HENDRICK SKILLED NURSING FACILITY

**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 infections for 1 (Resident #59) of 3 residents reviewed for infection control. <BR/>The facility failed to ensure: <BR/>PTA B cleaned the counter prior to setting up a barrier for setting up wound care supplies for Resident #59. <BR/>PTA B used a non-permeable barrier when setting up wound care supplies for Resident #59. <BR/>PT A cleaned scissors between dirty procedure and clean procedure during wound care for Resident #59. PT A used the same scissors after cutting off Resident #59's dirty [NAME]-boot dressing (plaster dressing used to squeeze fluid out of a closed wound) to cut his clean [NAME]-boot dressing. <BR/>These failures could place resident's at risk for cross contamination and the spread of infection. <BR/>The findings included: <BR/>Review of Resident #59's electronic record on 9/5/24 revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including debility and septic discitis of the thoracic region (spine infection). <BR/>Resident #59 was still in his MDS Assessment period. <BR/>Review of Resident #59's care plan dated 8/23/24 revealed: <BR/>Problem/ Need Problems: hospitalization abscess to leg <BR/>Resident will exhibit: Be free from infection during hospital stay; verbalize how to prevent disease. <BR/>Interventions: Teach patient about handwashing; assess every shift for signs and symptoms of infection; monitor vital signs and lab values; administer medication/ antibiotics as ordered; notify physician of any abnormal values; reinforce hygiene behavior; teach patient signs and symptoms of infection. <BR/>Wound #1 Right Antero-lateral leg/Venous Ulcer WDL (closed or open, chronic wound that occurs when the veins don't return blood to the heart properly. Resident #59's wounds were closed and seeped fluid) within defined limits, except ulceration, venous, no drainage, dressing in place <BR/>Review of Resident #59's Order Summary documented Rehab Services: wound care treatment orders: Order date 8/26/24 active. <BR/>Observation on 9/4/24 at 10:07 a.m., PT A entered Resident #59's room to do wound care. PT A sanitized his hands with alcohol based hand rub (ABHR) and donned gloves. Then after surveyor entered the room, PTA B entered the room and moved Resident #59's belongings to the side and placed a folded towel on the counter without sanitizing the counter and set up the wound care supplies. PT A cut off Resident #59's [NAME]-boot dressing (plaster soaked dressing that compresses as it dries) with a pair of clean scissors. PT A took off the gloves, sanitized hands with ABHR and donned a new pair of gloves. He took measurements of Resident #59's wounds. PT A then applied lotion to Resident #59's leg, then he applied a new [NAME]-boot dressing. When PT A got to the top of Resident #59's calf, PT A used the same, uncleaned scissors to cut the remainder of the [NAME]-boot dressing off. PT A put gauze over the [NAME]-boot dressing, the kerlix (self-adhesive gauze), and put a tube covering over it and left with no hand hygiene. <BR/>Interview on 9/5/24 at 1:01 p.m., PT A stated he knocked on Resident #59's door, asked about any issues, asked about pain, a student came in to set up supplies and they started the treatment. PT A said Resident #59 had the [NAME]-boot to treat edema. PT A said PTA B was the tech and she moved Resident #59's clothes and put down a clean towel. PT A stated the procedure was clean not sterile so as far as they knew a clean towel was enough. PT A said no one had talked to the PT department about using a non-permeable barrier when setting up wound care. PT A stated after the scissors were used they were considered dirty but they were used for the same resident. PT A said the facility policy was they could use the same instruments. Surveyor requested the policy. PT A stated he did not think it was a formal policy just a facility practice. <BR/>Interview on 9/5/24 at 1:30 p.m., the ICP stated the expectation for wound care was staff wear the proper PPE which would be gown and gloves. The ICP said she thought a chuck (absorbent pad with plastic on one side to prevent leaks) which was disposable would be acceptable for wound care. The ICP stated she was not sure what the policy stated. The ICP stated once the dressing was cut off the scissors were considered dirty, and the facility did have a spray the PT could have used to clean them. The ICP said hand hygiene was expected before donning PPE, in between glove changes, after touching patient surroundings, and when exiting the room. <BR/>In an interview on 9/5/24 at 2:21 p.m., the DON stated clean technique could be completed with a towel because the resident was the only person in the room. At this time PT A brought the mandatory in-services by the facility and infection control was completed 2/6/24. <BR/>In an interview on 09/05/24 at 3:33 p.m., the DON said they did not have a specific policy for wound care.