete hand hygiene during care to prevent the spread of infection.
Record review of the facility's policy COVID - 19, revised August 2023, reflected .H- PPE . 2. COVID - 19 PPE. a. The required PPE for COVID - 19 isolation rooms or when providing care or services to a COVID - 19 positive resident or a resident suspected of having COVID - 19, staff should wear an N95, face shield or goggles, gown and gloves
Record review of the facility's policy titled, Perineal Care, revised January 2018, reflected, .8. Turn resident to clean all areas of buttocks with new wipe or section of washcloth. 9. Dispose of gloves and used supplies and perform hand hygiene. 10. Apply new gloves and place new brief .
Record review of the facility's policy Hand Hygiene, revised January 2022, reflected .Procedure: 1. Hand hygiene is done: . After . H. Removal of medical/surgical or utility gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one (Resident #1) of 10 residents reviewed for ADLs.
The facility failed to provide incontinent care to Resident #1 for 13 hours on 12/31/23 9:05 pm to 01/01/24 at 10:22 AM.
CNA A was assigned to Resident #1 and failed to provide care to Resident #1 on night shift.
Resident #1 was not provided incontinent care for over 13 hours (including 8 hours of night shift of 12/31/23 and part of 1/1/24 day shift) on 12/31/23 9:05 pm to 01/01/24 at 10:22 AM. On 01/01/24 when Staffing Coordinator and CNA B provided incontinent care and found Resident #1's clothing and bedding soaked urine. Resident #1's brief was soaked in urine and had bowel movement.
These failures could place residents at risk of delay in ADL care including incontinent care and life-saving treatments, which could result in psychosocial harm.
Findings included:
Review of Resident #1's admission MDS assessment dated [DATE] revealed he was [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Critical illness myopathy (significant slowing of the muscle fiber) , hypertension, pneumonia, Diabetes mellitus, aphasia (loss of ability to understand or express speech, caused by brain damage) , Cerebrovascular Attack , Respiratory Failure, Dysphagia (difficult swallowing) , G-tube feeding dependent (G-tube is a tube inserted through the belly that brings nutrition directly to the stomach). Resident #1 required extensive assistance of at least two people with Activities of Daily Living. He was totally dependent with transfers and bathing. It revealed that resident#1 was always incontinent of urine and bowel. MDS assessment revealed BIMS of 99 indicating resident had severe cognitive impairment.
Review of Resident #1 admission Care Plan dated 12/9/2023 revealed Resident #1 is on Diuretic therapy , Furosemide 20 mg tablet 1 tablet 1 time per day; Resident will have decrease in edema during drug therapy.
( Furosemide is a diuretic will make a resident urinate more often to remove the body of excess fluid/fluid retention).
Review of Resident # 1 ADL Documentation on EHR for 12/31/23- 1/1/24 revealed incontinent care documented at 9 pm on 12/31/23 and 10 am on 1/1/24. There was no documentation of incontinent care on the ADL in the electronic health record or paper documentation.
Interview with Resident#1's Family Member A and Family Member B on 1/3/24 at 2:18 PM revealed that she was very concerned that Resident#1 was not changed during the night shift of 12/31/23. Resident# 1 admitted to the facility on [DATE]. She stated when she came to the facility around 11am on 1/1/24, she noted that resident#1's side support pillow and other pillow was placed on the chair in the room and was soaking wet and smelled of urine. She picked up the pillow from the chair and saw the chair was wet from the pillow. Shen then called Resident#1 Family Member B to check if she could review the camera to see when Resident#1 was last changed.
Family Member A also stated that per camera placed in the room revealed Resident#1 was not changed or repositioned from 12/31/23 at 9:05 PM until 1/4/24 at 10:20 AM. She also stated that she had requested LVN D to reposition Resident#1 around 7 am on 1/1/24 through the camera. She then stated that she went to LVN D who told her he started his shift at 6 AM on 1/1/24 and did not know which nursing staff was assigned for Resident #1 that worked on night shift of 10am -6AM on 12/31/23. Family Member A asked LVN D if he received shift report in the morning for resident# 1's care and which nursing staff provided the report. Per Family Member A , LVN D refused to talk to the Family Member A and directed her to the front office. She stated that she was not able to find any Administration nursing staff and was told ADON B had left for the day.
Family Member A also revealed that she had complained to the DON regarding her concerns with Resident# 1 ADL care earlier on 12/18/23 and approach the DON that Resident#1 needed two people assist on all ADL's including incontinent care. She also stated that on the night shift on 12/17-12/18/23 CNA A was changing and repositioning the resident by herself incorrectly when resident's Family Member B intervened from the camera and had to come to the facility at midnight to make sure that Resident #1 was okay. She stated that resident's Family Member B spoke with Charge Nurse LVN I on 12/18/23 who stated that she will have another CNA care for the resident for that night. She also stated that Resident#1 Family Member B spoke with the DON on 12/21/23 regarding needing two people assist on all ADL care including incontinent care and repositioning. She stated DON reported it was not the facility policy to turn the resident every 2 hours, but the DON and wife agreed on checking on the resident every four hours.
Interview with LVN D on 1/4/24 at 2:36 PM revealed that he had started working in the facility around November 2023, he reported he was the LVN who was taking care of Resident #1 on 1/1/24 morning shift from 6am-2 pm. He reported that he checked on Resident #1 around 7am on 1/1/24 and administered his G-tube (meds and check resident#1's blood glucose. He also reported that he briefly lifted Resident#1 sheets and it appeared that Resident #1 brief was dry. He stated that he did not physically check on Resident#1 for incontinence. He also stated that Family Member A talked to him from the camera around 7 am on 1/1/24 when he was providing G-tube care to the resident and asked him to reposition resident#1. He reported that since Resident#1 was 2-person assist, LVN D went to look for CNA and could not find the CNA, so he continued with his med pass and blood glucose checks to other residents in the hall. LVN D reported he did not reposition Resident #1. LVN D also stated that the Staffing Coordinator and CNA B provided incontinent care and repositioning around 10 AM on 1/1/24.
He also reported that Resident#1's Family Member A came to him at the nurse's station around 11am on 1/1/24 stating that Resident #1 was not changed on the night shift of 12/31/23 and asked for nursing staff that took care of the resident the previous night. LVN D redirected the Family Member A to the front office. He reported that Family Member A came to him again after some time (around noon) asking to put nystatin ointment on resident's peri-area by herself. LVN D informed Family Member A that since the ointment is a prescribed medication, it will need to be applied by a nursing staff. LVN D stated he did not feel comfortable entering the resident's room by himself and hence he, along with Staffing Coordinator entered the Resident's room and applied Nystatin ointment for resident#1. LVN D reported that nystatin was applied to resident's peri care area between 12:15 PM - 12:30 PM on 1/1/24.
LVN D reported that Nystatin was started on Resident #1 on 12/30/23 for diaper rash and it is usually used for fungal infection or skin irritation and can be caused if area is wet for a long time. LVN D stated that he did not report the allegation from the Family Member A that the resident was not changed over several hours of night shift to anyone. LVN D reported when he started at the facility about a month ago, he was provided with several in services that included abuse and neglect as well. He defined neglect as resident not being provided the needed care and services by the facility. He stated he knew to report any allegation of abuse and neglect to the Abuse Coordinator immediately. He stated that if the allegation from the Family Member A was true that the resident indeed did not receive incontinent or ADL care during the night shift, it looked like neglect to him, and he should have reported it then.
Interview with CNA E on 1/3/24 at 2:42 PM revealed that she worked in the facility for last 8-9 months. She stated that she did not work on the night shift from 10PM to 6 AM on 12/31/23 in the facility and She usually worked the 2PM -10 PM shift. She had taken care of Resident #1 in the past and was aware with Resident #1 care needs. She reported that Resident #1 needed two-person assist with all ADL care and she always takes help from the Nurse or CNA from other halls for changing or repositioning the resident. She reported that she was not aware of rounding policy for the facility, but she rounded on her residents at least every two hours. She also reported that resident#1 has Nystatin cream for diaper rash that was always applied by Nursing staff when they change the resident.
She also reported that he was provided abuse and neglect in services in the past and defined neglect as resident not getting the needed goods or services. She also stated that if a resident had not been provided ADL care may result in neglect and should be reported to the administration team immediately.
Interview with LVN C on 1/3/24 at 2:50 PM revealed that he worked at the facility for about 2 years. He reported that he worked the night shift 10PM - 6AM on 12/31/23. He reported that he hung a new tube feeding bag and reprogrammed the feeding pump around 10:30-11 PM on 12/31/23, but he did not check resident for incontinent care at that time nor did he repositioned Resident #1 at that time. LVN C also stated that he did not repositioned or provided incontinent care to Resident #1 at all during his shift because he thought the CNA would have provided that care. He also reported that he was the Charge Nurse for the unit on the night of 12/31/23. He reported as a Charge Nurse, he assigned residents to CNAs that they need to take care of during their shift. He reported that Resident #1 was assigned to CNA A along with all other residents on 500, 600, 700 Hall. He reported he became aware of the incident that family alleged that resident was not provided ADL care including incontinent care on the night shift of 12/31/23 when Resident #1's Family Member A approached him during his afternoon shift 2PM- 10 PM on 1/1/24. LVN C also stated that CNA A did not tell him that she will not be caring for Resident#1 anytime during the night shift of 12/31/23 when they worked the halls together. He stated that when he spoke with CNA A around 10 PM on 1/1/24 she told him she assumed he knew that she will not take care of Resident#1 because of some prior concerns that CNA A had with resident#1's family. He further added that he asked CNA A if she communicated this with him beforehand OR ask for swapping residents so other CNA could take care of the resident OR made nursing administration aware of her dispute or displeasure to work with Resident #1, CNA A replied NO to all his questions. He also stated that since CNA's usually take care of all ADL's, he did not check whether Resident #1 was provided ADL care including incontinent care. He also stated that Resident #1 was two persons assist and that most CNA's will ask for help from Nurses on the floor or CNAs from other halls. LVN C reported that he had received in-services on abuse and neglect and defined neglect as not providing good and services to the resident. He also said that CNA A not providing care was an example of neglect. He also stated that he was going to report the alleged Neglect to the Abuse Coordinator soon but waited to speak with CNA A about the incident.
In a phone interview with CNA A on 1/4/24 9:03 AM she revealed she was aware of Resident#1's care. She stated she worked the night shift 10pm-6am on 12/31/23 and was assigned to the Resident#1's care per assignments provided to her by the Charge Nurse, LVN C. She also stated that she did not provide any ADL care including incontinent care or repositioning to Resident #1 on the night shift from 10pm-6am on 12/31/23. She does not know if any other CNA or LVN provided care to the resident that night. She reported that she had a situation with the Family Member s of Resident#1 roughly 2 weeks ago, she does not remember the exact date - but thought it was around 18/19th of December. CNA A stated that the family was rude to her and was not happy with the ADL care she provided to the resident the night of December 18th. She stated the incident was reported to LVN I who was charge Nurse that shift since the family came to the facility at midnight. She reported she failed to communicate with LVN C about her decision to not provide care to Resident#1 on the night shift and further stated that she assumed LVN C was aware of her previous incident with the family and her decision to not care for Resident #1. She also stated that it was her fault for assuming and not communicating with the charge Nurse regarding her decision to not provide care. She reported that the risk to dependent resident for not providing ADL care including incontinent care over a period of 8-hour shift could lead to skin breakdown and diaper rash. She also revealed she has been provided Inservice regarding abuse and neglect. She defined neglect as not providing service to the resident. She acknowledged that her decision of not providing ADL care to Resident #1 and not communicating her decision to the charge Nurse on the night of 12/31/23 was a form of neglect. She reported that when she worked on the night shift of 1/1/24 at the facility, she had a conversation with LVN C about care not being provided on 12/31/23. She also stated that she continued to work in the facility on 1/1/24 on a different hall and was not assigned to care for Resident #1.
In an interview with CNA B on 1/4/24 9:28 AM revealed that she worked the morning shift 6 AM-2PM on 1/1/24 and was assigned to care for residents on three halls that included Resident#1. She reported that when she came to work in the morning, call lights for most residents were on and she was trying her best to take care of the resident needs one by one. It took her some time, after breakfast, around 10 am to go and check on Resident #1. She reported since Resident #1 was a two person assist for ADL's including incontinent care, she called for help from Staffing Coordinator , who was also an LVN to change the resident. She reported that as soon as she moved the support pillow it was soaking wet in urine. Then they removed the covers, Resident #1 was covered with urine from head to toe, brief was saturated with urine, and had a small bowel movement as well. They proceeded to clean, change and repositioned Resident #1. She reported that Resident #1 was not verbal but had distressed look on his face She also stated that the support pillow was left on the chair in the resident's room to dry and sheets were taken to laundry since they were saturated in urine. She also reported that when she came back to the resident's hall, she saw that the call light for Resident #1 was on, and the Family Member A was coming out of Resident #1 room to the nurse's station. The Family Member A looked very upset and stated to CNA B that resident# 1 was not changed through the entire night shift and showed CNA A the video recording of last time the resident was changed, which was around 9 pm on 12/31/23. She also asked for Nystatin cream to apply on Resident#1. CNA B reported that she would inform LVN D and left the room. She then communicated with LVN D regarding Family Member
A 's request for Nystatin cream. CNA B left to pass out Lunch trays after that. CNA B reported that she has been trained on abuse and neglect and defined neglect as not providing care to the resident. She also stated that she was aware any allegation of abuse and neglect needed to be reported to Abuse Coordinator immediately. She also stated that Family Member A alleged of resident#1 not been provided care during the night shift was an example of neglect. She stated that she told the Staffing Coordinator to bring it up in the morning meeting for the next day but did not report it to the Abuse Coordinator immediately per policy since she was very busy on her shift.
In an interview with Staffing Coordinator on 1/4/24 9:45 AM, she revealed she worked on 1/1/24 from around 8:30 AM to 7PM and was providing care on the floor. She reported that she was called by CNA A to assist with ADL care for resident#1. Around 10 am, when CNA A and Staffing Coordinator went to Resident#1, they found that Resident #1's sheet and pillows, support pillows were soaked in urine and had some feces in his brief. They cleaned, changed, and repositioned Resident #1. She was then called around noon by LVN D to help apply Nystatin cream to Resident#1. She reported Resident#1's Family Member A was present in the room, was visibly upset and complained that resident#1 was not changed or repositioned for the entire night shift of 12/31/23. Staffing Coordinator reported she had been provided several in services about abuse and neglect and defined neglect as resident not being provided goods and services. She revealed that Family Member A 's allegation of not providing care to the resident was an example of neglect and failed to report it to the Abuse Coordinator immediately per facility policy. She also reported that most residents should be checked or provided care every 2-3 hours but stated it also depended on staffing ratios. She was not sure if there was a facility policy on how often resident should be provided ADL care by the Nursing staff. She reported that if a resident is not provided ADL care including incontinent care, it can lead to skin breakdown and possible infections. She also reported that she was responsible for scheduling and was not aware of CNA A's concern with providing care to Resident #1. She stated that if she was made aware she would have not had CNA A work in the unit; Resident #1 was present.
In an interview with DON interview on 1/4/24 2:30 PM revealed that her expectation for dependent resident with incontinence was that there was no facility policy on how often residents should be checked for continence or nursing rounds. She expected that dependent resident who need incontinent care be changed when they were visibly spoiled or as needed and Nursing to round throughout the shift. DON also stated that as a Registered Nurse, she would check on resident at least three times per shift. DON stated that CNA and Nurses are responsible for providing ADL care including incontinent care. She also reported that if CNA does not provide care to resident, it was her expectation that she would notify Charge Nurse or Nursing administration immediately. She also stated that Staffing Coordinator was responsible for scheduling and assigning CNAs to the residents for all the shifts.
She also stated there she was not aware of any restrictions for any CNA's that cannot go to resident room and if there were any restrictions Staffing Coordinator should have been aware. If there were any changes to be made, Charge nurses can reassign CNAs on duty as needed. DON reported that she was not aware if CNA A had any restrictions on caring for Resident#1 and hence there was no communication to Nurses on the floor. She also stated that CNAs cannot decide about not caring for Resident that they are assigned to. If CNA had any reservation regarding resident's care, she should be communicating it with charge nurses or nursing administration.
DON stated that she was aware Resident#1's family had some concerns with care provided by CNA A since the family spoke to the DON about it on the 12/18/23 and 12/21/23. DON reported that Resident#1 family was speaking to CNA A over the camera that Resident #1 was a two person assist and that she was providing care by herself. She also reported that family came to the facility midnight and verbal threats that were made by family and CNA A. DON reported she was not sure if any grievances were filed regarding the incident, but she was still investigating the incident at the time of this interview. DON reported that management had not provided any direction to CNA to not enter Resident #1's room or provide care to Resident #1. DON also stated Resident #1 was on therapy and needed maximum assistance for transfers, however not for all ADL care. DON reported that maximum assistance was defined as resident needing 2 people to provide care. She stated that Resident#1's family requested two persons assist on all ADL cares. DON reported the risk to resident for not providing ADL care that included incontinent care for dependent resident may lead to skin breakdown and infections.
DON defined Abuse and Neglect as follows : Abuse is willfully doing something wrong to the resident that may result in harm. Neglect defined as not providing service or goods to resident. DON also stated that if CNA does not provide care to the resident assigned to her is an example of neglect. She sated she expected staff to report any allegation of abuse and neglect immediately to the Abuse Coordinator , who is the Facility Administrator and DON was the backup for Abuse Coordinator .
Review of facility's Restorative Policy titled Perineal care/Incontinence Care Dated April, 2012, revised 01/06/2024 stated Staff will perform perineal/incontinent care with each bath and after each incontinent episode. Care will be provided frequently as defined as every 2 to 3 hours and as needed to meet resident needs, prevent skin breakdown, and infection. Staff will document in EHR after care has been provided for incontinent episodes. In the event that POC devices are not operable, paper documentation will be utilized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all alleged violations involving neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for one (Resident #1) of 10 residents reviewed for neglect.
The facility staff failed to immediately report a 13 hour delay in incontinent care for Resident # 1 to the abuse coordinator.
This deficient practice could place residents at risk for not having potential neglect reported and investigated by the abuse coordinator.
Findings included:
Review of Resident #1's admission MDS assessment dated [DATE] revealed he was [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Critical illness myopathy (significant slowing of the muscle fiber) , hypertension, pneumonia, Diabetes mellitus, aphasia (loss of ability to understand or express speech, caused by brain damage) , Cerebrovascular Attack , Respiratory Failure, Dysphagia (difficult swallowing) , tube feeding dependent (Tube feeding is a therapy where a feeding tube inserted into the belly, supplies nutrients to people who cannot get enough nutrition through eating). Resident #1 required extensive assistance of at least two people with Activities of Daily Living. He was totally dependent with transfers and bathing. It revealed that Resident #1 was always incontinent of urine and bowel. MDS assessment revealed BIMS of 99 indicating resident had severe cognitive impairment.
Review of Resident #1's Comprehensive Care Plan reflected the following dated 12/14/2023 revealed:
Review of Resident #1's physician order dated 12/20/23 revealed resident #1 was on Furosemide 20 mg tablet 1 tablet by mouth per day prescribed for dx of high blood pressure. ( Furosemide will make a resident urinate more often to remove the body of excess fluid/fluid retention).
Review of Resident #1's physician order dated 12/23023 revealed resident #1 was on Nystatin 100,000 unit/gram topical cream 2 times per day for rash.
Review of Resident # 1 ADL Documentation on EHR for 12/31/23- 1/1/24 revealed incontinent care documented at 9 pm on 12/31/23 and 10 am on 1/1/24.
Review of Resident #1 Nurses note on the EHR revealed that there was no documentation for 12/31/23. Record Review of LVN D Nurse's progress noted dated 1/1/24 charted on 12:32 PM on 1/1/24 revealed Resident #1 family member A came to nurse station upset and yelling that Resident #1 was not changed overnight. This nurse informed family member A that his shift started at 0600 and was unsure who worked last night. Family member A stated that nobody was on camera and wanted to talk to manager. Told resident to go to front and speak to secretary. Resident also stated she saw this nurse give meds and asked for Resident #1 to be pulled up. Resident is a TWO PERSON ASSIST with everything per family request. This LVN C could not find CNA at the time and continued with my med pass and FSBS checks. Resident is clean and dry. Resting comfortably in bed with call light within reach.
Interview with LVN C on 1/3/24 at 2:50 PM revealed he worked on the 10PM-6AM night shift on 12/31/23. Interview revealed he did not reposition or provide incontinent care to Resident # 1 because he thought the CNA would provide the care. LVN C stated family member A approached him on 01/01/24 on his afternoon shift of 2PM -10PM about the resident not receiving incontinent care. LVN C also stated that CNA A did not tell him that she will not be caring for Resident #1 anytime during the night shift of 12/31/23 when they worked the halls together. He stated that when he spoke with CNA A around 10 PM on 1/1/24 she told him she assumed he knew that she will not take care of Resident #1 because of some prior concerns that CNA A had with Resident #1's family. He further added that he asked CNA A if she communicated this with him beforehand OR ask for swapping residents so other CNA could take care of the resident OR made nursing administration aware of her dispute or displeasure to work with Resident #1, CNA A replied NO to all his questions. He also stated that since CNA's usually took care of all ADL's, he did not check whether Resident #1 was provided ADL care including incontinent care. He also stated that Resident #1 was two persons assist and that most CNA's will ask for help from Nurses on the floor or CNAs from other halls. LVN C reported that he had received in-services on abuse and neglect and defined neglect as not providing good and services to the resident. He also said that CNA A not providing care was an example of neglect. He also stated that he was going to report the alleged Neglect to the Abuse coordinator soon but waited to speak with CNA A about the incident.
