SUNNY SPRINGS NURSING & REHAB

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and establish policies and procedures to report and investigate such allegations, for 1 of 6 residents (Resident #3) reviewed for abuse.<BR/>The facility did not implement the policy on investigating an injury of unknown origin to the state agency for Resident #3 when Resident # 3 was found with bruising and a skin tear on 02/11/2025 on the left arm.<BR/>This failure could place the residents at increased risk of abuse and neglect.<BR/>Findings included:<BR/>Record review of Resident #3's face sheet, dated 04/09/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (diseases that affect memory, thinking, and the ability to perform daily activities), diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily living).<BR/>Record review of Resident #3's annual MDS assessment, dated 02/26/25, indicated Resident #3 rarely understood and was rarely understood by others. Resident #3's BIMS score was 00, which meant she was severely cognitively impaired. The MDS indicated Resident #3 required extensive help with toileting, bed mobility, dressing, transfers, personal hygiene, and supervision with eating. The MDS did not indicate Resident #3 had wounds or skin problems. <BR/>Record review of Resident #3's progress note dated 2/11/25 at 6:22 pm, written by LVN A, revealed Resident #3's family member reported 2 open areas to her left arm, both less than 0.25 x 0.25 in diameter. Both showed no signs of infection. The nurse provided first aid to both, and neither area showed signs of infection. The resident denied pain. The call light was in reach.<BR/>Record review of Resident #3's progress note updated 2/11/25 at 6:42 pm, written by LVN A revealed Resident #3 had one open area and one bruise to her left arm. <BR/>Record review of Resident #3's progress note dated 2/12/25 at 2:40 am, written by LVN C revealed to continue to monitor skin tear and bruising to the left arm for Resident #3. No signs or symptoms of infection, pain, or discomfort were noted. <BR/>Record review of Resident #3's physician orders, dated 02/01/25 through 02/28/23, did not reveal any orders for monitoring bruise to the left arm.<BR/>Record review of Resident #3's physician orders, dated 02/01/25 through 02/28/25, did not reveal any orders for treating a skin tear to her left arm. <BR/>Record review of Resident #3's skin assessment dated [DATE] did not indicate a skin assessment was done after the bruise and skin tear were noted. <BR/>Record review of Resident #3's skin assessment dated [DATE] charted by LVN C did not indicate a bruise or skin tear to her left arm.<BR/>Record review of Resident #3's care plan revised on 03/26/25 did not indicate a bruise or skin tear to her left arm on 02/11/25.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN B said she was the treatment nurse. She said if a resident had a skin tear or a bruise, it should be reported to the nurse, the nurse would then report it to her, and she would assess and determine what type of treatment was needed, if any. She said if a skin tear were noted, she would look at it daily and document it in the TAR. If a bruise were noted, she would put in an order to monitor weekly till resolved. LVN B said that Resident #3 had several bruises over time because she would attempt to get up by herself. She said she could not recall this particular bruise or skin tear. She said part of her process was if a bruise or skin tear were reported, she would investigate to see what happened. She said Resident #3 was not normally able to say what happened related to her cognitive status. LVN C said if she could not figure out what happened, she would report it to the Administrator or DON.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN A said she was the charge nurse on duty when a family member reported Resident #3 had a skin tear and bruise on her left arm. LVN C said she was not aware how Resident #3 received the bruise or skin tear. She said she did not ask the staff or the family member who reported the skin tear or bruise if they knew what happened. LVN A said if an unknown skin tear or bruise was reported to her, she was supposed to notify the Administrator, DON, the physician, and the family. LVN A said she reported the bruise and skin tear to the Administrator and the DON. She said she was new to the facility during the incident and was told to do a progress note. She said she did not recall the Administrator or the DON questioning her about the incident once she reported it. She said since this incident, she had been educated to do an incident report and progress note, notify management, the physician, and the family. <BR/>During an interview on 04/09/25 at 6:55 a.m., LVN C said she was the 10 pm-6 am nurse for Resident #3. She said she could not recall the skin tear or bruise from 02/12/25 on Resident #3. LVN C said if she charted it, then it was either given to her in the report or was on the 24-hour report. She said if a bruise or skin tear occurred and staff was unaware of how it occurred, staff would report it to the ADON or DON, and they would investigate it. She said the nurses were supposed to do an incident report, document a progress note, and notify the physician, the family, the Administrator, and the DON of any skin tears or bruises of unknown origin. She said even if the nurses did not report something, it was on the 24-hour report, and management was supposed to review it daily. She said she did not recall being asked about Resident #3's skin tear or bruise by the Administrator or DON. <BR/>During an interview on 4/9/25 at 10:00 a.m., the ADON said if a resident had a bruise or skin tear of an unknown origin, she would investigate to see if she could figure out what happened. She said the nurses should document the incident in the progress notes, do an incident report, and notify the physician, the family, the Administrator, and the DON. She said the nurses were to chart the incident for 72 hours. She said even if a nurse forgot to report the incident, she would see it on the 24-hour report or while reading the nurses' notes. She said she could recall the incident on 02/11/25 but could not remember the details. The ADON reviewed Resident #3's chart and did not see an incident report on 02/11/25.<BR/>During an interview on 04/09/25 at 10:53 a.m., LVN B said she was the treatment nurse, and she had done a skin assessment on Resident #3 earlier on the 6 am-2 pm shift on 02/11/25. She said Resident #3 did not have any skin tears or bruises during her assessment. She said LVN A charted the skin tear and bruise at 6:22 pm after her shift. <BR/>During an interview on 04/09/25 at 11:03 a.m., the DON said he expected if a resident had a bruise or skin tear of an unknown source that staff would report it to him and the Administrator. He said they would do an internal investigation to see if they could see what happened, and if they could not figure out what happened, they would report it to the State of Texas. He said he could not recall the skin tear or bruise for Resident #3 around 02/11/25. He said Resident #3 had often scratched herself, or she could have bumped it on the wall, but since he did not remember investigating it, he could not say what happened. He said they do review the 24-hour reports in the morning meeting, and it must have been overlooked. He said that although he did not feel like abuse occurred, it was important to report and investigate abuse/neglect to prevent further abuse/neglect from occurring.<BR/>During an interview on 04/09/25 at 4:37 p.m., the Administrator said she was unaware of Resident #3's skin tear or bruise; therefore, it was not investigated or reported. She said she was not contacted for all skin tears or bruises, only if suspicion of abuse. She said if there was suspicion of abuse, the nurses should have called and reported it to her, and then they would have investigated and reported if needed. She said, after looking at Resident #3's chart, that LVN A was a new nurse during the incident and did not follow all the necessary steps, such as notification. She said they would educate LVN A. The Administrator said when injuries of unknown origin were not reported promptly, abuse could continue to occur. <BR/>Record review of the facility policy titled Abuse Prohibition Policy, revised 08/2020, indicated, Purpose: To ensure the facility established, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. VI. Investigation: A. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal activity. IX. Reporting: The facility will report allegations of abuse, neglect, exploitation, mistreatment, and injuries of unknown source, etc . immediately but no longer than two hours

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 6 residents (Resident #3) reviewed for abuse and neglect. <BR/>The facility staff did not report to the state agency that Resident #3 had a bruise and a skin tear to the left arm of unknown origin on 02/11/25.<BR/>This failure could place the residents at increased risk for abuse and neglect or further potential abuse due to unreported allegations of abuse and neglect.<BR/>Findings included:<BR/>Record review of Resident #3's face sheet, dated 04/09/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (diseases that affect memory, thinking, and the ability to perform daily activities), diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily living).<BR/>Record review of Resident #3's annual MDS assessment, dated 02/26/25, indicated Resident #3 rarely understood and was rarely understood by others. Resident #3's BIMS score was 00, which meant she was severely cognitively impaired. The MDS indicated Resident #3 required extensive help with toileting, bed mobility, dressing, transfers, personal hygiene, and supervision with eating. The MDS did not indicate Resident #3 had wounds or skin problems. <BR/>Record review of Resident #3's progress note dated 2/11/25 at 6:22 pm, written by LVN A, revealed Resident #3's family member reported 2 open areas to her left arm, both less than 0.25 x 0.25 in diameter. Both showed no signs of infection. The nurse provided first aid to both, and neither area showed signs of infection. The resident denied pain. The call light was in reach.<BR/>Record review of Resident #3's progress note updated 2/11/25 at 6:42 pm, written by LVN A revealed Resident #3 had one open area and one bruise to her left arm. <BR/>Record review of Resident #3's progress note dated 2/12/25 at 2:40 am, written by LVN C, revealed to continue to monitor skin tear and bruising to the left arm for Resident #3. No signs or symptoms of infection, pain, or discomfort were noted. <BR/>Record review of Resident #3's physician orders, dated 02/01/25 through 02/28/23, did not reveal any orders for monitoring bruising to the left arm.<BR/>Record review of Resident #3's physician orders, dated 02/01/25 through 02/28/25, did not reveal any orders for treating a skin tear to her left arm. <BR/>Record review of Resident #3's skin assessment dated [DATE] did not indicate a skin assessment was done after the bruise and skin tear were noted. <BR/>Record review of Resident #3's skin assessment dated [DATE], charted by LVN C, did not indicate a bruise or skin tear to her left arm.<BR/>Record review of Resident #3's care plan, revised on 03/26/25, did not indicate a bruise or skin tear to her left arm on 02/11/25.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN B said she was the treatment nurse. She said if a resident had a skin tear or a bruise, it should be reported to the nurse, the nurse would then report it to her, and she would assess and determine what type of treatment was needed, if any. She said if a skin tear were noted, she would look at it daily and document it in the TAR. If a bruise were noted, she would put in an order to monitor weekly till resolved. LVN B said that Resident #3 had several bruises over time because she would attempt to get up by herself. She said she could not recall this particular bruise or skin tear. She said part of her process was if a bruise or skin tear were reported, she would investigate to see what happened. She said Resident #3 was not normally able to say what happened related to her cognitive status. LVN C said if she could not figure out what happened, she would report it to the Administrator or DON.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN A said she was the charge nurse on duty when a family member reported Resident #3 had a skin tear and bruise on her left arm. LVN C said she was not aware how Resident #3 received the bruise or skin tear. She said she did not ask the staff or the family member who reported the skin tear or bruise if they knew what happened. LVN A said if an unknown skin tear or bruise was reported to her, she was supposed to notify the Administrator, DON, the physician, and the family. LVN A said she reported the bruise and skin tear to the Administrator and the DON. She said she was new to the facility during the incident and was told to do a progress note. She said she did not recall the Administrator or the DON questioning her about the incident once she reported it. She said since this incident, she had been educated to do an incident report and progress note, notify management, the physician, and the family. <BR/>During an interview on 04/09/25 at 6:55 a.m., LVN C said she was the 10 pm-6 am nurse for Resident #3. She said she could not recall the skin tear or bruise from 02/12/25 on Resident #3. LVN C said if she charted it, then it was either given to her in the report or was on the 24-hour report. She said if a bruise or skin tear occurred and staff were unaware of how it occurred, staff would report it to the ADON or DON, and they would investigate it. She said the nurses were supposed to do an incident report, document a progress note, and notify the physician, the family, the Administrator, and the DON of any skin tears or bruises of unknown origin. She said even if the nurses did not report something, it was on the 24-hour report, and management was supposed to review it daily. She said she did not recall being asked about Resident #3's skin tear or bruise by the Administrator or DON. <BR/>During an interview on 4/9/25 at 10:00 a.m., the ADON said if a resident had a bruise or skin tear of an unknown origin, she would investigate to see if she could figure out what happened. She said the nurses should document the incident in the progress notes, do an incident report, and notify the physician, the family, the Administrator, and the DON. She said the nurses were to chart the incident for 72 hours. She said even if a nurse forgot to report the incident, she would see it on the 24-hour report or while reading the nurses' notes. She said she could recall the incident on 02/11/25, but could not remember the details. The ADON reviewed Resident #3's chart and did not see an incident report on 02/11/25.<BR/>During an interview on 04/09/25 at 10:53 a.m., LVN B said she was the treatment nurse, and she had done a skin assessment on Resident #3 earlier on the 6 am-2 pm shift on 02/11/25. She said Resident #3 did not have any skin tears or bruises during her assessment. She said LVN A charted the skin tear and bruise at 6:22 pm after her shift. <BR/>During an interview on 04/09/25 at 11:03 a.m., the DON said he expected if a resident had a bruise or skin tear of an unknown source that staff would report it to him and the Administrator. He said they would do an internal investigation to see if they could figure out what happened, and if they could not figure out what happened, they would report it to the State of Texas. He said he could not recall the skin tear or bruise for Resident #3 around 02/11/25. He said Resident #3 had often scratched herself, or she could have bumped it on the wall, but since he did not remember investigating it, he could not say what happened. He said they do review the 24-hour reports in the morning meeting, and it must have been overlooked. He said that although he did not feel like abuse occurred, it was important to report and investigate abuse/neglect to prevent further abuse/neglect from occurring.<BR/>During an interview on 04/09/25 at 4:37 p.m., the Administrator said she was unaware of Resident #3's skin tear or bruise; therefore, it was not investigated or reported. She said she was not contacted for all skin tears or bruises, only if suspicion of abuse. She said if there was suspicion of abuse, the nurses should have called and reported it to her, and then they would have investigated and reported if needed. She said, after looking at Resident #3's chart, that LVN A was a new nurse during the incident and did not follow all the necessary steps, such as notification. She said they would educate LVN A. The Administrator said when injuries of unknown origin were not reported promptly, abuse could continue to occur. <BR/>Record review of the facility policy titled Abuse Prohibition Policy, revised 08/2020, indicated, Purpose: To ensure the facility established, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. VI. Investigation: A. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal activity. IX. Reporting: The facility will report allegations of abuse, neglect, exploitation, mistreatment, and injuries of unknown source, etc . immediately but no longer than two hours

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 2 of 4 (Resident #1 and Resident #2) residents reviewed for the care plan.<BR/>1. The facility failed to ensure urinalysis results on 04/05/2025 for Resident #1's contact isolation was care planned on 04/06/2025 for a diagnosis of Extended-Spectrum Beta-Lactamase, also known as ESBL (a bacteria that can be spread from person to person on contaminated hands of both patients and healthcare workers.<BR/>2. The facility failed on 04/03/2025 to ensure Resident #2's contact isolation was care planned for methicillin-resistant Staphylococcus aureus also known as MRSA (an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections) and for her refusal to stay in her room related to her being on isolation.<BR/>These failures could affect residents by placing them at risk of not receiving appropriate care and interventions to meet their needs.<BR/>Findings included:<BR/>1.Record review of Resident #1's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included urinary tract infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), extended-spectrum beta-lactamase also known as ESBL (occurs when bacteria producing the enzyme ESBL, which renders them resistant to many common antibiotics, causes an infection), diabetes (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), and stroke.<BR/>Record review of Resident 1's quarterly MDS assessment, dated 02/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 03, indicating she was severely cognitively impaired. The MDS indicated Resident #1 required assistance with her transfers, toileting, dressing, hygiene, and supervision for eating. The MDS indicated she was always incontinent of urine and was on an antibiotic. <BR/>Record review of Resident #1's electronic medical records revealed a urinalysis dated 04/05/25 which detected extended-spectrum beta-lactamase, also known as ESBL.<BR/>Record review of Resident #1's comprehensive care plan dated 04/06/25 indicated Resident #1 had a UTI. The intervention was for staff to encourage adequate fluids and monitor side effects. The care plan did not mention anything about being on contact isolation for ESBL.<BR/>Record review of Resident #1's physician's order dated 04/07/25 indicated: Doxycycline 100mg, give 1 capsule by mouth two times a day related to Urinary tract infection for 5 days. <BR/>Record review of Resident #1's Physician order dated 04/07/25 indicated Contact isolation precautions in place related to ESBL.<BR/>During an observation on 04/08/25 at 12:09 p.m., a contact isolation sign was noted on Resident #1's door. The isolation cart was noted 1 door to the right of Resident #1's room.<BR/>2.Record review of Resident #2's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia(a general term for a group of diseases that cause a decline in memory, thinking, and reasoning abilities, significantly affecting a person's daily life), Urinary Tract Infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), and anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident 2's quarterly MDS assessment, dated 01/30/25, indicated Resident #2 usually understood and was usually understood by others. Resident #2's BIMS score was 15, indicating she was cognitively intact. The MDS indicated Resident #2 required set-up assistance with her dressing and hygiene, independent with toileting and eating. The MDS indicated she was continent of bladder.<BR/>Record review of Resident #2's comprehensive care plan dated 03/29/23 indicated Resident #2 was occasionally incontinent of urine. The intervention was for staff to monitor for signs and symptoms of UTI. The care plan did not indicate a care plan for contact isolation or refusal to comply with contact isolation for MRSA. <BR/>Record review of Resident #2's electronic medical records revealed a urinalysis dated 04/03/25, which detected MRSA. <BR/>Record review of Resident #2's physician's order dated 04/06/25 indicated: Rifampin 300mg, give 1 capsule by mouth two times a day related to MRSA in urine until 04/20/25. <BR/>Record review of Resident #2's Physician order dated 04/06/25 indicated contact isolation precautions in place related to the diagnosis of MRSA.<BR/>Record review of Resident #2's comprehensive care plan after surveyor intervention was dated 04/06/25 but updated on 04/09/25, indicating Resident #1 required isolation. The intervention was to follow the facility's isolation policy and give medication as ordered.<BR/>During an observation on 04/08/25 at 11:00 a.m., Resident #2 was in the dining room attending an activity with 8 other residents while positive for MRSA. Resident #2 had a contact isolation sign on her door and an isolation cart outside her room door.<BR/>During an interview on 04/09/25 at 10:00 a.m., the ADON said the MDS nurses were responsible for the care plans. She said she and the DON were responsible for updating the acute care plans. She looked at Resident #1's and Resident #2's care plan and said she did not see their contact isolation care plan, nor Resident #2's refusal to stay in her room. She said she was aware they were on contact precautions but had not had a chance to update the care plan. She said she was aware of all new orders or changes a resident might have because they discussed the residents in the morning meeting, and she read the 24-hour reports. She said care plans were updated so staff would be aware of the care the residents needed.<BR/>During an interview on 04/09/25 at 11:08 a.m., the Regional MDS nurse said the MDS nurse was responsible for the comprehensive care plan, and the management team was responsible for updating the acute care plans. She said any changes about new orders should be updated within 24-48 hours, depending on when the order was received. She said care plans were done to direct the care of the resident.<BR/>During an interview on 04/09/25 at 11:22 a.m., the DON said the MDS nurses were responsible for the care plans. He said he and the ADON were responsible for the acute care plans. He said he was not aware that Resident #1 or Resident #2's care plan had not been updated related to contact isolation and the refusal of Resident #2 to stay in her room. He said care plans were done to ensure staff conducted the plan of care for each resident.<BR/>During an interview on 04/09/25 at 12:16 p.m., the Administrator said care plans were a team effort with the interdisciplinary team, but the MDS nurses were the overseers. She said the MDS nurse last day at the facility was last week; therefore, the DON/ADON was responsible for updating Resident #1 and #2's care plan. She said care plans were generated to provide each resident with the best care.