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan with necessary information within 48 hours of the resident ' s admission for 3 of 3 residents (Resident #101, Resident #51, Resident #103) reviewed for baseline care plans. <BR/>The facility failed to include physician orders for medications and diets in Resident #101, Resident #51, and Resident #103 ' s baseline care plan. <BR/>This failure placed residents at risk of not receiving continuity of care and communication among nursing staff and residents as well as increased risk of resident safety and safeguard against adverse events that are most likely to occur after admission. <BR/>Findings included: <BR/>Resident #101 <BR/>Review of Resident #101 ' s patient profile revealed Resident #101 was [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of right hip fracture. <BR/>Review of Resident #101 ' s admission assessment dated [DATE] revealed BIMS of 15, indicating resident was cognitively intact. <BR/>Review of Resident #101 ' s physician orders dated 07/19/2023 revealed resident was prescribed Aspirin 325mg two times per day with breakfast and supper, atorvastatin 40mg at bedtime, levothyroxine 137mg before breakfast, multivitamin 1 tablet daily, Prednisolone ophthalmic drops four times per day to right eye, paroxetine 20mg daily, MiraLAX 1 packet daily, as needed sliding scale insulin for blood glucose above 200, 1800 ADA Carbohydrate Control diet, and Glucerna Vanilla shakes twice a day. <BR/>Review of Resident #101 ' s baseline care plan dated 07/20/2023 revealed no evidence of focus, objectives or interventions for Aspirin 325mg two times per day with breakfast and supper, atorvastatin 40mg at bedtime, levothyroxine 137mg before breakfast, multivitamin 1 tablet daily, Prednisolone ophthalmic drops four times per day to right eye, paroxetine 20mg daily, MiraLAX 1 packet daily, as needed sliding scale insulin for blood glucose above 200, 1800 ADA Carbohydrate Control diet, and Glucerna Vanilla shakes twice a day. <BR/>During an interview on 07/25/2023 at 10:05 am, Resident #101 stated she did not remember participating in care plan meetings. <BR/>Resident #51 <BR/>Review of Resident #51 ' s patient profile revealed Resident #51 was [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of [NAME] fracture of proximal end of left tibia (fracture left lower leg). <BR/>Review of Resident #51 ' s admission assessment dated [DATE] revealed BIMS of 13, indicating resident was cognitively intact. <BR/>Review of Resident #51 ' s physician orders dated 07/18/2023 revealed resident was prescribed ascorbic acid 200mg daily, Aspirin 81mg 2 times per day with meals, furosemide 40mg daily, losartan 25mg daily, Multivitamin Vitamin B Complex with C and Folic Acid daily, MiraLAX 1 packet daily, heel protectors, and Ensure Enlive Shakes two times per day. <BR/>Review of Resident #51 ' s baseline care plan dated 07/19/2023 revealed no evidence of focus, objectives or interventions for ascorbic acid 200mg daily, Aspirin 81mg 2 times per day with meals, furosemide 40mg daily, losartan 25mg daily, Multivitamin Vitamin B Complex with C and Folic Acid daily, MiraLAX 1 packet daily, heel protectors, and Ensure Enlive Shakes two times per day. <BR/>During an interview on 07/25/2023 at 10:14 am, Resident #51 stated not knowing anything about care plans. <BR/>Resident #103 <BR/>Review of Resident #103 ' s patient profile revealed Resident #103 was [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of fracture of left ulna (fracture of left upper arm). <BR/>Review of Resident #103 ' s admission assessment dated [DATE] revealed BIMS of 14, indicating resident was cognitively intact. <BR/>Review of Resident #103 ' s physician orders dated 07/21/2023 revealed resident was prescribed amiodarone 100mg daily, apixaban 2.5mg two times per day, celecoxib 200mg two times per day, losartan 100mg daily, metoprolol succinate XL 50mg daily, probenecid 500mg two times per day, rosuvastatin 20mg at bedtime, regular diet, and Ensure Enlive shakes two times a day. <BR/>Review of Resident #103 ' s baseline care plan dated 07/22/2023 revealed no evidence of focus, objectives or interventions for amiodarone 100mg daily, apixaban 2.5mg two times per day, celecoxib 200mg two times per