Interview with LVN D on 01/04/24 at 2:36 PM revealed he was the charge nurse responsible for Resident # 1 on 01/01/24 for the 6am-2pm day shift. LVN D stated that the Staffing coordinator and CNA B provided incontinent care and repositioning around 10 am on 1/1/24. Interview revealed he talked with family member A around 11AM on 01/01/24 about Resident # 1 not being provided incontinent care on the night shift on 12/31/23. LVN D stated he redirected the family member A to the front office . Interview with LVN D revealed he did not immediately report the delay in care to anyone. He stated that if the allegation from the family member A was true that the resident indeed did not receive incontinent or ADL care during the night shift, it looked like neglect to him, and he should have reported it then.
Interview with ADON B on 1/3/24 at 3:05 PM revealed that she was familiar with Resident #1's care. She also reported that family approached her about 30 minutes before this interview regarding their allegation of Resident #1 not being provided ADL care, including incontinent care, during the night shift of 12/31/23. She also stated that no other staff member including Charge nurses, CNA or floor Nurses reported the allegation to her before the family member. She reported she will file a grievance report and investigate the incident soon. She also reported that she was the on-call Nurse Manager for night shifts of 12/30/23, 12/31/23 and 1/1/24. She also stated that she had not reported the allegation of potential neglect for not providing care to the resident at the time of this interview and was preparing to send the email to the Abuse coordinator.
In a phone interview with CNA A on 1/4/24 9:03 AM she revealed she was aware of Resident #1's care. She stated she worked the night shift 10pm-6am on 12/31/23 and was assigned to the Resident #1's care per assignments provided to her by the Charge Nurse, LVN C. She also stated that she did not provide any ADL care including incontinent care or repositioning to resident #1 on the night shift from 10pm-6am on 12/31/23. She does not know if any other CNA or LVN provided care to the resident that night. She reported that she had a situation with the family members of Resident #1 roughly 2 weeks ago, she does not remember the exact date - but thought it was around 18/19th of December. CNA A stated that the family was rude to her and was not happy with the ADL care she provided to the resident the night of December 18th. She stated the incident was reported to LVN I who was charge Nurse that shift since the family came to the facility at midnight. She reported she failed to communicate with LVN C about her decision to not provide care to Resident #1 on the night shift and further stated that she assumed LVN C was aware of her previous incident with the family and her decision to not care for Resident #1. She also stated that it was her fault for assuming and not communicating with the charge Nurse regarding her decision to not provide care. She reported that the risk to dependent resident for not providing ADL care including incontinent care over a period of 8-hour shift could lead to skin breakdown and diaper rash. She also revealed she has been provided Inservice regarding abuse and neglect. She defined neglect as not providing service to the resident. She acknowledged that her decision of not providing ADL care to resident #1 and not communicating her decision to the charge Nurse on the night of 12/31/23 was a form of neglect. She reported that when she worked on the night shift of 1/1/24 at the facility, she had a conversation with LVN C about care not being provided on 12/31/23. She also stated that she continued to work in the facility on 1/1/24 on a different hall and was not assigned to care for Resident #1.
In an interview with CNA B on 1/4/24 9:28 AM revealed that she worked the morning shift 6 AM-2PM on 1/1/24 and was assigned to care for residents on three halls that included Resident #1. She reported that when she came to work in the morning, call lights for most residents were on and she was trying her best to take care of the resident needs one by one. It took her some time, after breakfast, around 10 AM to go and check on Resident #1. She reported since Resident #1 was a two person assist for ADL's including incontinent care, she called for help from Staffing Coordinator, who was also an LVN to change the resident. She reported that as soon as she moved the support pillow it was soaking wet in urine. Then they removed the covers, Resident #1 was covered with urine from head to toe, brief was saturated with urine, and had a small bowel movement as well. They proceeded to clean, change and repositioned Resident #1. She reported that Resident #1 was not verbal but had distressed look on his face. She also stated that the support pillow was left on the chair in the resident's room to dry and sheets were taken to laundry since they were saturated in urine. She also reported that when she came back to the resident's hall, she saw that the call light for Resident #1 was on, and the family member A was coming out of Resident #1 room to the nurse's station. The family member A looked very upset and stated to CNA B that Resident# 1 was not changed through the entire night shift and showed CNA B the video recording of last time the resident was changed, which was around 9 pm on 12/31/23. She also asked for Nystatin cream to apply on Resident #1. CNA B reported that she would inform LVN D and left the room. She then communicated with LVN D regarding family member A 's request for Nystatin cream. CNA B left to pass out Lunch trays after that.
CNA B reported that she has been trained on abuse and neglect and defined neglect as not providing care to the resident. She also stated that she was aware any allegation of abuse and neglect needed to be reported to Abuse coordinator immediately. She also stated that family member A alleged of Resident #1 not been provided care during the night shift was an example of neglect. She stated that she told the Staffing coordinator to bring it up in the morning meeting for the next day but did not report it to the abuse coordinator immediately per policy since she was very busy on her shift.
In an interview with Staffing Coordinator on 1/4/24 9:45 AM, she revealed she worked on 1/1/24 from around 8:30 AM to 7PM and was providing care on the floor. She reported that she was called by CNA A to assist with ADL care for Resident #1. Around 10 am, when CNA A and Staffing coordinator went to Resident #1, they found that Resident #1's sheet and pillows, support pillows were soaked in urine and had some feces in his brief. They cleaned, changed, and repositioned Resident #1. She was then called around noon by LVN D to help apply Nystatin cream to Resident #1. She reported Resident #1 family member A was present in the room, was visibly upset and complained that Resident #1 was not changed or repositioned for the entire night shift of 12/31/23. Staffing coordinator reported she had been provided several in services about abuse and neglect and defined neglect as resident not being provided goods and services. She revealed that Family Member A 's allegation of not providing care to the resident was an example of neglect and failed to report it to the abuse coordinator immediately per facility policy. She also reported that most residents should be checked or provided care every 2-3 hours but stated it also depended on staffing ratios. She was not sure if there was a facility policy on how often resident should be provided ADL care by the Nursing staff. She reported that if a resident is not provided ADL care including incontinent care, it can lead to skin breakdown and possible infections. She also reported that she was responsible for scheduling and was not aware of CNA A's concern with providing care to Resident #1. She stated that if she was made aware she would have not had CNA A work in the unit; Resident #1 was present.
In an interview with DON interview on 1/4/24 2:30 PM revealed she was aware Resident #1's family had some concerns with care provided by CNA A since the family spoke to the DON about it on the 12/18/23 and 12/21/23. DON reported that Resident #1 family was speaking to CNA A over the camera that Resident #1 was a two person assist and that she was providing care by herself. She also reported that family came to the facility midnight and verbal threats that were made by family and CNA A. DON reported she was not sure if any grievances were filed regarding the incident, but she was still investigating the incident at the time of this interview. She stated she expected staff to report any allegation of abuse and neglect immediately to the Abuse coordinator, who is the Facility Administrator and DON was the backup for Abuse Coordinator. The DON also added that facility administrator was responsible for reporting abuse and neglect allegation to TX HHS and the incident was reported to the TX HHS on 1/3/24.
In an interview with Facility Administrator on 1/4/24 at 3:03 PM revealed that he was made aware of the incident regarding allegation that CNA A did not provide ADL care including incontinent care to Resident #1 on 1/3/24 at 3:45 PM. He reported that he was in the process of investigating the incident and was talking to Nursing Staff from Night shift of 12/32/23 and Morning shift of 1/1/24. He also reported that CNA A was suspended yesterday (1/3/24) pending outcome of the investigation. Administrator stated that he had provided numerous in-services to all staff for abuse and neglect, and it was his expectation to report any allegation of abuse and neglect to him immediately. He defined abuse willfully, regardless of intent, harming the resident and Neglect was when good or services are not provided to the resident. He added that he explained that his simple explanation to staff regarding abuse and neglect was To abuse to occur - I must be facing you.
To neglect - I actively turn my back on you. He stated that as an abuse coordinator , his role was to investigate the allegation thoroughly and report to TX HHS within 2 hours of the incident . He also reported that he was not aware of any grievance filed by resident # 1 family. Administrator added that he reported the incident to TX HHS within 2 hours of him being notified , he provided the Intake #47443. TULIP was checked to see if the intake was received by TX HHS.
Record reviews of Employee files for CNA A revealed she was provided Abuse and neglect policy and reporting requirements upon hire on 11/4/23.
Record Review of Employee file for CNA B revealed she was provided Abuse and neglect policy and reporting requirements upon hire on 11/4/23.
Record Review of Employee file for LVN D revealed she was provided Abuse and neglect policy and reporting requirements upon hire on 11/4/23.
Record Review of Employee file of Staffing Coordinator revealed she was provided Abuse and neglect policy and reporting requirements upon hire on 11/14/23.
Record review of Facility's Resident abuse, neglect and Exploitation and misappropriation of resident property dated 06/23/2017 revealed that Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. 3.2 All facility staff members have a duty to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the Administrator of the facility, who serves as the Abuse Coordinator. In the Administrator's absence, the Director of Nursing (DON) or another designee will be appointed to function as the interim Abuse Coordinator. Upon learning of a suspected incident of resident abuse, neglect, exploitation, and/or misappropriation of resident property, the Charge Nurse or other Department Manager or Supervisor must immediately notify the Abuse Coordinator or the DON of the incident. The person receiving the report or designee must document all incidents of alleged abuse/neglect on incident reports, which are to forwarded directly to the Abuse Coordinator . 3.3 Upon receiving an allegation abuse, neglect, exploitation or misappropriation, the Abuse Coordinator will a) notify the Regional Director of Operations and Regional Nurse Consultant, b) initiate an investigation into the allegation, c) in conjunction with the Regional Director of Operations and Regional Nurse Consultant determine whether the allegation is reportable under federal and state regulations, and d) if the allegation is reportable, report such allegation to the State Regulatory Agency, Adult Protective Services (where state law provides for jurisdiction in skilled nursing or assisted living facilities), and in certain cases, local law enforcement, within the following timeframes: not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the resident's right to be free from abuse for one (Resident #1) of 10 residents reviewed for abuse.
CNA A, who was assigned to Resident #1 for the night shift from 12/31/23 to 1/1/24 failed to provide care or check on Resident #1 during the entire shift from 10:00 PM 12/31/2023 - 6 AM 1/1/2024 and CNA B who failed to provide care on her shift from 6 AM 1/1/2024 to 10:22 AM 1/1/24. As a result, Resident #1 was not provided incontinent care or repositioned for over 13 hours on 12/31/23 9:05 PM to 01/01/24 at 10:22 AM.
These failures could affect the residents by placing them at deprivation of goods abuse, risk for a delay in ADL care including incontinent care and life-saving treatments, which could result in psychosocial harm.
Findings included:
Review of Resident #1's admission MDS assessment dated [DATE] revealed he was [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Critical illness myopathy (significant slowing of the muscle fiber) , hypertension, pneumonia, Diabetes mellitus, aphasia (loss of ability to understand or express speech, caused by brain damage) , Cerebrovascular Attack , Respiratory Failure, Dysphagia (difficult swallowing) , G-tube feeding dependent (G-tube is a tube inserted through the belly that brings nutrition directly to the stomach). Resident #1 required extensive assistance of at least two people with Activities of Daily Living. He was totally dependent with transfers and bathing. It revealed that Resident#1 was always incontinent of urine and bowel. MDS assessment revealed BIMS of 99 indicating resident had severe cognitive impairment.
Review of Resident #1's physician order dated 12/20/23 revealed Resident #1 was on Furosemide 20 mg tablet 1 tablet by mouth per day which was prescribed for DX of primary hypertension (high blood pressure). ( Furosemide is a diuretic will make a resident urinate more often to remove the body of excess fluid/fluid retention).
Review of Resident #1's physician order dated 12/23023 revealed Resident #1 was on Nystatin 100,000 unit/gram topical cream 2 times per day for rash on the peri area.
Review of Resident # 1 ADL Documentation on EHR for 12/31/23- 1/1/24 revealed incontinent care documented at 9 PM on 12/31/23 and 10 am on 1/1/24. There was no documentation of incontinent care on the ADL in the electronic health record or paper documentation.
Review of Resident #1 admission Care Plan dated 12/9/2023 revealed Resident #1 was on Diuretic therapy , Furosemide 20 mg tablet 1 tablet 1 time per day; Resident will have decrease in edema during drug therapy.
Review of Resident #1 Nurses note on the EHR revealed that there was no documentation for 12/31/23.
Record Review of LVN D Nurse's progress noted dated 1/1/24 charted on 12:32 PM on 1/1/24 revealed Resident #1 Family Member A came to nurse station upset and yelling that Resident #1 was not changed overnight. This nurse informed Family Member A that his shift started at 0600 and was unsure who worked last night. Family Member A stated that nobody was on camera and wanted to talk to manager. Told resident to go to front and speak to secretary. Resident also stated she saw this nurse give meds and asked for Resident #1 to be pulled up. Resident is a TWO PERSON ASSIST with everything per family request. This LVN C could not find CNA at the time and continued with my med pass and blood glucose checks. Resident is clean and dry. Resting comfortably in bed with call light within reach.
Observation on 1/3/24 at 2:18 PM of Resident #1 room revealed resident had Blink camera in the room that detects any motion close to the resident in the room. Observed Resident #1 was lying in the bed and covered with sheets. Resident #1 looked groomed, and no odors noted. Also observed tube feeding pump next to the bed and infusing tube feed formula. Observed call light within reach.
Interview with Resident #1 attempted on 1/3/24 at 2:20 PM revealed resident is not verbal and cannot respond as stated by the resident's #1 Family Member A that was present in the room.
Interview with Resident#1's Family Member A and Family Member B on 1/3/24 at 2:18 PM revealed that she was very concerned that Resident#1 was not changed during the night shift of 12/31/23. Resident# 1 admitted to the facility on [DATE]. She stated when she came to the facility around 11 am on 1/1/24, she noted that Resident#1's side support pillow and other pillow was placed on the chair in the room and was soaking wet and smelled of urine. She picked up the pillow from the chair and saw the chair was wet from the pillow. She then called Resident#1 Family Member B to check if she could review the camera to see when Resident#1 was last changed.
Family Member A also stated that per camera placed in the room revealed Resident#1 was not changed or repositioned from 12/31/23 at 9:05 PM until 1/4/24 at 10:20 AM. She also stated that she had requested LVN D to reposition resident#1 around 7 am on 1/1/24 through the camera. She then stated that she went to LVN D who told her he started his shift at 6 AM on 1/1/24 and did not know which nursing staff was assigned for Resident #1 that worked on night shift of 10 am -6 AM on 12/31/23. Family Member A asked LVN D if he received shift report in the morning for Resident# 1's care and which nursing staff provided the report. Per Family Member A , LVN D refused to talk to the Family Member A and directed her to the front office. She stated that she was not able to find any Administrator nursing staff and was told ADON B had left for the day.
Family Member A also revealed that she had complained to the DON regarding her concerns with Resident# 1 ADL care earlier on 12/18/23 and approached the DON that Resident#1 needed two people assist on all ADL's, including incontinent care. She also stated that on the night shift on 12/17-12/18/23 CNA A was changing and repositioning the resident by herself incorrectly when resident's Family Member B intervened from the camera and had to come to the facility at midnight to make sure that Resident #1 was okay. She stated that resident's Family Member B spoke with Charge Nurse LVN I on 12/18/23, who stated that she will have another CNA care for the resident for that night. She also stated that Resident#1's Family Member B spoke with the DON on 12/21/23 regarding needing two people assist on all ADL care including incontinent care and repositioning. Family Member B also stated that she had told the Nurse that Resident #1 had a diaper rash and they started ointment on it couple of days back. She stated the DON reported it was not the facility policy to turn the resident every 2 hours, but the DON and Family Member A agreed on checking on the resident every four hours.
Family Member A reported that Resident #1's room was fitted with a Blink Mini indoor plug-In HD Smart security motor detection camera and will detect any motion that will take place around the resident. It will not show any activity on the camera if there is no motion around the resident.
Review of Resident #1's electronic monitoring video along with Family Member A date and time stamped on 12/31/23/20 at 9:05 PM revealed 2 staff members providing incontinent care and repositioning Resident # 1.
Review of Resident #1's electronic monitoring video along with Family Member A date and time stamped on 12/31/23/20 at 10:43-10:45 PM revealed LVN C changed the tube feeding bag and worked on the tube feed pump setting.
Review of Resident #1's electronic monitoring video along with Family Member A revealed no motion detection from 12/31/23 at 10:45 PM to 1/1/24 6:47 AM.
Review of Resident #1's electronic monitoring video along with Family Member A date and time stamped on 1/1/24 at 6:47 AM revealed LVN D walking into the Resident #1 room and briefly lifted Resident #1 sheets to check for possible incontinence.
Review of Resident #1's electronic monitoring video along with Family Member A date and time stamped on 1/1/24 at 7:01 AM to 7:03 AM revealed that LVN D providing G-tube medications and checking blood sugar levels. LVN D did not reposition or provide incontinent care to Resident #1 between 7:01 am - 7:03 am.
Review of Resident #1's electronic monitoring video along with Family Member A date and time stamped on 1/1/24 at 8:30 AM revealed LVN D resetting the tube feeding pump. LVN D did not reposition or provide incontinent care to Resident #1 at 8:30 am
Review of Resident #1's electronic monitoring video along with Family Member A date and time stamped on 1/1/24 at 10:22 AM revealed that CNA B and Staffing Coordinator changed the resident.
Resident# 1's Family Member A was unable to provide actual video recording as a continuous stream of events from 9:05 PM 12/31/23 -10:20 AM on 1/1/24 due to technical difficulties.
Interview with LVN D on 1/4/24 at 2:36 PM revealed that he had started working in the facility around November 2023, he reported he was the LVN who was taking care of Resident #1 on 1/1/24 morning shift from 6 AM-2 PM. He reported that he checked on Resident #1 around 7am on 1/1/24 and administered his G-tube (medications and checked Resident#1's blood glucose). He also reported that he briefly lifted Resident#1 sheets and it appeared that Resident #1 brief was dry. He stated that he did not physically check on Resident#1 for incontinence. He also stated that Family Member A talked to him from the camera around 7 am on 1/1/24 when he was providing G-tube care to the resident and asked him to reposition Resident#1. He reported that since Resident#1 was 2-person assist, LVN D went to look for CNA and could not find the CNA, so he continued with his med pass and blood glucose checks to other residents in the hall. LVN D reported he did not reposition Resident #1. LVN D also stated that the Staffing Coordinator and CNA B provided incontinent care and repositioning around 10 am on 1/1/24.
He also reported that Resident#1's Family Member A came to him at the nurse's station around 11am on 1/1/24 stating that Resident #1 was not changed on the night shift of 12/31/23 and asked for nursing staff that took care of the resident the previous night. LVN D redirected Family Member A to the front office. He reported that Family Member A came to him again after some time (around noon) asking to put Nystatin ointment on resident's peri-area by herself. LVN D informed Family Member A that since the ointment is a prescribed medication, it will need to be applied by a nursing staff. LVN D stated he did not feel comfortable entering the resident's room by himself and hence he, along with Staffing Coordinator entered the Resident's room and applied Nystatin ointment for Resident#1. LVN D reported that Nystatin was applied to resident's peri care area between 12:15 PM - 12:30 PM on 1/1/24.
LVN D reported that Nystatin was started on Resident #1 on 12/30/23 for diaper rash and it was usually used for fungal infection or skin irritation that can be caused if area was wet for a long time. LVN D stated that he did not report the allegation from the Family Member A that the resident was not changed over several hours of night shift to anyone. LVN D reported when he started at the facility about a month ago, he was provided with several in services that included abuse and neglect as well. He defined neglect as resident not being provided the needed care and services by the facility. He stated he knew to report any allegation of abuse and neglect to the Abuse Coordinator immediately. He stated that if the allegation from the Family Member A was true that the resident indeed did not receive incontinent or ADL care during the night shift, it looked like neglect to him, and he should have reported it then.
Interview with CNA E on 1/3/24 at 2:42 PM revealed that she worked in the facility for last 8-9 months. She stated that she did not work on the night shift from 10PM to 6 AM on 12/31/23 in the facility and She usually worked the 2PM -10 PM shift. She had taken care of Resident #1 in the past and was aware with Resident #1 care needs. She reported that Resident #1 needed two-person assist with all ADL care and she always took help from the Nurse or CNA from other halls for changing or repositioning the resident. She reported that she was not aware of rounding policy for the facility, but she rounded on her residents at least every two hours. She also reported that resident#1 has Nystatin cream for diaper rash that was always applied by Nursing staff when they change the resident.
CNA E also reported that he was provided abuse and neglect in services in the past and defined neglect as resident not getting the needed goods or services. She also stated that if a resident had not been provided ADL care may result in neglect and should be reported to the administration team immediately.