<BR/>Record review of the facility's policy, Care Plan (Comprehensive), revised 10/24/22, indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. V. The IDT will revise the Comprehensive Care Plan as needed at the following intervals: A. Per RAI schedules; B. As dictated by changes in the resident's condition, C. In preparation for discharge, D. To address changes in behavior and care, and E. Other times as appropriate or necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #1 and Resident #2) reviewed for infection control.<BR/> The facility failed to ensure LVN D wore the proper PPE (gown and gloves) while checking Resident #1's blood sugar or administering insulin on 04/08/25, who was positive for ESBL.<BR/>The facility failed to ensure CNA E wore the proper PPE (gown and gloves) while providing care to Resident #1, who was positive for ESBL on 04/09/25. <BR/>The facility failed to ensure Resident #2 understood contact isolation precautions when the resident was in activities with other residents and positive for MRSA on 04/08/25.<BR/>These failures could place residents and staff at risk for cross-contamination and spread of infection and could potentially affect all others in the building. <BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included urinary tract infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), extended-spectrum beta-lactamase also known as ESBL (occurs when bacteria producing the enzyme ESBL, which renders them resistant to many common antibiotics, causes an infection), diabetes (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), and stroke.<BR/>Record review of Resident 1's quarterly MDS assessment, dated 02/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 03, indicating she was severely cognitively impaired. The MDS indicated Resident #1 required assistance with his transfers, toileting, dressing, hygiene, and supervision for eating. The MDS indicated she was always incontinent of urine and was on an antibiotic.<BR/>Record review of Resident #1's electronic medical records revealed a urinalysis dated 04/05/25 which detected extended-spectrum beta-lactamase, also known as ESBL.<BR/>Record review of Resident #1's comprehensive care plan dated 04/06/25 indicated Resident #1 had a UTI. The intervention was for staff to encourage adequate fluids and monitor side effects. The care plan did not indicate Resident #1 was on contact isolation.<BR/>Record review of Resident #1's physician's order dated 04/07/25 indicated: Doxycycline 100mg, give 1 capsule by mouth two times a day related to Urinary tract infection for 5 days. <BR/>Record review of Resident #1's Physician order dated 04/07/25 indicated contact isolation precautions in place related to the diagnosis of ESBL.<BR/>During an observation on 04/08/25 at 12:09 p.m., a contact isolation sign was noted on Resident #1's door. LVN D walked into Resident #1's room to check her blood sugar without applying a gown. LVN D reached over Resident #1 to check her blood sugar on her left finger. LVN D then left Resident #1's room to gather her insulin, reentered the room without a gown, and administered her insulin.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN A said she was the nurse who received Resident #1's diagnosis of ESBL related to her lab results and the order for Doxycycline. She said she gave the initial dose on 04/07/25 and posted an isolation sign on Resident #1's door. She said she reported it to the oncoming nurse about Resident #1's isolation and new order for Doxycycline. She said she also placed it on the 24-hour report sheet.<BR/>During an interview on 04/09/25 at 9:15 a.m., LVN D said she was the charge nurse for Resident #1 and Resident #2. She said Resident #1 was on contact precautions for ESBL in her urine, and Resident #2 was on contact precautions for MRSA in her urine. LVN D said staff should have on a gown and gloves when entering Resident #1 and Resident #2's rooms. She said she did not wear a gown when she went into Resident #1's room to check her blood sugar or when she administered her insulin. She said she honestly forgot she was in contact isolation. She said Resident #2 had rights, and if she wished to come out of her room, then she could. She said she could not recall if she had personally asked Resident #2 to stay in her room related to her contact isolation orders. She said if staff were not wearing gowns or gloves, they could spread the infection to others.<BR/>During an observation on 04/09/25 at 9:45 a.m., CNA E went into Resident #1's room to provide care. CNA E did not have on her gown or gloves when entering Resident #1's room. <BR/>During an observation and interview on 04/09/25 at 10:09 a.m., CNA E came out of Resident #1's room and disposed of her linen in the laundry barrel without it being in a yellow bag. She said she was aware Resident #1 was on contact precautions for something in her urine. She said she did not see a cart next to her door and did not see any boxes in her room, so she assumed she did not have to wear anything while in the room. She said that in the past, if a resident was on isolation, they would have a cart with equipment next to the door and boxes in the room with red bags for the trash and yellow bags for the linen. She said she worked yesterday (04/08/25) and did not wear a gown while providing care for Resident #1. She said she could spread infection since she did not properly dispose of her linen or wear a gown while in the room. <BR/>During an observation on 04/09/25 at 10:15 a.m., no linen or trash boxes were noted in Resident #1's room. The isolation cart was noted 1 door to the right of Resident#1's room.<BR/>2.Record review of Resident #2's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia(a general term for a group of diseases that cause a decline in memory, thinking, and reasoning abilities, significantly affecting a person's daily life), Urinary Tract Infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), and anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident 2's quarterly MDS assessment, dated 01/30/25, indicated Resident #2 usually understood and was usually understood by others. Resident #2's BIMS score was 15, indicating she was cognitively intact. The MDS indicated Resident #2 required set-up assistance with her dressing and hygiene, independent with toileting and eating. The MDS indicated she was continent of bladder.<BR/>Record review of Resident #2's comprehensive care plan dated 03/29/23 indicated Resident #1 was occasionally incontinent of urine. The intervention was for staff to monitor for signs and symptoms of UTI. The care plan did not indicate a care plan for contact isolation or refusal to comply with contact isolation. <BR/>Record review of Resident #2's electronic medical records revealed a urinalysis dated 04/03/25, which detected MRSA (an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections). <BR/>Record review of Resident #2's physician's order dated 04/06/25 indicated: Rifampin 300mg, give 1 capsule by mouth two times a day related to MRSA in urine until 04/20/25. <BR/>Record review of Resident #2's Physician order dated 04/06/25 indicated Contact isolation precautions in place related to MRSA.<BR/>Record review of Resident #2's comprehensive care plan after surveyor intervention was dated 04/06/25 but updated on 04/09/25, indicating Resident #1 required isolation. The intervention was to follow facility isolation policy and give medication as ordered.<BR/>During an observation on 04/08/25 at 11:00 a.m., Resident #2 was in the dining room attending an activity with 8 other residents while positive for MRSA.<BR/>During an interview on 04/08/25 at 3:30 p.m., Resident #2 said the staff told her she had something in her bladder and to make sure she washed her hands after using the bathroom. She said they did not tell her she had something that someone might catch or to stay in her room.<BR/>During an observation on 04/09/25 at 9:28 a.m., Resident #2 was in the day room sitting on the couch talking to another resident.<BR/>During an interview on 04/09/25 at 10:00 a.m., the ADON said if a resident were in contact isolation, staff would know because of the sign posted on the door. She said staff should wear gowns and gloves when they enter contact-isolated rooms. She said they encourage handwashing before and after care for all residents. She said she was not sure what the policy said on contact isolation for a resident. She said she thought the contact isolated residents could walk the facility. She said she knew they had educated Resident #2 on hand washing.<BR/>During an interview on 04/09/25 at 11:22 a.m., the DON said he expected all staff to follow the guidelines on the sign posted on the door. He said they should be wearing the proper PPE (gown and gloves) to protect themselves and to keep the spread of infection from other residents. He said if the resident were on contact isolation, then staff should be educating the resident on why they need to stay in their room and encouraging them to stay in their rooms. If the resident refuses to stay in their room, then the staff should document the refusal and add it to the resident's care plan.<BR/>During an interview on 04/09/25 at 12:16 p.m., the Administrator said when a resident was on contact isolation, staff should wear gowns and gloves when entering the room. She said the DON oversaw infection control. The Administrator said staff should ensure they had on the proper PPE to protect themselves and the residents and to prevent the spread of infection. She said residents who were on contact isolation should be encouraged to stay in their rooms and practice good hygiene to prevent the spread of infection. <BR/>Record review of the facility's policy titled, Infection Prevention and Control Program, revised 06/2020, indicated, Purpose: Ensure the facility established and maintained an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements. Policy: The facility must establish an infection prevention and control program under which it: #1 identifies, investigates, controls, and prevents infections in the facility .<BR/>Record review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions, revised 6/2020, indicated, To ensure that transmission-based precautions are used when caring for residents with communicable diseases or transmittable infections. III. Contact Precautions A. Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. I. Examples of infections requiring Contact Precautions include, but are not limited to: A. Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-drug resistant organisms (e.g., MRSA). C. Gloves and Handwashing: I. As outlined under Standard Precautions, gloves (clean, non-sterile) are worn when entering the room. D. Gown: I. As outlined under Standard Precautions, a (clean, non-sterile) gown is worn for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. G. Notice: I. The Facility alerts staff to the type of precaution a resident requires. ii. The Facility also ensures that the resident's care plan indicates the type of precautions implemented for the resident. iii. The Facility may utilize a sign requesting visitors to check in at the nursing station before entering a resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to ensure residents were free from abuse for 3 of 13 residents (Resident #1, #2 and Resident #3) reviewed for resident abuse. <BR/>1. The facility did not ensure Resident #1 was free from abuse when Resident #3 struck Resident #1 on the shoulder 11/8/24. <BR/>2. The facility did not ensure Resident #2 was free from abuse when Resident #4 reached out and grabbed Resident #2 under the arm on 12/9/24. <BR/>3. The facility did not ensure Resident #3 was free from abuse when Resident #5 pushed Resident #3 head on 12/9/24. <BR/>The noncompliance was identified as PNC. The past noncompliance began on 11/8/24 and ended on 12/14/24. The facility had corrected the noncompliance before the survey began. <BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings included: <BR/>1. Resident #1<BR/>Record review of Resident #1's face sheet, dated 11/12/24, reflected Resident #1 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Type 1 fracture of sacrum and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life).<BR/>Record review of the quarterly MDS assessment, dated 1/12/25, indicated Resident #1 usually made herself understood and usually understood others. Resident #1 BIMS score was 00, which indicated her cognition was severely impaired. Resident #1 used a wheelchair for mobility and required either setup/clean or supervision/touching assistance for most ADLs. <BR/>Record review of the undated comprehensive care plan reflected Resident #1 had impaired cognitive function/dementia or impaired thought processes related to dementia. The care plan interventions included: engage the resident in simple, structured activities that avoid overly demanding tasks, keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion, and use task segmentation to support short term memory deficits.<BR/>Resident #3<BR/>Record review of Resident #3's face sheet, dated 11/12/24, reflected Resident #3 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 12/17/24, indicated Resident #3 usually made herself understood and usually understood others. The MDS assessment did not address Resident #3's BIMS score. Resident #3 did not have any indicators of psychosis or exhibited any behaviors during the look back period. Resident #3 used a wheelchair for mobility and required wither substantial/maximum assistance or dependent for most ADLs. <BR/>Record review of the undated comprehensive care plan reflected Resident #3 had impaired cognitive function/dementia or impaired thought processes related to dementia. The care plan interventions included: administer medications as ordered, engage her in simple, structured activities that avoid overly demanding tasks and provide a program of activities that accommodates her ability. <BR/>Record review of the facility's PIR dated 11/12/24 with an incident category of abuse was signed by the Administrator on 11/13/24. The PIR reflected the Dietary Manager heard commotion in the dining room, went in and noted two residents (Resident #1 and #3) in an altercation. Resident #6 was present and reported Resident #3 struck Resident #1 on the left shoulder. The PIR included a form titled Witness Statement completed on 11/8/24 for Resident #6 who stated Resident #3 hit Resident #1 in the left shoulder. Resident #1 attempted to push Resident #3's arm away. The Dietary Manager immediately separated the residents. The DON conducted the interview. The PIR included a skin assessment completed 11/8/24, pain evaluation completed 11/8/24, trauma screen completed 11/8/24, incident report for both residents completed 11/8/24 and a 1:1 monitoring log for Resident #3 completed 11/8/24. The PIR reflected staff was in-serviced promptly on resident-to-resident abuse, customer service, intervention for Resident #3, and dementia related diseases dated 11/8/24. <BR/>Record review of the physical aggression report dated 11/8/24 indicated Resident #6 witnessed Resident #3 hit another resident (Resident #1) in the left shoulder and Resident #1 pushed Resident #3 arm away. The Dietary Manager immediately separated the residents. <BR/>Record review of undated handwritten statement, the Dietary Manager indicated she came into the dining room, Resident #1 pushed back Resident #3 hand from her, and Resident #3 was saying that stuff was hers. Moved Resident #3 and reported to the nurse. <BR/>During an interview on 1/28/25 at 8:12 a.m., Resident #3 was sitting in bed eating breakfast. Resident #3 stated repeatedly I don't remember when asked about the incident between her and Resident #1. <BR/>During an interview on 1/28/25 at 9:13 a.m., the Dietary Manager stated she heard something in the dining room and went out and saw Resident #1 had a fingernail file and lip gloss in her hand. The Dietary Manager stated they both were saying the items were theirs. The Dietary Manager stated Resident #1 pushed Resident #3 hand back and stated, no it's mine. The Dietary Manager stated she removed Resident #3 from the situation and brought her to the hallway by the nursing station and grabbed a nurse.<BR/>During an interview on 1/28/25 at 10:38 a.m., Resident #1 stated, It's been so long ago, I don't remember when asked about the incident between her and Resident #3. <BR/>2. Resident #2 <BR/>Record review of Resident #2's face sheet, dated 12/10/24, reflected Resident #2 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia (low levels of oxygen in the body tissues). <BR/>Record review of Resident #2's quarterly MDS assessment, dated 12/16/24, indicated Resident #2 usually made himself understood and usually understood others. Resident #2's BIMS score was 15, which indicated his cognition was intact. Resident #2 required setup/clean up assistance for most ADLs. <BR/>Record review of the undated comprehensive care plan reflected Resident #2 had an ADL Self Care Performance Deficit related to activity intolerance. The care plan interventions included: praise all efforts of care and encourage him to fully participate possible with each interaction.<BR/>Resident #4<BR/>Record review of Resident #4's face sheet, dated 12/10/24, reflected Resident #4 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow).<BR/>Record review of a Medicare 5-day assessment, dated 12/9/24, indicated Resident #4 sometimes made himself understood and sometimes understood others. Resident #4's BIMS score was 00, which indicated his cognition was severely impaired. Resident #4 exhibited hallucinations, delusions and physical behavior directed toward others one to three days during the look back period. Resident #4 required substantial/maximum assistance for most ADLs. <BR/>Record review of the undated comprehensive care plan reflected Resident #4 was physically and verbally towards staff and residents. The care plan interventions included: keep all residents safe, psych referral with increased behaviors and redirect in times of agitation. <BR/>Record review of the facility's PIR dated 12/9/24 with an incident category of abuse was signed by the Administrator on 12/10/24. The PIR reflected while passing each other in the hallway Resident #4 swung at Resident #2. When the nurse asked Resident #2 did, he gets you, Resident #2 responded no, approximately 4 hours later Resident #2 reported to the nurse that Resident #4 did grab him under his arm but did not hit him. The PIR included a skin assessment completed 12/9/24, trauma screen completed 12/9/24, 1:1 monitoring log for Resident #4 started on 12/9/24 and ended 12/10/24, safe surveys with no areas of concerns dated for 12/9/24. The PIR reflected staff was in-serviced promptly on resident-to-resident abuse/neglect dated for 12/9/24. <BR/>During a telephone interview on 1/27/25 at 10:45 p.m., RN A stated Resident #4 and Resident #2 was both in a wheelchair in the hallway. RN A stated Resident #4 swung at Resident #2 as Resident #2 was passing him. RN A stated there was an aide standing there during the incident and she heard her holler out and that was when RN A went to see what was going on. RN A stated she asked Resident #2 while she was standing between both residents did, he get you and he responded, no he didn't get me. RN A stated she separated both residents and then had one of the aides to stay with Resident #4 while she contacted the DON and Administrator. RN A stated 1:1 was provided for Resident #4 because he was very agitated. RN A stated she completed assessment with no injury noted. RN A stated approximately 4 hours Resident #2 came to her and reported that Resident #4 did grab him under his arm but did not hit him. RN A stated she completed another skin assessment to check for injuries, no injuries noted. RN A stated she contacted the DON/Administrator and responsible parties to inform them of the change. <BR/>During a telephone interview on 1/27/25 at 11:07 p.m., CNA B stated she witnessed Resident #4 touching Resident #2 shirt while passing each other in the hallway. CNA B stated she did not see Resident #4 grabbed Resident #2's arm. CNA B stated Resident #4 was new to the facility. CNA B stated she went immediately to RN A and reported the incident. CNA B stated RN A immediately came to intervene. CNA B stated there was a sitter with Resident #4 throughout the night. <BR/>During an interview on 1/28/25 at 9:45 a.m., Resident #2 stated Resident #4 grabbed him under his armpit while passing him in the hallway. Resident #2 stated Resident #4 did not want him to pass him.<BR/>3. Resident #3<BR/>Record review of Resident #3's face sheet, dated 11/12/24, reflected Resident #3 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 12/17/24, indicated Resident #3 usually made herself understood and usually understood others. The MDS assessment did not address Resident #3's BIMS score. Resident #3 used a wheelchair for mobility and required wither substantial/maximum assistance or dependent for most ADLs. <BR/>Record review of the undated comprehensive care plan reflected Resident #3 had impaired cognitive function/dementia or impaired thought processes related to dementia. The care plan interventions included: administer medications as ordered, engage her in simple, structured activities that avoid overly demanding tasks and provide a program of activities that accommodates her ability. <BR/>Resident #5<BR/>Record review of Resident #5's face sheet, dated 12/10/24, reflected Resident #5 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included anxiety disorder. <BR/>Record review of Resident #5's annual MDS assessment, dated 12/26/24, indicated Resident #5 usually made herself understood and usually understood others. Resident #5's BIMS score was 13, which indicated her cognition was intact. Resident #3 did not have any indicators of psychosis or exhibited any behaviors during the look back period. Resident #5 required setup/cleanup assistance for most ADLs. <BR/>Record review of the undated comprehensive care plan reflected Resident #5 had a potential to demonstrate physical behaviors related to anger, poor impulse control. The care plan interventions included: assess/address for contributing sensory deficits, modify environment: reduce noise and when the resident became agitated to intervene before agitation escalates. <BR/>Record review of the facility's PIR dated 12/12/24 with an incident category of abuse was signed by the Administrator on 12/12/24. The PIR reflected that LVN C looked up and saw Resident #5 push Resident #3 head and yelled at her, I said to shut up and go away. Resident #5 stated, she was getting on my nerves, and I wanted her to go away. The PIR included a skin assessment completed 12/9/24 &12/10/24, trauma screen completed 12/10/24, psychiatric assessment for both residents completed 12/10/24, 1:1 monitoring log for Resident #5 started on 12/9/24 and ended 12/10/24, safe surveys with no areas of concerns dated for 12/10/24. The PIR reflected staff was in-serviced promptly on resident-to-resident abuse/neglect dated for 12/9/24. <BR/>During an interview on 1/28/25 at 8:12 a.m., Resident #3 was sitting in bed eating breakfast. Resident #3 stated repeatedly I don't remember when asked about the incident on 11/8/24 between her and Resident #5. <BR/>During an interview on 1/28/25 at 10:41 a.m., Resident #5 was lying in bed. Resident #5 stated she did not recall hitting anyone upside their head. Resident #5 stated if I did say go way, I did not mean it that way. Resident #5 stated, I'm not mean. <BR/>During an interview on 1/28/25 at 11:40 a.m., LVN C stated Resident #5 was sitting in the front lobby on the couch with her peers. LVN C stated Resident #3 family member came in and stopped to talk to the group on the couch. LVN C stated Resident #3 saw him and rolled over to see him. LVN C stated Resident #3 bumped the table next to the door and almost knocked over the monitor on top of it. LVN C stated Resident #5 became upset and stated something to Resident #3. LVN C stated she told Resident #5 that it was ok, she did not break anything she just wanted to talk to her family member. LVN C stated Resident #5 started mumbling under her breath about Resident #3. LVN C stated Resident #3 then rolled backwards and was rolling behind the couch, Resident #3 was talking to her family member when Resident #5 turned around, pushed Resident #3 head, and told her I said shut up and go away. LVN C stated she immediately separated the residents, making sure the other resident was ok. LVN C stated Resident #3's family member was next to her. LVN C stated she had a CNA took Resident #3 to her room so she could lay down and visit with her family. LVN C stated she contacted the abuse coordinator which was the Administrator and informed her of the incident. LVN C stated the other nurse on duty went and performed a skin assessment on the other resident. <BR/>During interviews on 01/27/25 and 01/28/25 with 10 residents regarding abuse and neglect with a focus presented on physical abuse revealed they all denied abuse with the exceptions of the above mentioned.