day, losartan 100mg daily, metoprolol succinate XL 50mg daily, probenecid 500mg two times per day, rosuvastatin 20mg at bedtime, regular diet, and Ensure Enlive shakes two times a day. <BR/>During an interview on 07/25/2023 at 1:29 pm, Resident #103 stated she had not been informed of care plans. <BR/>During an interview on 07/26/2023 3:44 pm, the DON stated the facility had no policy or procedures on baseline care plans. She stated that the facility follows Texas Administrative Code for baseline care plans. DON stated that each discipline creates their portion of the baseline care plan upon the resident ' s admission. <BR/>Review of Texas Administrative Code 554.802(a) https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=26&pt=1&ch=554&rl=802 accessed 07/28/2023 revealed: <BR/>(a) Baseline care plans. <BR/>(1) The facility must 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. The baseline care plan must: <BR/> (A) be developed within 48 hours of a resident's admission; <BR/> (B) include the minimum healthcare information necessary to properly care for a resident, including: <BR/> (i) initial goals based on admission orders; <BR/> (ii) physician orders; <BR/> (iii) dietary orders; <BR/> (iv) therapy services; <BR/> (v) social services; and <BR/> (vi) PASRR recommendation, if applicable.

**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 infections for 1 (Resident #59) of 3 residents reviewed for infection control. <BR/>The facility failed to ensure: <BR/>PTA B cleaned the counter prior to setting up a barrier for setting up wound care supplies for Resident #59. <BR/>PTA B used a non-permeable barrier when setting up wound care supplies for Resident #59. <BR/>PT A cleaned scissors between dirty procedure and clean procedure during wound care for Resident #59. PT A used the same scissors after cutting off Resident #59's dirty [NAME]-boot dressing (plaster dressing used to squeeze fluid out of a closed wound) to cut his clean [NAME]-boot dressing. <BR/>These failures could place resident's at risk for cross contamination and the spread of infection. <BR/>The findings included: <BR/>Review of Resident #59's electronic record on 9/5/24 revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including debility and septic discitis of the thoracic region (spine infection). <BR/>Resident #59 was still in his MDS Assessment period. <BR/>Review of Resident #59's care plan dated 8/23/24 revealed: <BR/>Problem/ Need Problems: hospitalization abscess to leg <BR/>Resident will exhibit: Be free from infection during hospital stay; verbalize how to prevent disease. <BR/>Interventions: Teach patient about handwashing; assess every shift for signs and symptoms of infection; monitor vital signs and lab values; administer medication/ antibiotics as ordered; notify physician of any abnormal values; reinforce hygiene behavior; teach patient signs and symptoms of infection. <BR/>Wound #1 Right Antero-lateral leg/Venous Ulcer WDL (closed or open, chronic wound that occurs when the veins don't return blood to the heart properly. Resident #59's wounds were closed and seeped fluid) within defined limits, except ulceration, venous, no drainage, dressing in place <BR/>Review of Resident #59's Order Summary documented Rehab Services: wound care treatment orders: Order date 8/26/24 active. <BR/>Observation on 9/4/24 at 10:07 a.m., PT A entered Resident #59's room to do wound care. PT A sanitized his hands with alcohol based hand rub (ABHR) and donned gloves. Then after surveyor entered the room, PTA B entered the room and moved Resident #59's belongings to the side and placed a folded towel on the counter without sanitizing the counter and set up the wound care supplies. PT A cut off Resident #59's [NAME]-boot dressing (plaster soaked dressing that compresses as it dries) with a pair of clean scissors. PT A took off the gloves, sanitized hands with ABHR and donned a new pair of gloves. He took measurements of Resident #59's wounds. PT A then applied lotion to Resident #59's leg, then he applied a new [NAME]-boot dressing. When PT A got to the top of Resident #59's calf, PT A used the same, uncleaned scissors to cut the remainder of the [NAME]-boot dressing off. PT A put gauze over the [NAME]-boot dressing, the kerlix (self-adhesive gauze), and put a tube covering over it and left with no hand hygiene. <BR/>Interview on 9/5/24 at 1:01 p.m., PT A stated he knocked on Resident #59's door, asked about any issues, asked about pain, a student came in to set up supplies and they started the treatment. PT A said Resident #59 had the [NAME]-boot to treat edema. PT