Interview with LVN C on 1/3/24 at 2:50 PM revealed that he worked at the facility for about 2 years. He reported that he worked the night shift 10PM - 6AM on 12/31/23. He reported that he hung a new tube feeding bag and reprogrammed the feeding pump around 10:30-11 PM on 12/31/23, but he did not check resident for incontinent care at that time nor did he repositioned Resident #1 at that time. LVN C also stated that he did not repositioned or provided incontinent care to Resident #1 at all during his shift because he thought the CNA would have provided that care. He also reported that he was the Charge Nurse for the unit on the night of 12/31/23. He reported as a Charge Nurse, he assigned residents to CNA's that they need to take care of during their shift. He reported that Resident #1 was assigned to CNA A along with all other residents on 500, 600, 700 Hall. He reported he became aware of the incident that family alleged that resident was not provided ADL care including incontinent care on the night shift of 12/31/23 when Resident #1's Family Member A approached him during his afternoon shift 2PM- 10 PM on 1/1/24. LVN C also stated that CNA A did not tell him that she will not be caring for Resident#1 anytime during the night shift of 12/31/23 when they worked the halls together. He stated that when he spoke with CNA A around 10 PM on 1/1/24 she told him she assumed he knew that she will not take care of Resident#1 because of some prior concerns that CNA A had with Resident#1's family. He further added that he asked CNA A if she communicated this with him beforehand OR ask for swapping residents so other CNA could take care of the resident OR made nursing administration aware of her dispute or displeasure to work with Resident #1, CNA A replied NO to all his questions. He also stated that since CNA's usually took care of all ADL's, he did not check whether Resident #1 was provided ADL care, including incontinent care. He also stated that Resident #1 was two persons assist and that most CNA's will ask for help from Nurses on the floor or CNAs from other halls. LVN C reported that he had received in-services on abuse and neglect and defined neglect as not providing good and services to the resident. He also said that CNA A not providing care was an example of neglect. He also stated that he was going to report the alleged Neglect to the Abuse Coordinator soon but waited to speak with CNA A about the incident.
Interview with ADON B on 1/3/24 at 3:05 PM revealed that she was familiar with Resident#1's care. She stated she spoke with Resident#1's Family Member B during the admission care conference. She had not spoken with the Family Member regarding family's concern for two persons assist for ADL's; however, she was aware of family requesting two-person assist with ADL care from the DON. She stated that she was not aware if DON had filed any grievance report regarding family concern of resident care. She also reported that family approached her about 30 minutes before this interview regarding their allegation of Resident#1 not being provided ADL care included incontinent care during the night shift of 12/31/23. She also stated that no other staff member including Charge nurses, CNA or floor Nurses reported the allegation to her before the Family Member . She reported she will file a grievance report and investigate the incident soon. She also reported that she was the on-call Nurse Manager for night shifts of 12/30/23, 12/31/23 and 1/1/24. She also stated that she had not reported the allegation of potential neglect for not providing care to the resident at the time of this interview and was preparing to send the email to the Abuse Coordinator .
ADON B stated that if Family Member A 's allegation of not providing resident with ADL care throughout the night shift was true, that would be an example of neglect since the resident was not provided with service he needed. She also reported that any resident can have rash in peri area if the area was wet for long time. She also stated that Resident#1 cannot reposition himself and her expectation was staff checked on resident every two hours for ADL care. She stated that if ADL care including incontinent care was not provided in a timely manner it can lead to rash, skin breakdown and Resident's dignity and comfort can be compromised.
Attempted phone interview with CNA A on 1/3/24 3:16 PM, left voicemail to call back.
In a phone interview with CNA A on 1/4/24 9:03 AM she revealed she was aware of Resident#1's care. She stated she worked the night shift 10pm-6am on 12/31/23 and was assigned to the resident#1's care per assignments provided to her by the Charge Nurse, LVN C. She also stated that she did not provide any ADL care including incontinent care or repositioning to Resident #1 on the night shift from 10pm-6am on 12/31/23. She does not know if any other CNA or LVN provided care to the resident that night. She reported that she had a situation with the Family Member s of Resident#1 roughly 2 weeks ago, she does not remember the exact date - but thought it was around 18/19th of December. CNA A stated that the family was rude to her and was not happy with the ADL care she provided to the resident the night of December 18th. She stated the incident was reported to LVN I who was charge Nurse that shift since the family came to the facility at midnight. She reported she failed to communicate with LVN C about her decision to not provide care to Resident#1 on the night shift and further stated that she assumed LVN C was aware of her previous incident with the family and her decision to not care for Resident #1. She also stated that it was her fault for assuming and not communicating with the Charge Nurse regarding her decision to not provide care. She reported that the risk to dependent resident for not providing ADL care, including incontinent care over a period of 8-hour shift, could lead to skin breakdown and diaper rash. She also revealed she has been provided Inservice education regarding abuse and neglect. She defined neglect as not providing service to the resident. She acknowledged that her decision of not providing ADL care to Resident #1 and not communicating her decision to the charge Nurse on the night of 12/31/23 was a form of neglect. She reported that when she worked on the night shift of 1/1/24 at the facility, she had a conversation with LVN C about care not being provided on 12/31/23. She also stated that she continued to work in the facility on 1/1/24 on a different hall and was not assigned to care for Resident #1.
In an interview with CNA B on 1/4/24 9:28 AM revealed that she worked the morning shift 6 AM-2PM on 1/1/24 and was assigned to care for residents on three halls that included Resident#1. She reported that when she came to work in the morning, call lights for most residents were on and she was trying her best to take care of the resident needs one by one. It took her some time, after breakfast, around 10 am to go and check on Resident #1. She reported since Resident #1 was a two person assist for ADL's, including incontinent care, she called for help from Staffing Coordinator , who is also an LVN to change the resident. She reported that as soon as she moved the support pillow it was soaking wet in urine. Then they removed the covers, Resident #1 was covered with urine from head to toe, the brief was saturated with urine, and had a small bowel movement as well. They proceeded to clean, change and repositioned Resident #1. She reported that Resident #1 was not verbal but had distressed look on his face She also stated that the support pillow was left on the chair in the resident's room to dry and sheets were taken to laundry since they were saturated in urine. She also reported that when she came back to the resident's hall, she saw that the call light for Resident #1 was on, and the Family Member A was coming out of Resident #1 room to the nurse's station. The Family Member A looked very upset and stated to CNA B that resident# 1 was not changed through the entire night shift and showed CNA B the video recording of last time the resident was changed, which was around 9 pm on 12/31/23. She also asked for Nystatin cream to apply on Resident#1. CNA B reported that she would inform LVN D and left the room. She then communicated with LVN D regarding Family Member
A 's request for Nystatin cream. CNA B left to pass out Lunch trays after that.
CNA B reported that she has been trained on abuse and neglect and defined neglect as not providing care to the resident. She also stated that she was aware any allegation of abuse and neglect needed to be reported to Abuse Coordinator immediately. She also stated that Family Member A alleged Resident#1 had not been provided care during the night shift was an example of neglect. She stated that she told the Staffing Coordinator to bring it up in the morning meeting for the next day but did not report it to the Abuse Coordinator immediately per policy since she was very busy on her shift.
In an interview with Staffing Coordinator on 1/4/24 9:45 AM, she revealed she worked on 1/1/24 from around 8:30 am to 7PM and was providing care on the floor. She reported that she was called by CNA A to assist with ADL care for Resident#1. Around 10 am, when CNA A and Staffing Coordinator went to Resident#1, they found that Resident #1's sheet and pillows, support pillows were soaked in urine and had some feces in his brief. They cleaned, changed, and repositioned Resident #1. She was then called around noon by LVN D to help apply nystatin cream to Resident#1. She reported Resident#1's Family Member A was present in the room, was visibly upset and complained that Resident#1 was not changed or repositioned for the entire night shift of 12/31/23. Staffing Coordinator reported she had been provided several in services about abuse and neglect and defined neglect as resident not being provided goods and services. She revealed that Family Member A 's allegation of not providing care to the resident was an example of neglect and she failed to report it to the Abuse Coordinator immediately per facility policy. She also reported that most residents should be checked or provided care every 2-3 hours but stated it also depended on staffing ratios. She was not sure if there was a facility policy on how often resident should be provided ADL care by the Nursing staff. She reported that if a resident is not provided ADL care including incontinent care, it can lead to skin breakdown and possible infections. The Staffing Coordinator also reported that she was responsible for scheduling and was not aware of CNA A's concern with providing care to Resident #1. She stated that if she was made aware she would have not had CNA A work in the unit; Resident #1 was present.
Record Review of Nurse and CNA Assignments for 12/31/23 revealed that there was a total of 4 CNA's (CNA A, CNA F, CNA G, CNA H that were scheduled on the 10 pm - 6am shift on 12/31/23.
In a phone interview with CNA F on 1/4/24 at 10:25 AM revealed that she worked the night shift on 12/31/23 on Unit 1 and did not take care of Resident #1 who was in Unit 2. She has worked Unit 2 on prior nights and was aware of care needs for Resident #1 and that he was on 2 persons assist for ADL's. She also revealed that she has been provided Inservice on abuse and neglect and knows she needed to report any allegations of abuse or neglect immediately.
In a phone interview with CNA G on 1/4/24 at 11:05 AM; she revealed that she worked the night shift on 12/31/23 on Unit 1 and she does not remember going to Unit 2 on 12/31/23 where Resident #1 was. She also stated that about a week or two ago, she remembered changing assignments and taking care of Resident #1 as instructed by LVN I since CNA A had issues with the family; so CNA G and CNA H took care of the resident since Resident#1 was two-person assist. She also stated that on the night of 12/31/23, no one instructed them to change assignments, hence she did not take care of the Resident #1. She revealed she was provided abuse and neglect in service and defined neglect as not taking care of resident needs. She stated she knows she needed to report any allegation of abuse and neglect to the Abuse Coordinator immediately.
In a phone interview with CNA H on 1/4/24 11:21 AM revealed that she called out on 12/31/23 and did not work that night at the facility. She also reported that some days back, she does not remember the date but recollected that she and CNA G took care of Resident #1 as instructed by LVN I since Resident #1's family had some concerns with CNA's care to Resident #1. She reported that she has been provided numerous in services on abuse and neglect; and defined neglect as not providing care to resident and to report any abuse or neglect to the Abuse Coordinator immediately.
Attempted phone interview for LVN I on 1/4/24 at 1:48 PM, left voicemail to call back the writer.
In an interview with DON interview on 1/4/24 2:30 PM revealed that her expectation for dependent resident with incontinence was that there was no facility policy on how often residents should be checked for continence or nursing rounds. She expected that dependent resident who needed incontinent care be changed when they are visibly spoiled or as needed and Nursing to round throughout the shift. DON also stated that as a Registered Nurse, she would check on resident at least three times per shift. DON stated that CNA and Nurses were responsible for providing ADL care including incontinent care. She also reported that if CNA did not provide care to resident, it was her expectation that she would notify Charge Nurse or Nursing Administration immediately. She also stated that Staffing Coordinator was responsible for scheduling and assigning CNAs to the residents for all the shifts.
The DON also stated there she was not aware of any restrictions for any CNA's that cannot go to resident room and if there were any restrictions Staffing Coordinator should have been aware. If there were any changes to be made, Charge Nurses can reassign CNAs on duty as needed. DON reported that she was not aware if CNA A had any restrictions on caring for Resident#1 and hence there was no communication to Nurses on the floor. She also stated that CNAs cannot decide about not caring for Resident that they were assigned to. If a CNA had any reservation regarding resident's care, she should be communicating it with charge nurses or nursing administration.
The DON stated that she was aware Resident#1's family had some concerns with care provided by CNA A since the family spoke to the DON about it on the 12/18/23 and 12/21/23. DON reported that Resident#1 family was speaking to CNA A over the camera that Resident #1 was a two person assist and that she was providing care by herself. She also reported that family came to the facility midnight and verbal threats that were made by family and CNA A. DON reported she was not sure if any grievances were filed regarding the incident, but she was still investigating the incident at the time of this interview. DON reported that management had not provided any direction to CNA to not enter Resident #1's room or provide care to Resident #1. DON also stated Resident #1 was on therapy and needed maximum assistance for transfers, however not for all ADL care. DON reported that maximum assistance was defined as resident needing 2 people to provide care. She stated that Resident#1's family requested two persons assist on all ADL cares. DON reported the risk to resident for not providing ADL care that included incontinent care for dependent resident may lead to skin breakdown and infections.
DON defined Abuse and Neglect as follows : Abuse is willfully doing something wrong to the resident that may result in harm. Neglect defined as not providing service or goods to resident. DON also stated that if CNA does not provide care to the resident assigned to her is an example of neglect. She sated she expected staff to report any allegation of abuse and neglect immediately to the Abuse Coordinator , who is the Facility Administrator and DON was the backup for Abuse Coordinator .
In an interview with Facility Administrator on 1/4/24 at 3:03 PM revealed that he was made aware of the incident regarding allegation that CNA A did not provide ADL care including incontinent care to Resident #1 on 1/3/24 at 3:45 PM. He reported that he was in the process of investigating the incident and was talking to Nursing Staff from Night shift of 12/32/23 and Morning shift of 1/1/24. He also reported that CNA A was suspended yesterday pending outcome of the investigation.
The Administrator stated that he had provided numerous in-services to all staff for abuse and neglect, and it was his expectation to report any allegation of abuse and neglect to him immediately. He defined abuse willfully, regardless of intent, harming the resident and Neglect was when good or services are not provided to the resident. He added that he explained that his simple explanation to staff regarding abuse and neglect was To abuse to occur - I must be facing you.
To neglect - I actively turn my back on you. He stated that as an Abuse Coordinator, his role was to investigate the allegation thoroughly and report to TX HHS within 2 hours of the incident . He also reported that he was not aware of any grievance filed by Resident # 1 family. He stated that about a week after Resident #1 admission, around 17th or 18th of December , family had concerns with care provided by CNA A and requested two persons assist for all ADL care. DON spoke with the family and provided Inservice that Resident #1 will need two persons assist for all ADL care. He also stated that Management had not told CNA A that she could not go to Resident #1 room or take care of the resident. He continued I think it's her (CNA A) impression that she could not go to the room. Administrator also reported that risk to a dependent resident for not providing ADL care, including incontinent care, was potential skin breakdown and infections.
Record reviews of Employee files for CNA A revealed she was provided Abuse and neglect policy and reporting requirements upon hire on 11/4/23.
Record Review of Employee file for CNA B revealed she was provided Abuse and neglect policy and reporting requirements upon hire on 11/4/23.
Record Review of Employee file for LVN D revealed she was provided Abuse and neglect policy and reporting requirements upon hire on 11/4/23.
Record Review of Employee file of Staffing Coordinator revealed she was provided Abuse and neglect policy and reporting requirements upon hire on 11/14/23.
Record review of Facility's Resident abuse, neglect and Exploitation and misappropriation of resident property dated 06/23/2017 revealed that Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, Family Member s, legal guardians, resident representative, friends, [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to establish and implement policies addressing resident admission to the facility for one (Resident #1) of three residents reviewed for admissions in that:
Resident #1 was not provided a signed admission agreement or information upon admission to the facility on [DATE]. Resident was discharged on 12/26/23 without a signed admission agreement.
This failure could affect residents by placing them at risk for not being aware of what services the facility is providing.
Findings included:
Record Review of Resident #1's face sheet dated 12/28/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and discharged on 12/26/23. Resident #1's diagnoses included hyperlipidemia (high cholesterol), hypertension (high blood pressure), diverticulosis (inflammation or infection in one or more small pouches in the digestive tract), chronic diastolic congestive heart failure (heart's main pumping chamber becomes still and unable to fill properly) and dysphagia (difficulty swallowing).
Record Review of Resident #1's electronic clinical record revealed the admission MDS assessment was in progress and was incomplete. Resident #1's baseline care plan did not reveal Resident #1's cognition.
Record review of Resident #1's electronic clinical record revealed no completed or signed admission agreement on file.
Interview on 12/28/23 at 11:28 AM with the admission Coordinator revealed it was her responsibility to complete admission agreements with all residents upon admission, including Resident #1. The admission Coordinator confirmed the facility did not have any admission paperwork or agreements for Resident #1 including they did not have a power of attorney. The admission Coordinator stated she did not know the facility's timeframe for completing the admission paperwork or agreements. The admission Coordinator stated the importance of the admission paperwork was to ensure the family members were aware of the facility's policies and procedures.
Interview on 12/28/23 at 11:45 AM with the Administrator revealed it was solely the responsibility of the admission Coordinator to have admission paperwork completed within 2-3 days of the admission, the basic resident information should be started at the time of admission, was a digital process that can be started and sent to the family electronically to get the admission paperwork started even prior to the resident's arrival to the facility. The Administrator stated he would have expected for Resident #1's admission paperwork to have been completed prior to his discharge on [DATE]. The Administrator stated the admission paperwork was important to ensure the family was aware of the facility's policies, procedures, and services.
Interview on 12/28/23 at 12:10 PM with Resident #1's Family Member A revealed she did not complete an admission paperwork with the facility during admission on [DATE]. She stated she was not sure what services the facility was responsible for providing and she had not spoken to any facility staff about an admission agreement and did not sign an admission agreement.
Interview on 12/28/23 at 1:23 PM with the Administrator revealed the facility did not have an actual policy on the completion of admission paperwork or agreements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for two (room [ROOM NUMBER] and room [ROOM NUMBER]) of five bedrooms reviewed for environment,
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The facility failed to ensure room [ROOM NUMBER] did not contain a red sticky substance on the floor and oxygen machine
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The facility failed to ensure room [ROOM NUMBER] did not have crumbs on the floor, a thick white substance on the floor, and used medical supplies on the bedside table.
These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.
The findings included:
Observation on 12/05/2023 at 11:00 AM revealed room [ROOM NUMBER] had a red sticky substance on the floor and had red substance splashed on the oxygen machine.
Interview on 12/05/2023 at 11:00 AM resident #2 revealed she has spilled the red soda on the floor the day before (12/04/2023) and housekeeping had not been in to clean it. Resident #2 stated she has made clinical staff aware of the spill.
Observation on 12/05/2023 at 11:40 AM revealed room [ROOM NUMBER] had crumbs on the floor around both sides of the bed, a thick white substance on the floor and used medical supplies for IV flushing on the bedside table.
Interview on 12/05/2023 at 11:40 AM with Resident #3 revealed his room had been dirty for a few days and he had asked housekeeping to come in and clean the room however it had not been don.
Interview on 12/05/2023 at 1:35PM with housekeeping supervisor stated there are currently 2 housekeeping staff which include himself. The Housekeeping Supervisor stated they try to clean each room once a day. The Housekeeping Supervisor stated clinical staff would have to let him know if any rooms needed additional cleaning. The Housekeeping Supervisor stated he was not informed that room [ROOM NUMBER] and 409 needed to be serviced. The Housekeeping observed the rooms that were identified as needed to be cleaned and stated it was only he and one other housekeeping staff working and they had not had a chance to get to the room. The Housekeeping supervisor was not asked about the risk of having an unsanitary environment.
Review of the facility policy Resident room cleaning, dated November 2021 revealed General inspection: Survey the resident's room and pick up loose trash. Be alert for needles and other sharp objects. Pick up sharps using a brush or dustpan and have a nurse place them into a sharp's container. Inspect the room and report all damage, including to walls, furniture, room divider and window curtains (note cleanliness) resident belongings and sinks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect the confidentiality of personal health care information for one of three (Resident #1) residents reviewed for confidentiality of records.
The facility failed to ensure LVN A locked and closed the laptop during the medication pass exposing Resident #1's personal information to include some of her medications.
This failure could affect residents by placing them at risk for loss of privacy and dignity.
The Findings included:
Review of Resident #1's face sheet dated 12/04/2023 revealed a 91 year- old male admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses that included metabolic encephalopathy (a brain problem caused by chemical imbalance in the blood), type 2 diabetes (problem with regulating sugar), congestive heart failure problems with the heart muscle)
Observation and interview on 12/05/2023 at 11:03 AM of the computer screen on LVN A's medication cart being unlocked for approximately 2-3 minutes while LVN A was inside the resident room passing medication. The medication cart was on the wall facing the hall and exposed to residents and staff who walked down the hall. The computer displayed the medication that was being provided to Resident #1. LVN A returned from Resident #1's room and started documenting that the medication had been given. There was staff observed walking down the hall while the computer screen was unlocked. LVN A stated the computer should have been locked but she forgot. LVN A stated the risk of leaving the computer unlocked would be a violation of privacy.
Interview on 12/05/2023 at 2:24PM with the Director of Nursing revealed during medication pass the computer screen should be locked or minimized when not in sight. The Director of Nursing stated the risk of leaving the computer unlocked would be patient information would be visible to residents or staff walking down the hall.
Review of the facility resident agreement stated the resident received acknowledgement of the privacy act statement- health care statement- health care records however does not go in to detail regarding the policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise when the facility failed to implement significant weight loss interventions for two (Residents #58 and #28) of seven residents reviewed for significant weight loss, in that:
1.