<BR/>During interviews on 1/27/25 and 1/28/25 beginning at 8:30 a.m., RN (A, K, L), LVN (C, G, N, O), CNA (B, D, E, F, H, M,P), MA Q, COTA R, ADON, DON, Administrator, Dietary Manager, Maintenance Supervisor were able to define abuse, when to report, and whom to report. <BR/>During an interview on 1/28/25 at 2:49 p.m., the DON stated he was knowledgeable of the abuse allegations. The DON stated the victims did not have any changes in behavior since the incident. The DON stated personality wise none of the perpetrators showed any type of behaviors. The DON stated Resident #4 was a new admission prior to his incident. The DON stated residents were immediately separated and aggressor kept on 1:1 monitoring until a psychiatric evaluation was completed. The DON stated the investigation for Resident #3 and #6 was completed on 11/13/24. The DON stated the investigation for Resident #2 and #4, Resident #3 and #5 was completed was on 12/14/24. The DON stated staff were provided education on abuse and neglect related to all situations. The DON stated the Administrator was the abuse coordinator. The DON stated the last in-service on abuse and neglect was within the last few weeks. <BR/>During an interview on 1/28/25 at 3:05 p.m., the Administrator stated she was the abuse coordinator for the facility. The Administrator stated abuse was monitored daily during rounds asking questions about abuse and monitoring for abuse. The Administrator stated once the facility learned of any allegation, they acted appropriately to protect all the residents.<BR/>Record review of the facility's policy titled Abuse Prevention and Prohibition Program revised 10/24/22 indicated . each resident has the right to be free from . abuse . The facility has zero-tolerance for abuse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Residents #7) reviewed for pharmacy services.<BR/>1. The facility did not ensure Resident #7 medications were administered during the scheduled time. <BR/>2. The facility did not ensure Resident #7 was given Estrace Vaginal Cream 0.01 mg/gm as scheduled. <BR/>3. The facility did not ensure Resident #7 was given Vitamin B-12 2000 mcg. <BR/>These failures could place the residents at risk of not having medications available for use, drug diversion, not receiving their medications as ordered, and exacerbation of their disease processes. <BR/>Findings included:<BR/>1. Record review of Resident #7's face sheet, dated 01/28/25, reflected Resident #7 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). <BR/>Record review of the order summary report dated 01/28/25 indicated Resident #7 was ordered: <BR/>_Calcium 600: give 1 tablet by mouth two times a day for osteoporosis (disease that weakens bone to the point where they break easily) at 8:00 a.m. <BR/>_Pantoprazole sodium 20 mg: give 1 tablet by mouth two times a day for heartburn at 5:00 p.m.<BR/>_Sitagliptin-metformin HCI 50-500 mg: give 1 tablet by mouth two times a day for diabetes mellitus at 9:00 a.m. and 5:00 p.m.<BR/>_Calcium 600: give 1 tablet by mouth two times a day for osteoporosis at 5:00 p.m. <BR/>Record review of the Medication Administration Audit Report dated 1/28/25 indicated Resident #7 received her medications on 12/07/24 by MA Q as listed: <BR/>_Calcium 600 at 9:49 a.m.<BR/>_Pantoprazole sodium 20 mg at 7:29 p.m.<BR/>_Sitagliptin-metformin HCI 50-500 mg at 7:29 p.m. <BR/>_Calcium 600 at 7:29 p.m.<BR/>2. Record review of a telephone order, dated 12/06/24, indicated Resident #7 had an order for Estrace vaginal cream 0.1 mg/gm applicator at bedtime every Monday, Wednesday, Friday for atrophy vaginitis. <BR/>Record review of the MAR dated 12/1/24-12/31/24 indicated Resident #7 was given Estrace vaginal cream 0.1 mg/gm applicator at bedtime every Monday, Wednesday, Friday for atrophy vaginitis (vaginal tissue thins due to low estrogen levels) on 12/25/24 by the ADON.<BR/>During a confidential interview, the interviewee stated Resident #7's medications were administered late on 12/07/24. The interviewee stated Resident #7 was not given the vaginal suppository on 12/25/24. <BR/>During a telephone interview on 1/28/25 at 2:09 p.m., MA Q stated sometimes Resident #7 refused her calcium until she has had breakfast. MA Q stated she could not recall if that had occurred on 12/7/24 at 8:00 a.m. MA Q stated medications that were scheduled at 5:00 p.m. should have been given between 4:00 p.m.-6:00 p.m. MA Q stated she did not remember given Resident #7 anything that late. MA Q stated this failure could potentially cause an adverse effect. <BR/>During an interview on 1/28/25 at 12:08 p.m., the ADON stated on 12/25/24 she was the charge nurse for Resident #7. The ADON stated she went to give her the suppository and something happened (unable to recall) and forgot to administer the medication. The ADON stated she did click off the task as completed prior to administering the medication but the medication was not given. The ADON stated she was not aware until Resident #7 family member told her that she did not give her the suppository on 12/25/24. The ADON stated she did offer to move the date, but the family member stated do not worry about it. <BR/>During an interview on 1/28/25 at 2:49 p.m., the DON stated he expected medications to be administered one hour before or one hour after the scheduled time. The DON stated he was responsible for monitoring and overseeing by reviewing the 24-hour progress noted Monday-Friday and on Monday the weekend was reviewed. The DON stated it was important to ensure medications were administered timely to ensure the dosage stay consistent in the bloodstream. <BR/>During an interview on 1/28/25 at 3:05 p.m., the Administrator stated she expected the medications to be administered according to the schedule to ensure effectiveness. The Administrator stated the DON, and the ADONs were responsible for overseeing and monitoring. The Administrator stated it was important to follow the physician orders to prevent an adverse effect. <BR/>3. Record review of Resident #7's face sheet, dated 01/28/25, reflected Resident #7 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). <BR/>Record review of the order summary report dated 01/28/25 indicated Resident #7 was ordered: <BR/>Vitamin B-12 1000 mcg; give 2000 mcg by mouth in the morning related to anemia. <BR/>During observation and interview on 1/28/25 at 9:18 a.m., MA S was preparing Resident #7's medication for administration. MA S obtained a bottle of Vitamin B-12 1000 mcg and placed 1 tablet (1000mg) in a plastic cup. MA S finished preparing the remainder of Resident #7's morning medications. MA S stated she should have given 2 tablets of Vitamin B12 1,000 mcg. MA S stated this failure could potentially cause more of a vitamin deficiency. <BR/>During an interview on 1/28/25 at 2:49 p.m., the DON stated he expected medications to be given per the physician orders. The DON stated he was responsible for monitoring and overseeing by reviewing the 24-hour progress noted Monday-Friday and on Monday the weekend was reviewed. The DON stated he has not been aware of medications not been administered correctly. The DON stated the risk associated with not giving the correct dose was the desired effect not achieved. <BR/>During an interview on 1/28/25 at 3:05 p.m., the Administrator stated she expected the correct dose to be given. The Administrator stated the DON, and the ADONs were responsible for overseeing and monitoring. The Administrator stated it was important to follow the physician orders to prevent a medication error. <BR/>Record review of the facility's undated policy titled, Medication-Administration indicated, . to provide practice standards for safe administration of medications for residents in the facility . IV. The licensed nurse must know the following information about any medication they are administering E. the drugs usual dosage . V. Medications may be administered one hour before or after the scheduled medication administered time. IV. Nursing staff will keep in mind the seven rights of medication when administering medication: B. the right amount . D. The right time .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to be informed of and participate in his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment, and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #179) reviewed for resident rights.<BR/>The facility failed to obtain informed consent based on the information of the benefits and risks for Resident #179 before administering Bupropion HCL ER (Wellbutrin - a medication used to treat depression). <BR/>This failure could place residents at risk of receiving medications they had not consented to, experiencing potential adverse reactions, and a potential decline in physical and mental health status.<BR/>Findings included:<BR/>Record review of Resident #179's face sheet, dated 08/22/24, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses which included Spinal stenosis (pain in the lower back that can cause cramping in one or both legs), Schizophrenia (a chronic mental illness that affects how a person thinks, feels, and behaves), depression (sadness), and post-traumatic stress disorder also known as PTSD (a mental health condition that's caused by an extremely stressful or terrifying event).<BR/>Record review of Resident #179's admission MDS assessment, dated 08/12/24, indicated Resident #179 understood and was understood by others. Resident #179's BIMS score was 15, which indicated he was cognitively intact. The MDS indicated Resident #179 required extensive help with toileting bed mobility, dressing, transfers, set up for personal hygiene, and being independent with eating. The MDS indicated he took antidepressant medication during the 7-day look-back period.<BR/>Record review of Resident #179's care plan dated 08/07/24 indicated he required antidepressant medication. The intervention of the care plan indicated staff would give medication as ordered, staff would monitor for signs and symptoms of depression such as sadness, crying, or shame, etc., and educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms.<BR/>Record review of Resident #179's physician order dated 08/05/24 for Bupropion HCL ER(Wellbutrin) 150mg, give 1 tablet by mouth daily for depression.<BR/>Record review of Resident #179's records revealed there was no consent for the use of psychotropic medication, Bupropion HCL ER(Wellbutrin) documented in his chart.<BR/>During an interview on 08/21/24 at 4:00 p.m., Resident #179 said he took a lot of medicine and was unsure of all the names.<BR/>During an interview on 08/21/24 at 4:21 p.m., LVN A said consent(s) should be obtained for all psychotropic medication before being given. LVN A said Resident #179 was given, Bupropion HCL ER (Wellbutrin) for depression but did not know his consent was not done until mentioned by the State Surveyor. LVN A said consents were usually obtained during the admission process by the charge nurse. LVN A said psychotropic medications could change a resident's demeanor and this was why the resident or their responsible party should be aware of all medications and the possible side effects or behaviors from the medications.<BR/>During an interview on 08/21/24 at 4:44 p.m., the ADON said the consent for psychotropic medications should be completed before the resident received the medication. The ADON said they normally got consent for all psychotropic medication because those types of medications could alter the mind and could cause other risks. The ADON said the nurse who received the order was responsible for getting the consent. The ADON said she was the admitting nurse for Resident #179 and did not realize she did not get his consent for Bupropion HCL ER (Wellbutrin) until questioned by the state surveyor. The ADON said failure to get consent could lead to a side effect or behaviors and the family or resident would not know why.<BR/>During an interview on 08/22/24 at 2:30 p.m., the DON said consent should be signed prior to medication being administered. The DON said one reason consents were obtain was to inform the family or resident about the risk and benefits prior to receiving medications. The DON said they had psychiatrist services who would usually obtain consent if they place the resident on psychotropic medication. He said if the charge nurse received the order, they were responsible for obtaining the consent. He said the IDT was the overseer for ensuring residents had consent in place. The DON said failure to obtain consent could cause the resident not to know what medications he was taken or if he wanted to take them.<BR/>During an interview on 08/22/24 at 03:00 p.m., the Administrator said consent should be done to inform families or residents of risk and/or benefits of medication. The Administrator said the ADON and the DON oversaw that process. The Administrator said failure to get consent could lead to families or residents not having a voice in resident care.<BR/>Record review of the facility's policy titled; Psychotherapeutic Drug Management revised date of 06/2020, Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or decreasing or negatively impacting the residents' quality of life .G. The Licensed Nurse will not administer the psychotherapeutic medication until an informed consent from has been obtained and document by the attending physician from the resident and/or surrogate decision maker unless it is an emergency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the right to formulate an advanced directive was provided for 1 of 26 residents (Residents #13) reviewed for advanced directives. The facility did not ensure Resident #13 had a physician's order in his chart for DNR. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #13's face sheet, dated [DATE], reflected Resident #13 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). Record review of Resident #13's admission MDS assessment, dated [DATE], reflected Resident #13 usually made himself understood, and usually understood others. Resident #13's BIMS score was 12, which reflected his cognition was moderately impaired. Record review of Resident #13's undated comprehensive care plan, reflected Resident #13 had an order for DNR. The care plan interventions specified, in absence of b/p, pulse, respiration, CPR will not be initiated. Record review of Resident #13's physician order report, dated [DATE], reflected an active physician's order for code status: DNR with an order date [DATE]. Record review of Resident #13's OOH-DNR form reflected Resident #13 had an active DNR since [DATE]. During an interview on [DATE] at 3:33 p.m., the ADON stated the nurse that readmitted Resident #13 was responsible for putting in the DNR. The ADON stated Resident #13 came in at the end of one shift and that nurse started the orders and the 2nd shift nurse completed the orders. The ADON stated she was responsible for monitoring and overseeing all orders were put in correctly after a resident was admitted to the facility by reviewing the orders after each admission/readmission. When asked why there was not a physician order for Resident #13 advance directive status, the ADON stated, it was just missed. The ADON stated it was important an order for DNR was placed in the residents' electronic medical records to respect the resident's wishes. During an interview on [DATE] at 5:05 p.m., the DON stated she expected a DNR order to be in PCC when a resident admitted to the facility or if the status changed. The DON stated charge nurses were responsible for inputting code status upon admission. The DON stated the ADON was responsible for monitoring by reviewing the orders against the discharged orders after every admission. The DON stated it was important an order was placed in the resident's chart to ensure his wishes was respected. During an interview on [DATE] at 6:40 p.m., the Administrator stated she expected a DNR order to be placed in PCC upon admission. The Administrator stated the charge nurse was responsible for ensuring that the order was input into the resident's chart after he was readmitted to the facility. The Administrator stated the ADON was responsible for monitoring and overseeing orders when a resident admit to the facility. The Administrator stated it was important to ensure an order was placed in PCC to ensure the resident wishes was respected. Record review of the facility's policy Do Not Resuscitate Orders and the Withholding or Withdrawal of Life Support and Life Sustaining Treatment, revised on 08/2020, reflected. to ensure that the facility abides by state and federal law as well as resident preferences regarding withdrawal of life support and life sustaining treatment and orders not to resuscitate. D. ii. All documents concerning decision-makers consulted by the facility and the attending physician will be in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 2 of 4 (Resident #1 and Resident #2) residents reviewed for the care plan.<BR/>1. The facility failed to ensure urinalysis results on 04/05/2025 for Resident #1's contact isolation was care planned on 04/06/2025 for a diagnosis of Extended-Spectrum Beta-Lactamase, also known as ESBL (a bacteria that can be spread from person to person on contaminated hands of both patients and healthcare workers.<BR/>2. The facility failed on 04/03/2025 to ensure Resident #2's contact isolation was care planned for methicillin-resistant Staphylococcus aureus also known as MRSA (an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections) and for her refusal to stay in her room related to her being on isolation.<BR/>These failures could affect residents by placing them at risk of not receiving appropriate care and interventions to meet their needs.<BR/>Findings included:<BR/>1.Record review of Resident #1's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included urinary tract infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), extended-spectrum beta-lactamase also known as ESBL (occurs when bacteria producing the enzyme ESBL, which renders them resistant to many common antibiotics, causes an infection), diabetes (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), and stroke.<BR/>Record review of Resident 1's quarterly MDS assessment, dated 02/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 03, indicating she was severely cognitively impaired. The MDS indicated Resident #1 required assistance with her transfers, toileting, dressing, hygiene, and supervision for eating. The MDS indicated she was always incontinent of urine and was on an antibiotic. <BR/>Record review of Resident #1's electronic medical records revealed a urinalysis dated 04/05/25 which detected extended-spectrum beta-lactamase, also known as ESBL.<BR/>Record review of Resident #1's comprehensive care plan dated 04/06/25 indicated Resident #1 had a UTI. The intervention was for staff to encourage adequate fluids and monitor side effects. The care plan did not mention anything about being on contact isolation for ESBL.<BR/>Record review of Resident #1's physician's order dated 04/07/25 indicated: Doxycycline 100mg, give 1 capsule by mouth two times a day related to Urinary tract infection for 5 days. <BR/>Record review of Resident #1's Physician order dated 04/07/25 indicated Contact isolation precautions in place related to ESBL.<BR/>During an observation on 04/08/25 at 12:09 p.m., a contact isolation sign was noted on Resident #1's door. The isolation cart was noted 1 door to the right of Resident #1's room.<BR/>2.Record review of Resident #2's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia(a general term for a group of diseases that cause a decline in memory, thinking, and reasoning abilities, significantly affecting a person's daily life), Urinary Tract Infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), and anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident 2's quarterly MDS assessment, dated 01/30/25, indicated Resident #2 usually understood and was usually understood by others. Resident #2's BIMS score was 15, indicating she was cognitively intact. The MDS indicated Resident #2 required set-up assistance with her dressing and hygiene, independent with toileting and eating. The MDS indicated she was continent of bladder.<BR/>Record review of Resident #2's comprehensive care plan dated 03/29/23 indicated Resident #2 was occasionally incontinent of urine. The intervention was for staff to monitor for signs and symptoms of UTI. The care plan did not indicate a care plan for contact isolation or refusal to comply with contact isolation for MRSA. <BR/>Record review of Resident #2's electronic medical records revealed a urinalysis dated 04/03/25, which detected MRSA. <BR/>Record review of Resident #2's physician's order dated 04/06/25 indicated: Rifampin 300mg, give 1 capsule by mouth two times a day related to MRSA in urine until 04/20/25. <BR/>Record review of Resident #2's Physician order dated 04/06/25 indicated contact isolation precautions in place related to the diagnosis of MRSA.<BR/>Record review of Resident #2's comprehensive care plan after surveyor intervention was dated 04/06/25 but updated on 04/09/25, indicating Resident #1 required isolation. The intervention was to follow the facility's isolation policy and give medication as ordered.<BR/>During an observation on 04/08/25 at 11:00 a.m., Resident #2 was in the dining room attending an activity with 8 other residents while positive for MRSA. Resident #2 had a contact isolation sign on her door and an isolation cart outside her room door.<BR/>During an interview on 04/09/25 at 10:00 a.m., the ADON said the MDS nurses were responsible for the care plans. She said she and the DON were responsible for updating the acute care plans. She looked at Resident #1's and Resident #2's care plan and said she did not see their contact isolation care plan, nor Resident #2's refusal to stay in her room. She said she was aware they were on contact precautions but had not had a chance to update the care plan. She said she was aware of all new orders or changes a resident might have because they discussed the residents in the morning meeting, and she read the 24-hour reports. She said care plans were updated so staff would be aware of the care the residents needed.<BR/>During an interview on 04/09/25 at 11:08 a.m., the Regional MDS nurse said the MDS nurse was responsible for the comprehensive care plan, and the management team was responsible for updating the acute care plans. She said any changes about new orders should be updated within 24-48 hours, depending on when the order was received. She said care plans were done to direct the care of the resident.<BR/>During an interview on 04/09/25 at 11:22 a.m., the DON said the MDS nurses were responsible for the care plans. He said he and the ADON were responsible for the acute care plans. He said he was not aware that Resident #1 or Resident #2's care plan had not been updated related to contact isolation and the refusal of Resident #2 to stay in her room. He said care plans were done to ensure staff conducted the plan of care for each resident.<BR/>During an interview on 04/09/25 at 12:16 p.m., the Administrator said care plans were a team effort with the interdisciplinary team, but the MDS nurses were the overseers. She said the MDS nurse last day at the facility was last week; therefore, the DON/ADON was responsible for updating Resident #1 and #2's care plan. She said care plans were generated to provide each resident with the best care.