A said PTA B was the tech and she moved Resident #59's clothes and put down a clean towel. PT A stated the procedure was clean not sterile so as far as they knew a clean towel was enough. PT A said no one had talked to the PT department about using a non-permeable barrier when setting up wound care. PT A stated after the scissors were used they were considered dirty but they were used for the same resident. PT A said the facility policy was they could use the same instruments. Surveyor requested the policy. PT A stated he did not think it was a formal policy just a facility practice. <BR/>Interview on 9/5/24 at 1:30 p.m., the ICP stated the expectation for wound care was staff wear the proper PPE which would be gown and gloves. The ICP said she thought a chuck (absorbent pad with plastic on one side to prevent leaks) which was disposable would be acceptable for wound care. The ICP stated she was not sure what the policy stated. The ICP stated once the dressing was cut off the scissors were considered dirty, and the facility did have a spray the PT could have used to clean them. The ICP said hand hygiene was expected before donning PPE, in between glove changes, after touching patient surroundings, and when exiting the room. <BR/>In an interview on 9/5/24 at 2:21 p.m., the DON stated clean technique could be completed with a towel because the resident was the only person in the room. At this time PT A brought the mandatory in-services by the facility and infection control was completed 2/6/24. <BR/>In an interview on 09/05/24 at 3:33 p.m., the DON said they did not have a specific policy for wound care.<BR/>

Based on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, the results of the most recent survey of the facility reviewed for resident rights. <BR/>The facility failed to ensure the most recent survey results was posted for residents, family members, and visitors to review. <BR/>The failure placed residents and their family members and representatives at risk for violation of the right to review the findings from State surveys and investigations conducted in the facility without asking to review the reports. <BR/>Findings included: <BR/>During an initial observation on 07/25/2023 at 7:45 am, the last survey results could not be located. <BR/>Review of facility's survey history revealed last re-certification survey occurred on 09/18/2019. <BR/>During an interview on 07/26/2023 at 3:45 pm, the DON stated she was not aware survey results had to be posted. DON stated that the facility followed required postings from https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/regulatory-services-facility-surveyors-liaisons/required-postings. <BR/>Review of facility provided document titled Required Postings | Texas Health and Human Services dated 06/15/23 revealed F577 - Most Recent Survey/Inspection Results and Notice of Availability of Survey/Inspection Results <BR/>42 CFR Section 483.10(g)(11) - An NF must: <BR/>Post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility. <BR/>Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the three preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request. <BR/>Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. <BR/>Review of https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/regulatory-services-facility-surveyors-liaisons/required-postings accessed on 07/26/2023 revealed: F577 - Most Recent Survey/Inspection Results and Notice of Availability of Survey/Inspection Results <BR/>42 CFR Section 483.10(g)(11) - An NF must: <BR/>Post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility. <BR/>Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the three preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request. <BR/>Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. <BR/>Review of website https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/regulatory-services-facility-surveyors-liaisons/required-postings accessed on 07/26/2023 revealed: F577 - Most Recent Survey/Inspection Results and Notice of Availability of Survey/Inspection Results <BR/>42 CFR Section 483.10(g)(11) - An NF must: <BR/>Post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility. <BR/>Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the three preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request. <BR/>Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. <BR/>Review of https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/regulatory-services-facility-surveyors-liaisons/required-postings accessed on 07/26/2023 revealed: F577 - Most Recent Survey/Inspection Results