Dietitian failed to communicate and follow-up on Resident #58's significant weight loss of 18 pounds from 01/31/23 to 05/10/23 to the facility and verify adequate nutrition was provided via enteral tube feeding or PEG tube (surgical placement of feeding tube in the stomach to provide nutrition, hydration and/or medicines) for Resident #58. Dietitian also failed to implement resident centered enteral tube feeding nutrition plan for Resident #58.
2.
LVN G, LVN I and LVN F failed to administer enteral feedings to Resident #58 as ordered by the physician for last 72 hours (May 13, May 14, and May 15).
3.
Facility failed to notify the physician regarding resident's significant weight loss and failed to initiate timely intervention to prevent weight loss when Resident #58 experienced continuous significant weight loss of -7.85% (11.5 pounds) in the last three months since 2/22/2023 AND -12% (18.5 pounds) since admit weight of 2/3/2023.
4.
Dietitian failed to communicate reweights timely and follow-up on Resident #28's significant weight loss of 20.8% on 05/02/23 since admission on [DATE]. Dietitian failed to put significant weight loss intervention in place for Resident #28 who a had a low body mass index until 05/12/23 when Resident #28 continued to have significant weight loss of 23% on 05/11/23. DON failed to follow up to ensure Resident #28 had significant weight loss interventions in place.
An Immediate Jeopardy (IJ) situation was identified on 05/17/23 at 5:39 PM. While the IJ was removed on 05/20/23 at 5:30 PM, the facility remained out of compliance at a scope of pattern at the severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their corrective systems.
These failures could place residents who are completely dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown and overall decline in quality of care.
Findings included:
1. Review of MDS assessment dated [DATE] for Resident #58 reflected he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of Parkinson's disease (brain disorder that causes unintended or uncontrollable moments), Dysphagia of oropharyngeal phase (difficulty swallowing), Pneumonitis due to inhalation of food and vomit (lung infection caused by inhaling food, saliva or other), Cognitive Communication deficit ( inability to communicate properly) , Dysarthria (difficulty in speaking related to weak muscles), Dysphonia (difficulty speaking related to physical disorders of vocal cords), Muscle weakness and other chronic pain conditions. Review revealed the resident had a BIMS score of (09), which meant the resident was moderately impaired cognition. The resident required extensive assistance with ADLs and was incontinent of bowel and bladder. It reflected that patient had PEG tube in place for enteral feedings on admission and was NPO, dependent on PEG tube feedings for nutrition and hydration. The resident was at risk for weight loss. The resident's height was 5 feet 8 inches, and the hospital admission weight was 153 pounds. Residents' # 58 Ideal body weight: 154 pounds (+/- 10%)
In an observation with Resident # 58, on 05/16/2023, at 10:44 a.m., it was noted that the resident was resting in his recliner. Observed tube feeding pump next to the recliner on the pole was off. Resident # 58 was not interviewable at time of visit. Resident # 58 could only answer in yes and no questions, however, did not have clear perception of time, date or place. During exit from resident's room, Noted X-ray tech had entered Resident # 58's room to take images.
In a phone interview with Resident #58's responsible party at 11:44 am on 5/16/2023, it was revealed that resident had lost some weight and looked skinny and bony lately than from time of admit in January. They also stated that the resident had missed some of his nocturnal tube feeds via pump for couple days in the past but had not seen that lately. Responsible party could not substantiate time frame as to when exactly the resident did not get feedings or who reported this to her. Responsible party did not voice any other concerns for the resident at that time.
Record Review of weight chart for the resident included the following:
Date
Weight (in Pounds)
02/03/2023
153.5
02/15/2023
153.5
02/22/2023
146.5
03/01/2023
143.9
03/08/2023
142.0
03/15/2023
143.7
03/22/2023
143.2
03/29/2023
140.5
04/06/2023
140.5
04/19/2023
139.5
05/03/2023
140.0
05/10/2023
135.0
On 5/10/2023, residents' weight was 135 pounds and triggered for significant weight loss of -7.85% (11.5 pounds) in the last three months since 2/22/2023 AND -12% (18.5 pounds) since admit weight of 2/4/2023.
Record review for Nutrition assessment by Dietitian indicated the following:
1/31/2023: Diabetisource AC 50ml/hr x 22-hour continuous feeding via PEG tube via pump per hospital orders. Ideal body weight: 154 pounds +/- 10%
2/3/2023: Dietitian changed orders to Diabetisource AC 75ml/hr x 10 hours (from 8pm-6 am) + Diabetisource AC Bolus feeds (250 ml each) three times per day bolus feeds via PEG Tube. This provided 1800kcal/ 90g protein and 2008 ml total fluids. Per Dietitian notes, admission enteral order was changed since it did not meet resident's nutrition needs and Resident # 58 expressed not wanting to push the tube feeding pole down the hall during therapy. Hence, nocturnal 10 hour feeding regimen + bolus feeding regimen in the daytime was added.
2/27/2023: Dietitian documented significant weight loss of -2.6% x 7 days AND -6.4% x 1 month. Tube feeds orders changed to Diabetisource AC 80 ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day via PEG Tube which provided 1860 kcal/ 93 g protein and 2090 ml total fluids.
3/13/2023: Dietitian changed Tube feeds orders again to Diabetisource AC 85ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day via PEG Tube to provide 1920 kcal/ 96 g protein and 2091 ml fluids + med flush.
3/24/2023: Dietitian documented weight stable this month with increased tube feed rate to 85ml/hr since 3/13/2023. She documented she suspected weights of 153.5 pounds (weighed on 2/15) and 153.5 pounds (weighed on 2/3/2023) were inaccurate.
4/30/2023: no changes to enteral orders. Weekly weight monitoring continued. No excess residuals, distensions, or other signs of intolerance noted in Dietitian note.
5/14/2023: Dietitian documented significant weight loss of - 12.05% x 6 months and -8.79% x 3 months. Dietitian noted that current enteral feeding should have been adequate in meeting estimated nutritional needs however resident had exhibited significant weight loss. Dietitian deemed recent infection Pneumonia and Shortness of breath likely contributed to weight loss.
Record Review of Resident's #58 progress notes revealed that he was NPO and dependent on enteral tube feeding for his nutrition and hydration. Resident #58 had a deficit of 900 kcal in past 72 hours and 45 grams deficit in past 72 hours as indicated by pump history record review.
Record Review of Resident #58 MAR indicated that Tube feed formula Diabetisource AC 85ml/hr x 10 hours on at 8 pm and off at 6 am + 250 ml Diabetisource three times per day via bolus feeding daily. Clear pump and record intake.
Record review of TAR between 5/1/2023 - 5/16/2023 on 6 am shift indicated that pump feeding records had values ranging from 85,520,680, 800, 1000 ml. Similarly, on the 8 pm shift from 5/1/2023-5/16/2023, TAR revealed that values were between 85, 100, 180, 200, 240, 250, 320, 500 ml. There was no consistency in documenting between the actual volume of feedings resident received.
Record review of care plans revealed that significant weight loss Care plan was added on 5/14/2023, however there were no Goals or Interventions for the associated care plan. As of 5/16/2023, there was no documentation for change in condition in the care plan documentation based on significant weight loss triggered on 5/10/2023.
Record review of care plan also had no documentation regarding any behavior resident #58 was displaying such as moving about in the night, thus accidentally disconnecting the feeding pump.
In an observation with LVN G on 5/16/2023 12:16 pm, Resident # 58 was standing at the door of his room with his walker. LVN G performed hand hygiene, don gloves and proceeded to administer resident with one can (250 ml) of Diabetisource AC via PEG tube via bolus feed. Also noted that, Resident #58 got two crush medicine (Carbidopa and Entacapone) mixed with water along with bolus tube feeding. LVN G then administered appropriate amount of water flush post medicine and feed administration. Tube feed kangaroo pump history was reviewed with LVN G. Observation on 05/16/2023 at 12:25 pm the Kangaroo pump (used for tube feeding) revealed that for the last 72 hours Resident #58 received 60 ml/hr for PEG tube feeding and total volume fed was at 2008 ml. Water flush was set at 200ml every 4 hours, water flush administered via pump was at 1740 ml. Reviewed physician orders along with LVN for the tube feeding pump, the feed rate in the physician order was for 85ml/hr, dated March 13, 2023 per MAR. LVN G stated he was not aware of the 85ml/hr physician order. On asking, if the feed rate set on the kangaroo pump (used for tube feeding) was checked against the physician orders in chart, LVN G answered he usually would take the resident off the pump during his shift and did not note the pump rate or record actual feed volume on the pump or cleared the pump settings after the tube feeding administration was completed, which was also noted on the physician orders.
In an interview with LVN G on 5/16/2023 at 2:02 p.m., LVN G was working with the facility for six weeks now as a full time LVN, he worked as an agency LVN before in the same facility. He usually worked 6am-2pm shift and had known the resident well. He worked the morning 6am-2pm and afternoon 2pm-10 pm shift on Monday 15th, 2023 and morning 6am-2pm shift on Tuesday 16th, 2023. Weights were also reviewed with LVN G. Resident had triggered for weight loss pattern since admit. Resident had 7.85% significant weight loss over a three-month period from 02/22/23 to 05/10/23. LVN G noted that he had not seen any weight loss, and no one had made him aware of resident losing weight. LVN G agreed he was seeing weight loss on the weight chart in electronic medical record and stated that if someone had made him aware of it, he would have paid closer attention to resident's tube feeding rate. He also stated that he is not sure if resident's physician had been informed about significant weight loss that was triggered on 5/10/2023. LVN G stated that if a resident who is dependent on tube feeds for all his nutrition and hydration does not get prescribed tube feeding, it would result in weight loss and possible skin breakdown.
In an interview with LVN J, on 5/16/2023 at 3:05 p.m., LVN J revealed that he was not familiar with Resident # 58 tube feeding rate or pump since it was his first time working with the resident that day (2pm-10 pm shift on 5/16/2023). LVN J was not aware of any significant weight loss Resident # 58 was experiencing. LVN J revealed he had seen the Resident # 58 walking the hallways multiple times with his walker when he worked the other halls.
In an interview with Agency LVN H on 5/15/2023 at 3:42 p.m., She worked the 10pm- 6 am shift on the following days - May 9, 10, 11th 2023Agency LVN H stated she had disconnected the Resident # 58 tube feeding pump at 6 am when the tube feeding was completed; however, she did not remember the actual rate but thought the pump had been on feed rate of 65ml/hr. She did not document the total fed rate (as shown on the kangaroo pump) on MAR or TAR, nor did she clear the pump after the shift ended. She did not double check the physician order in the EMR since she thought the pump has already been programmed to the correct rate. She also stated that she was not provided any training on PEG feedings / kangaroo pump administration by the facility since she is Agency RN, they are expected to know PEG feedings/ how Kangaroo pump functions. She has only worked 10pm-6 am shifts at the facility and has been responsible for disconnecting the resident's feeding tube at 6 am by the end of the shift.
In an interview with LVN I, full time facility LVN on 5/16/2023 at 3:49 p.m., stated that he worked 5/13 and 5/14 on 10pm-6 am shift. He verbalized he disconnected resident's feeding tube as part of his night shift duties at 6 am in the morning when his shift ended. He mentioned he did not usually look at the pump rate when he disconnected the feeding from the resident and did not check the enteral pump feed rate against the physician orders. He also he did not typically record volume infused on the pump or clear the pump settings as outlined in the physician order. LVN I also stated that patient had some behavior issues such as resident would be irritable at night, get up by himself and move himself from recliner to bed in the night, and in the process resident's PEG tube would be disconnected sometimes in the night. He also stated that he knows some agency LVN's who forgot to administer resident's nightly tube feeds at 8 pm, and then would bolus a can of feeding at that time; this happened 1-2 occasions in the last 3 months. LVN I did not provide names of agency RN's. He also stated he did not document this in the Nursing progress notes. LVN I stated that he was not aware that Resident # 58 was losing weight or triggered for significant weight loss on 5/10/2023, but he thought that the resident looked [NAME] at times. Again, LVN I did not bought up Resident # 58 behavior issues in the night or not receiving tube feed formula via pump to any other Nursing staff in the facility.
In an interview with Dietitian, on 5/16/2023 at 4:10 p.m., it was revealed that she wrote tube feeding orders for the facility. She also stated that she had known Resident # 58 and was not aware of any issues with resident tolerating tube feeds. She acknowledged Resident # 58 had lost weight since admit to the facility, however stated that resident's weight was stable in the last month. Dietitian also stated that the resident had antibiotic treatment started recently for pneumonia which could be the cause of recent weight loss in the last week. Dietitian stated that she provided a list of residents who triggered for weight loss either weekly or monthly via email to the DON. She was not sure of the process the facility had in place for reweighing residents once weight loss was identified. She did not make any additional changes to Resident # 58's enteral feeding since she found significant weight loss that was triggered on 5/10. She was due to see the resident on the day of this interview. She revealed that she had not seen a reweigh was done on the resident since 5/10 significant weight loss. Dietitian stated that she had not seen any high blood glucose levels on the resident's labs since admit, hence specialty Glucose controlled formula was not required; but was not clear on why higher calorie tube feed formula (v/s the current 1.2 Diabetisource formula) was not used despite continued weight loss pattern Resident # 58 displayed. She revealed that she usually goes to resident's room to check on feeding pump, but she did not check on residents # 58 pump settings in the room since the order was changed to Diabetisource 85ml/hr x 10 hours in March. She also verbalized that since she had seen the resident sleeping in his recliner most times and wanted to change Resident # 58 tube feedings to 22-hour continuous regimen. She noted that she had not consulted with DON, Charge nurse or resident's treating physician on this recommendation. Dietitian reported she was not aware of resident being mobile and walked the hallways with walker. Dietitian failed to communicate and follow-up on significant weight loss of 18 pounds from 01/31/23 to 05/10/23 to the facility; verify adequate nutrition was provided via PEG tube as ordered and implement resident centered enteral tube feeding nutrition plan.
Record reviews of Resident # 58 laboratory report dated 5/12/2023 indicated that Blood glucose was within normal range.
Attempted to reach LVN L who worked 5/13/2023 on Morning shift 6am-2pm and afternoon shift 2pm-10 pm, however she could not be reached despite leaving voicemail for her at 4:16 p.m. on 5/16/2023; also asked the facility to contact LVN L. No call back received.
In a phone interview with Agency LVN F on 5/17/2023 at 8:55 a.m., she stated that she worked on 5/14/2023 from 2 pm-10 pm shift. She reported she double checked the tube feed rate with the orders. She does not remember the feed rate on the pump. Agency LVN F stated that she did not had to reprogram or clear the pump when she started the pump that evening to administer the feeding. Agency LVN F also did not documented fed volume from the pump to eMAR. Agency LVN F noted that she was not provided any training by the facility regarding PEG tube/ weights/ kangaroo pump functioning when she started working at the facility.
In an interview with Restorative Aide on 5/17/2023 at 10:50 AM, it was revealed that she did the weekly weights in the facility for the past one year for most residents. Weekly weights were performed every Wednesday and Resident # 58 was on weekly weight list since February 2023. Restorative Aide confirmed she weighed the patient on February 22, April 5, April 19, May 3 and May 10. Restorative Aide noted that resident can walk up to the weighing scale independently with a walker and can stand up unassisted on the weighing scale. Restorative Aide also stated that she saw Resident # 58 walking hallways of the facility on many occasions with a walker.
In an interview DON on 5/17/2023 at 11:40 a.m., revealed the DON had been at the facility for about four weeks only. Restorative Aide was responsible for doing the weekly weights and Staffing Coordinator was responsible to ensure weekly weights and re-weighs were completed. DON stated after Dietitian informed her on 05/10/23 of residents including Resident #58 who need to be re-weighed she included the Staffing Coordinator in a text to have these residents' re-weights. She had been informed of Resident #58 needing to be re-weighed on 05/10/23 but had not followed through to ensure re-weight was completed for Resident #58. She stated ADON's were responsible for monitoring weights, but they were both new to the facility as well. She reported that ADON's are responsible to see if the residents are receiving the enteral formula as ordered by the physician. She stated the risk for residents who are NPO and dependent on enteral feeding for all their nutrition and hydration orders are weight loss, hydration issues, potential skin breakdown and deranged lab values.
Interview with the ADON A on 5/17/2023 at 12:10 p.m., revealed she had started at the facility about 2 weeks ago. She was not aware who was the designated person for weight monitoring. ADON A stated that she did not receive training for monitoring of weights and is still learning the system. She stated she had not had the opportunity to look at Resident #58's enteral feeding pump to ensure Resident #58 received the physician ordered enteral feeding.
Interview with the DON on 05/17/23 at 12:42 p.m., revealed on Resident #58's kangaroo feeding pump if the settings were not cleared by nurse, you can go back and see the volume history of how much enteral feeding Resident #58 received. DON stated she was unaware of nurses lack of administering Resident #58's appropriate tube feeding for Resident #58 nocturnal feeding at 85 ml/hour for 10 hours. She stated she had not had an opportunity to look at Resident #58's enteral feeding pump to ensure Resident #58 received the appropriate enteral feeding.
In an interview with Physician A on 5/17/2023 at 1:39 p.m., he stated that he was notified of significant weight loss earlier, but he did not remember when exactly, he recollected couple of months ago. He does not recollect recent notification for weight loss. Physician A was not aware of significant weight loss that was triggered on 5/10/2023; he was not informed. Physician A stated that he expected the physician order as put in by Dietitian to be followed for all enteral feeding patients. Physician A also stated that he was not aware that the Resident # 58 is not getting his prescribed feedings.
2. Review of Resident #28's admission MDS assessment dated [DATE] reflected Resident #28 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of wedge compression fracture of vertebra, hypertension, Alzheimer's disease and dementia. Resident #28's height was 62 inches and weight of 113. She had a BIMS of 7 indicating she was severely cognitively impaired. Resident #28 required extensive assistance with ADLs except for toileting. Resident #28 eating ADL occurred once or twice with one person physical assistance.
Review of Resident #28's Hospital discharge paperwork dated 04/21/23 did not reflect a height or weight for Resident #28.
Review of Resident #28's Weight Record reflected the following:
Date
Weight (in Pounds)
04/21/2023
113
05/02/2023
89.5
05/11/2023
87
05/18/2023
89.5
Weight Loss calculations reflected on 05/02/23 - Resident #28 had a 20.8% weight loss with 23.5 lb loss since admission, 05/11/2023 had a 23% weight loss with 26 lbs lost since admission.
Review of Resident #28 Nutrition Assessments reflected:
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Record date of 04/24/23 and signed 05/03/23 by Registered Dietitian reflected Resident #28 was regular diet with thin liquids, oral intake was 75 to 100%, current weight of 89.5 lbs, 16.4 BMI (underweight) and adjusted body weight IBW (ideal body weight) 110+/-10%, hospital labs potassium low (3.3), BUN high (28), creatine low (0.5). Interventions included diet as prescribed, recommended 1) Nursing - please obtain reweight to confirm true weight loss 2) Nursing: Weekly weight x 4 weeks. Please follow to assure cessation of weight loss. 3) Nursing: Add order for diet texture.
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Record date and signed date of 05/12/23 by Registered Dietitian reflected RD note to address sig wt loss for 5/2023- Resident is receiving a regular diet (no therapeutic diet restrictions). Tolerating without issue - consuming 75-100% of meals. She is independent/occasional staff assist with eating and usually eats in her room. Impaired cognition per notes. No constipation per staff - on Colace. No pressure wounds or skin breakdown noted on today's wound report. Labs/meds reviewed- MVI QD. UA still pending. Estimated needs: Kcals/day: 1260-1440 kcal/d (30-35 kcal/kg CBW)*underweight. Prot gm/day: 49-53 gm/d (1.2-1.3 gm/kg CBW)*underweight.Fluid ml/day: 1500 ml/d minimum or per MD. Anticipate alteration in nutrition and hydration status r/t impaired cognition, BMI status and sig wt loss.Weights: (5/11) 87, (5/2) 89.5, (4/21) 113.CBW (5/11) 87 - significant wt loss of -2.79% x 7 days and -23% since admission.BMI 15.91 underweight. She is at high risk for malnutrition. Question accuracy of 4/21 weight.Anticipate alteration in nutrition and hydration status r/t impaired cognition, BMI status and sig wt loss. Recommend: 1) Nursing: Weekly weights x 4 weeks. Please follow to assure cessation of weight loss. 2 Nursing: Add .order for diet texture. 3) Nursing: Encourage meals in dining room for monitoring and additional assistance as needed. 4)Boost 1 carton po QD at 230 pm (240 kcal, 10 gm prot) for weight maintenance. RD to follow as needed.
Review of the DON's email with subject line RD visit and recommendations 5/2/23 from Registered Dietitian dated 05/04/23 at 5:26 PM reflected Registered Dietitian emailed the Administrator, ADONs and the DON about Resident #28 being a new admit and possible weight loss. Registered Dietitian reflected recommendations of (Nursing - Please obtain reweight to confirm true weight loss. 2) Nursing: Weekly weights x 4 weeks. [NAME] follow to assure cessation of weight loss. 3) Nursing: Add order for diet texture.
Review of Resident #28's Meal Intake for May 2023 reflected Resident #28 had meal intake of 50 to 100% intake.
Review of Resident #28's Physician Orders and eMAR for May 2023 reflected Resident #78 was started on boost daily. No other weight loss interventions were in place as of 05/17/23 and 05/19/23.