<BR/>Record review of the facility's policy, Care Plan (Comprehensive), revised 10/24/22, indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. V. The IDT will revise the Comprehensive Care Plan as needed at the following intervals: A. Per RAI schedules; B. As dictated by changes in the resident's condition, C. In preparation for discharge, D. To address changes in behavior and care, and E. Other times as appropriate or necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was unable to conduct activities of daily living received the necessary services to maintain grooming, personal, and oral hygiene were provided for 1 of 6 residents (Resident #1) reviewed for ADL care. The facility failed to ensure Resident #1 was showered or bed bathed during the dates of 09/01/25 through 09/10/25. This failure could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity. Findings included: Record review of Resident #1's face sheet, dated 09/10/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included obesity, depression (sadness), diabetes, and Chronic obstructive pulmonary disease, also known as COPD (a group of lung diseases that cause airflow obstruction and breathing problems). Record review of Resident #1's quarterly MDS assessment, dated 08/20/25, indicated Resident #1 understood and was understood by others. Her BIMs score was a 15, which indicated she was cognitively intact. The MDS indicated she required total assistance for showering, dressing, and transferring. The MDS indicated she was always incontinent of bowel and bladder. Record review of the care plan dated 07/21/25 indicated Resident #1 had an ADL self-care performance deficit. The interventions were for staff to assist with bathing. Record review of Resident #1's point of care history dated 09/01/25-09/10/25, did not indicate Resident #1 was bathed on the following dates:09/01/25, 09/02/25, 09/03/25, 09/04/25, 09/05/25, 09/06,25, 09/07/25, 09/08/25, 09/09/25, or 09/10/25. During an interview on 09/08/25 11:26 p.m., Resident #1 said she was not getting her showers three times a week. She said she had not had a shower or bed bath in about 2 weeks. She said she was supposed to be showered/bed bathed on the day shift. She said she was scheduled to have her showers on Monday and Friday and her bed baths on Wednesdays. She said they did not offer her a shower on Monday (09/01/25) or a bed bath on Wednesday (09/03/25). She said they told her something was wrong with the shower on Friday (09/05/25), but they did not even offer a bed bath. She said she felt dirty and wanted a shower. She said today (09/08/25) was her shower day but had not been offered a shower yet. During an interview on 09/09/25 at 3:58 p.m., Resident #1 was in bed and said she did not receive her shower yesterday (09/08/25) or even offered a bed bath. During an interview on 09/10/25 at 1:37 p.m., CNA G said she was assigned to Resident #1 on Monday (09/08/25) but did not shower or bed bathe her. She said the shower room was out of order, so she just wiped Resident #1 off and changed her gown. During an interview on 09/10/25 at 1:48 p.m., CNA L said she was the shower aide, but had not given Resident #1 a shower in about 2 weeks. She said the aides were supposed to bring Resident #1 to her, and they did not, so she did not shower her. She said she did not ask the aides why Resident #1 was not coming to get a shower. During an interview on 09/10/25 at 4:19 p.m., Resident #1 was in bed and said she did not receive her shower today (09/10/25) or even offered a bed bath. During an interview on 09/10/25 at 4:36 p.m., RN K said she was Resident #1's evening nurse (2 pm-10 pm). She said showers should be given according to the shower schedule. She said Resident #1 was a day shift bath but had not heard of her refusing her baths in the past. She said she was usually compliant with her showers and bed baths. She said residents should receive their baths for hygiene purposes. During an interview on 09/10/25 at 5:50 p.m., the DON said she expected showers to be given according to the shower schedule. She said she was unaware that Resident #1 missed showers. She said if a resident refused his/her shower(s), then the charge nurse was supposed to talk with the resident and see why they were refusing and document it in his/her chart. She said showers should be given for cleanliness and prevention of skin breakdown or infection. During an interview on 09/10/25 at 6:11 p.m., the Administrator said she expected the residents to receive their baths and expected the staff to document if they did not receive them. The Administrator said the aides were supposed to give the baths, and the charge nurse was responsible for ensuring the showers were completed. She said showers were given to prevent skin breakdown and maintain hygiene. She said she had staff to give Resident #1 a shower/bed bath today (09/10/25) after surveyor intervention. Record review of the facility's policy titled, Showering a Resident, undated, indicated, Purpose: A shower bath is given to the resident to provide cleanliness, comfort, and to prevent body odors. Policy: Residents are offered a shower at a minimum of once weekly and given per the residents' request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident in making appointments for 1 of 26 residents (Resident #51). The facility failed to ensure Resident #11 had his ketorolac eye drops by 08/31/25 to ensure he had his surgery on 09/02/25. This failure placed resident at risk of a delay in treatments for the residents' conditions. Findings included: Record review of Resident #51's face sheet dated 09/10/25 indicated he was a[AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of legal blindness, unspecified cataract, need for assistance with personal care, Parkinsonism (clinical syndrome characterized by tremor, slow heart rates, and postural instability), and heart failure. Record review of Resident #51's admission MDS assessment dated [DATE] indicated he was able to make himself understood and able to understand others. The MDS also indicate he had a BIMS score of 14 which meant his cognition was intact. The MDS also indicated he required moderate assistance from staff for toileting, bathing, dressing, and transfers, and he was independent with eating. Record review of Resident #51's care plan dated 03/26/25 indicated he was legally blind as defined in the USA and had cataracts with the goal to maintain optimal quality of life within limitation imposed by visual function and interventions to identify/record factors affecting visual function, monitor/document/report to Medical Doctor signs and symptoms of acute eye problems. Record review of Resident #51's order summary report dated 09/10/25 that included orders that were active, completed, and discontinued indicated he had and order for:1) Ketorolac Tromethamine Ophthalmic Solution 0.4 % Instill 1 drop in right eye four times a day for preventative that was discontinued but was dated 09/01/2025 with a start date of 09/01/2025. Record review of Resident #11's prescription from the ophthalmologist office visit dated 07/24/25 indicated:1) Ketorolac 0.5% eye drops Dispense:5 (five) milliliter Instill drop by ophthalmic route 4 times every day into the left eye starting 2 days before surgery (09/02/25), (which meant he should have started the eye drops on 08/31/25) Record review of Resident #11's progress notes dated 09/01/25 at 8:56 PM indicated the ketorolac was not received from the pharmacy. Record review of Resident #11's progress notes dated 09/02/25 at 10:02 AM indicated his cataract surgery would be rescheduled per charge nurse. During an interview on 09/09/25 at 11:12 AM the Social Worker said she charted Resident #11's surgery was rescheduled on 09/02/25 because LVN B told her the appointment was rescheduled. She said she did not assist in scheduling the appointments for Resident #11's cataract surgery. During an interview on 09/09/25 at 11:15 AM, LVN B said she input Resident #11's order on 09/01/25 and attempted to order it from the pharmacy, but the pharmacy was out of the medication and had to order it, and it came the next day. She said since Resident #11 did not get his eye drops in time, the surgery was rescheduled to 09/30/25. LVN B said the facility had the ketorolac eye drops in the facility to ensure Resident #11 would get them on time. She said she should have input the order when she received it but guessed she forgot to chart the medication order and input the order in the computer when she received the order. LVN B said she would have to find paperwork because she could not remember the exact day since it had been a while. LVN B said she had to go give medications and would let the surveyor know when she found more information. During an interview on 09/09/25 at 11:46 AM the facility pharmacist said the pharmacy received the order for Resident #11's Ketorolac on 09/01/25 at 11:43 AM and they did not have the medication at on hand. The pharmacist said the pharmacy ordered the medication and se to the pharmacy on 09/02/25 morning run. The pharmacist said if the facility had the facility sent the order at an earlier date the pharmacy would have sent the medication earlier. During an interview on 09/10/2025 at 4:51 PM the ADON said LVN B did not input the ketorolac order when she received the order from the ophthalmologist and thought she could get the ketorolac in the facility in time. The ADON said LVN B got the order in the computer the day before the surgery on 09/01/25 and when she ordered the ketorolac, it did not come in. The ADON said she called the pharmacy to check on the ketorolac and the pharmacy told her the ketorolac was on back order and they did not receive the medication until 9/2/25. The ADON said the failure placed a risk id for Resident #11 having worsening eyesight or psychological effects. During an interview on 09/10/2025 at 6:04 PM the DON said she was not aware of when the medication ketorolac was supposed to be started for Resident #11's eye surgery until 09/10/25. The DON said LVN B should have placed the order in the computer when she received it from the ophthalmologist to prevent it from being missed. The DON said LVN could have set the start date to begin in future on 08/31/25. The DON said the Social Worker had been helping with setting up appointments and now that they have a Medical Records Personnel, she would begin to follow up on appointments being made. The DON said the failure placed a risk of Resident #11 not getting the care he needs and having to wait longer for his eye surgery. During an interview on 09/10/2025 at 6:17 PM the Administrator said her expectation was for all nurses to input orders in a timely manner to prevent errors. The Administrator said the failure placed a risk for Resident #11 not being provided services and Resident #11 at risk for increased difficulties related to his vision. She said charge nurses were responsible for inputting orders and DON and ADON should have been following up to ensure orders were in timely. Record review of the facility policy Telephone Orders for Medication revised 1/2025 indicated:Purpose: To reduce errors associated with misinterpreted verbal or telephone communication of physicianPolicy: I. Verbal communication of a prescription or medication orders.Procedure: I. Receiving a Telephone Order.B The receiver documents the order immediately on the prescriber order form. Record review of the facility policy Referrals to Outside services revised 8/2020 indicated:Purpose: To provide residents with outside services as required by physician orders or the Care Plan. Policy: I. The Director of Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the Facility.II. This policy does not give the Director of Social Services the authority to unilaterally enter into any service provider contract. Examples of service provider contracts that the Director of Social Services may coordinate include, but are not limited to dental, audiology, vision, psychiatric, and podiatry services . V. The Director of Social Services or his or her designee will coordinate with Nursing Staff to ensure that the Attending Physician's order and referral to outside provider is documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents environment remained free of accident hazards for 1 of 26 residents (Residents #11) reviewed for accident hazards. The facility failed to ensure a safe environment to prevent accidents and hazards for Residents #11 by not ensuring 3 razors (1 razor that did not have a cover over the blades and 2 razors in the open package) in his drawer were stored securely. This failure could place residents at risk for injuries. Findings included: Record review of Resident #11's face sheet dated 09/10/25 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses legal blindness, high blood pressure, malignant neoplasm of the prostate (prostate cancer), and depression. Record review of Resident #11's quarterly MDS assessment dated [DATE] indicated he usually understood others and usually made himself understood. The MDS also indicated he had a BIMS score of 15 which meant he was cognitively intact. The MDS also indicated he required total assistance with toileting, transfers, bathing, and bed mobility and required setup assistance for eating and hygiene. Record review of Resident #11's undated care plan indicated he had impaired visual function related to cataracts, poor vision, and macular degeneration and ADL self-care performance deficit with interventions of dependent staff participation in toileting, transfers, bed mobility, bathing, and personal hygiene. During an interview and observation on 09/08/25 at 3:05 PM, Resident #11 said the facility removed items from the residents' rooms in the facility and then returned items back to them. Resident #11 told surveyor to look in his drawer. Resident #11 had 3 razors (1 razor that did not have a cover over the blades and 2 razors in the open package). He said the staff shaved him when needed. During an interview on 09/10/2025 at 4:58 PM, the ADON said Resident #11 should not have had the razors in his room. She said the failure placed a risk for someone getting the razors and cutting themselves. She stated the facility does have wanders that goes all over the facility and open doors. During an interview on 09/10/2025 at 6:08 PM, Tthe DON said Resident #11 should not have had the razors in his room. The DON said the failure placed a risk for other residents getting the razors out of the drawers and cutting themselves, and the risk for Resident #11 using the wrong items related to him being blind. She said Resident #11 could have reached in drawer and cut himself. During an interview on 09/10/2025 at 6:23 PM, the Administrator said Resident #11 should not have had the razors in his drawers. She said the razors were hazardous items and placed a risk for Resident #11 cutting his hands. The Administrator said the department heads were responsible for monitoring each residents' room daily. She said the CNAs should have removed the razors after care. Record review of the facility's policy Resident Rooms and Environment revised 08/2020 indicated:PurposeTo provide residents with a safe, clean, comfortable and homelike environment.PolicyThe Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain 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 for 1 of 2 residents reviewed for nutritional status (Resident #12). The facility failed to ensure Resident #12's enteral feeding (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) was administered as ordered by the physician on 09/08/25. This failure could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life.Findings included: Record review of Resident #12's face sheet dated 09/10/25, indicated a [AGE] year-old male who readmitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) and gastrostomy status (surgical opening in stomach to provide nutrition and medications). Record review of Resident #12's quarterly MDS assessment dated [DATE], indicated usually understood and usually understood others. Resident #12 had short and long-term memory problems. The MDS assessment did not indicate Resident #12 had a weight loss or weight gain of 5% or more in the last month or 10% or more in the last 6 months. Resident #12 had a feeding tube. Record review of Resident #12's comprehensive care plan dated 01/13/23, indicated Resident #12 had a NPO diet and had a peg tube for feeding and medication purposes. The care plan interventions included the nurse to administer feeding as ordered. Record review of Resident #12's order summary report dated 09/10/25, indicated the following orders:*Enteral Feed Order every shift, Jevity 1.5 or equivalent (ie isosource 1.5) at 78 ml/hr for at least 20 hours daily with a start date of 07/03/25. Record review of Resident #12's nurse administration record dated 09/01/25-09/30/25, indicated Resident #12's enteral feeding nutrition was removed in the morning at 11:00 AM. The record indicated it had been completed daily. The nurse administration record did not indicate the time Resident #12's feeding needed to be restarted. During an observation on 09/08/25 at 11:10 AM, Resident #12 was sitting up in his wheelchair in his room. Resident #12's enteral feeding pump was off. During an observation and interview on 09/08/25 at 4:20 PM, Resident #12's enteral feeding pump continued to be off. LVN A said Resident #12's pump could be off for 4 hours. LVN A said she was not aware Resident #12's feeding was turned off and LVN B did not relay it in report. She said if LVN B told her to check Resident #12's machine, she would have checked it. LVN A said the nurses were responsible for ensuring Resident #12's feeding was turned on within the timeframe. LVN A said by not administering his enteral feeding as ordered, Resident #12 was at risk for weight loss. During an interview on 09/10/25 at 11:45 AM, LVN B said Resident #12's enteral feeding pump could be off for 4 hours. LVN B said they turned the pump off for incontinent care and showers. LVN B said Resident #12 sometimes removed the feeding himself. LVN B said on 09/08/25, she did not relay in report to LVN A that Resident #12's feeding was off. She said she usually set an alarm on her phone to turn Resident #12's pump back on, but she did not set one on 09/08/25 since she had been busy. She said Resident #12 was at risk for not receiving his nutrition for the day since he had been left off for an hour more than the ordered amount. LVN B said she was responsible to ensure Resident #12's feeding was restarted as per physician orders. During an interview on 09/10/25 at 1:25 PM, the Registered Dietician said depending on the care being provided to Resident #12, the feeding could have exceeded the time frame of 4 hours. She said Resident #12's feeding being off for an extra hour was not going to affect him. She said nursing was responsible for ensuring Resident #12's feeding was being administered as ordered. During an interview on 09/10/25 at 4:19 PM, the DON said Resident #12 had an order to turn off the feeding at 11:00 AM and there was not an order to turn it back on. She said Resident #12's feeding order was for 20 hours a day and had a 4 hour down time for ADL care. The DON said the nurses were responsible for ensuring Resident #12's feeding was not off for a prolonged time. She said if happened often, Resident #12 was at risk for weight loss. During an interview on 09/10/25 at 4:45 PM, the Administrator said she expected the nurses to follow the physician orders. The Administrator said failure to provide the enteral feedings as ordered could cause Resident #12 to have weight loss. Record review of the facility's policy Tube Feeding/TPN/PPN revised 09/24/24, indicated . To ensure that the facility meets the nutritional guidelines and residents' nutritional requirements per physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 3 residents (Resident #54 and Resident #75) reviewed for respiratory care.<BR/>1. The facility did not ensure Resident #54 had a physician's order for oxygen that she wore continuously. <BR/>2. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #75.<BR/>These failures could place residents who receive respiratory care at risk for developing respiratory complications.<BR/>The findings included: <BR/>1. Record review of the face sheet, dated 07/11/2023, revealed Resident #54 was an [AGE] year-old female who initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of chronic respiratory failure with hypoxia (not enough oxygen in the blood), shortness of breath, and COPD - chronic obstructive respiratory disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs).<BR/>Record review of the MDS assessment, dated 06/27/2023, revealed Resident #54 had clear speech and was usually understood by staff. The MDS revealed Resident #54 was usually able to understand others. The MDS revealed Resident #54 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #54 had shortness of breath or trouble breathing with exertion (walking, bathing, transferring), when sitting at rest, and when lying flat. The MDS revealed Resident #54 received oxygen while a resident at the facility during the 14-day look-back period. <BR/>Record review of the comprehensive care plan, revised on 04/11/2023, revealed Resident #54 had a diagnosis of COPD. The interventions included Give oxygen therapy as ordered by the physician.<BR/>Record review of the order summary report, dated 07/12/2023, revealed Resident #54 had no physician order for oxygen.<BR/>During an observation and interview on 07/10/2023 at 9:09 AM, Resident #54 was sitting up in her bed with the head of the bed elevated. She was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute. Resident #54 stated she had worn oxygen continuously, since she admitted to the facility, because she had problems breathing. Resident #54 stated the facility staff change her oxygen tubing weekly and checked her oxygen saturations daily.<BR/>During an observation on 07/10/2023 at 2:18 PM, Resident #54 was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute. <BR/>During an observation on 07/11/2023 at 9:33 AM, Resident #54 was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute.<BR/>During an observation on 07/11/2023 at 4:25 PM, Resident #54 was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute.<BR/>During an interview on 07/13/2023 at 2:03 PM, LVN E stated Resident #54 wore oxygen continuously. LVN E stated the charge nurses were responsible for putting orders for oxygen in the electronic charting system. LVN E stated Resident #54 should have a physician's order for oxygen. LVN E stated the order probably did not get put back on when she came back from the hospital. LVN E stated the nurses try to check each other when residents readmit from the hospital. LVN E stated it was important to ensure Resident #54 had a physician's order for oxygen because you need a doctor's order for it. <BR/>During an interview on 07/13/2023 at 3:43 PM, the DON stated nurses were responsible for ensuring physician orders for oxygen were in the computer. The DON stated that was monitored by reconciling with the physician and performing 24-72-hour chart audits and admissions and readmission. The DON stated Resident #54 should have a physician's order for oxygen. The DON stated she expected nursing staff to ensure a physician's order for oxygen was placed in the electronic monitoring system. The DON stated it was important to ensure an order for oxygen was placed in the computer for the safety and well-being of residents and to follow the plan of care. <BR/>During an interview on 07/14/2023 at 12:04 PM, the Administrator stated he expected the nursing staff to ensure an order for oxygen was placed in the computer. The Administrator stated the DON and ADON were responsible for monitoring orders during the clinical morning meeting. The Administrator stated it was important to ensure orders were placed in the computer to ensure the facility staff are following all physician's orders and provide treatment that was required. <BR/>2. Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), acute respiratory failure with hypoxia (not enough oxygen in blood), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (chronic condition that affects the way the body processes blood sugar with progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). <BR/>Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #75 was usually understood and usually understood others. The MDS assessment indicated Resident #75's BIMS was an 8, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #75 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS assessment indicated Resident #75 was receiving oxygen therapy.<BR/>Record review of Resident #75's care plan with date initiated 07/11/2023, indicated he had altered respiratory status/difficulty breathing related to a pulmonary nodule (small growth in the lungs that can be non-cancerous or cancerous) with an intervention to provide oxygen as ordered. <BR/>Record review of Resident #75's order summary report dated 07/11/2023, indicated an order to check oxygen saturation three times a day, as needed, and every shift, and apply oxygen at 2 liters per minute via nasal canula for oxygen saturation less than 90% with a start date of 06/30/2023. <BR/>During an observation on 07/10/2023 at 11:02 AM, Resident #75 was sitting on the side of the bed with oxygen on via nasal canula at 4 liters per minute. <BR/>During an observation on 07/12/2023 at 9:05 AM, Resident #75 was in bed with oxygen via nasal canula on, set between 3-4 liter per minute. <BR/>During an interview on 07/12/2023 at 5:48 PM, RN B said oxygen should be administered per the physician's orders. RN B said Resident #75's oxygen should have been set at 2 liter per minute per the physician's order, and he only used it as needed. RN B said setting the oxygen higher than the prescribed rate could make the residents sicker. <BR/>During an interview on 07/13/2023 at 9:01 AM, the ADON said the nurses were responsible for making sure oxygen was administered per the physician's order. The ADON said the nurses should be checking the oxygen to make sure it was set at the correct prescription. The ADON said if the oxygen was set higher than the prescribed rate it could be counterproductive for certain diseases and could cause more harm than good. <BR/>During an interview on 07/13/2023 at 10:40 AM, the DON said the nurses were responsible for ensuring oxygen was administered per the physician's order. The DON said Resident #75's oxygen via nasal canula was as needed, and he could put it on himself when he felt short of breath. The DON said setting the oxygen higher than the physician's order could cause lightheadedness and dizziness. <BR/>During an interview on 07/13/2023 at 2:34 PM, the Administrator said the charge nurses were responsible for making sure oxygen was administered per the physician's order. The Administrator said he expected the nurses to follow the physicians' orders. The Administrator said it was important that oxygen be administered per the physician's order to avoid respiratory distress. <BR/>Record review of the facility's policy titled, Oxygen Administration, with date revised 06/2020, indicated, . Initiation of oxygen A. A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include: i. Oxygen flow rate ii. Method of administration (e.g., nasal cannula) iii. Usage of therapy (continuous or prn) iv. Titration instructions (if indicated) v. Indication of use . Explain the procedure to the resident II. Check the physician's order . VI. Turn on oxygen at the prescribed rate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Residents #7) reviewed for pharmacy services.<BR/>1. The facility did not ensure Resident #7 medications were administered during the scheduled time. <BR/>2. The facility did not ensure Resident #7 was given Estrace Vaginal Cream 0.01 mg/gm as scheduled. <BR/>3. The facility did not ensure Resident #7 was given Vitamin B-12 2000 mcg. <BR/>These failures could place the residents at risk of not having medications available for use, drug diversion, not receiving their medications as ordered, and exacerbation of their disease processes. <BR/>Findings included:<BR/>1. Record review of Resident #7's face sheet, dated 01/28/25, reflected Resident #7 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). <BR/>Record review of the order summary report dated 01/28/25 indicated Resident #7 was ordered: <BR/>_Calcium 600: give 1 tablet by mouth two times a day for osteoporosis (disease that weakens bone to the point where they break easily) at 8:00 a.m. <BR/>_Pantoprazole sodium 20 mg: give 1 tablet by mouth two times a day for heartburn at 5:00 p.m.<BR/>_Sitagliptin-metformin HCI 50-500 mg: give 1 tablet by mouth two times a day for diabetes mellitus at 9:00 a.m. and 5:00 p.m.<BR/>_Calcium 600: give 1 tablet by mouth two times a day for osteoporosis at 5:00 p.m. <BR/>Record review of the Medication Administration Audit Report dated 1/28/25 indicated Resident #7 received her medications on 12/07/24 by MA Q as listed: <BR/>_Calcium 600 at 9:49 a.m.<BR/>_Pantoprazole sodium 20 mg at 7:29 p.m.<BR/>_Sitagliptin-metformin HCI 50-500 mg at 7:29 p.m. <BR/>_Calcium 600 at 7:29 p.m.<BR/>2. Record review of a telephone order, dated 12/06/24, indicated Resident #7 had an order for Estrace vaginal cream 0.1 mg/gm applicator at bedtime every Monday, Wednesday, Friday for atrophy vaginitis. <BR/>Record review of the MAR dated 12/1/24-12/31/24 indicated Resident #7 was given Estrace vaginal cream 0.1 mg/gm applicator at bedtime every Monday, Wednesday, Friday for atrophy vaginitis (vaginal tissue thins due to low estrogen levels) on 12/25/24 by the ADON.<BR/>During a confidential interview, the interviewee stated Resident #7's medications were administered late on 12/07/24. The interviewee stated Resident #7 was not given the vaginal suppository on 12/25/24. <BR/>During a telephone interview on 1/28/25 at 2:09 p.m., MA Q stated sometimes Resident #7 refused her calcium until she has had breakfast. MA Q stated she could not recall if that had occurred on 12/7/24 at 8:00 a.m. MA Q stated medications that were scheduled at 5:00 p.m. should have been given between 4:00 p.m.-6:00 p.m. MA Q stated she did not remember given Resident #7 anything that late. MA Q stated this failure could potentially cause an adverse effect. <BR/>During an interview on 1/28/25 at 12:08 p.m., the ADON stated on 12/25/24 she was the charge nurse for Resident #7. The ADON stated she went to give her the suppository and something happened (unable to recall) and forgot to administer the medication. The ADON stated she did click off the task as completed prior to administering the medication but the medication was not given. The ADON stated she was not aware until Resident #7 family member told her that she did not give her the suppository on 12/25/24. The ADON stated she did offer to move the date, but the family member stated do not worry about it. <BR/>During an interview on 1/28/25 at 2:49 p.m., the DON stated he expected medications to be administered one hour before or one hour after the scheduled time. The DON stated he was responsible for monitoring and overseeing by reviewing the 24-hour progress noted Monday-Friday and on Monday the weekend was reviewed. The DON stated it was important to ensure medications were administered timely to ensure the dosage stay consistent in the bloodstream. <BR/>During an interview on 1/28/25 at 3:05 p.m., the Administrator stated she expected the medications to be administered according to the schedule to ensure effectiveness. The Administrator stated the DON, and the ADONs were responsible for overseeing and monitoring. The Administrator stated it was important to follow the physician orders to prevent an adverse effect. <BR/>3. Record review of Resident #7's face sheet, dated 01/28/25, reflected Resident #7 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). <BR/>Record review of the order summary report dated 01/28/25 indicated Resident #7 was ordered: <BR/>Vitamin B-12 1000 mcg; give 2000 mcg by mouth in the morning related to anemia. <BR/>During observation and interview on 1/28/25 at 9:18 a.m., MA S was preparing Resident #7's medication for administration. MA S obtained a bottle of Vitamin B-12 1000 mcg and placed 1 tablet (1000mg) in a plastic cup. MA S finished preparing the remainder of Resident #7's morning medications. MA S stated she should have given 2 tablets of Vitamin B12 1,000 mcg. MA S stated this failure could potentially cause more of a vitamin deficiency. <BR/>During an interview on 1/28/25 at 2:49 p.m., the DON stated he expected medications to be given per the physician orders. The DON stated he was responsible for monitoring and overseeing by reviewing the 24-hour progress noted Monday-Friday and on Monday the weekend was reviewed. The DON stated he has not been aware of medications not been administered correctly. The DON stated the risk associated with not giving the correct dose was the desired effect not achieved. <BR/>During an interview on 1/28/25 at 3:05 p.m., the Administrator stated she expected the correct dose to be given. The Administrator stated the DON, and the ADONs were responsible for overseeing and monitoring. The Administrator stated it was important to follow the physician orders to prevent a medication error. <BR/>Record review of the facility's undated policy titled, Medication-Administration indicated, . to provide practice standards for safe administration of medications for residents in the facility . IV. The licensed nurse must know the following information about any medication they are administering E. the drugs usual dosage . V. Medications may be administered one hour before or after the scheduled medication administered time. IV. Nursing staff will keep in mind the seven rights of medication when administering medication: B. the right amount . D. The right time .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 23 (Resident #11) residents and 1 of 3 meals (lunch) reviewed for palatability. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #11, who complained the food was cold and not good. The dietary staff failed to provide food that was palatable for the lunch meal observed on 09/10/25. Findings included: Record review of Resident #11's face sheet dated 09/10/25 indicated he was a [AGE] year-old male who was admitted to the facility on [DATE] with the diagnoses of legal blindness, high blood pressure, malignant neoplasm of the prostate (prostate cancer), and depression. Record review of Resident #11's quarterly MDS dated [DATE] indicated he usually understood others and usually made himself understood. The MDS also indicated he had a BIMS score of 15 which meant he was cognitively intact. The MDS also indicated he required total assistance with toileting, transfers, bathing, and bed mobility, and required setup assistance for eating and hygiene. Record review of Resident #11's undated care plan indicated he had impaired visual function related to cataracts, poor vision, and macular degeneration, and an ADL self-care performance deficit with interventions of dependent staff participation in toileting, transfers, bed mobility, bathing, and personal hygiene. During an interview on 09/8/25, at 4:50 p.m., Resident #11 said his food was not good and was always cold when he received it in his room. He said he had never asked the staff to warm it up because he felt the facility staff were short-handed. During a confidential group interview on 09/09/25 at 2:30 p.m., the confidential group with 4 residents complained about the food being cold and bland. During an observation and interview on 09/09/25 at 1:16 p.m., the Dietary Manager and four surveyors sampled a lunch tray. The sample tray consisted of fajita chicken, refried beans, and Spanish rice. The Fajita chicken tasted good and was warm. The refried beans and Spanish rice were lukewarm and bland. The Dietary Manager said she felt all the food tasted good and was at a good temperature. During an interview on 09/09/25 at 2:00 p.m., the Dietitian said she was not aware of any food complaints. The Dietitian said the dietary cook was responsible for ensuring the residents received food that was palatable and at the appropriate temperature. The Dietitian said the Dietary Manager's responsibility was to follow up to ensure the food was palatable and temperatures were correct. The Dietitian said it was important for the residents to receive food that was palatable and at the appropriate temperature for nutritional status. During an interview on 09/10/25 at 5:01 p.m., the Dietary manager said she expected the food to be good. She said she was the overseer of the kitchen. She said they had resident council meetings, and in those meetings, the residents would say the food was good. She said she was not aware of any food concerns. She said if the food was not good or at a temperature the resident prefers, it could cause them to not eat. During an interview on 09/10/25 at 5:50 p.m., the DON said the dietary staff was responsible for the palatable and appetizing food. She said she had not heard the residents complain about the food not being good or cold. She said that if the residents did not like the food, it could cause them to lose weight. During an interview on 09/10/25 at 6:11 p.m., the Administrator said she expected the food to be served at the correct temperature, and the food was seasoned and cooked according to the recipe. She said she was not aware that the food was not good or cold. The Administrator said the Dietary Manager was the overseer of the kitchen. She said it was important to ensure food was palatable and had an appetizing temperature because it was their right and to prevent potential weight loss. Record review of the facility's policy titled, Meal Service, dated 01/01/25, indicated, Purpose: To ensure the facility provides meals to the resident that meet the requirements of the food and nutrition board of the National Research Council of the National Academy of Sciences. Record review of the facility's policy titled, Food Temperatures, dated 01/01/25, indicated, Purpose: to provide the dietary department with guidelines for food preparation and service temperature. Policy: Foods prepared and served in the facility will be served at proper temperature to ensure food safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide food and drink that accommodated the residents' preferences for 1 of 23 residents (Resident #1) reviewed for preferences. The facility did not honor Resident #1's preference for two milks with her breakfast on 09/09/25 and 09/10/25. This failure could result in a decrease in resident choices. Findings included: Record review of Resident #1's face sheet, dated 09/10/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included shortness of breath also known as SOB, (feeling of difficulty breathing or not being able to get enough air), obesity, depression (sadness), diabetes, and Chronic obstructive pulmonary disease, also known as COPD (a group of lung diseases that cause airflow obstruction and breathing problems. Record review of Resident #1's quarterly MDS assessment, dated 08/20/25, indicated Resident #1 understood and was understood by others. Her BIMs score was a 15, which indicated she was cognitively intact. The MDS indicated she required total assistance for showering, dressing, grooming, and transferring, and was set up for eating. Record review of Resident #1 's physician orders dated 08/16/25, indicated Regular diet, Regular texture, Regular consistency. Record review of Resident #1's comprehensive care plan dated 07/21/25, indicated Resident #1 had a potential for nutritional problems related to obesity. The interventions were to serve the diet as ordered and consult a dietitian as needed. Record review of the breakfast meal ticket dated 09/10/25 for Resident #1 indicated regular diet, and under the note section indicated two milks with all meals. During an observation on 09/09/25 at 9:01 a.m., Resident #1 was in her bed eating her breakfast, and had one juice and one milk on her tray. During an observation and interview on 09/10/25 at 8:10 a.m., Resident #1 had her breakfast and only had one milk on her tray. Resident #1 said they only bring her one glass of milk most of the time, and the nurses must go back and get her another milk to take her medications. She said she likes two milks, one for her breakfast meal, and the other to help get her medications down. The Social Worker walked into the room and verified that the tray card said two milks. The Social Worker walked to the kitchen and brought Resident #1 a glass of milk. During an interview on 09/10/25 at 8:13 a.m., CNA K said she was the aide who served Resident #1 her breakfast tray this morning (09/10/25). She said she did not give her two milks; she said it was an oversight. She said the aides were responsible for putting the drinks on the hall trays. During an interview on 09/10/2025 at 10:35 a.m., MA N said most days she had to get Resident #1 either her milk or juice. She said she would not take her medication unless she had one or the other. She said Resident #1 preferred milk. She said she was not aware who was supposed to put the beverage on the tray, but knew she did not have the beverage most days when she administered medications to Resident #1. During an interview on 09/10/2025 at 10:37 a.m., RN D said she was the nurse who checked the trays before they left the dining room. She said the aides passed out the beverages on the halls, so she was unaware of why Resident #1 did not receive the milk she requested. She said she did not usually give medication, so she was unaware that Resident #1 was not receiving her milk. During an interview on 09/10/25 at 5:11 p.m., the Dietary Manager said she expected Resident #1 to receive her two milks as requested. She said she could not remember who told her Resident #1 wanted two milks with breakfast, but she added it on her tray card. She said the kitchen staff were responsible for the beverages in the dining room, but the nursing staff was responsible for the hallways. The Dietary Manager said it was important for Resident #1's beverage preference to be followed because it was what she wanted. During an interview on 09/10/25 at 5:50 p.m., the DON said if Resident #1 wanted two glasses of milk, then staff should be providing her with them. She said the aides were responsible for ensuring they provided the milk to Resident #1 according to her meal ticket. She said it was important to honor their wish because this was their home, and they should have what they wanted. During an interview on 09/10/25 at 6:11 p.m., the Administrator said she expected the meal tickets and food preferences to be followed. The Administrator said the aides should ensure it was on the tray, and the nursing staff was responsible for overseeing that it was. She said if it helped Resident #1 to take her medications more easily, then she wanted her to have it. The Administrator said it was important for their food/beverage preferences to be followed because it was their right. Record review of the facility's policy titled, Meal Service, dated 01/01/25, indicated, Purpose: To ensure the facility provides meals to the resident that meet the requirements of the food and nutrition board of the National Research Council of the National Academy of Sciences. Procedure: V. Nothing in this policy limits the resident's right to make personal nutrition choices. Record review of the facility's policy titled Resident preference interview, revised 12/2020, indicated . Procedure: #3 Resident preference will be reflected on the tray card and updated in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the arbitration agreement was explained in a form and manner, including a language the resident or representative understood for 3 of 3 residents (Residents #56, #57, and #70) reviewed for arbitration agreements. The facility failed to ensure the binding arbitration agreement was fully understood and explained to Residents #57, #70, and #56's responsible party, prior to signing it as part of the admission packet. These failures could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. The findings included: 1. Record review of Resident #57's face sheet, dated 09/10/25, reflected Resident #57 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke). Record review of Resident #57's admission MDS assessment, dated 09/02/25, reflected Resident #57 usually made herself understood and usually understood others. Resident #57's BIMS score was 11, which reflected her cognition was moderately impaired. Record review of the updated comprehensive care plan reflected Resident #57 had impaired cognitive function/dementia or impaired thought processes related to confusion. The care plan inventions included administer medications as ordered, communicate with the resident/family/caregivers regarding residents' capabilities, needs, discuss concerns about confusion, disease process and nursing home placement with the resident/family/caregivers. Record review of the What is Arbitration (page 16 of the admission Packet) revealed Resident #57 electronically signed the form on 09/03/25 at 1:36 p.m. The form further revealed the Central Intake admission Director signed the form as the facility representative on 09/03/25 at 1:36 p.m. During an interview on 09/10/25 at 8:42 a.m., the State Surveyor and the Regional Nurse Consultant went into Resident #57's room to asked if she remembered signing an arbitration agreement. The state surveyor explained to Resident #57 what the agreement meant, and Resident #57 stated she was unaware she had signed an arbitration agreement with the facility. Resident #57 expressed she was not provided a thorough explanation of the arbitration agreement because if they would have explained it to her, she would not have sign it. During a telephone interview on 09/10/25 at 10:49 a.m., the Central Intake admission Director stated the arbitration agreements were a part of the admission packet. The Central Intake admission Director stated the admission packet was either sent to the families electronically or completed at the facility. The Central Intake admission Director stated the responsibility of ensuring the admission packets were completed by the admission Coordinator, but she assisted him. The Central Intake admission Director stated when the admission packets were completed either at the facility or electronically, she went over every page individually with the resident/families. The Central Intake admission Director stated the arbitration agreement was not required to have been signed as part of admitting to the facility. The Central Intake admission Director stated Resident #57's completed the paperwork electronically. The Central Intake admission Director stated she explained the arbitration agreement word from word and provided Resident #57 with a realistic example. The Central Intake admission Director stated Resident #57 did not have any questions after she signed it. The Central Intake admission Director stated after she realized Resident #57 had a POA, she contacted her, and she also signed it electronically. The Central Intake admission Director stated Resident #57's POA was also explained the arbitration agreement and she did not have any questions either. The Central Intake admission Director stated it was important to ensure the residents or responsible parties were aware of what paperwork they were signing because they could have entered into legally binding agreements without their knowledge. During an attempted telephone interview on 09/10/25 at 11:45 a.m. with Resident #57's POA was unsuccessful. 