and Notice of Availability of Survey/Inspection Results <BR/>42 CFR Section 483.10(g)(11) - An NF must: <BR/>Post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility. <BR/>Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the three preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request. <BR/>Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 3 residents (Resident #101, Resident #51, Resident #103) reviewed for dignity. <BR/>The facility did not ensure nursing staff entered Resident #101, Resident #51, and Resident #103 ' s rooms with permission prior to administering medications and providing ADL care. <BR/>This failure could place residents at risk for decreased quality of life and quality of care. <BR/>Findings included: <BR/>Resident #101 <BR/>Review of Resident #101 ' s patient profile undated revealed Resident #101 was [AGE] year old female who was admitted to the facility on [DATE] with diagnosis of right hip fracture. <BR/>Review of Resident #101 ' s admission assessment dated [DATE] revealed BIMS of 15, indicating resident was cognitively intact. <BR/>During an observation on 07/25/2023 at 1:47 pm, LVN-A entered Resident #101 ' s room without asking permission prior to entering to administer medications. <BR/>During an observation on 07/26/2023 at 8:47 am, LVN-B entered Resident #101 ' s room without asking permission prior to entering to administer medications. <BR/>Resident #51 <BR/>Review of Resident #51 ' s patient profile revealed Resident #51 was [AGE] year old female who was admitted to the facility on [DATE] with diagnosis of [NAME] fracture of proximal end of left tibia (fracture left lower leg). <BR/>Review of Resident #51 ' s admission assessment dated [DATE] revealed BIMS of 13, indicating resident was cognitively intact. <BR/>During an observation on 07/25/2023 at 10:58 am, LVN-A and RN-A knocked on resident ' s room and entered without asking resident permission to enter. <BR/>During an interview on 07/26/2023 at 8:02 am, Resident #51 stated that nurses knocked on the door and say hello but never ask permission prior to entering the room. <BR/>Resident #103 <BR/>Review of Resident #103 ' s patient profile revealed Resident #103 was [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of fracture of left ulna (fracture of left upper arm). <BR/>Review of Resident #103 ' s admission assessment dated [DATE] revealed BIMS of 14, indicating resident was cognitively intact. <BR/>During an observation on 07/26/2023 at 8:58 am, LVN-B entered Resident #103 ' s room without asking permission prior to entering to administer medications. <BR/>During an interview on 07/26/2023 at 3:40 pm, DON stated that facility staff were trained in the acronym of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank You). Staff are not trained to ask permission prior to entering resident ' s room. The DON also stated the facility did not have a policy or procedure regarding asking permission prior to entering a resident ' s room.

Based on observation, interviews, and record reviews, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors that included: The facility name, the current census, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift(Registered nurses, Licensed practical nurses or licensed vocational nurses or Certified nurse aides) for 1 of 1 Staffing Log reviewed for nursing services. <BR/>The facility failed to ensure the Direct Care Nursing/Staff Daily Log dated July 25, 2023, was completed with the facility name, current census, and the total number of hours worked and the actual hours worked by the RN and the LVN. <BR/>This failure could place residents, their families, and visitors at risk of not having the staffing information readily accessible for review, residents and visitors are not able to know how many staff are currently working to provide care on all shifts.<BR/>Findings Included:<BR/>Observation on 07/25/2023 at 10:58 AM on the wall across from the nurse's station revealed a dry erase board with the date and names of charge nurse and nurse. There was no evidence of the facility's name, resident census or the number of hours or the actual hours worked by licensed staff providing direct care.