Interview on 05/19/23 at 10:35 AM, with Registered Dietitian reflected she completed her first nutrition note for Resident #28 on 05/02/23 and she did see there was a concern with weight loss. She stated Resident #28 had good oral intake of 75 to 100% intake and did not add any weight loss interventions since resident was eating well. She stated she recommended weekly weights and put texture order in system. She stated Resident #28 was a new admit already on weekly weights. She did not ask for re-weights on 05/02/23 and sent the DON her recommendations via email as she normally did. She did not follow up with DON or nursing to ensure re-weight was completed. She stated nursing was responsible for notifying the physician of significant weight loss. She stated she either communicated in passing or in email her recommendations to the DON. She stated on 05/12/23 when Resident #28 continued to lose weight of 2.5 lbs more she recommended Resident #28 to be put on one boost shake daily. She stated she had not followed up to see how Resident #28 was tolerating and if compliant with boost shake. She stated she questioned the admission weight but did not communicate with DON about it. She stated Resident #28 did have a low body mass index but she had good oral intake.
Review of DON's text dated 05/10/23 at 9:22 PM reflected resident reweights for Residents #28 and #58 who was included in the text message.
Interview on 05/19/23 at 11:19 AM with DON revealed she did not request re-weights for Resident #28 until 05/10/23. She had only been at the facility about 4 weeks. She stated reweights should have been completed with 24 hours on 05/02/23 when significant weight loss triggered. She stated the Registered Dietitian could have communicated with me on 05/02/23 when she reviewed the weight for Resident #28 to have her re-weighed and about her significant weight loss. She stated she was ultimately responsible for ensuring weights were monitored. She stated the communication with the Registered Dietitian was by email about her recommendations, but she did not include in her documentation about what the percentage of the significant weight loss was. She stated Resident #28 was a new admit and should have been weighed weekly for at least 4 weeks. She stated Resident #28 would be notified today of significant weight loss and should have been notified on 05/02/23 when first triggered for significant weight loss.
In an interview with Medical Director, who is Resident #28's Physician at 5/17/2023 on 1:48 p.m., was asked what the risk for a resident who is dependent on enteral feeds for nutrition and hydration, NPO status and not receiving Enteral feeds as ordered. The Medical Director responded, resident would be at risk for dehydration, malnutrition, weight loss and skin breakdown. He also stated he would like to be notified if one of his residents had significant weight loss and if physician orders were not followed.
Review of facility's policy Weight Monitoring revised 01/12/20 reflected Resident weights will be recorded and monitored at a minimum frequency of monthly. Procedures: 1. Nursing weighs residents within 24 hours of admission and re-admission. Newly admitted residents are weighed upon admission and then weekly x4 and then monthly thereafter, unless otherwise indicated by physician's order. 2. Weights and re-weigh results are recommended to be recorded in the EHR .3. If the month-to-month show more than a five percent (5%) gain or loss, the resident is reweighed within 24 hours. If there is an actual five percent (5%) or more gain or loss in one moth, the resident/family, physician and the Registered Dietitian are notified by the Nursing Department. The date of such notification is documented in the nurses note in the EHR. 5. The Registered Dietitian reviews the resident's nutritional status and makes recommendations for intervention in the nutritional therapy assessment if significant weight change is noted. 6. Significant, unplanned changes in weights are reviewed at the Standards of Care Committee meeting. The Committee will also identify any gradual weight loss trends. Significant changes in weights are documented in the plan of care with goals and approaches/interventions listed .8. Unplanned and undesired weight variance will be evaluated for significance utilizing the Resident Assessment Instrument Guidelines. Suggested guidelines are as followed: 5% in 30 days 7.5% in 90 days and 10% in 180 days.
Review of facility's policy Enteral Nutrition for Closed System Nasogastric, Nasointestinal, Gastric and Jejunal feeding tubes last revised 01/12/20 reflected Enteral nutrition therapy will be performed in a safe manner by qualified licensed nurses according to standard practice guidelines .Procedures: .3. Check physician's order for formula, route, rate and frequency .9. Turn on pump. Follow manufacturer's specifications.
The Administrator was notified of the Immediate Jeopardy on 05/17/23 at 5:36 PM due to the above failures and provided the IJ template. A Plan of Removal was requested.
The Facility's Plan of Removal was accepted on 05/19/23 at 2:36 PM and included the following:
The facility's response to the IJ for the facility to implement a Plan of Removal to prohibit weight loss for Resident #58 on enteral feedings. On 5/17/2023 the facility failed to ensure that nursing staff implemented the interventions of enteral feeding at 85 ml/hr. for 10 hours. Resident #58 had a 7.85% significant weight loss over a three-month period from 02/22/23 to 05/10/23.
Process
Due Date
Note: When ADON is referenced in this plan of removal, it is referencing to the ADON assigned to the room the resident resides in. ADON and rooms are detailed below:
Rooms 200 thru 406, [NAME] Valentine LVN ADON A
Rooms 407 thru 716, ADON B
Within 24 hours of the resident's admission or readmission, the resident will be weighed by the admission nurse. The admission nurse will then enter the weight [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #29) observed for infection control.
Facility failed to ensure CNA N performed hand hygiene while providing incontinence care to Resident #29.
This failure could place the residents at risk for infection.
Findings include:
A record review of Resident #29's Comprehensive MDS assessment, dated 03/30/2023, reflected Resident #29 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, tremor (an involuntary quivering movement), and dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain. Resident #29 had a BIMS of 08 which indicated Resident #29's cognition was moderately impaired. Resident#29 required extensive assistance of one-person physical assistance with toilet use and personal hygiene
Observation on 05/16/23 at 10:34 AM revealed CNA N provided incontinent care to Resident #29. CNA N was observed completing hand hygiene before care, then she informed the resident she was providing incontinent care. CNA N donned clean gloves. CNA N positioned the resident and unfastened the brief and proceeded to clean Resident #29's front area with wipes. CNA N discarded the dirty gloves, without hand hygiene she donned clean gloves. CNA N positioned the resident on the side which revealed a medium bowel movement. CNA N cleaned the resident's bottom area. After cleaning the resident CNA N took off and discarded the dirty brief and without change of gloves or hand hygiene, CNA N applied the clean brief. CNA N changed gloves without hand hygiene and continued with dressing the resident.
In an interview on 05/16/23 at 10:45 AM with CNA N she stated she was to wash hands before and after care. CNA N also stated she was supposed to change gloves and complete hand hygiene after removing the dirty gloves. CNA N stated she did not complete hand hygiene or change gloves after cleaning the resident because she was nervous. CNA N stated she was supposed to change gloves and complete hand hygiene to prevent the spread of infection.
In an interview on 05/18/23 at 02:33 PM with the DON she stated during incontinent care the staff were to complete hand hygiene before and after care. The DON also stated in between care CNA was to complete hand hygiene and change gloves because her hands were considered dirty after cleaning the resident. The DON stated the staff were to complete hand hygiene during care to prevent the spread of infection.
Record review of the facility policy reviewed January 2022, titled Hand Hygiene for Staff and Residents reflected, Purpose: To reduce the spread of infection with proper hand hygiene. Procedures: 1. Hand hygiene is done: . After: . H. removal of medical/surgical or utility gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Residents #58 and #61) of 24 residents reviewed for comprehensive care plans.
1. The facility failed to develop a comprehensive person-centered care plan to address Resident #58's significant weight loss interventions of 7.85% for 3 months and 3.5% in 1 week. The facility failed to develop a care plan for Resident #58's behavior of moving about in the night and accidentally disconnecting the feeding pump.
2. The facility failed to develop a comprehensive person-centered care plan to address Resident #61's oxygen therapy use.
These failures could place residents at risk of not receiving individualized care and services to meet their needs.
Findings included:
1. Review of MDS assessment dated [DATE] for Resident #58 reflected he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of Parkinson's disease (brain disorder that causes unintended or uncontrollable moments), Dysphagia of oropharyngeal phase (difficulty swallowing), Pneumonitis due to inhalation of food and vomit (lung infection caused by inhaling food, saliva or other), Cognitive Communication deficit ( inability to communicate properly) , Dysarthria (difficulty in speaking related to weak muscles), Dysphonia (difficulty speaking related to physical disorders of vocal cords), Muscle weakness and other chronic pain conditions. Review revealed the resident had a BIMS score of (09), which meant the resident was moderately impaired cognition. The resident required extensive assistance with ADLs and was incontinent of bowel and bladder. It reflected that patient had PEG tube in place for enteral feedings on admission and was NPO, dependent on PEG tube feedings for nutrition and hydration. The resident was at risk for weight loss. The resident's height was 5 feet 8 inches, and the hospital admission weight was 153 pounds. Residents' # 58 Ideal body weight: 154 pounds (+/- 10%).
Record review of Resident #58's comprehensive care plan dated 02/03/23 reflected significant weight loss care plan was added on 5/14/2023, however there were no goals or interventions for the associated care plan. There was no documentation regarding any behavior that Resident #58 was displaying such as moving about in the night, thus accidentally disconnecting the feeding pump.
In an observation, at 10:44 pm 05/16/2023, it was noted that Resident #58 was resting in his recliner. Observed tube feeding pump next to the recliner on the pole was off.
In a phone interview with Resident #58's responsible party at 11:44 am on 5/16/2023, it was revealed she had some concerns of Resident #58 losing some weight and looked skinny and bony lately than from time of admit in January. She had not been informed of any significant weight loss by the facility.'
Record review of weight chart for the resident included the following:
Date
Weight (in Pounds)
2/03/2023
153.5
2/15/2023
153.5
2/22/2023
146.5
03/01/2023
143.9
3/08/2023
142.0
3/15/2023
143.7
3/22/2023
143.2
3/29/23
140.5
4/06/23
140.5
4/19/2023
139.5
5/03/2023
140
5/10/2023
135
On 5/10/2023, residents' weight was 135 pounds and triggered for significant weight loss of -7.85% (11.5 pounds) in the last three months since 2/22/2023 AND -12% (18.5 pounds) since admit weight of 2/4/2023.
Record review for Nutrition assessment by Dietitian indicated the following:
1/31/2023: Diabetisource AC 50ml/hr x 22-hour continuous feeding via PEG tube via pump per hospital orders. Ideal body weight: 154 pounds +/- 10%
2/3/2023: Dietitian changed orders to Diabetisource AC 75ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day bolus feeds via PEG Tube. This provided 1800kcal/ 90g protein and 2008 ml total fluids. Per Dietitian notes, admission enteral order was changed since it did not meet resident's nutrition needs and resident # 58 expressed not wanting to push the tube feeding pole down the hall during therapy. Hence, nocturnal 10 hour feeding regimen + bolus feeding regimen in the daytime was added.
2/27/2023: Dietitian documented significant weight loss of -2.6% x 7 days AND -6.4% x 1 month. Tube feeds orders changed to Diabetisource AC 80 ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day via PEG Tube which provided 1860 kcal/ 93 g protein and 2090 ml total fluids.
3/13/2023: Dietitian changed Tube feeding orders to Diabetisource AC 85ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day via PEG Tube to provide 1920 kcal/ 96 g protein and 2091 ml fluids + med flush.
3/24/2023: Dietitian documented weight stable this month with increased tube feed rate to 85ml/hr since 3/13/2023. She documented she suspected weights of 153.5 pounds (weighed on 2/15) and 153.5 pounds (weighed on 2/3/2023) were inaccurate.
4/30/2023: no changes to enteral orders. Weekly weight monitoring continued. No excess residuals, distensions, or other signs of intolerance noted in Dietitian note.
5/14/2023: Dietitian documented significant weight loss of - 12.05% x 6 months and -8.79% x 3 months. Dietitian noted that current enteral feeding should have been adequate in meeting estimated nutritional needs however resident had exhibited significant weight loss. Dietitian deemed recent infection Pneumonia and Shortness of breath likely contributed to weight loss.
Record review of Resident #58s MAR indicated that Tube feed Diabetisource AC 85ml/hr x 10 hours on at 8 pm and off at 6 am + 250 ml Diabetisource three times per day via bolus feeding daily. Clear pump and record intake.
In an interview with LVN G on 5/16/2023 at 2:02 p.m., LVN G was working with the facility for six weeks now as a full time LVN, he worked as an agency LVN before in the same facility. He usually worked 6am-2pm shift and had known the resident well. He worked the morning 6am-2pm and afternoon 2pm-10 pm shift on Monday 15th, 2023 and morning 6am-2pm shift on Tuesday 16th, 2023. Weights were also reviewed with LVN G. Resident had triggered for weight loss pattern since admit. Resident had 7.85% significant weight loss over a three-month period from 02/22/23 to 05/10/23. LVN G noted that he had not seen any weight loss, and no one had made him aware of resident losing weight. LVN G agreed he was seeing weight loss on the weight chart in electronic medical record and stated that if someone had made him aware of it, he would have paid closer attention to resident's tube feeding rate. He also stated that he is not sure if resident's physician had been informed about significant weight loss that was triggered on 5/10/2023. LVN G stated that if a resident who is dependent on tube feeds for all his nutrition and hydration does not get prescribed tube feeding, it would result in weight loss and possible skin breakdown.
In an interview with LVN J, on 5/16/2023 at 3:05 p.m., LVN J revealed that he was not familiar with Resident # 58 tube feeding rate or pump since it was his first time working with the resident that day (2pm-10 pm shift on 5/16/2023). LVN J was not aware of any significant weight loss resident # 58 was experiencing. LVN J revealed he had seen the Resident # 58 walking the hallways multiple times with his walker when he worked the other halls.
In an interview with LVN I, full time facility LVN on 5/16/2023 at 3:49 p.m., stated that he worked 5/13 and 5/14 on 10pm-6 am shift. He verbalized he disconnected resident's feeding tube as part of his night shift duties at 6 am in the morning when his shift ended. LVN I also stated that patient had some behavior issues such as resident would be irritable at night, get up by himself and move himself from recliner to bed in the night, and in the process resident's PEG tube would be disconnected sometimes in the night. He also stated he did not document this in the Nursing progress notes. LVN I stated that he was not aware that resident # 58 was losing weight or triggered for significant weight loss on 5/10/2023, but he thought that the resident looked [NAME] at times. LVN I stated he had not brought up Resident #58 behavior issues in the night.
In an interview with Dietitian, on 5/16/2023 at 4:10 p.m., it was revealed she acknowledged Resident #58 had lost weight since admit to the facility, however stated that resident's weight was stable in the last month. She also stated that the resident had antibiotic treatment started recently for pneumonia which could be the cause of recent weight loss in the last week. Dietitian stated that she provided a list of residents who triggered for weight loss either weekly or monthly via email to the DON. She did not make any additional changes to Resident #58's enteral feeding since she found significant weight loss that was triggered on 5/10/23. She was due to see the resident on the day of this interview. She revealed that she had not seen a reweigh was done on the resident since 5/10 significant weight loss. Dietitian stated that she hadn't seen any high blood glucose levels on the resident's labs since admit, hence specialty Glucose controlled formula wasn't required; but was not clear on why higher calorie tube feed formula (v/s the current 1.2 Diabetisource formula) was not used despite continued weight loss pattern resident # 58 displayed. She revealed that she usually goes to resident's room to check on feeding pump, but she did not check on residents # 58 pump settings in the room since the order was changed to Diabetisource 85ml/hr x 10 hours in March 2023. Dietitian reported she wasn't aware of resident being mobile and walked the hallways with walker. Dietitian failed to communicate and follow-up on significant weight loss of 18 pounds from 01/31/23 to 05/10/23 to the facility.
In an interview with the Restorative Aide on 5/17/2023 at 10:50 AM it was revealed that she did the weekly weights in the facility for the past one year for most residents. Weekly weights were performed every Wednesday and Resident #58 was on weekly weight list since February 2023. Restorative Aide confirmed she weighed the patient on February 22, April 5, April 19, May 3 and May 10. Restorative Aide noted that resident can walk up to the weighing scale independently with a walker and can stand up unassisted on the weighing scale. Restorative Aide also stated that she saw resident # 58 walking hallways of the facility on many occasions with a walker.
In an interview DON on 5/17/2023 at 11:40 a.m., revealed that DON had been at the facility for about four weeks only. She stated ADON's were responsible for monitoring weights, but they were both new to the facility as well.
2. Review of Resident #61's face sheet dated 05/17/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of end stage renal disease (kidney failure), generalized muscle weakness, unsteadiness on feet and sepsis (serious condition in which the body responds improperly to an infection).
Review of Resident #61's admission MDS assessment dated [DATE] reflected he had a BIMS of 6 indicating he was severely cognitively impaired. He required extensive assistance with ADLs except supervision with eating only. It did not reflect he was on oxygen therapy while at the facility.
Review of Resident #61's Care Plan last updated 04/24/23 reflected no care plan for oxygen therapy.
Review of Resident #61's consolidated physician orders dated 05/18/23 reflected Resident #61 had no physician order for oxygen use.
Observation on 05/18/23 at 1:08 PM revealed Resident #61 was lying in bed on oxygen via nasal cannula at 3 liters per minute.
Interview on 05/18/23 at 1:10 PM with Resident #61 revealed he had been on continuous oxygen since he was readmitted from the hospital recently and currently had pneumonia.
Observation on 05/18/23 at 1:20 PM with LVN G revealed Resident #61 was lying in bed on oxygen via nasal cannula at 3 liters per minute.
Interview on 05/18/23 at 1:24 PM with LVN G revealed Resident #61 was on continuous oxygen via nasal cannula. He could not find the oxygen order in Resident #61's physician orders or the nurse administration record. He stated he thought Resident #61 came back from the hospital on oxygen.
Interview on 05/20/23 at 2:55 PM with Agency LVN P revealed he was the charge nurse for Resident #61 when he was readmitted from the hospital. He did recall Resident #61 returned from the hospital on oxygen therapy but was not certain of what oxygen rate it should be at for Resident #61.
Interview on 05/18/23 at 3:05 PM with DON revealed she could not find a physician order for Resident #61's oxygen therapy in the hospital discharge orders. DON stated she could not find a current physician order for Resident #61's oxygen therapy. She stated his oxygen therapy should have been care planned.
Interview on 05/18/23 at 9:47 AM with MDS Coordinator D revealed she said that acute care plans were usually not put in by MDS Nurses. She stated that acute care plans were usually done by ADON/DON unless they reached out to the MDS Coordinators to complete an acute care plan for them. MDS Coordinator D stated the facility did not have stable DON/ADON for last few months in the facility.
Interview on 05/18/23 at 10:10 AM with DON revealed ADONs were responsible for ensuring acute care plans were developed but the ADONs were fairly new to the facility too. She stated Resident #58's significant weight loss should have been care planned to include interventions put in place to address the weight loss.
Interview on 05/18/23 at 11:40 AM, with Interim Corporate DON revealed that she was at the facility for the last 2 weeks in March 2023 and first 2 weeks in April 2023. She stayed on further to help train current DON for couple of weeks more. Interim Corporate DON also stated that Nursing management is typically responsible for documenting acute care plans. However, she was unable to pinpoint who was responsible for writing acute care plans when she was in the facility during her tenure.
Review of facility's policy Person Centered Care Plan revised 2017 reflected the comprehensive care plan will be reviewed and updated as new needs are identified and after each MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to have physician orders for the resident's immediate care for one (Resident #61) of eight residents reviewed for admission physician orders.
The facility failed to have a physician order for Resident #61's oxygen use.
This failure could affect residents by placing them at risk for not receiving the appropriate care and treatment services.
Findings included:
Review of Resident #61's face sheet dated 05/17/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of end stage renal disease (kidney failure), generalized muscle weakness, unsteadiness on feet and sepsis (serious condition in which the body responds improperly to an infection).
Review of Resident #61's admission MDS assessment dated [DATE] reflected he had a BIMS of 6 indicating he was severely cognitively impaired. He required extensive assistance with ADLs except supervision with eating only. It did not reflect he was oxygen therapy while at the facility.
Review of Resident #61's Care Plan last updated 04/24/23 reflected no care plan for oxygen therapy.
Review of Resident #61's consolidated physician orders dated 05/18/23 reflected Resident #61 had no physician order for oxygen use.
Review of Resident #61's hospital discharge paperwork dated 05/08/23 reflected no discharge hospital oxygen orders for Resident #61 on medication administration record and physician discharge progress note.
Observation on 05/18/23 at 1:08 PM revealed Resident #61 was lying in bed on oxygen via nasal cannula at 3 liters per minute.
Interview on 05/18/23 at 1:10 PM with Resident #61 revealed he had been on continuous oxygen since he was readmitted from the hospital recently and currently had pneumonia.
Observation on 05/18/23 at 1:20 PM with LVN G revealed Resident #61 was lying in bed on oxygen via nasal cannula at 3 liters per minute.
Interview on 05/18/23 at 1:24 PM with LVN G revealed Resident #61 was on continuous oxygen via nasal cannula. He could not find the oxygen order in Resident #61's physician orders or the nurse administration record. He stated he thought Resident #61 came back from the hospital on oxygen. He stated the admitting nurse should have reviewed with Resident #61's physician about Resident #61's oxygen to get an order for the oxygen and the amount to be administered via nasal cannula.
Interview on 05/20/23 at 2:55 PM with Agency LVN P revealed he was the charge nurse for Resident #61 when he was readmitted from the hospital but another nurse assisted him in reviewing hospital discharge paperwork and contacting the physician about orders. LVN P could not recall what nurse assisted him with Resident #61's readmission. He did recall Resident #61 returned from the hospital on oxygen therapy but was not certain of what oxygen rate it should be at for Resident #61.