2. Record review of Resident #70's face sheet, dated 09/10/25, reflected Resident #70 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of Resident #70's significant change in status MDS assessment, dated 08/06/25, reflected Resident #70 usually made herself understood and usually understood others. Resident #70's BIMS score was 13, which reflected her cognition was intact. Record review of the undated comprehensive care plan reflected Resident #70 had impaired cognitive function/dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The care plan interventions included administer medications as ordered. Record review of the What is Arbitration (page 16 of the admission Packet) revealed Resident #70 electronically signed the form on 06/18/25 at 4:06 p.m. The form further revealed the admission Coordinator signed the form as the facility representative on 06/18/25 at 4:06 p.m. During a group meeting on 09/09/25 at 2:30 p.m., the state surveyor with the residents their choices regarding arbitration. Resident #70 stated she was unaware she had signed an arbitration agreement with the facility. Resident #70 expressed she was not provided a thorough explanation of the arbitration agreement. Resident #70 stated she would have never signed it if she was knowledgeable of what was presented. During a telephone interview on 09/10/25 at 11:18 a.m., the admission Coordinator stated him, and the Central Intake admission Director worked on the admission packets together. The admission Coordinator stated he was in the facility with Resident #70 when she signed the arbitration agreement electronically. The admission Coordinator stated Resident #70 was explained what an arbitration was and asked if she had any questions which she did not. The admission Coordinator stated he did not give an example of what she was signing during the conversation. The admission Coordinator stated residents could refuse to sign and still be admitted to the facility. The admission Coordinator stated the Administrator completed Resident #56's admission packet. The admission Coordinator stated it was important to ensure the residents or responsible parties were aware of what paperwork they were signing because it was their right. 3. Record review of Resident #56's face sheet, dated 09/10/25, reflected Resident #56 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included cerebrovascular disease (group of conditions that affect the blood vessels in the brain). Record review of Resident #56's quarterly MDS assessment, dated 08/27/25, reflected Resident #56 rarely/never made himself understood and rarely/never understood others. Resident #56's BIMS score was 0, which reflected his cognition was severely impaired. Record review of the undated comprehensive care plan reflected Resident #56 had impaired cognitive function/dementia or impaired thought processes related to dementia. The care plan interventions included communicate with Resident #56 family/caregivers regarding resident's capabilities and needs. Record review of the What is Arbitration (page 16 of the admission Packet) revealed Resident #56 electronically signed the form on 06/30/25 at 1:05 p.m. The form further revealed the Administrator signed the form as the facility representative on 06/30/25 at 1:05 p.m. During a telephone interview on 09/10/25 at 11:13 a.m., Resident #56's Responsible Party stated she did not know what arbitration was or if she had signed an arbitration agreement when Resident #56 was admitted to the facility. The Responsible Party stated a gentleman (unsure of name) emailed her the admission paperwork to her and told her he needed it by end of day. The Responsible Party stated he did not go over the paperwork and she just signed it and sent it back. The Responsible Party stated she was told by the gentleman the admission paperwork would be given to her brother when he came to the facility, but the paperwork was never given. The Responsible Party stated she would have liked to have had a Spanish copy of the paperwork as well so her family would be able to understand. During an interview on 09/10/25 at 6:40 p.m., the Administrator stated the admission coordinator sent the family member of Resident #56 the arbitration agreement electronically. The Administrator stated when she saw the admission packet was completed, she went into the system, signed it and locked which indicated the admission packet was complete. The Administrator stated she expected the staff member completing the admission packet to explain the arbitration agreement to the resident or family. The Administrator stated the admission Coordinator, and the Central Intake admission Director were responsible for monitoring to ensure the residents and family were aware of what they were signing as part of the admission packet. The Administrator stated it was important to ensure the residents and families knew what they were signing before they signed so they could exercise their rights and make informed decisions. Record review of the Arbitration Agreement, dated 10/24/2022, reflected, to provide a lawful opportunity for a provider of health services and residents/responsible parties to ensure into an enforceable written contact to settle a dispute out of court through an arbitration process. The federal government has expressed a policy of support of arbitration agreements because they reduce the burden on court systems to resolve disputes. IV. The person tasked with obtaining signatures for Arbitration Agreements will know how to explain the Agreement to residents/responsible parties. The terms and conditions of the Arbitration Agreement must be clearly explained to the resident/responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 2 residents (Resident #68) reviewed for hospice services.<BR/>The facility did not ensure Resident #68's hospice records were a part of their records in the facility<BR/>This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. <BR/>The findings were: <BR/>Record review of a face sheet dated 07/11/2023, indicated Resident #68 was a [AGE] year-old female initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included severe protein-calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets can lead to muscle loss, fat loss, and your body not working as it usually would), cerebral infarction unspecified (damage to tissues in the brain due to a loss of oxygen to the area), and atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). <BR/>Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #68 was understood and understood others. The MDS assessment indicated Resident #68 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #68 received hospice services while a resident at the facility. <BR/>Record review of the care plan with date initiated 03/21/2023, indicated Resident #68 had a terminal prognosis related to severe protein calorie malnutrition with a goal of dignity and autonomy will be maintained at the highest level through the review date. Interventions included to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. <BR/>Record review of the order summary report dated 07/11/2023 indicated Resident #68 had an order to admit to hospice under the diagnosis of severe protein calorie malnutrition with start date of 03/10/2023. <BR/>Record review of Resident #68's electronic health record did not reveal any hospice related records to include: (a) the most recent hospice plan of care; (b) the hospice election form; (c) physician certification and recertification of the terminal illness; (d) hospice medication information; (e) hospice physician orders; and (f) any progress notes from any hospice visits. <BR/>During an interview on 07/12/2023 at 9:39 AM, LVN E said the residents hospice records were kept in a binder at the nurse's station. LVN E said Resident #68 did not have a binder with her hospice records in it. LVN E said she would call the hospice to have them bring the hospice records to the facility. <BR/>During an interview on 07/12/2023 9:43 AM, Hospice RN F said she was Resident #68's hospice case manager. Hospice RN F said she thought she had sent them by e-mail to someone at the facility, but she must have sent it to the wrong email (she was unable to specify to who she had sent them). Hospice RN F said the facility had not requested that she take Resident #68's hospice records to the facility. Hospice RN F said she should have made sure the hospice records were taken to the facility. Hospice RN F said it was important for the facility to have the hospice records so the staff could refer to them and reference back to the nurses' visits, aide visits, the medication list and have the hospice diagnosis and hospice orders. <BR/>During an interview on 07/13/2023 at 08:56 AM, the ADON said the resident's hospice records were kept in a hospice binder. The ADON said the nurses should be making sure the hospice records were in the facility. The ADON said that she was aware there was no system in placed to ensure the hospice records were in the facility. The ADON said she was not aware Resident #68's hospice records were not in the facility. The ADON said it was important for the hospice records to be in the facility to make sure the care was matching, the medications were correct, the facility knew of the hospice scheduled visits, and to ensure any new orders given by the hospice were implemented. <BR/>During an interview on 07/13/2023 at 10:02 AM, the DON said the hospice residents had hospice binders containing all the hospice records. The DON said the charge nurses were responsible for making sure the hospice records were in the facility. The DON said she did not know why Resident #68's hospice records were not in the facility. The DON said it was important for the residents' hospice records to be in the facility to be able to work in collaboration with the hospice and so all the staff would be on the same page with the residents' plan of care. <BR/>During an interview on 07/13/2023 at 1:54 PM, LVN A said the residents' hospice records were kept in binders. LVN A said she did not know who was responsible for making sure the residents' hospice records were in the facility. LVN A said she had not noticed Resident #68 did not have a hospice binder with her hospice records. LVN A said it was important to have the residents' hospice records, so the facility staff knew what was going on and the hospice staff knew what was going on. <BR/>During an interview on 07/13/2023 at 2:32 PM, the Administrator said nursing management was responsible for making sure the residents hospice records were in the facility. The Administrator said the nurses should have requested the hospice records from the hospice provider. The Administrator said it was important for the facility to have the residents' hospice records for coordination of care.<BR/>Record review of the Hospice and Long Term Care Facility Agreement, with an effective date of September 20, 2021, indicated, . Each Party shall allow reasonable access to the records of the other party in order to carry out their respective rights, duties, and obligations under this agreement. Insofar as Plans of Care, clinical records notes, meeting minutes IDG/IDT records, orders, reassessments and updates to the Plans of Care and similar documents have been integrated by Hospice and Provider, each party shall retain a copy of such records . <BR/>Record review of the facility's Nursing Policy and Procedure, Palliative Care, with an effective date of 05/2017, did not address obtaining the residents hospice records.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #1 and Resident #2) reviewed for infection control.<BR/> The facility failed to ensure LVN D wore the proper PPE (gown and gloves) while checking Resident #1's blood sugar or administering insulin on 04/08/25, who was positive for ESBL.<BR/>The facility failed to ensure CNA E wore the proper PPE (gown and gloves) while providing care to Resident #1, who was positive for ESBL on 04/09/25. <BR/>The facility failed to ensure Resident #2 understood contact isolation precautions when the resident was in activities with other residents and positive for MRSA on 04/08/25.<BR/>These failures could place residents and staff at risk for cross-contamination and spread of infection and could potentially affect all others in the building. <BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included urinary tract infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), extended-spectrum beta-lactamase also known as ESBL (occurs when bacteria producing the enzyme ESBL, which renders them resistant to many common antibiotics, causes an infection), diabetes (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), and stroke.<BR/>Record review of Resident 1's quarterly MDS assessment, dated 02/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 03, indicating she was severely cognitively impaired. The MDS indicated Resident #1 required assistance with his transfers, toileting, dressing, hygiene, and supervision for eating. The MDS indicated she was always incontinent of urine and was on an antibiotic.<BR/>Record review of Resident #1's electronic medical records revealed a urinalysis dated 04/05/25 which detected extended-spectrum beta-lactamase, also known as ESBL.<BR/>Record review of Resident #1's comprehensive care plan dated 04/06/25 indicated Resident #1 had a UTI. The intervention was for staff to encourage adequate fluids and monitor side effects. The care plan did not indicate Resident #1 was on contact isolation.<BR/>Record review of Resident #1's physician's order dated 04/07/25 indicated: Doxycycline 100mg, give 1 capsule by mouth two times a day related to Urinary tract infection for 5 days. <BR/>Record review of Resident #1's Physician order dated 04/07/25 indicated contact isolation precautions in place related to the diagnosis of ESBL.<BR/>During an observation on 04/08/25 at 12:09 p.m., a contact isolation sign was noted on Resident #1's door. LVN D walked into Resident #1's room to check her blood sugar without applying a gown. LVN D reached over Resident #1 to check her blood sugar on her left finger. LVN D then left Resident #1's room to gather her insulin, reentered the room without a gown, and administered her insulin.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN A said she was the nurse who received Resident #1's diagnosis of ESBL related to her lab results and the order for Doxycycline. She said she gave the initial dose on 04/07/25 and posted an isolation sign on Resident #1's door. She said she reported it to the oncoming nurse about Resident #1's isolation and new order for Doxycycline. She said she also placed it on the 24-hour report sheet.<BR/>During an interview on 04/09/25 at 9:15 a.m., LVN D said she was the charge nurse for Resident #1 and Resident #2. She said Resident #1 was on contact precautions for ESBL in her urine, and Resident #2 was on contact precautions for MRSA in her urine. LVN D said staff should have on a gown and gloves when entering Resident #1 and Resident #2's rooms. She said she did not wear a gown when she went into Resident #1's room to check her blood sugar or when she administered her insulin. She said she honestly forgot she was in contact isolation. She said Resident #2 had rights, and if she wished to come out of her room, then she could. She said she could not recall if she had personally asked Resident #2 to stay in her room related to her contact isolation orders. She said if staff were not wearing gowns or gloves, they could spread the infection to others.<BR/>During an observation on 04/09/25 at 9:45 a.m., CNA E went into Resident #1's room to provide care. CNA E did not have on her gown or gloves when entering Resident #1's room. <BR/>During an observation and interview on 04/09/25 at 10:09 a.m., CNA E came out of Resident #1's room and disposed of her linen in the laundry barrel without it being in a yellow bag. She said she was aware Resident #1 was on contact precautions for something in her urine. She said she did not see a cart next to her door and did not see any boxes in her room, so she assumed she did not have to wear anything while in the room. She said that in the past, if a resident was on isolation, they would have a cart with equipment next to the door and boxes in the room with red bags for the trash and yellow bags for the linen. She said she worked yesterday (04/08/25) and did not wear a gown while providing care for Resident #1. She said she could spread infection since she did not properly dispose of her linen or wear a gown while in the room. <BR/>During an observation on 04/09/25 at 10:15 a.m., no linen or trash boxes were noted in Resident #1's room. The isolation cart was noted 1 door to the right of Resident#1's room.<BR/>2.Record review of Resident #2's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia(a general term for a group of diseases that cause a decline in memory, thinking, and reasoning abilities, significantly affecting a person's daily life), Urinary Tract Infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), and anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident 2's quarterly MDS assessment, dated 01/30/25, indicated Resident #2 usually understood and was usually understood by others. Resident #2's BIMS score was 15, indicating she was cognitively intact. The MDS indicated Resident #2 required set-up assistance with her dressing and hygiene, independent with toileting and eating. The MDS indicated she was continent of bladder.<BR/>Record review of Resident #2's comprehensive care plan dated 03/29/23 indicated Resident #1 was occasionally incontinent of urine. The intervention was for staff to monitor for signs and symptoms of UTI. The care plan did not indicate a care plan for contact isolation or refusal to comply with contact isolation. <BR/>Record review of Resident #2's electronic medical records revealed a urinalysis dated 04/03/25, which detected MRSA (an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections). <BR/>Record review of Resident #2's physician's order dated 04/06/25 indicated: Rifampin 300mg, give 1 capsule by mouth two times a day related to MRSA in urine until 04/20/25. <BR/>Record review of Resident #2's Physician order dated 04/06/25 indicated Contact isolation precautions in place related to MRSA.<BR/>Record review of Resident #2's comprehensive care plan after surveyor intervention was dated 04/06/25 but updated on 04/09/25, indicating Resident #1 required isolation. The intervention was to follow facility isolation policy and give medication as ordered.<BR/>During an observation on 04/08/25 at 11:00 a.m., Resident #2 was in the dining room attending an activity with 8 other residents while positive for MRSA.<BR/>During an interview on 04/08/25 at 3:30 p.m., Resident #2 said the staff told her she had something in her bladder and to make sure she washed her hands after using the bathroom. She said they did not tell her she had something that someone might catch or to stay in her room.<BR/>During an observation on 04/09/25 at 9:28 a.m., Resident #2 was in the day room sitting on the couch talking to another resident.<BR/>During an interview on 04/09/25 at 10:00 a.m., the ADON said if a resident were in contact isolation, staff would know because of the sign posted on the door. She said staff should wear gowns and gloves when they enter contact-isolated rooms. She said they encourage handwashing before and after care for all residents. She said she was not sure what the policy said on contact isolation for a resident. She said she thought the contact isolated residents could walk the facility. She said she knew they had educated Resident #2 on hand washing.<BR/>During an interview on 04/09/25 at 11:22 a.m., the DON said he expected all staff to follow the guidelines on the sign posted on the door. He said they should be wearing the proper PPE (gown and gloves) to protect themselves and to keep the spread of infection from other residents. He said if the resident were on contact isolation, then staff should be educating the resident on why they need to stay in their room and encouraging them to stay in their rooms. If the resident refuses to stay in their room, then the staff should document the refusal and add it to the resident's care plan.<BR/>During an interview on 04/09/25 at 12:16 p.m., the Administrator said when a resident was on contact isolation, staff should wear gowns and gloves when entering the room. She said the DON oversaw infection control. The Administrator said staff should ensure they had on the proper PPE to protect themselves and the residents and to prevent the spread of infection. She said residents who were on contact isolation should be encouraged to stay in their rooms and practice good hygiene to prevent the spread of infection. <BR/>Record review of the facility's policy titled, Infection Prevention and Control Program, revised 06/2020, indicated, Purpose: Ensure the facility established and maintained an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements. Policy: The facility must establish an infection prevention and control program under which it: #1 identifies, investigates, controls, and prevents infections in the facility .<BR/>Record review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions, revised 6/2020, indicated, To ensure that transmission-based precautions are used when caring for residents with communicable diseases or transmittable infections. III. Contact Precautions A. Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. I. Examples of infections requiring Contact Precautions include, but are not limited to: A. Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-drug resistant organisms (e.g., MRSA). C. Gloves and Handwashing: I. As outlined under Standard Precautions, gloves (clean, non-sterile) are worn when entering the room. D. Gown: I. As outlined under Standard Precautions, a (clean, non-sterile) gown is worn for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. G. Notice: I. The Facility alerts staff to the type of precaution a resident requires. ii. The Facility also ensures that the resident's care plan indicates the type of precautions implemented for the resident. iii. The Facility may utilize a sign requesting visitors to check in at the nursing station before entering a resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Residents #7) reviewed for pharmacy services.<BR/>1. The facility did not ensure Resident #7 medications were administered during the scheduled time. <BR/>2. The facility did not ensure Resident #7 was given Estrace Vaginal Cream 0.01 mg/gm as scheduled. <BR/>3. The facility did not ensure Resident #7 was given Vitamin B-12 2000 mcg. <BR/>These failures could place the residents at risk of not having medications available for use, drug diversion, not receiving their medications as ordered, and exacerbation of their disease processes. <BR/>Findings included:<BR/>1. Record review of Resident #7's face sheet, dated 01/28/25, reflected Resident #7 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). <BR/>Record review of the order summary report dated 01/28/25 indicated Resident #7 was ordered: <BR/>_Calcium 600: give 1 tablet by mouth two times a day for osteoporosis (disease that weakens bone to the point where they break easily) at 8:00 a.m. <BR/>_Pantoprazole sodium 20 mg: give 1 tablet by mouth two times a day for heartburn at 5:00 p.m.<BR/>_Sitagliptin-metformin HCI 50-500 mg: give 1 tablet by mouth two times a day for diabetes mellitus at 9:00 a.m. and 5:00 p.m.<BR/>_Calcium 600: give 1 tablet by mouth two times a day for osteoporosis at 5:00 p.m. <BR/>Record review of the Medication Administration Audit Report dated 1/28/25 indicated Resident #7 received her medications on 12/07/24 by MA Q as listed: <BR/>_Calcium 600 at 9:49 a.m.<BR/>_Pantoprazole sodium 20 mg at 7:29 p.m.<BR/>_Sitagliptin-metformin HCI 50-500 mg at 7:29 p.m. <BR/>_Calcium 600 at 7:29 p.m.<BR/>2. Record review of a telephone order, dated 12/06/24, indicated Resident #7 had an order for Estrace vaginal cream 0.1 mg/gm applicator at bedtime every Monday, Wednesday, Friday for atrophy vaginitis. <BR/>Record review of the MAR dated 12/1/24-12/31/24 indicated Resident #7 was given Estrace vaginal cream 0.1 mg/gm applicator at bedtime every Monday, Wednesday, Friday for atrophy vaginitis (vaginal tissue thins due to low estrogen levels) on 12/25/24 by the ADON.