<BR/>During an interview on 07/25/2023 at 11:05 AM the DON stated the nurses staffing was posted on the dry erase board on the wall across from the nurses' station. The DON stated she followed what the TAC required for posting. The DON stated she did not know why she did not have the facility's name, resident census or the number of hours or the actual hours worked by licensed staff providing direct care written on on the board. The DON stated she must have overlooked the part about the facility name, the census and the nursing hours. <BR/>Review of facility provided document titled Required Postings | Texas Health and Human Services dated 06/15/23 revealed F732/N1518-1520 and N1932 - Nursing Staffing Information<BR/>42 CFR Section 483.35(g) and 26 TAC Section 554.1001(b)(1)-(2) and Section 554.1921(e)(13) - An NF must conspicuously and prominently post the following information, in a clear and readable format and a prominent place readily accessible and available to residents, employees, and visitors, in accordance with Section 554.1921(e):<BR/>On a daily basis:<BR/>Facility name<BR/>Current date<BR/>Resident census<BR/>Specific shifts for the day<BR/>At the beginning of each shift, the total number of hours and actual time of day to be worked by the following licensed and unlicensed nursing staff, including relief personnel directly responsible for resident care:<BR/>Registered nurses (RNs)<BR/>Licensed vocational nurses (LVNs)<BR/>Certified nurse aides (CNAs)<BR/>In addition, the licensed NF must make the information required to be posted available to the public upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 3 residents (Resident #101, Resident #51, Resident #103) reviewed for dignity. <BR/>The facility did not ensure nursing staff entered Resident #101, Resident #51, and Resident #103 ' s rooms with permission prior to administering medications and providing ADL care. <BR/>This failure could place residents at risk for decreased quality of life and quality of care. <BR/>Findings included: <BR/>Resident #101 <BR/>Review of Resident #101 ' s patient profile undated revealed Resident #101 was [AGE] year old female who was admitted to the facility on [DATE] with diagnosis of right hip fracture. <BR/>Review of Resident #101 ' s admission assessment dated [DATE] revealed BIMS of 15, indicating resident was cognitively intact. <BR/>During an observation on 07/25/2023 at 1:47 pm, LVN-A entered Resident #101 ' s room without asking permission prior to entering to administer medications. <BR/>During an observation on 07/26/2023 at 8:47 am, LVN-B entered Resident #101 ' s room without asking permission prior to entering to administer medications. <BR/>Resident #51 <BR/>Review of Resident #51 ' s patient profile revealed Resident #51 was [AGE] year old female who was admitted to the facility on [DATE] with diagnosis of [NAME] fracture of proximal end of left tibia (fracture left lower leg). <BR/>Review of Resident #51 ' s admission assessment dated [DATE] revealed BIMS of 13, indicating resident was cognitively intact. <BR/>During an observation on 07/25/2023 at 10:58 am, LVN-A and RN-A knocked on resident ' s room and entered without asking resident permission to enter. <BR/>During an interview on 07/26/2023 at 8:02 am, Resident #51 stated that nurses knocked on the door and say hello but never ask permission prior to entering the room. <BR/>Resident #103 <BR/>Review of Resident #103 ' s patient profile revealed Resident #103 was [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of fracture of left ulna (fracture of left upper arm). <BR/>Review of Resident #103 ' s admission assessment dated [DATE] revealed BIMS of 14, indicating resident was cognitively intact. <BR/>During an observation on 07/26/2023 at 8:58 am, LVN-B entered Resident #103 ' s room without asking permission prior to entering to administer medications. <BR/>During an interview on 07/26/2023 at 3:40 pm, DON stated that facility staff were trained in the acronym of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank You). Staff are not trained to ask permission prior to entering resident ' s room. The DON also stated the facility did not have a policy or procedure regarding asking permission prior to entering a resident ' s room.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS . <BR/>The facility failed to submit staffing information to CMS for FY Quarter 2 2023 (January 1- March 31).<BR/>The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.<BR/>The findings included:<BR/>Record review of the facility's Staffing Data Report for FY Quarter 2 2023 (January 1- March 31) revealed the facility triggered for Failed to Submit Data for the Quarter and One Star Staffing Rating. <BR/>During an interview on 07/26/2023at 12:20 PM, the DON stated her expectation was that the facility followed CMS guidelines . The DON stated during the 2nd Quarter, they did not have residents and was not aware of who would have been responsible for reporting the staffing information.