Interview on 05/18/23 at 3:05 PM with DON revealed she could not find a physician order for Resident #61's oxygen therapy in the hospital discharge orders. She stated if Resident #61's discharge physician orders reflected oxygen therapy order at a set rate they could have used it to put an admitting physician order for oxygen therapy. She stated since there was no hospital discharge physician order for oxygen therapy the admitting nurse should have reached out to physician to obtain an order for oxygen therapy including the oxygen liter rate to be set at. She stated not having a physician order for oxygen therapy could place resident at risk for potential of oxygen toxicity. She stated they will reach out to Resident #61's physician to get an oxygen therapy order for Resident #61.
Review of facility's policy Physician Orders (Admission) revised 01/12/20 reflected The licensed nurse with obtain and transcribe orders according to practice guidelines .Procedures: 1. The licensed nurse reviews orders from the transfer record from an acute care hospital or other entity. 2. A call is placed to the physician to confirm the orders and request any additional orders as needed.
Review of facility's policy Applying an Oxygen Delivery Device revised 01/12/20 reflected Staff will apply oxygen delivery devices in accordance with standard guidelines .Validate physician orders.
Review of facility's policy Physician Orders - Electronic revised 01/12/20 reflected The licensed nursing staff will provide residents with medications and treatments as ordered by his/her physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's physician and responsible party when there was a significant change in the physical status for two (Resident #58 and Resident #28 ) of six residents reviewed for notification of changes.
1. The facility failed to notify the physician and responsible party of Resident #58's change of condition of significant weight loss on 05/10/23.
2. The facility failed to notify the physician and responsible party of Resident #28's change of condition of significant weight loss on 05/02/23 and 05/12/23.
These failures could place residents at risk for not notifying the physician for a change in condition.
Findings included:
1. Review of MDS assessment dated [DATE] for Resident #58 reflected he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnoses of Parkinson's disease (brain disorder that causes unintended or uncontrollable moments), Dysphagia of oropharyngeal phase (difficulty swallowing), Pneumonitis due to inhalation of food and vomit (lung infection caused by inhaling food, saliva or other), Cognitive Communication deficit ( inability to communicate properly) , Dysarthria (difficulty in speaking related to weak muscles), Dysphonia (difficulty speaking related to physical disorders of vocal cords), Muscle weakness and other chronic pain conditions. Review revealed the resident had a BIMS score of (09), which meant the resident was moderately impaired cognition. The resident required extensive assistance with ADLs and was incontinent of bowel and bladder. It reflected that patient had PEG tube in place for enteral feedings on admission and was NPO, dependent on PEG tube feedings for nutrition and hydration. The resident was at risk for weight loss. The Resident's # 58 height was 5 feet 8 inches, and the hospital admission weight was 153 pounds. Residents' # 58 Ideal body weight: 154 pounds (+/- 10%).
In an observation with Resident # 58, on 05/16/2023 at 10:44 p.m., it was noted that the resident was resting in his recliner. Observed tube feeding pump next to the recliner on the pole was off. Resident #58 was not interviewable at time of visit. Resident # 58 could only answer in yes and no questions, however, did not have clear perception of time, date, or place.
In a phone interview with Resident #58's responsible party on 5/16/2023 at 11:44 a.m., it was revealed that resident had lost some weight and looked skinny and bony lately than from time of admit in January. The responsible party stated the resident had missed some of his nocturnal tube feeds via pump for couple days in the past but had not seen that lately. Responsible party could not substantiate time frame as to when exactly the resident did not get feedings or who reported this to her. Responsible party did not voice any other concerns for the resident at that time.
Record review of weight chart for the resident included the following:
Date
Weight (in Pounds)
2/03/2023
153.5
2/15/2023
153.5
2/22/2023
146.5
03/01/2023
143.9
3/08/2023
142.0
3/15/2023
143.7
3/22/2023
143.2
3/29/23
140.5
4/06/23
140.5
4/19/2023
139.5
5/03/2023
140
5/10/2023
135
On 5/10/2023, residents' weight was 135 pounds and triggered for significant weight loss of -7.85% (11.5 pounds) in the last three months since 2/22/2023 AND -12% (18.5 pounds) since admit weight of 2/4/2023.
Record review of the Nutrition assessments by the Dietitian indicated the following:
1/31/2023: Diabetisource AC 50ml/hr x 22-hour continuous feeding via PEG tube via pump per hospital orders. Ideal body weight: 154 pounds +/- 10%
2/3/2023: Dietitian changed orders to Diabetisource AC 75ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day bolus feeds via PEG Tube. This provided 1800kcal/ 90g protein and 2008 ml total fluids. Per Dietitian notes, admission enteral order was changed since it did not meet resident's nutrition needs and Resident # 58 expressed not wanting to push the tube feeding pole down the hall during therapy. Hence, nocturnal 10 hour feeding regimen + bolus feeding regimen in the daytime was added.
2/27/2023: Dietitian documented significant weight loss of -2.6% x 7 days AND -6.4% x 1 month. Tube feeding orders changed to Diabetisource AC 80 ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day via PEG Tube which provided 1860 kcal/ 93 g protein and 2090 ml total fluids.
3/13/2023: Dietitian changed Tube feed orders to Diabetisource AC 85ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day via PEG Tube to provide 1920 kcal/ 96 g protein and 2091 ml fluids + med flush.
3/24/2023: Dietitian documented weight stable this month with increased tube feed rate to 85ml/hr since 3/13/2023. She documented she suspected weights of 153.5 pounds (weighed on 2/15) and 153.5 pounds (weighed on 2/3/2023) were inaccurate.
4/30/2023: no changes to enteral orders. Weekly weight monitoring continued. No excess residuals, distensions, or other signs of intolerance noted in Dietitian note.
5/14/2023: Dietitian documented significant weight loss of - 12.05% x 6 months and -8.79% x 3 months. Dietitian noted that current enteral feeding should have been adequate in meeting estimated nutritional needs however resident had exhibited significant weight loss. Dietitian deemed recent infection Pneumonia and Shortness of breath likely contributed to weight loss.
Record review of Resident #58's comprehensive care plan dated 02/03/2023 revealed that significant weight loss care plan was added on 5/14/2023, however there were no goals or interventions for the associated care plan.
In an interview with LVN G on 5/16/2023 at 2:02 p.m., LVN G said he had worked with the facility for six weeks as a full time LVN. He stated he worked as an agency LVN before in the same facility. He usually worked 6am-2pm shift and had known the resident well. He worked the morning 6am-2pm and afternoon 2pm-10 pm shift on Monday 15th, May 2023 and morning 6am-2pm shift on Tuesday 16th, May 2023. Weights were also reviewed with LVN G. Resident # 58 had triggered for weight loss pattern since admit. Resident # 58 had 7.85% significant weight loss over a three-month period from 02/22/23 to 05/10/23. LVN G noted that he had not seen any weight loss, and no one had made him aware of resident losing weight. LVN G agreed he was seeing weight loss on the weight chart in electronic medical record and stated that if someone had made him aware of it, he would have paid closer attention to resident's tube feeding rate. He also stated that he is not sure if resident's physician had been informed about significant weight loss that was triggered on 5/10/2023. LVN G stated that if a resident who is dependent on tube feeding for all his nutrition and hydration does not get prescribed tube feeding, it would result in weight loss and possible skin breakdown.
In an interview with LVN J, on 5/16/2023 at 3:05 p.m., LVN J revealed that he was not familiar with Resident #58's tube feeding rate or pump since it was his first time working with the resident that day (2pm-10 pm shift on 5/16/2023). LVN J was not aware of any significant weight loss Resident # 58 was experiencing. LVN J revealed he had seen Resident #58 walking the hallways multiple times with his walker when he worked the other halls.
In an interview with LVN I, full time facility LVN on 5/16/2023 at 3:49 p.m., stated that he worked 5/13/23 and 5/14/23 on 10pm-6 am shift. He verbalized he disconnected Resident #58's feeding tube as part of his night shift duties at 6 am in the morning when his shift ended. LVN I also stated that patient had some behavior issues such as resident would be irritable at night, get up by himself and move himself from recliner to bed in the night, and in the process resident's PEG tube would be disconnected sometimes in the night. He also stated he did not document this in the Nursing progress notes. LVN I stated that he was not aware that Resident # 58 was losing weight or triggered for significant weight loss on 5/10/2023, but he thought that the resident looked [NAME] at times. LVN I stated he had not brought up Resident #58's behavior issues in the night.
In an interview with Dietitian, on 5/16/2023 at 4:10 p.m., it was revealed she acknowledged Resident #58 had lost weight since admit to the facility, however stated that resident's weight was stable in the last month. She also stated that the resident had antibiotic treatment started recently for pneumonia which could be the cause of recent weight loss in the last week. Dietitian stated that she provided a list of residents who triggered for weight loss either weekly or monthly via email to the DON. She did not make any additional changes to Resident #58's enteral feeding since she found significant weight loss that was triggered on 5/10/23. She was due to see the resident on the day of this interview. She revealed that she had not seen a reweigh was done on the resident since 5/10/23 significant weight loss. Dietitian stated that she had not seen any high blood glucose levels on the resident's labs since admit, hence specialty Glucose controlled formula was not required; but was not clear on why higher calorie tube feed formula (v/s the current 1.2 Diabetisource formula) was not used despite continued weight loss pattern Resident # 58 displayed. She revealed that she usually goes to resident's room to check on feeding pump, but she did not check on residents # 58 pump settings in the room since the order was changed to Diabetisource 85ml/hr x 10 hours in March. Dietitian reported she was not aware of resident being mobile and walked the hallways with walker. She stated nursing was responsible for notifying the physician of significant weight loss. She stated she did not notify the physician herself of the significant change of condition for Resident #58.
In an interview with Restorative Aide on 5/17/2023 at 10:50 a.m., it was revealed that she did the weekly weights in the facility for the past one year for most residents. Weekly weights were performed every Wednesday and Resident #58 was on weekly weight list since February 2023. Restorative Aide confirmed she weighed the patient on February 22, April 5, April 19, May 3 and May 10. Restorative Aide noted that resident can walk up to the weighing scale independently with a walker and can stand up unassisted on the weighing scale. Restorative Aide also stated that she saw Resident # 58 walking hallways of the facility on many occasions with a walker.
In an interview with DON on 5/17/2023 at 11:40 a.m. and 12:03 p.m., revealed that DON had been at the facility for about four weeks only. The DON stated after Dietitian informed her on 05/10/23 of residents including Resident #58 who need to be re-weighed she included the Staffing Coordinator in a text to have these residents' re-weighed. She had been informed of Resident #58 needing to be re-weighed on 05/10/23 but had not followed through to ensure re-weight was completed for Resident #58. She stated ADONs were responsible for monitoring weights, but they were both new to the facility as well. She stated the risk for residents who are NPO and dependent on enteral feeding for all their nutrition and hydration orders were weight loss, hydration issues, potential skin breakdown and deranged lab values. She stated significant weight loss was a change of condition and did not know if physician was notified of Resident #58's change of condition.
Interview on 05/17/23 at 12:12 p.m., ADON A revealed any weight discrepancies the Dietitian noticed went to the DON. She stated she found out about Resident #58's significant weight loss on 5/16/2023. She stated she was not aware of Resident #58's physician being notified of the significant weight loss for Resident #58. She stated she had started at the facility about 2 weeks ago. She was not aware who the designated person for weight monitoring. ADON A stated she had not received any training for monitoring of weights and was still learning the system.
Interview on 05/17/23 at 1:39 p.m., Physician A revealed he was notified of significant weight loss, but he does not remember when exactly, he recollected couple of months ago. He did not recollect recent notification for significant weight loss for Resident #58. Physician A was not aware of, nor was he informed of significant weight loss that was triggered on 5/10/2023 for Resident #58. He said that he would defer to the Dietitian for recommendations to put in place for significant weight loss.
2. Review of Resident #28's admission MDS assessment dated [DATE] reflected Resident #28 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of wedge compression fracture of vertebra, hypertension, Alzheimer's disease and dementia. Resident #28's height was 62 inches and weight of 113. She had a BIMS of 7 indicating she was severely cognitively impaired. Resident #28 required extensive assistance with ADLs except for toileting. Resident #28 eating ADL occurred once or twice with one person physical assistance.
Review of Resident #28's Hospital discharge paperwork dated 04/21/23 did not reflect a height or weight for Resident #28.
Review of Resident #28's Weight Record reflected the following:
Date
Weight (in Pounds)
04/21/2023
113
05/02/2023
89.5
05/11/2023
87
05/18/2023
89.5
Weight Loss calculations reflected on 05/02/23 - Resident #28 had a 20.8% weight loss with 23.5 lb loss since admission, 05/11/2023 had a 23% weight loss with 26 lbs lost since admission.
Review of Resident #28's Nutrition Assessments reflected:
-
Record date of 04/24/23 and signed 05/03/23 by Registered Dietitian reflected Resident #28 was regular diet with thin liquids, oral intake was 75 to 100%, current weight of 89.5 lbs, 16.4 BMI (underweight) and adjusted body weight IBW (ideal body weight) 110+/-10%, hospital labs potassium low (3.3), BUN high (28), creatine low (0.5). Interventions included diet as prescribed, recommended 1) Nursing - please obtain reweight to confirm true weight loss 2) Nursing: Weekly weight x 4 weeks. Please follow to assure cessation of weight loss. 3) Nursing: Add order for diet texture.
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Record date and signed date of 05/12/23 by Registered Dietitian reflected RD note to address sig wt loss for 5/2023- Resident is receiving a regular diet (no therapeutic diet restrictions). Tolerating without issue - consuming 75-100% of meals. She is independent/occasional staff assist with eating and usually eats in her room. Impaired cognition per notes. No constipation per staff - on Colace. No pressure wounds or skin breakdown noted on today's wound report. Labs/meds reviewed- MVI QD. UA still pending. Estimated needs: Kcals/day: 1260-1440 kcal/d (30-35 kcal/kg CBW)*underweight. Prot gm/day: 49-53 gm/d (1.2-1.3 gm/kg CBW)*underweight. Fluid ml/day: 1500 ml/d minimum or per MD. Anticipate alteration in nutrition and hydration status r/t impaired cognition, BMI status and sig wt loss. Weights: (5/11) 87, (5/2) 89.5, (4/21) 113.CBW (5/11) 87 - significant wt loss of -2.79% x 7 days and -23% since admission.BMI 15.91 underweight. She is at high risk for malnutrition. Question accuracy of 4/21 weight. Anticipate alteration in nutrition and hydration status r/t impaired cognition, BMI status and sig wt loss. Recommend: 1) Nursing: Weekly weights x 4 weeks. Please follow to assure cessation of weight loss. 2 Nursing: Add .order for diet texture. 3) Nursing: Encourage meals in dining room for monitoring and additional assistance as needed. 4)Boost 1 carton po QD at 230 pm (240 kcal, 10 gm prot) for weight maintenance. RD to follow as needed.
Review of DON's email with subject line RD visit and recommendations 5/2/23 from Registered Dietitian dated 05/04/23 at 5:26 PM reflected Registered Dietitian emailed the Administrator, ADONs and the DON about Resident #28 being a new admit and possible weight loss. Registered Dietitian reflected recommendations of (Nursing - Please obtain reweight to confirm true weight loss. 2) Nursing: Weekly weights x 4 weeks. [NAME] follow to assure cessation of weight loss. 3) Nursing: Add order for diet texture.
Review of Resident #28's Meal Intake for May 2023 reflected Resident #28 had meal intake of 50 to 100% intake.
Review of Resident #28's Physician Orders and eMAR for May 2023 reflected Resident #78 was started on boost daily. No other weight loss interventions were in place as of 05/17/23 and 05/19/23.
Interview on 05/19/23 at 10:35 p.m., Registered Dietitian reflected she completed her first nutrition note for Resident #28 on 05/02/23 and she did see there was a concern with weight loss. She stated Resident #28 had good oral intake of 75 to 100% intake and did not add any weight loss interventions since resident was eating well. She stated she recommended weekly weights and put texture order in system. She stated Resident #28 was a new admit already on weekly weights. She did not ask for re-weights on 05/02/23 and sent the DON her recommendations via email as she normally did. She did not follow up with DON or nursing to ensure re-weight was completed. She stated nursing was responsible for notifying the physician of significant weight loss. She stated she either communicated in passing or in email her recommendations to the DON. She stated on 05/12/23 when Resident #28 continued to lose weight of 2.5 lbs more she recommended Resident #28 to be put on one boost shake daily. She stated she had not followed up to see how Resident #28 was tolerating and if compliant with boost shake. She stated she questioned the admission weight but did not communicate with DON about it. She stated Resident #28 did have a low body mass index but she had good oral intake.
Review of DON's text dated 05/10/23 at 9:22 PM reflected resident reweights for Residents #28 and #58 who was included in the text message.
Interview on 05/19/23 at 11:19 AM with DON revealed she did not request re-weights for Resident #28 until 05/10/23. She had only been at the facility about 4 weeks. She stated reweights should have been completed with 24 hours on 05/02/23 when significant weight loss triggered. She stated the Registered Dietitian could have communicated with me on 05/02/23 when she reviewed the weight for Resident #28 to have her re-weighed and about her significant weight loss. She stated she was ultimately responsible for ensuring weights were monitored. She stated the communication with the Registered Dietitian was by email about her recommendations, but she did not include in her documentation about what the percentage of the significant weight loss was. She stated Resident #28 was a new admit and should have been weighed weekly for at least 4 weeks. She stated Resident #28 would be notified today of significant weight loss and should have been notified on 05/02/23 when first triggered for significant weight loss.
Interview on 05/17/23 at 1:48 PM with the Medical Director, who is Resident #28's Physician, revealed he would like to be notified if resident had significant weight loss.
Review of facility's policy Change of Condition (Acute) revised 02/12/20 reflected The nurse assigned to the resident or supervising the care of the resident is responsible for notification of and communication to the medical staff regarding significant changes or significant deterioration in the resident's condition and for assuring that there is a physician response .Ac Acute change of condition is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. 'Clinically important' means a deviation that, without intervention, may result in complications or death .Categories are listed as: 1. Vital Signs 2. Laboratory Testes/Diagnostic Procedures 3. Signs and Symptoms. Notification is categorized as: Immediate Notification: any symptom, sign or apparent discomfort that is acute or sudden in onset, and: a marked change (i.e. more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed Non-immediate notification: new or worsening symptoms that do not meet above criteria .Change of Condition is completed prior to notification to practitioner, if not emergent. 4. The nurse notifies the responsible physician utilizing appropriate channels and chain of command. Notify physician in the following order unless otherwise indicated by physician order, by routine service, or as indicated by the patient condition: a) Attending Physician B) Advanced Practice Registered Nurse .5. Document in the medical record the date, time and name of each physician notified, actions taken and/or patient's response to treatment. Documentation should also include all nursing assessments and findings, nurse actions and notification of charge nurse/nurse supervisor .6. Patient families, guardians, or other appropriate people are to be contacted when there is a significant change in a patient's condition or health status. Examples of circumstances of when it is appropriate to communicate information to these parties may include, but are not limited to: a) Diagnosis of a new condition or a significant change in diagnosis .c) Unexpected deterioration in condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents were given the right to participate in the development and implementation of their plans of care for one (Resident #32) of 17 residents reviewed for resident rights.
The facility failed to ensure Resident #32 had an opportunity to participate in planning her care.
This failure could place residents at risk for decreased quality of care and a lack of notification of services and treatments being provided.
Findings included:
Review of Resident #32's quarterly MDS assessment dated [DATE] indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #32 was able to understand and able to make others understand her and had a BIMS of 15 which indicated she was cognitively intact. Resident #32 required extensive assistance of two people with all ADLs and rarely got out of bed. Resident #32's active diagnoses included anxiety disorder, functional quadriplegic (complete ability to move due to severe disability or frailty, not due to spinal cord damage or stroke) and chronic respiratory failure.
Record review of Resident #32's comprehensive care plan reflected it was reviewed and updated by MDS Coordinator C on 03/06/23.
Record review of Resident #32's care plan conference notes reflected the last care plan conference held with the resident was on 10/27/22 and was completed by the previous Social Worker. Care plan Conference note indicated Resident #32, Resident Representative, Social Services, Nursing and Therapy attended the meeting.
In an interview with Resident #32 on 05/16/23 at 10:27 a.m., she stated she had not been invited to her care plan conference this year. She stated they used to come to her room for her care plan meetings. She stated she wants to continue to participate in her care plan meetings.
In an interview with MDS Coordinator C on 05/19/23 at 11:00 a.m., she stated the Social Worker was responsible for scheduling the care plan conferences with the resident's and family members. She stated the SW had left about a month ago, and since then she and MDS Coordinator D had been doing the new admission care plan conference, but stated she was not sure if any of the long-term care residents had been invited to participate in care plans. She stated she could not recall the last time Resident #32 had been included in her care plan. She stated she had just completed her most recent quarterly MDS assessment on 05/06/23 and did not recall a care plan conference with the resident.