<BR/>During a confidential interview, the interviewee stated Resident #7's medications were administered late on 12/07/24. The interviewee stated Resident #7 was not given the vaginal suppository on 12/25/24. <BR/>During a telephone interview on 1/28/25 at 2:09 p.m., MA Q stated sometimes Resident #7 refused her calcium until she has had breakfast. MA Q stated she could not recall if that had occurred on 12/7/24 at 8:00 a.m. MA Q stated medications that were scheduled at 5:00 p.m. should have been given between 4:00 p.m.-6:00 p.m. MA Q stated she did not remember given Resident #7 anything that late. MA Q stated this failure could potentially cause an adverse effect. <BR/>During an interview on 1/28/25 at 12:08 p.m., the ADON stated on 12/25/24 she was the charge nurse for Resident #7. The ADON stated she went to give her the suppository and something happened (unable to recall) and forgot to administer the medication. The ADON stated she did click off the task as completed prior to administering the medication but the medication was not given. The ADON stated she was not aware until Resident #7 family member told her that she did not give her the suppository on 12/25/24. The ADON stated she did offer to move the date, but the family member stated do not worry about it. <BR/>During an interview on 1/28/25 at 2:49 p.m., the DON stated he expected medications to be administered one hour before or one hour after the scheduled time. The DON stated he was responsible for monitoring and overseeing by reviewing the 24-hour progress noted Monday-Friday and on Monday the weekend was reviewed. The DON stated it was important to ensure medications were administered timely to ensure the dosage stay consistent in the bloodstream. <BR/>During an interview on 1/28/25 at 3:05 p.m., the Administrator stated she expected the medications to be administered according to the schedule to ensure effectiveness. The Administrator stated the DON, and the ADONs were responsible for overseeing and monitoring. The Administrator stated it was important to follow the physician orders to prevent an adverse effect. <BR/>3. Record review of Resident #7's face sheet, dated 01/28/25, reflected Resident #7 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). <BR/>Record review of the order summary report dated 01/28/25 indicated Resident #7 was ordered: <BR/>Vitamin B-12 1000 mcg; give 2000 mcg by mouth in the morning related to anemia. <BR/>During observation and interview on 1/28/25 at 9:18 a.m., MA S was preparing Resident #7's medication for administration. MA S obtained a bottle of Vitamin B-12 1000 mcg and placed 1 tablet (1000mg) in a plastic cup. MA S finished preparing the remainder of Resident #7's morning medications. MA S stated she should have given 2 tablets of Vitamin B12 1,000 mcg. MA S stated this failure could potentially cause more of a vitamin deficiency. <BR/>During an interview on 1/28/25 at 2:49 p.m., the DON stated he expected medications to be given per the physician orders. The DON stated he was responsible for monitoring and overseeing by reviewing the 24-hour progress noted Monday-Friday and on Monday the weekend was reviewed. The DON stated he has not been aware of medications not been administered correctly. The DON stated the risk associated with not giving the correct dose was the desired effect not achieved. <BR/>During an interview on 1/28/25 at 3:05 p.m., the Administrator stated she expected the correct dose to be given. The Administrator stated the DON, and the ADONs were responsible for overseeing and monitoring. The Administrator stated it was important to follow the physician orders to prevent a medication error. <BR/>Record review of the facility's undated policy titled, Medication-Administration indicated, . to provide practice standards for safe administration of medications for residents in the facility . IV. The licensed nurse must know the following information about any medication they are administering E. the drugs usual dosage . V. Medications may be administered one hour before or after the scheduled medication administered time. IV. Nursing staff will keep in mind the seven rights of medication when administering medication: B. the right amount . D. The right time .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 2 residents (Resident #68) reviewed for hospice services.<BR/>The facility did not ensure Resident #68's hospice records were a part of their records in the facility<BR/>This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. <BR/>The findings were: <BR/>Record review of a face sheet dated 07/11/2023, indicated Resident #68 was a [AGE] year-old female initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included severe protein-calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets can lead to muscle loss, fat loss, and your body not working as it usually would), cerebral infarction unspecified (damage to tissues in the brain due to a loss of oxygen to the area), and atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). <BR/>Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #68 was understood and understood others. The MDS assessment indicated Resident #68 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #68 received hospice services while a resident at the facility. <BR/>Record review of the care plan with date initiated 03/21/2023, indicated Resident #68 had a terminal prognosis related to severe protein calorie malnutrition with a goal of dignity and autonomy will be maintained at the highest level through the review date. Interventions included to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. <BR/>Record review of the order summary report dated 07/11/2023 indicated Resident #68 had an order to admit to hospice under the diagnosis of severe protein calorie malnutrition with start date of 03/10/2023. <BR/>Record review of Resident #68's electronic health record did not reveal any hospice related records to include: (a) the most recent hospice plan of care; (b) the hospice election form; (c) physician certification and recertification of the terminal illness; (d) hospice medication information; (e) hospice physician orders; and (f) any progress notes from any hospice visits. <BR/>During an interview on 07/12/2023 at 9:39 AM, LVN E said the residents hospice records were kept in a binder at the nurse's station. LVN E said Resident #68 did not have a binder with her hospice records in it. LVN E said she would call the hospice to have them bring the hospice records to the facility. <BR/>During an interview on 07/12/2023 9:43 AM, Hospice RN F said she was Resident #68's hospice case manager. Hospice RN F said she thought she had sent them by e-mail to someone at the facility, but she must have sent it to the wrong email (she was unable to specify to who she had sent them). Hospice RN F said the facility had not requested that she take Resident #68's hospice records to the facility. Hospice RN F said she should have made sure the hospice records were taken to the facility. Hospice RN F said it was important for the facility to have the hospice records so the staff could refer to them and reference back to the nurses' visits, aide visits, the medication list and have the hospice diagnosis and hospice orders. <BR/>During an interview on 07/13/2023 at 08:56 AM, the ADON said the resident's hospice records were kept in a hospice binder. The ADON said the nurses should be making sure the hospice records were in the facility. The ADON said that she was aware there was no system in placed to ensure the hospice records were in the facility. The ADON said she was not aware Resident #68's hospice records were not in the facility. The ADON said it was important for the hospice records to be in the facility to make sure the care was matching, the medications were correct, the facility knew of the hospice scheduled visits, and to ensure any new orders given by the hospice were implemented. <BR/>During an interview on 07/13/2023 at 10:02 AM, the DON said the hospice residents had hospice binders containing all the hospice records. The DON said the charge nurses were responsible for making sure the hospice records were in the facility. The DON said she did not know why Resident #68's hospice records were not in the facility. The DON said it was important for the residents' hospice records to be in the facility to be able to work in collaboration with the hospice and so all the staff would be on the same page with the residents' plan of care. <BR/>During an interview on 07/13/2023 at 1:54 PM, LVN A said the residents' hospice records were kept in binders. LVN A said she did not know who was responsible for making sure the residents' hospice records were in the facility. LVN A said she had not noticed Resident #68 did not have a hospice binder with her hospice records. LVN A said it was important to have the residents' hospice records, so the facility staff knew what was going on and the hospice staff knew what was going on. <BR/>During an interview on 07/13/2023 at 2:32 PM, the Administrator said nursing management was responsible for making sure the residents hospice records were in the facility. The Administrator said the nurses should have requested the hospice records from the hospice provider. The Administrator said it was important for the facility to have the residents' hospice records for coordination of care.<BR/>Record review of the Hospice and Long Term Care Facility Agreement, with an effective date of September 20, 2021, indicated, . Each Party shall allow reasonable access to the records of the other party in order to carry out their respective rights, duties, and obligations under this agreement. Insofar as Plans of Care, clinical records notes, meeting minutes IDG/IDT records, orders, reassessments and updates to the Plans of Care and similar documents have been integrated by Hospice and Provider, each party shall retain a copy of such records . <BR/>Record review of the facility's Nursing Policy and Procedure, Palliative Care, with an effective date of 05/2017, did not address obtaining the residents hospice records.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 2 of 4 (Resident #1 and Resident #2) residents reviewed for the care plan.<BR/>1. The facility failed to ensure urinalysis results on 04/05/2025 for Resident #1's contact isolation was care planned on 04/06/2025 for a diagnosis of Extended-Spectrum Beta-Lactamase, also known as ESBL (a bacteria that can be spread from person to person on contaminated hands of both patients and healthcare workers.<BR/>2. The facility failed on 04/03/2025 to ensure Resident #2's contact isolation was care planned for methicillin-resistant Staphylococcus aureus also known as MRSA (an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections) and for her refusal to stay in her room related to her being on isolation.<BR/>These failures could affect residents by placing them at risk of not receiving appropriate care and interventions to meet their needs.<BR/>Findings included:<BR/>1.Record review of Resident #1's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included urinary tract infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), extended-spectrum beta-lactamase also known as ESBL (occurs when bacteria producing the enzyme ESBL, which renders them resistant to many common antibiotics, causes an infection), diabetes (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), and stroke.<BR/>Record review of Resident 1's quarterly MDS assessment, dated 02/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 03, indicating she was severely cognitively impaired. The MDS indicated Resident #1 required assistance with her transfers, toileting, dressing, hygiene, and supervision for eating. The MDS indicated she was always incontinent of urine and was on an antibiotic. <BR/>Record review of Resident #1's electronic medical records revealed a urinalysis dated 04/05/25 which detected extended-spectrum beta-lactamase, also known as ESBL.<BR/>Record review of Resident #1's comprehensive care plan dated 04/06/25 indicated Resident #1 had a UTI. The intervention was for staff to encourage adequate fluids and monitor side effects. The care plan did not mention anything about being on contact isolation for ESBL.<BR/>Record review of Resident #1's physician's order dated 04/07/25 indicated: Doxycycline 100mg, give 1 capsule by mouth two times a day related to Urinary tract infection for 5 days. <BR/>Record review of Resident #1's Physician order dated 04/07/25 indicated Contact isolation precautions in place related to ESBL.<BR/>During an observation on 04/08/25 at 12:09 p.m., a contact isolation sign was noted on Resident #1's door. The isolation cart was noted 1 door to the right of Resident #1's room.<BR/>2.Record review of Resident #2's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia(a general term for a group of diseases that cause a decline in memory, thinking, and reasoning abilities, significantly affecting a person's daily life), Urinary Tract Infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), and anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident 2's quarterly MDS assessment, dated 01/30/25, indicated Resident #2 usually understood and was usually understood by others. Resident #2's BIMS score was 15, indicating she was cognitively intact. The MDS indicated Resident #2 required set-up assistance with her dressing and hygiene, independent with toileting and eating. The MDS indicated she was continent of bladder.<BR/>Record review of Resident #2's comprehensive care plan dated 03/29/23 indicated Resident #2 was occasionally incontinent of urine. The intervention was for staff to monitor for signs and symptoms of UTI. The care plan did not indicate a care plan for contact isolation or refusal to comply with contact isolation for MRSA. <BR/>Record review of Resident #2's electronic medical records revealed a urinalysis dated 04/03/25, which detected MRSA. <BR/>Record review of Resident #2's physician's order dated 04/06/25 indicated: Rifampin 300mg, give 1 capsule by mouth two times a day related to MRSA in urine until 04/20/25. <BR/>Record review of Resident #2's Physician order dated 04/06/25 indicated contact isolation precautions in place related to the diagnosis of MRSA.<BR/>Record review of Resident #2's comprehensive care plan after surveyor intervention was dated 04/06/25 but updated on 04/09/25, indicating Resident #1 required isolation. The intervention was to follow the facility's isolation policy and give medication as ordered.<BR/>During an observation on 04/08/25 at 11:00 a.m., Resident #2 was in the dining room attending an activity with 8 other residents while positive for MRSA. Resident #2 had a contact isolation sign on her door and an isolation cart outside her room door.<BR/>During an interview on 04/09/25 at 10:00 a.m., the ADON said the MDS nurses were responsible for the care plans. She said she and the DON were responsible for updating the acute care plans. She looked at Resident #1's and Resident #2's care plan and said she did not see their contact isolation care plan, nor Resident #2's refusal to stay in her room. She said she was aware they were on contact precautions but had not had a chance to update the care plan. She said she was aware of all new orders or changes a resident might have because they discussed the residents in the morning meeting, and she read the 24-hour reports. She said care plans were updated so staff would be aware of the care the residents needed.<BR/>During an interview on 04/09/25 at 11:08 a.m., the Regional MDS nurse said the MDS nurse was responsible for the comprehensive care plan, and the management team was responsible for updating the acute care plans. She said any changes about new orders should be updated within 24-48 hours, depending on when the order was received. She said care plans were done to direct the care of the resident.<BR/>During an interview on 04/09/25 at 11:22 a.m., the DON said the MDS nurses were responsible for the care plans. He said he and the ADON were responsible for the acute care plans. He said he was not aware that Resident #1 or Resident #2's care plan had not been updated related to contact isolation and the refusal of Resident #2 to stay in her room. He said care plans were done to ensure staff conducted the plan of care for each resident.<BR/>During an interview on 04/09/25 at 12:16 p.m., the Administrator said care plans were a team effort with the interdisciplinary team, but the MDS nurses were the overseers. She said the MDS nurse last day at the facility was last week; therefore, the DON/ADON was responsible for updating Resident #1 and #2's care plan. She said care plans were generated to provide each resident with the best care.<BR/>Record review of the facility's policy, Care Plan (Comprehensive), revised 10/24/22, indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. V. The IDT will revise the Comprehensive Care Plan as needed at the following intervals: A. Per RAI schedules; B. As dictated by changes in the resident's condition, C. In preparation for discharge, D. To address changes in behavior and care, and E. Other times as appropriate or necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide residents with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 2 of 4 residents (Resident #1 and Resident #2) reviewed for range of motion. <BR/>The facility failed to ensure CNA A provided restorative care to Resident #1 and Resident #2 according to their Nursing Restorative Care Program plan of care.<BR/>These failures could place residents at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being. <BR/>Findings included:<BR/>1. Record review of a face sheet dated 06/17/2024 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included muscle weakness, unsteadiness on feet, reduced mobility, and difficulty walking. <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #1 was usually able to make herself understood and usually understood others. The MDS assessment indicated Resident #1 had a BIMS score of 6, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #1 did not have limitation in range of motion to her upper or lower extremity. The MDS assessment indicated Resident #1 required maximum assistance with dressing, showering, bathing self, and was dependent for toileting. The MDS assessment did not indicate Resident #1 received a restorative program. <BR/>Record review of Resident #1's care plan date initiated 01/09/2024 did not address Resident #1's restorative program. <BR/>Record review of Resident #1's Order Summary Report dated 06/17/2024 did not indicate any orders for the restorative program. <BR/>Record review of Resident #1's Task documentation in the electronic health record on 06/17/2024 did not indicate any documentation for the nursing restorative program. <BR/>Record review of Resident #1's ambulation and transfer Nursing Restorative Care Program plan of care with date restorative initiated 05/29/2024 for the month of June 2024 indicated goals to increase/maintain ability to ambulate 100 feet safely using a walker one time a day as tolerated and to increase/maintain ability to transfer to and from with minimal to moderate assistance as tolerated. The approaches included for Resident #1 to ambulate 100 feet using a walker for safety and for 10 sit to stands and 5 wheelchair pushups and 5 weight shifting. Resident #1's Nursing Restorative Care Program indicated:<BR/>06/01/2024-06/06/2024 no documentation.<BR/>06/07/2024 Resident #1 refused documented by CNA A.<BR/>06/08/2024-06/12/2024 no documentation.<BR/>06/13/2024 and 06/14/2024 15 minutes of restorative program were provided documented by CNA A.<BR/>06/15/2024-06/16/2024 no documentation.<BR/>During an interview on 06/17/2024 at 9:44 AM, Resident #1 said she was receiving therapy to help her legs get stronger. Resident #1 said sometimes she received it and sometimes she did not. <BR/>2. Record review of a face sheet dated 06/17/2024 indicated Resident #2 initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included muscle weakness, abnormalities of gait and mobility, and reduced mobility. <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was usually able to make herself understood and usually understood others. The MDS assessment indicated Resident #2 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had functional limitation in range of motion in both upper extremities and on one side on the lower extremity. The MDS assessment indicated Resident #2 was dependent with dressing, bathing, and toileting hygiene and required partial to moderate assistance with personal hygiene. The MDS assessment did not indicate Resident #2 received a restorative program. <BR/>Record review of Resident #2's care plan with date initiated 06/06/2024 did not address Resident #2's restorative program. <BR/>Record review of Resident #2's Order Summary Report dated 06/17/2024 did not indicate any orders for the restorative program. <BR/>Record review of Resident #2's Task documentation in the electronic health record on 06/17/2024 did not indicate any documentation for the nursing restorative program.<BR/>Record review of Resident #2's active range of motion and bed mobility Nursing Restorative Care Program plan of care with date restorative initiated 05/01/2024 for the month of June 2024 indicated goals to increase/maintain upper and lower extremity strength and range of motion one time a day or as tolerated. The approaches included 10 upper extremity range of motion 2 times, 10 bicep curls 2 times, 10 punches 2 times, 10 foot rotations 2 times, 10 knee highs 2 times, 10 side to side 2 times with assistance when needed and turn in the bed 5 times with maximum assistance to both sides. <BR/>Resident #2's Nursing Restorative Care Program indicated:<BR/>06/01/2024-06/05/2024 no documentation.<BR/>06/06/2024-06/07/2024 15 minutes of restorative program were provided documented by CNA A.<BR/>06/08/2024-06/11/2024 no documentation.<BR/>06/12/2024-06/14/2024 15 minutes of restorative program were provided documented by CNA A.<BR/>06/15/2024-06/16/2024 no documentation.