An interview with the Corp Social Worker on 05/19/23 at 11:15 a.m., she stated care plan meetings were held every three months and were triggered off the scheduled MDS assessments. She stated all resident's had the right participate in their care plans and should be invited. She stated the new S.W. is scheduled to start next week.
In an interview with the DON on 05/19/23 at 12:00 p.m. she stated the previous S. W's last day was 04/18/23. She stated she was told the MDS Coordinators would be scheduling the care plan conference with the resident's and families until a new S.W. was hired. She stated they were supposed to call the families and notify the resident when their care plans were due. She stated by not including residents or families in the care planning process could lead to a breakdown in communication and the facility not knowing what the resident's wishes were. She stated she would make sure a care plan conference was schedule with Resident #32.
Review of the facility's undated Resident Rights in the State of Texas from the Resident and family handbook, reflected, Participation of care. You have the right to .participate in developing a plan of care, to refuse treatment, and to refuse to participate in experimental research .be informed in a language you understand about your total medical condition, recommended treatment, and expected results (including reasonably expected effects, side effects and associated risks), and be notified whenever there is a significant change in your condition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #19, Resident #29, Resident #61) of 8 residents reviewed for ADLs.
The facility failed to ensure:
1- Resident #19 had his fingernails cleaned and trimmed.
2- Resident #29 had her fingernails cleaned.
3- Resident #61 had his fingernails trimmed and lotion applied to his feet and legs.
This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.
Findings include:
1- A record review of Resident #19's Comprehensive MDS assessment dated [DATE] reflected Resident #19 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, cerebrovascular accident (a loss of blood flow to part of the brain, which damages brain tissue), and hemiplegia (paralysis of one side of the body. Resident #19 had a BIMS of 03 which indicated Resident #19's cognition was severely impaired. He required extensive assistance of one-person physical assistance with personal hygiene.
A record review of Resident #19's Comprehensive Care Plan, revised 05/02/23, reflected the following: care area/problem: Self-care deficit. Goal: Resident will maintain or improve self-care area of dressing, grooming hygiene and bathing over the next 90 days. Interventions: Provide assistance with self-care as needed.
An observation and interview on 05/17/23 at 11:15 AM revealed Resident #19 was laying in his bed. The nails on the right hand were approximately 0.3 centimeter in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #19 unable to answer questions.
2- A record review of Resident #29's Comprehensive MDS assessment, dated 03/30/2023, reflected Resident #29 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, tremor (an involuntary quivering movement), and dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain. Resident #29 had a BIMS of 08 which indicated Resident #29's cognition was moderately impaired. Resident#29 required extensive assistance of one-person physical assistance with toilet use and personal hygiene.
A record review of Resident #29's Comprehensive Care Plan reflected the concern was not care planed.
Observation and interview on 05/17/23 at 12:05 PM revealed Resident #29 was laying in her bed. The nails on both hands were discolored tan and the underside had dark brown colored residue, and the bed of the nails had dark brown colored residue. Resident #29 stated she scratched sometimes her bottom because it was itching.
Interview on 05/17/23 at 1:52 PM, CNA N stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA N stated she would clean Resident #19 and Resident #29's nails right then. CNA N stated she would talk to the nurse about Resident #19 long nails because he was diabetic.
Interview on 05/17/23 at 3:54 PM, RN O stated CNAs were responsible to clean and trim residents' nails as needed. RN O stated only nurses cut residents' nails if they were diabetic. RN O stated no one notified him Resident #19's nails were long and dirty, and he had not noticed the nails himself. RN O stated Resident#29 was diabetic he would clean and trim his nails.
3- Review of Resident #61's face sheet dated 05/17/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of end stage renal disease (kidney failure), generalized muscle weakness, unsteadiness on feet and sepsis (serious condition in which the body responds improperly to an infection).
Review of Resident #61's admission MDS assessment dated [DATE] reflected he had a BIMS of 6 indicating he was severely cognitively impaired. He required extensive assistance with ADLs except supervision with eating only.
Observation and Interview on 05/16/23 at 10:36 AM revealed Resident #61 was lying in his bed with his fingernails were about 0.4 cm extended from the tip of his thumbs and 0.2 cm extended from the tip of the rest of his fingers on both hands. Resident #61 stated the CNAs would not trim his fingernails but they did bathe him. He stated he was not a diabetic.
Observation and interview on 05/18/23 at 1:08 PM revealed Resident #61 was lying on bed with oxygen via nasal cannula at 3 liters per minute. Resident #61 stated the CNAs would not trim his nails since he got back from the hospital, but CNA Q did trim his fingernails when he was on a different hall. Resident #61 stated he preferred a bed bath. Resident #61 stated he asked CNAs to lotion his feet and legs.
Observation on 05/18/23 at 1:18 PM with LVN G revealed Resident #61's feet on bottom were dry and flaky with no open areas. Resident #61's lower legs below the knees had dry skin. Resident #61's toenails were thick and about 0.5 cm extended from the tip of the toes. He stated nurses were responsible for trimming resident's fingernails and toenails if residents were not diabetic. LVN G asked Resident #61 if he would like him to trim his fingernails and Resident #61 told him yes. LVN G stated he would come back and trim Resident #61's fingernails.
Interview on 05/18/23 at 1:24 PM with LVN G revealed Resident #61 did have flaky and dry on bottom of both feet along with dry skin on his legs. He stated he was not aware of CNAs not putting lotion on his feet. He stated Resident #61 had no open areas on his feet. He would need to contact Resident #61's physician about getting a prescription lotion to help Resident #61's dry and flaky skin on his feet because the regular lotion CNAs would put on would not help him with the dryness.
Observation and Interview on 05/18/23 at 1:43 PM with DON revealed Resident #61's had flaky, dry skin on his feet with no open areas on his feet. His toenails were thick on both feet about 0.5 cm extending from the tip of his toes.
Interview on 05/18/23 at 1:50 PM with DON revealed Resident #61 would need to see a podiatrist about his dry and flaky skin and look at his toenails since they were too thick and long for nurse to trim Resident #61's toenails. She stated she will follow-up with nursing to ensure Resident #61 got a prescribed lotion to help with the dry and flaky skin and reach out to podiatrist to come out to facility for Resident #61. She stated Resident #61 not having toenails trimmed could place resident at risk of ingrown toenails. She stated Resident #61 not receiving lotion on his feet could place him at risk for skin breakdown on his feet.
Interview on 05/20/23 at 11:08 AM with CNA R revealed he provided Resident #61 bed baths on 05/11/23, 05/13/23 and 05/16/23 along with lotion on his legs and feet and cleaned his fingernails when he worked on the 2nd shift. He stated nurses were responsible for trimming fingernails.
Review of Resident#61's showers sheets for 05/11/23, 05/16/23 and 05/16/23 reflected Resident#61 was bathed, fingernails cleaned and toenails cleaned by CNA R. It did not reflect fingernails trimmed.
Interview on 05/18/23 at 2:33 PM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty nails could be an infection control issue. The DON stated she was responsible to do routine rounds for monitoring. The DON stated she had not noticed the nails herself.
Record review of the facility's policy titled Foot and Toenail Care, Routine, revised 02/12/2020, reflected . Residents will receive routine nail care in accordance with standard practice guidelines. Staff will provide bathing services for residents within standard practice guidelines . Perform hand hygiene and perform nail care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #48) of one resident reviewed for respiratory care.
LVN D failed to maintain a sterile/clean field for supplies necessary for tracheostomy care and failed to keep her dominant (Right) hand sterile while providing trach care for Resident #48.
This failure could place residents with tracheostomies at risk for respiratory infections.
Findings included:
Review of Resident #48'S's quarterly MDS assessment, dated 03/29/23, reflected a [AGE] year-old male with an admission date of 11/03/21 and readmission date of 11/16/22. Resident #48 was unable to participate in the interview for cognition and was assessed by the staff to be severely impaired. His active diagnoses included pneumonia and tracheostomy (a surgical opening in the neck providing a direct airway through the trachea). In Section O-Special Treatments, Procedures, and Programs it revealed that he required tracheostomy care and oxygen therapy during the 14 days look back period.
Review of Resident #48's Physician consolidated orders dated 05/19/23, reflected, .Trach Care every am pm shift (6 am- 2pm-10-pm) Portex (cuffed trach tube) size 7. Cleanse outer trach stoma with NS, Pat Dry Apply dressing. Change ties when soiled Trach Care as needed .Remove and replace disposable inner canula .Suction Trach as needed .Observe for changes in sputum, notify MD of increase viscosity in color of sputum, bloody sputum, and increase in sputum production .Give oral care may suction oral cavity .Start date 11/16/22.
Review of Resident #48's care plan revised on 04/23/23, reflected, .Tracheostomy .Trach Care every am pm shift .Goal .Effective airway will be maintained and monitored over the next 90 days .Interventions .Change dressings and ties every day or when they become soiled .Clean tracheostomy tube, inner cannula per physician's order .Observe stoma for redness, swelling, bleeding and signs of infection .
An observation on 05/17/23 at 8:25 a.m., revealed LVN D and Agency LVN E entered Resident #48's room to provide tracheal suctioning and tracheostomy care. Both staff washed their hands and put on clean gloves. LVN E placed a towel over the bedside table without sanitizing the table and placed a sterile suctioning kit onto the table. Agency LVN E was observed giving step by step instructions to LVN D on set up and performance of sterile suctioning. After gathering supplies LVN D removed her gloves and washed her hands and opened the sterile suction kit and put on sterile gloves. LVN D turned on the suction pump with her non dominant (left) hand and attached the suction tubing to the suction catheter and provided suctioning. Once LVN D completed the suctioning she removed her gloves and indicated she was done. Agency LVN E stated she needed to provide tracheostomy care, since the suctioning had produced a large amount of phlegm and the stoma dressing and trach ties were soiled. LVN D washed her hands and put on clean gloves to gather supplies which were stored on the top of resident's bedside chest of drawers. LVN D place 3 packages of 4x4 gauze, a bottle of normal saline and a sterile trach kit on top of the towel on the bedside table. LVN D opened the Trach kit and removed the sterile drape and placed it on the resident's chest under the trach collar. The soiled stoma dressing had not been removed. LVN D then removed her gloves, washed her hands, and put on her sterile gloves and removed a small container out of the kit and placed it on the bedside table. LVN D then opened the packages of gauze and the bottle of saline which were not sterile, which contaminated her sterile gloves. LVN D then poured normal saline into the small container. Agency LVN E stated she would remove the soiled stoma dressing since LVN D had failed to remove it before putting on her sterile gloves. LVN D then picked up the gauze in her left hand and picked up the bottle of saline with her right hand and poured it over the gauze and then wiped around the outside of the trach with the wet gauze. LVN D repeated the step three times. LVN D then picked up the package of ties and removed the soiled tie from the trach collar and replaced the ties with the assistance of Agency LVN E. LVN D then wiped under the trach collar around the stoma site with moistened gauze, while wearing contaminated gloves. LVN D then took the brush from the trach kit, dipped it in the normal saline and scrubbed around the outside of the trach. LVN D then opened a package of sterile trach stoma dressing and placed it around the stoma while still wearing contaminated gloves.
In an interview with LVN D on 05/17/23 at 9:20 a.m., she stated she had not been doing the trach care on Resident #48 and stated the night nurse was doing it. She stated she was providing suctioning and changing out the stoma dressing when it got dirty. She stated she did not realize this was considered part of trach care. She stated she was a new nurse. She stated she knew how to perform trach care and suctioning and knew it was a sterile procedure. She stated she realized she had touched items with her sterile gloves that should had already been opened before she put on her sterile gloves. She stated she should had removed the dirty stoma dressing before she put on her sterile gloves. She stated these failures placed the resident at risk of infections.
In an interview on 05/17/23 at 10:02 a.m., the DON stated trach care was considered a sterile procedure. She stated when LVN D contaminated her gloves and did not follow the proper steps of trach care she posed the risk of respiratory infections to the resident.
Review of LVN D's personnel record reflected a hire date of 11/08/22. Review of her skills Respiratory competency evaluation reflected she had been skills checked on Tracheal Suctioning on 05/16/23, but not on Tracheostomy Care.
In an interview on 05/17/23 at 03:30 p.m., the facility's RT Consultant stated she was contracted with the facility to provide Respiratory evaluations and provided training to the staff on trach care and was available by phone for any questions. She stated the facility reached out to her on 05/16/23 and asked her to come and train LVN D on sterile suctioning. She stated when she finished the training on suctioning, she asked LVN D if she needed training on trach care, and she stated no she didn't need any additional training. RT Consultant stated the resident had been in the facility since November 2022 and she had been doing bedside training with some of the staff on trach care and suctioning with the resident. She stated she had been teaching trach care as a clean technique, but stated the staff needed to have all their supplies opened and set up prior to putting on the sterile gloves to prevent the risk of cross contamination and infection. She stated the staff needed to change gloves and perform hand hygiene when going from dirty to clean.
In a follow up interview with the DON 05/18/23 at 10:22 a.m., she stated LVN D had not been previously skills checked for trach care. She stated she had started at the facility about six weeks ago and had been told LVN D had worked at the facility since November when the resident first arrived, and she assumed she had been trained on trach care. She stated the staffing coordinator was responsible for scheduling the staff and ensuring they were trained. She stated going forward she was going to be the one ensuring the nurses assigned to specialty care were trained and qualified. She stated LVN D had been removed until she completed all her skills checks.
In an interview with the Staffing Coordinator on 05/18/23 at 1:00 p.m., stated she was responsible for making sure new hires had received orientation and had all their skills checks completed. She stated she was on medical leave from October 2022 through January 2023. She stated the pervious DON was responsible for ensuring the training had been completed but had since discovered some of those duties had been assigned to a CNA. She stated the new DON had stated she would be taking over the responsibility of ensuring the staff had been trained and skills checked.
Review of the facility's policy, Performing Tracheostomy Care' revised January 2020, reflected, Standard of Practice: Staff will provide care for residents with a tracheostomy in accordance with standard practice Guidelines .
The Nursing Services-Respiratory Competency Evaluation for Tracheostomy care reflected .Verify orders for type and size of tracheostomy tube and inner cannula
.Gather trach care kit and suctions supplies, ensure emergency supplies are kept at bed side . Wash hands and apply PPE appropriate for risk of contact with secretions .Open and prepare trach care kit .Wash hands and apply gloves .Grasp the flange with dominant hand .Cleanse outer cannula surfaces and skin around the stoma using a circulation motion from stoma site outward .While securing trach tube, remove old tracheostomy tie .replace trach ties ensuring one or two finger widths between neck and tie .Ensure tube is midline and replace dressing under faceplate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for one (Resident #58) of the four residents reviewed for enteral tube feeding, in that:
1.
Dietitian failed to communicate and follow-up on Resident #58's significant weight loss of 18 pounds from 01/31/23 to 05/10/23 to the facility and verify adequate nutrition was provided via enteral tube feeding or PEG tube (surgical placement of feeding tube in the stomach to provide nutrition, hydration and/or medicines) for Resident #58. Dietitian also failed to implement resident centered enteral tube feeding nutrition plan for Resident #58.
2.
LVN G, LVN I and LVN F failed to administer enteral feedings to Resident #58 as ordered by the physician for last 72 hours (May 13, May 14, and May 15).
Resident #58 experienced continuous significant weight loss of -7.85% (11.5 pounds) in the last three months since 2/22/2023 AND -12% (18.5 pounds) since admit weight of 2/3/2023.
An Immediate Jeopardy (IJ) situation was identified on 05/17/23 at 5:39 PM. While the IJ was removed on 05/20/23 at 5:30 PM, the facility remained out of compliance at a scope of isolated at the severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their corrective systems.
These failures could place residents who are completely dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown and overall decline in quality of care.
Findings included:
Review of MDS assessment dated [DATE] for Resident #58 reflected he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of Parkinson's disease (brain disorder that causes unintended or uncontrollable moments), Dysphagia of oropharyngeal phase (difficulty swallowing), Pneumonitis due to inhalation of food and vomit (lung infection caused by inhaling food, saliva or other), Cognitive Communication deficit ( inability to communicate properly) , Dysarthria (difficulty in speaking related to weak muscles), Dysphonia (difficulty speaking related to physical disorders of vocal cords), Muscle weakness and other chronic pain conditions. Review revealed the resident had a BIMS score of (09), which meant the resident was moderately impaired cognition. The resident required extensive assistance with ADLs and was incontinent of bowel and bladder. It reflected that patient had PEG tube in place for enteral feedings on admission and was NPO, dependent on PEG tube feedings for nutrition and hydration. The resident was at risk for weight loss. The resident's height was 5 feet 8 inches, and the hospital admission weight was 153 pounds. Residents' # 58 Ideal body weight: 154 pounds (+/- 10%)
In an observation for Resident # 58 on 05/16/2023 at 10:44 pm, it was noted that the resident was resting in his recliner. Observed tube feeding pump next to the recliner on the pole was off. Resident was not interviewable at time of visit. Resident could only answer in yes and no questions, however, did not have clear perception of time, date or place. During exit from resident's room, Noted X-ray tech had entered resident's room to take images.
In a phone interview with Resident #58's responsible party on 5/16/2023 at 11:44 am , it was revealed that Resident # 58 had lost some weight and looked skinny and bony lately than from time of admit in January. They also stated that the resident had missed some of his nocturnal tube feeds via pump for couple days in the past but had not seen that lately. Responsible party could not substantiate time frame as to when exactly the resident did not get feedings or who reported this to her. Responsible party did not voiced any other concerns for the resident at that time.
Record review of weight chart for the resident included the following:
Date
Weight (in Pounds)
02/03/2023
153.5
02/15/2023
153.5
02/22/2023
146.5
03/01/2023
143.9
03/08/2023
142.0
03/15/2023
143.7
03/22/2023
143.2
03/29/2023
140.5
04/06/2023
140.5
04/19/2023
139.5
05/03/2023
140.0
05/10/2023
135.0
On 05/10/2023, Resident # 58's weight was 135 pounds and triggered for significant weight loss of -7.85% (11.5 pounds) in the last three months since 2/22/2023 AND -12% (18.5 pounds) since admit weight of 2/4/2023.
Record review for Nutrition assessment by Dietitian indicated the following:
01/31/2023: Diabetisource AC 50ml/hr x 22-hour continuous feeding via PEG tube via pump per hospital orders. Ideal body weight: 154 pounds +/- 10%
02/03/2023: Dietitian changed orders to Diabetisource AC 75ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day bolus feeds via PEG Tube. This provided 1800kcal/ 90g protein and 2008 ml total fluids. Per Dietitian notes, admission enteral order was changed since it did not meet resident's nutrition needs and Resident # 58 expressed not wanting to push the tube feeding pole down the hall during therapy. Hence, nocturnal 10 hour feeding regimen + bolus feeding regimen in the daytime was added.
02/27/2023: Dietitian documented significant weight loss of -2.6% x 7 days AND -6.4% x 1 month. Tube feeds orders changed to Diabetisource AC 80 ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day via PEG Tube which provided 1860 kcal/ 93 g protein and 2090 ml total fluids.
03/13/2023: Dietitian changed Tube feeds orders again to Diabetisource AC 85ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day via PEG Tube to provide 1920 kcal/ 96 g protein and 2091 ml fluids + med flush.
3/24/2023: Dietitian documented weight stable this month with increased tube feed rate to 85ml/hr since 3/13/2023. She documented she suspected weights of 153.5 pounds (weighed on 2/15) and 153.5 pounds (weighed on 2/3/2023) were inaccurate.
04/30/2023: no changes to enteral orders. Weekly weight monitoring continued. No excess residuals, distensions, or other signs of intolerance noted in Dietitian note.
05/14/2023: Dietitian documented significant weight loss of - 12.05% x 6 months and -8.79% x 3 months. Dietitian noted that current enteral feeding should have been adequate in meeting estimated nutritional needs however resident had exhibited significant weight loss. Dietitian deemed recent infection Pneumonia and Shortness of breath likely contributed to weight loss.
Record Review of resident's #58 progress notes revealed that he was NPO and dependent on enteral tube feeding for his nutrition and hydration. Resident #58 had a deficit of 900 kcal in past 72 hours and 45 grams deficit in past 72 hours as indicated by pump history record review.
Record Review of Resident #58 MAR indicated that Tube feed Diabetisource AC 85ml/hr x 10 hours on at 8 pm and off at 6 am + 250 ml Diabetisource three times per day via bolus feeding daily. Clear pump and record intake.
Record review of TAR between 5/1/23 - 5/16/23 on 6 am shift indicated that pump feeding records had values ranging from 85,520,680, 800, 1000 ml. Similarly, on the 8 pm shift from 5/1/23-5/16/23, TAR revealed that values were between 85, 100, 180, 200, 240, 250, 320, 500 ml. There was no consistency in documenting between the actual volume of feedings resident received.
Record review of Resident # 58's care plans revealed that significant weight loss Care plan was added on 5/14/2023, however there were no Goals or Interventions for the associated care plan. As of 5/16/2023, there was no documentation for change in condition in the care plan documentation based on significant weight loss triggered on 5/10/2023.
Record review of care plan dated 02/03/2023 had no documentation regarding any behavior Resident #58 was displaying such as moving about in the night, thus accidentally disconnecting the feeding pump.
In an observation with LVN G 12:16 pm on 5/16/2023, Resident # 58 was standing at the door of
his room with his walker. LVN G performed hand hygiene, don gloves and proceeded to administer resident with 1 can (250 ml) of Diabetisource AC via PEG tube via bolus feed. Also noted that, Resident # 58 got two crush medicine (Carbidopa and Entacapone) mixed with water along with bolus tube feeding. LVN G then administered appropriate amount of water flush post medicine and feed administration. Tube feed kangaroo pump history was reviewed with LVN G. Observation on Tube feed Kangaroo pump revealed that for the last 72 hours resident #58 received 60 ml/hr for PEG tube feeding and total volume fed was at 2008 ml. Water flush was set at 200ml every 4 hours, water flush administered was at 1740 ml. Reviewed physician orders along with LVN for the tube feeding pump, the feed rate in the physician order was for 85ml/hr, dated March 13, 2023 per MAR. LVN G stated he wasn't aware of the 85ml/hr physician order. On asking, if the feed rate set on the enteral feeding pump was checked against the physician orders in chart, LVN G answered he usually would take the resident off the pump during his shift and did not note the pump rate or record actual feed volume on the pump or clear the pump settings after the tube feeding administration was completed, which was also noted on the physician orders.
In an interview with LVN G on 5/16/2023 atr 2:02 p.m., LVN G was working with the facility for six weeks now as a full time LVN, he worked as an agency LVN before in the same facility. He usually worked 6am-2pm shift and had known the resident well. He worked the morning 6am-2pm and afternoon 2pm-10 pm shift on Monday 15th, 2023 and morning 6am-2pm shift on Tuesday 16th, 2023. Weights were also reviewed with LVN G. Resident had triggered for weight loss pattern since admit. Resident had 7.85% significant weight loss over a three-month period from 02/22/23 to 05/10/23. LVN G noted that he had not seen any weight loss, and no one had made him aware of resident losing weight. LVN G agreed he was seeing weight loss on the weight chart in electronic medical record and stated that if someone had made him aware of it, he would have paid closer attention to resident's tube feeding rate. He also stated that he is not sure if resident's physician had been informed about significant weight loss that was triggered on 5/10/2023. LVN G stated that if a resident who is dependent on tube feeds for all his nutrition and hydration does not get prescribed tube feeding, it would result in weight loss and possible skin breakdown.
In an interview with LVN J, on 5/16/2023 at 3:05 p.m., LVN J revealed that he was not familiar with Resident # 58 tube feeding rate or pump since it was his first time working with the resident that day (2pm-10 pm shift on 5/16/2023). LVN J was not aware of any significant weight loss Resident # 58 was experiencing. LVN J revealed he had seen the Resident # 58 walking the hallways multiple times with his walker when he worked the other halls.
In an interview with Agency LVN H on 5/15/2023 at 3:42 p.m. , She worked the 10pm- 6 am shift on the following days - May 9, 10, 11th, 2023. Agency LVN H stated she had disconnected the Resident # 58 tube feeding pump at 6 am when the tube feeding was completed; however, she did not remember the actual rate but thought the pump had been on feed rate of 65ml/hr. She did not document the total fed rate (as seen on the pump) on MAR or TAR, nor did she clear the pump after the shift ended. She did not double check the physician order in the EMR since she thought the pump has already been programmed to the correct rate. She also stated that she wasn't provided any training on PEG feeding / kangaroo pump administration by the facility since she is Agency RN, they are expected to know PEG feedings/ how Kangaroo pump functions. She has only worked 10pm-6 am shifts at the facility and has been responsible for disconnecting the resident's feeding tube at 6 am by the end of the shift.
In an interview with LVN I, full time facility LVN at 3:49 pm on 5/16/2023 at 3:49 p.m. , stated that he worked 5/13/23 and 5/14/23 on 10pm-6 am shift. He verbalized he disconnected resident's feeding tube as part of his night shift duties at 6 am in the morning when his shift ended. He mentioned he did not usually look at the pump rate when he disconnected the feeding from the resident and did not check the enteral pump feed rate against the physician orders. He also he did not typically record volume infused on the pump or clear the pump settings as outlined in the physician order. LVN I also stated that patient had some behavior issues such as resident would be irritable at night, get up by himself and move himself from recliner to bed in the night, and in the process resident's PEG tube would be disconnected sometimes in the night. He also stated that he knows some agency LVN's who forgot to administer resident's nightly tube feeds at 8 pm, and then would bolus a can of feeding ( 250 ml Diabetisource AC formula) at that time; this happened 1-2 occasions in the last 3 months. LVN I did not provide names of agency RN's. He also stated he failed to document that certain Agency Nurses did not administer tube feeding via pump in the Nursing progress notes. LVN I stated that he was not aware that Resident # 58 was losing weight or triggered for significant weight loss on 5/10/2023, but he thought that the resident looked [NAME] at times. LVN I did not bought up Resident # 58 behavior issues in the night to any other Nursing staff in the facility.
In an interview with Dietitianon 5/16/2023 at 4:10 p.m., it was revealed that she wrote tube feeding orders for the facility. She also stated that she had known Resident # 58 and was not aware of any issues with resident tolerating tube feeds. She acknowledged resident had lost weight since admit to the facility, however stated that resident's weight was stable in the last month. She also stated that the resident had antibiotic treatment started recently for pneumonia which could be the cause of recent weight loss in the last week. Dietitian stated that she provided a list of residents who triggered for weight loss either weekly or monthly via email to the DON. She was not sure of the process the facility had in place for reweighing residents once weight loss was identified. She did not make any additional changes to Resident # 58 tube feeding since she found significant weight loss that was triggered on 5/10/23. She was due to see the resident on the day of this interview. She revealed that she had not seen a reweigh was done on the Resident # 58 since 5/10/2023 significant weekly weight loss. Dietitian stated that she had not seen any high blood glucose levels on the resident's labs since admit, hence specialty Glucose controlled formula was not required; but was not clear on why higher calorie tube feed formula (v/s the current 1.2 Diabetisource formula) was not used despite continued weight loss pattern Resident # 58 displayed. She revealed that she usually goes to resident's room to check on feeding pump, but she did not check on Residents # 58 pump settings in the room since change order of Diabetisource 85ml/hr x 10 hours in March, 2023. She also verbalized that since she had seen the resident sleeping in his recliner most times and wanted to change Resident # 58 tube feedings to 22-hour continuous regimen. She noted that she had not consulted with DON, Charge nurse or Resident # 58 treating physician on this recommendation. Dietitian reported she was not aware of resident being mobile and walked the hallways with walker. Dietitian said she failed to verify adequate nutrition was provided via PEG tube as ordered and implement resident centered enteral tube feeding nutrition plan.
Record reviews of Resident # 58 laboratory report dated 5/12/2023 indicated that Blood glucose was within normal range.
Attempted to reach LVN L who worked 5/13/2023 on Morning shift 6am-2pm and afternoon shift 2pm-10 pm, however she could not be reached despite leaving voicemail for her on 5/16/2023 at 4:16 pm ; also asked the facility to contact LVN L. No call back received.
In a phone interview with Agency LVN F on 5/17/2023 at 8:55am she stated that she worked on 5/14/2023 from 2 pm-10 pm shift. She reported she double checked the tube feed rate with the orders. She does not remember the feed rate on the pump. Agency LVN F stated that she did not had to reprogram or clear the pump when she started the pump that evening to administer the feeding. Agency LVN F also did not documented fed volume from the pump to eMAR. Agency LVN F noted that she was not provided any training by the facility regarding PEG tube/ weights/ kangaroo pump functioning when she started working at the facility.
In an interview with Restorative Aide on 5/17/2023 at 10:50 a.m., it was revealed that she did the weekly weights in the facility for the past one year for most residents. Weekly weights were performed every Wednesday and Resident # 58 was on weekly weight list since February 2023. Restorative Aide confirmed she weighed the patient on February 22, April 5, April 19, May 3 and May 10. Restorative Aide noted that resident can walk up to the weighing scale independently with a walker and can stand up unassisted on the weighing scale. Restorative Aide also stated that she saw Resident # 58 walking hallways of the facility on many occasions with a walker.
In an interview DON on 5/17/2023 at 11:40 a.m., revealed that DON had been at the facility for about four weeks only. Restorative Aide was responsible for doing the weekly weights and Staffing Coordinator was responsible to ensure weekly weights and re-weighs were completed. DON stated after Dietitian informed her on 05/10/23 of residents including Resident #58 who need to be re-weighed she included the Staffing Coordinator in a text to have these residents' re-weighed. She had been informed of Resident #58 needing to be re-weighed on 05/10/23 but had not followed through to ensure re-weight was completed for Resident #58. She stated ADON's were responsible for monitoring weights, but they were both new to the facility as well. She reported that ADON's are responsible to see if the residents are receiving the enteral formula as ordered by the physician. She stated the risk for residents who are NPO and dependent on enteral feeding for all their nutrition and hydration orders are weight loss, hydration issues, potential skin breakdown and deranged lab values.
Interview with the ADON A 5/17/2023 at 12:10 p.m., revealed she started at the facility about 2 weeks ago. She was not aware who was the designated person for weight monitoring. ADON A stated that she did not receive training for monitoring of weights and is still learning the system. She stated she had not had the opportunity to look at Resident #58's enteral feeding pump to ensure Resident #58 received the physician ordered enteral feeding.
Interview with the DON on 05/17/2023 at 12:42 p.m., revealed on Resident #58's enteral feeding pump if the settings were not cleared by nurse you can go back and see the volume history of how much enteral feeding Resident #58 received. DON stated she was unaware of nurses lack of administering Resident #58's appropriate enteral feeding for Resident #58 nocturnal feeding at 85 ml/hour for 10 hours. She stated she had not had an opportunity to look at Resident #58's enteral feeding pump to ensure Resident #58 received the appropriate enteral feeding.
In an interview with Physician A on 5/17/2023 at 1:39 p.m. at he stated that he was notified of significant weight loss earlier, but he does not remember when exactly, he recollected couple of months ago. He does not recollect recent notification for weight loss. Physician A was not aware of significant weight loss that was triggered on 5/10/2023; he was not informed. Physician A stated that he expected the physician order as put in by Dietitian to be followed for all enteral feeding patients. Physician A also stated that he was not aware that the resident is not getting his prescribed feedings.
In an interview with Medical Director on 5/17/2023, at 1:48 p.m., was asked what the risk for a resident who is dependent on enteral feeds for nutrition and hydration, NPO status and not receiving Enteral feeds as ordered. The Medical Director responded, resident would be at risk for dehydration, malnutrition, weight loss and skin breakdown. He also stated that he would be like to be notified if resident has significant weight loss or if physician orders are not followed as ordered.
Review of facility's policy Enteral Nutrition for Closed System Nasogastric, Nasointestinal, Gastric and Jejunal feeding tubes last revised 01/12/20 reflected Enteral nutrition therapy will be performed in a safe manner by qualified licensed nurses according to standard practice guidelines .Procedures: .3. Check physician's order for formula, route, rate and frequency .9. Turn on pump. Follow manufacturer's specifications.
Review of facility's policy Enteral or Parenteral Nutrition Care: effective 08/01/18 reflected Enteral nutrition will be available for residents who are unable to meet their metabolic needs via oral intake. Procedure: 1. Residents identified with orders for enteral or parenteral nutrition will be assessed by the dietitian according to state and federal guidelines and professional standards of practice. 2. The assessment will include a calculation of the resident's nutritional requirements and a comparison will be made between the resident's requirements and the physician ordered enteral formula.3. The dietitian will routinely assess the nutrition status of the resident receiving enteral nutrition support and determine the appropriateness of continued enteral feeding for nutrition support .The dietitian will review how the formula is being administered, monitor weight, skin condition, labs, physical symptoms, tolerance to feeding,, and oral food/fluid intakes when applicable.
The Administrator was notified of the Immediate Jeopardy on 05/17/23 at 5:36 PM due to the above failures and provided the IJ template. A Plan of Removal was requested.
The Facility's Plan of Removal was accepted on 05/19/23 at 2:36 PM and included the following:
The facility's response to the IJ for the facility to implement a Plan of Removal to prohibit weight loss for resident #58 on enteral feedings. On 5/17/2023 the facility failed to ensure that nursing staff implemented the interventions of enteral feeding at 85 ml/hr. for 10 hours. Resident #58 had a 7.85% significant weight loss over a three-month period from 02/22/23 to 05/10/23.
Process
Due Date
Note: When ADON is referenced in this plan of removal, it is referencing to the ADON assigned to the room the resident resides in. ADON and rooms are detailed below:
Rooms 200 thru 406, ADON A
Rooms 407 thru 716, ADON B
An order will be added for each resident utilizing a g-tube pump that has the charge nurse clear out the pump at the end of their shift and document completion on MAR.
For each resident on nutritional support, the charge nurse will document the cc intake during their shift on the Medication Administration Record.
ADON will monitor the intake for each resident receiving nutritional support in the morning clinical meeting and the clearing of the pumps. If intake does not match the physician order, the ADON will investigate the root cause of such variance. Corrective actions will be made including notification to physician and one on one in-service with nurse or nurses responsible.
The DON is the back-up for this process when the respective ADON is not available.
Nurse Consultant will train DON and Administrator on this process.
DON will train the ADONs and other nursing staff on this process prior to the start of their shift. 5-19-23
5-19-23
The charge nurse (onging and offgoing) will round each shift when providing shift-to-shift report and visualize residents utilizing g-tube pumps and compare the ordered rate to the rate set on the pump. If a discrepancy is identified, the charge nurse will correct the pump setting, notify the ADON, and enter the information on the 24-hour report.
The ADON /DON / or Designee will round each morning, on residents utilizing g-tube pumps and compare the ordered rate to the rate set on the pump. If a discrepancy is identified an investigation will be started to identify the root cause of the discrepancy.
The ADON will provide one on one in-service for any deficiencies found. Corrective actions will be made including notification to physician and one on one in-service with nurse or nurses responsible
The Director of Nursing will be the back-up for this process if the ADON is not available.
Nurse Consultant will train DON and Administrator on this process.
DON will train the ADONs and other nursing staff on this process prior to the start of their shift. 5-19-23
5-19-23
For any residents on continuous enteral feedings the RD, DON, ADON, Therapy Manager will meet to ensure a person-centered care plan is in place. This meeting will be held prior to the RD assessment. The care plan will be updated.
Nurse Consultant will train the RD, DON, ADONs, Therapy Manager, and Administrator on this process.
5-19-23
Education and Training & Immediate Actions
1:1 Inservice on resident centered care to RD given by head of dietary services.
5-19-23
100% was performed on all resident with enteral feeding orders. The sweep found that all orders and careplan were accurate.
5-19-23
1:1 Nurses given to all charge nurses on hall 300.
Inservice on:
Following doctors' orders
5-19-23
An immediate sweep of all G-Tube residents. Matched the orders to the flow rate, with updated resident centered care plans have been updated.
5-19-23
Policies and procedures reviewed and updated by Chief of Clinical Operations
RNC will train DON/ ADON A /ADON B / Staffing / Primary Aid / Back Up Aid on Policies and procedures and changes
5-1-23
RNC to Inservice all Clinical Management on G-Tube Feedings
5-19-23
RNC to Inservice all Clinical Management on Orders
5-19-23
Inservice on all nurse staff on G-Tube Feedings
5-19-23
Competency on all nurse staff on G-Tube Feedings
5-1-23
RNC will train DON/ ADON A /ADON B / Staffing on weight systems, G-Tube, and competencies.
5-19-23
DON and RD will do a 6 month look back of all weights and identify any residents with a weight loss.
5-19-23
DON and RD will do a 6 month look back of all weights and identify any residents that are at risk for weight loss.
5-19-23
Any Identified residents with weight loss and or high-risk RD completed a new assessment. Care plan to be updated.
5-19-23
Staffing will be responsible for ensuring that any agency nurse has been trained on G-Tubes and G-Tube Process prior to the start of any shift.
ADON will be back up for this process
5-19-23
The DON is ultimately responsible for the oversight of the enteral feeding orders and this proces. 5-19-23
The facility's implementation of IJ Plan of Removal was verified through the following:
Review of Resident #58's Clinical Record on 05/20/23 revealed interventions were put in place for Resident #58's significant weight loss and Resident #58's current enteral feeding physician order was Isosource 1.5 bolus 375 ml via peg tube for times daily. Resident #58's responsible party and physician was notified. Review of Resident #58's MAR reflected current tube feeding volumes recorded correctly at the ordered times per physician order.
Observation on 05/20/23 at 12:27 PM of Resident #58's bolus feeding with LVN S revealed Resident was administered the correct dosage of enteral feeding as ordered by physician with no issues with enteral feeding.
Observations on 05/20/23 at 1:20 PM and 1:34 PM of Residents #45 and #75 revealed no issues with enteral feedings. Observations and Interviews with Agency LVN K and RN O revealed able to demonstrate and show surveyors which information they record on the MAR for resident's enteral feedings and knew the process of g-tube administration to ensure physician orders were followed for residents.
Reviewed Resident #45 and #75's clinical record on 05/20/23 for current physician orders for resident enteral feedings, correct documentation on Nurse MAR on g-tubes.
Interviews on 05/20/23 from 12:27 PM to 4:20 PM with nine nurses from all shifts including facility, weekend and agency nurses (Agency LVN F, LVN G, LVN H, LVN I, Agency LVN K, RN O, LVN P, LVN S, Agency LVN T) revealed nurses had been in-serviced on weight monitoring, enteral feeding pump training, following physician orders and documenting intake for g-tube residents' feeding and change of condition. All nine nurses were aware physician and resident and/or resident responsible party must be notified of change of condition including significant weight loss. All nine nurses were aware of new admits and readmits must be weighed within 24 hours and cannot use the hospital weight to input as new admit weight for residents. All nine residents were able to describe the process to verify physician orders for enteral feedings, how to set up a resident on enteral feeding pump, how to find the volume of enteral feeding intake from the pump, where to document setting and intake of enteral feeding pump. All nine nurses were aware to document about g-tube feedings for residents on 24 hour report.
Interviews on 05/20/23 at 4:32 PM to 4:45 PM with ADON A and ADON B revealed were knowledgeable of enteral feeding pumps and how to monitor to ensure residents receive the correct physician ordered enteral feedings. Both were knowledgeable of nurses expected to document on MARs with ongoing and offgoing nurse to review the enteral feeding pump settings at[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices for one (Resident #4) of four residents reviewed for quality of care.
The facility failed to follow Resident #4's treatment orders and care plan to ensure that previously identified wounds did not worsen.
This failure could place residents at risk for not receiving appropriate care and treatment resulting in infection, delayed healing, pain, and diminished quality of life.
Findings include:
Review of Resident #4's face sheet dated 5/12/2023 revealed an [AGE] year-old female who admitted to the facility 09/15/2022 with a readmission date of 12/5/2022.
Review of the quarterly MDS dated [DATE] revealed the following diagnoses: kidney failure (poor kidney function), and diabetes (inability to process sugar). Resident #4 had a BIMS score of 10 indicative of moderate cognitive impairment. Resident #4 required the assistance of 1 staff member for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing.
Review of Resident #4's care plan, dated 5/12/2023, reflected Resident #4 was at risk for skin breakdown with approaches including: Negative Pressure Dressing: Change dressing as directed assure dressing remains intact with airtight seal, and prescribed negative pressure is administered.
Review of Resident #4's physician's orders reflected: as of 5/10/2023 Cleanse wound to left heel with ns (normal saline), pat dry, apply wound vac [vacuum assisted closure (suction, pump and tubing to remove excessive fluids and promote healing)] at 125mmhg (millimeters of mercury) continuously Change Monday, and Friday and PRN (as needed).
Review of Resident #4's, Nurses Notes dated 5/10/2023 at 5:10 PM written by FWCN, reflected: Wound culture revealed MRSA (specific bacteria resistant to antibiotics), wound vac to be placed and changed 2 times a week once on Mondays in office and Fridays at facility.
Review of Residents #4's TAR dated May 2023 revealed no evidence that a wound vac had been applied to Resident #4's left heel.
In an observation on 5/12/2023 at 12:40 PM, Resident #4 was noted to have clear plastic tubing coming out of the top of the dressing on the left leg. The tubing was clean as if it had not been used. At the visible end of the tubing was a blue cap not connected to anything. No wound vac was noted in the room of Resident #4. Upon visualization of the left heel was a circular dressing covering foam attached to the left heal. The center of the circular dressing was attached the clear tubing to be attached to the wound vac.
In an interview on 5/12/2023 at 5:12 PM with the DON, revealed that Resident #4 received treatment for her wound outside of the facility. The DON stated that the FWCN entered a new physician's order that as of 5/10/2023 Resident #4 was to have a wound vac applied to the wound on the left heel. The DON explained that she was not aware that the facility was expected to initiate the wound vac for Resident #4. DON stated not implementing the wound vac on 5/10/2023 could cause the wound to deteriorate.
In an interview on 5/15/2023 at 10:06 AM with the OPCRN, revealed that orders for wound care was faxed to the facility on 5/9/2023. She confirmed receipt of the orders with FWCN, and they agreed that the wound vac would be initiated by the facility on 5/10/2023. OPCRN was not aware the wound vac was not initiated until the afternoon of 5/12/2023.
In an interview on 5/15/2023 at 1:30 PM, DON was asked for a policy regarding following physician orders. At 2:45 PM, DON stated there was no policy regarding the implementation of physician orders.