<BR/>During an interview on 06/17/2024 at 10:30 AM, the DOR said the DON was responsible for overseeing the restorative program. The DOR said therapy assisted with writing the plan of care for the nursing restorative program and provided education for it. The DOR said CNA A was the restorative nurse aide. <BR/>During an interview on 06/17/2024 at 1:16 PM, CNA A said she was responsible for providing the restorative exercises to the residents in the restorative program. CNA A said the DON was the one who provided oversight. CNA A said therapy wrote the orders and she followed them. CNA A said she was supposed to document when she provided restorative care to the residents, the length of time she provided it, and if they refused on the plan of care form and in the electronic health record. CNA A said she was supposed to document in the electronic health record, but some of the residents did not have an area to document it in under their tasks. CNA A said she was supposed to offer Resident #1 restorative care daily. CNA A said Resident #2's schedule was changed by the DON to three times a week instead of daily, but she was unable to recall when it was changed. CNA A said the DON should have updated the nursing restorative plan of care to three times a week when it was changed, but she did not know why it was not updated. CNA A said if she was weighing residents or was having to work the floor she was not offering restorative care to the residents. CNA A said she had not been offering Resident #1 to perform the restorative care daily. CNA A said she had missed Resident #2's restorative care as well. CNA A said when she had to weigh residents, she forgets about the restorative care. CNA A said if it was not documented on the sheet she did not offer or complete the restorative care. CNA A said it was important for the residents to receive restorative care, so the residents did not decline. <BR/>During an interview on 06/17/2024 at 1:24 PM, Resident #2's family member said Resident #2 had not been receiving restorative care daily. Resident #2 said she had been having issues with CNA A not providing restorative care and had notified the Administrator, and the Administrator said it would be changed to Wednesday, Thursday, and Friday. Resident #2's family member said prior to notifying the Administrator she had notified the DON, but he had not addressed the issue. Resident #2's family member said the DON had told her the restorative care was not completed because CNA was on vacation or because CNA A was weighing the other residents. <BR/>During an interview on 06/17/2024 at 2:28 PM, the DOR said the frequency of one time a day as tolerated on the restorative plan of care indicated the restorative care should be offered daily to the residents. The DOR said the purpose of the restorative care program was to maintain the resident's function. The DOR said if the restorative care program was not being done the residents could have a decline in function. <BR/>During an interview on 06/17/2024 at 5:11 PM, the DON said he was responsible for overseeing the restorative program. The DON said the therapy team assisted with writing the restorative plan of care, then he looked at it and signed it. The DON said he was not aware the restorative program was not being followed properly. The DON said he had glanced at the book in the past but he was not reviewing it on a routine basis. The DON said he randomly reviewed the restorative program logs. The DON said he was not sure how frequently he should be reviewing the restorative program logs to ensure the restorative care was being provided, but he believed the policy said on a regular interval. The DON said he assumed the MDS Coordinator was adding the restorative care to the resident's electronic health record for the CNAs to document in the electronic health record. The DON said any CNA could complete restorative care with the residents. The DON said Resident #2's restorative plan of care did not need to be updated to reflect she was to receive restorative care on Wednesday, Thursday, and Friday because he believed the one-time day covered it. The DON said it was important for restorative care to be provided to the residents to continue with strength training, keep up with the level of strength the residents had built up, and to minimize loss of ability. <BR/>During an interview on 06/17/2024 at 5:38 PM, the MDS Coordinator said if he knew residents received restorative care himself or therapy added it to the resident's care plan. The MDS Coordinator said he was not aware Resident #1 and Resident #2 received restorative care. The MDS Coordinator said he was not sure if it was his responsibility to ensure the residents restorative care was included in their care plan. The MDS Coordinator said he was new to the MDS position he had only been MDS Coordinator for 3 months and he was still learning his roles. The MDS Coordinator said it was important to ensure the residents received restorative care so their strength would be maintained. <BR/>During an interview on 06/17/2024 at 5:46 PM, the Administrator said the DON was responsible for the restorative program. The Administrator said she expected for the DON to know what the policy required for the restorative program and the necessary systems to have in place to ensure it was being provided to the residents. The Administrator said she expected the DON to monitor the restorative program according to the policy. The Administrator said it was important for restorative care to be provided to the residents to maintain their functional abilities and prevent the residents decline. <BR/>Record review of the facility's policy titled, Restorative Nursing Program Guidelines, revised 06/2020, indicated, Purpose The Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning .II. The Director of Nursing Services (DNS), or their designee, manages and directs the Restorative Nursing Program. Licensed rehabilitation professionals, (physical therapists, occupational therapists, and speech therapists) provide ongoing consultation and education for the Restorative Nursing Program . Documentation A <BR/>Restorative program developed by therapy will be completed on paper and the facility wlll enter RNP In PCC as appropriate B. The documentation will be done in Point Click Care (PCC) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 2 residents (Resident #68) reviewed for hospice services.<BR/>The facility did not ensure Resident #68's hospice records were a part of their records in the facility<BR/>This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. <BR/>The findings were: <BR/>Record review of a face sheet dated 07/11/2023, indicated Resident #68 was a [AGE] year-old female initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included severe protein-calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets can lead to muscle loss, fat loss, and your body not working as it usually would), cerebral infarction unspecified (damage to tissues in the brain due to a loss of oxygen to the area), and atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). <BR/>Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #68 was understood and understood others. The MDS assessment indicated Resident #68 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #68 received hospice services while a resident at the facility. <BR/>Record review of the care plan with date initiated 03/21/2023, indicated Resident #68 had a terminal prognosis related to severe protein calorie malnutrition with a goal of dignity and autonomy will be maintained at the highest level through the review date. Interventions included to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. <BR/>Record review of the order summary report dated 07/11/2023 indicated Resident #68 had an order to admit to hospice under the diagnosis of severe protein calorie malnutrition with start date of 03/10/2023. <BR/>Record review of Resident #68's electronic health record did not reveal any hospice related records to include: (a) the most recent hospice plan of care; (b) the hospice election form; (c) physician certification and recertification of the terminal illness; (d) hospice medication information; (e) hospice physician orders; and (f) any progress notes from any hospice visits. <BR/>During an interview on 07/12/2023 at 9:39 AM, LVN E said the residents hospice records were kept in a binder at the nurse's station. LVN E said Resident #68 did not have a binder with her hospice records in it. LVN E said she would call the hospice to have them bring the hospice records to the facility. <BR/>During an interview on 07/12/2023 9:43 AM, Hospice RN F said she was Resident #68's hospice case manager. Hospice RN F said she thought she had sent them by e-mail to someone at the facility, but she must have sent it to the wrong email (she was unable to specify to who she had sent them). Hospice RN F said the facility had not requested that she take Resident #68's hospice records to the facility. Hospice RN F said she should have made sure the hospice records were taken to the facility. Hospice RN F said it was important for the facility to have the hospice records so the staff could refer to them and reference back to the nurses' visits, aide visits, the medication list and have the hospice diagnosis and hospice orders. <BR/>During an interview on 07/13/2023 at 08:56 AM, the ADON said the resident's hospice records were kept in a hospice binder. The ADON said the nurses should be making sure the hospice records were in the facility. The ADON said that she was aware there was no system in placed to ensure the hospice records were in the facility. The ADON said she was not aware Resident #68's hospice records were not in the facility. The ADON said it was important for the hospice records to be in the facility to make sure the care was matching, the medications were correct, the facility knew of the hospice scheduled visits, and to ensure any new orders given by the hospice were implemented. <BR/>During an interview on 07/13/2023 at 10:02 AM, the DON said the hospice residents had hospice binders containing all the hospice records. The DON said the charge nurses were responsible for making sure the hospice records were in the facility. The DON said she did not know why Resident #68's hospice records were not in the facility. The DON said it was important for the residents' hospice records to be in the facility to be able to work in collaboration with the hospice and so all the staff would be on the same page with the residents' plan of care. <BR/>During an interview on 07/13/2023 at 1:54 PM, LVN A said the residents' hospice records were kept in binders. LVN A said she did not know who was responsible for making sure the residents' hospice records were in the facility. LVN A said she had not noticed Resident #68 did not have a hospice binder with her hospice records. LVN A said it was important to have the residents' hospice records, so the facility staff knew what was going on and the hospice staff knew what was going on. <BR/>During an interview on 07/13/2023 at 2:32 PM, the Administrator said nursing management was responsible for making sure the residents hospice records were in the facility. The Administrator said the nurses should have requested the hospice records from the hospice provider. The Administrator said it was important for the facility to have the residents' hospice records for coordination of care.<BR/>Record review of the Hospice and Long Term Care Facility Agreement, with an effective date of September 20, 2021, indicated, . Each Party shall allow reasonable access to the records of the other party in order to carry out their respective rights, duties, and obligations under this agreement. Insofar as Plans of Care, clinical records notes, meeting minutes IDG/IDT records, orders, reassessments and updates to the Plans of Care and similar documents have been integrated by Hospice and Provider, each party shall retain a copy of such records . <BR/>Record review of the facility's Nursing Policy and Procedure, Palliative Care, with an effective date of 05/2017, did not address obtaining the residents hospice records.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to be informed of and participate in his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment, and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #179) reviewed for resident rights.<BR/>The facility failed to obtain informed consent based on the information of the benefits and risks for Resident #179 before administering Bupropion HCL ER (Wellbutrin - a medication used to treat depression). <BR/>This failure could place residents at risk of receiving medications they had not consented to, experiencing potential adverse reactions, and a potential decline in physical and mental health status.<BR/>Findings included:<BR/>Record review of Resident #179's face sheet, dated 08/22/24, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses which included Spinal stenosis (pain in the lower back that can cause cramping in one or both legs), Schizophrenia (a chronic mental illness that affects how a person thinks, feels, and behaves), depression (sadness), and post-traumatic stress disorder also known as PTSD (a mental health condition that's caused by an extremely stressful or terrifying event).<BR/>Record review of Resident #179's admission MDS assessment, dated 08/12/24, indicated Resident #179 understood and was understood by others. Resident #179's BIMS score was 15, which indicated he was cognitively intact. The MDS indicated Resident #179 required extensive help with toileting bed mobility, dressing, transfers, set up for personal hygiene, and being independent with eating. The MDS indicated he took antidepressant medication during the 7-day look-back period.<BR/>Record review of Resident #179's care plan dated 08/07/24 indicated he required antidepressant medication. The intervention of the care plan indicated staff would give medication as ordered, staff would monitor for signs and symptoms of depression such as sadness, crying, or shame, etc., and educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms.<BR/>Record review of Resident #179's physician order dated 08/05/24 for Bupropion HCL ER(Wellbutrin) 150mg, give 1 tablet by mouth daily for depression.<BR/>Record review of Resident #179's records revealed there was no consent for the use of psychotropic medication, Bupropion HCL ER(Wellbutrin) documented in his chart.<BR/>During an interview on 08/21/24 at 4:00 p.m., Resident #179 said he took a lot of medicine and was unsure of all the names.<BR/>During an interview on 08/21/24 at 4:21 p.m., LVN A said consent(s) should be obtained for all psychotropic medication before being given. LVN A said Resident #179 was given, Bupropion HCL ER (Wellbutrin) for depression but did not know his consent was not done until mentioned by the State Surveyor. LVN A said consents were usually obtained during the admission process by the charge nurse. LVN A said psychotropic medications could change a resident's demeanor and this was why the resident or their responsible party should be aware of all medications and the possible side effects or behaviors from the medications.<BR/>During an interview on 08/21/24 at 4:44 p.m., the ADON said the consent for psychotropic medications should be completed before the resident received the medication. The ADON said they normally got consent for all psychotropic medication because those types of medications could alter the mind and could cause other risks. The ADON said the nurse who received the order was responsible for getting the consent. The ADON said she was the admitting nurse for Resident #179 and did not realize she did not get his consent for Bupropion HCL ER (Wellbutrin) until questioned by the state surveyor. The ADON said failure to get consent could lead to a side effect or behaviors and the family or resident would not know why.<BR/>During an interview on 08/22/24 at 2:30 p.m., the DON said consent should be signed prior to medication being administered. The DON said one reason consents were obtain was to inform the family or resident about the risk and benefits prior to receiving medications. The DON said they had psychiatrist services who would usually obtain consent if they place the resident on psychotropic medication. He said if the charge nurse received the order, they were responsible for obtaining the consent. He said the IDT was the overseer for ensuring residents had consent in place. The DON said failure to obtain consent could cause the resident not to know what medications he was taken or if he wanted to take them.<BR/>During an interview on 08/22/24 at 03:00 p.m., the Administrator said consent should be done to inform families or residents of risk and/or benefits of medication. The Administrator said the ADON and the DON oversaw that process. The Administrator said failure to get consent could lead to families or residents not having a voice in resident care.<BR/>Record review of the facility's policy titled; Psychotherapeutic Drug Management revised date of 06/2020, Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or decreasing or negatively impacting the residents' quality of life .G. The Licensed Nurse will not administer the psychotherapeutic medication until an informed consent from has been obtained and document by the attending physician from the resident and/or surrogate decision maker unless it is an emergency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately consult the physician when there was a significant change in the resident's physical and mental status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 13 residents (Resident #4) whose records were reviewed for change in condition.<BR/>1. The facility failed to notify Resident #4's physician when Resident #4 had an increase in bruising while taking an anticoagulant medication (blood thinner that works by preventing red blood cells from forming clots), which indicated a change of condition and resulted in a delay of treatment. <BR/>An Immediate Jeopardy (IJ) situation was identified on 07/13/23 at 9:30 AM. While the IJ was removed on 07/14/23 at 11:56 AM, the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk of a delay in medical intervention and puts residents at an increased risk for adverse reaction while taking an anticoagulant medication (blood thinners), such as severe bruising, external or internal bleeding, or death.<BR/>The findings included: <BR/>Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), history of cerebral infarction (stroke), history of a heart attack, hypertension (high blood pressure), mitral (valve) stenosis (narrowing of the mitral valve of the heart that causes tiredness and shortness of breath), and congestive heart failure (progressive heart disease that affects pumping action of the heart muscles). <BR/>Record review of the MDS assessment, dated 05/30/23, revealed Resident #4 had clear speech and was usually understood by staff. The MDS revealed Resident #4 was usually able to understand others. The MDS revealed Resident #4 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #4 had no behaviors or refusal of care. The MDS revealed Resident #4 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene with a one or two staff assistance. <BR/>Record review of the comprehensive care plan, revised on 01/28/23, revealed Resident #4 was on anticoagulant therapy. The interventions included Monitor/document/report to the doctor as needed for signs and symptoms of anticoagulant complications: .bruising .<BR/>Record review of the order summary report, dated 07/12/23, revealed Resident #4 had an order, which started on 12/14/21, for Anticoagulant Monitoring - Place letter of symptoms of excess bleeding .every shift .F. bruising. The orders also revealed an order, which started on 12/13/21, for Aggrenox (blood thinner) Capsule 25-200 mg by mouth two times a day for blood thinner.<BR/>Record review of the Nurse Administration Record, dated July 2023, revealed bruising was present on the following dates: 07/01/23, 07/03/23, 07/04/23, 07/05/23, 07/06/23, and 07/11/2023. The Nurse Administration Record did not specify the location of the bruising. <BR/>Record review of the Weekly Skin Check, dated 07/04/23, revealed Resident #4 had no bruising. <BR/>Record review of the CNA Shower Report, dated 07/10/23, revealed Resident #4 had no skin problems. <BR/>Record review of the Weekly Skin Check, snipped on 07/11/2023 at 5:27 PM, revealed Resident #4 had no bruising. <BR/>During an interview on 07/11/23 at 5:55 PM, a copy of Resident #4's Weekly Skin Check dated 07/11/23 was requested from the DON. <BR/>Record review of the Weekly Skin Check provided by the facility, dated 07/11/23, revealed Resident #4 had the following newly documented skin problem areas: reddish, burgundy discoloration to back of left hand, front of right shoulder, left lower leg (below the knee), front of the left leg (above the knee), front of the right leg (above the knee), and the upper inner arm; bright reddish tint to right and left heel; small scabbing to second right toe and small scabbing to first, second, and fifth toes; red linear scratch to left shoulder in the front; and purplish discoloration to right lateral foot below the fifth toe.<BR/>During an observation and attempted interview on 07/10/23 at 9:09 AM, Resident #4 was laying in her bed with her bed sheets pulled up. She was moving her legs up and down and holding the bed sheets in her hands close to her face. Resident #4's arms and legs were visible from the door and several large, reddish-purple bruises were observed to Resident #4's upper legs and arms. Resident #4 was unable to remember how the bruising occurred and stared at the surveyor when questions were asked. <BR/>During an interview on 07/12/23 at 12:02 PM, LVN L stated she was the treatment nurse at the facility and had worked at the facility since March of 2022. LVN L stated Resident #4 had discoloration to several areas on her skin. LVN L stated Resident #4 had the discoloration and skin problems prior to 07/11/23, when they were documented. However, the skin issues did not require a treatment, so they were not documented on the weekly skin assessment. LVN L stated Resident #4 has always had terrible skin and the discoloration came and went frequently. LVN L stated she was unsure if Resident #4 was taking a blood thinning medication. LVN L stated she had not notified anyone of Resident #4's new skin areas of discoloration. LVN L stated the facility staff were aware of Resident #4's skin status because it had been discussed several times, especially regarding transfers. LVN L stated she was unsure how the areas of discoloration occurred on Resident #4's skin. LVN L stated the discoloration had been present since she started working at the facility but had come and went in the same area. LVN L was unable to say if the discoloration was the same or was in the same area. LVN L stated new skin problems or discoloration should have been reported to physician as soon as it was noticed. <BR/>During an interview on 07/12/23 at 12:20 PM, the ADON stated she used to be the treatment nurse at the facility. The ADON stated weekly skin assessments should have been a complete head to toe assessment, to include discoloration or bruising. The ADON stated new bruising or discoloration should have been monitored for 72 hours, initially, then weekly on the skin assessments. The ADON stated new bruising or discoloration should have been reported to the physician. <BR/>During an interview on 07/12/23 at 1:44 PM, the DON stated she was unaware of Resident #4's increased bruising until this week. The DON stated she expected staff to monitor for bruising and other signs of bleeding every shift for residents taking a blood thinning medication. The DON stated an increase in bruising for resident's taking a blood thinning medication should have been reported to the physician, as soon as it was noticed, because it would have been considered a change of condition. The DON stated the increased bruising for Resident #4 was reported to the physician on 07/12/23 and a new order for a STAT CBC and PT/INR was obtained. The DON stated it had not been reported to physician prior to 07/12/23. The DON stated documenting bruising on the weekly skin assessment, anticoagulant monitoring every shift, and reporting increased bruising to the physician were important to monitor and follow up on side effects of blood thinning medications such as bruising, metabolic functions, and fragile skin.<BR/>During an interview on 07/12/23 at 2:32 PM, Physician M stated he had been caring for Resident #4 for the last 15 to 20 years. Physician M stated Resident #4 had a history of minor skin areas such as small areas of bruising and skin tears, because of the tremors and fidgeting caused by Parkinson's disease. Physician M stated Resident #4 was taking a blood thinner called Aggrenox which had aspirin in it. Physician M stated Resident #4 was at an increased risk for GI bleeding, bruising, and bleeding because she was taking a blood thinning medication. Physician M stated he was notified on 07/12/23 for the increased bruising on Resident #4. Physician M stated he looked at it while he was making rounds and stated he believed it was bruising and it was on her left shoulder and elbow and right and left thighs. Physician M stated the bruising was not concerning or suspicious of abuse because there were no shapes or fingerprints. Physician M stated he wanted to be notified of increased bruising for residents who were taking a blood thinning medication as soon as it was noticed so he could have ordered some lab work to rule out acute or worsening medical problems. Physician M stated he ordered some STAT labs, which included a CBC to check for platelets and red blood cells, a CMP to check for protein, and a PT/INR to check for clotting factors. <BR/>Record review of the lab results, dated 07/12/23 at 5:01 PM, revealed on the CBC, Resident #4 had a low red blood cell count 3.2 (normal 3.8 - 5.1), hemoglobin (iron-containing oxygen carrying protein found in red blood cells) 8.8 (normal 11.6 - 15.4), and hematocrit (volume percentage of red blood cells) 28.0 (normal 34-45). The CMP revealed Resident #4 had a low total protein 5.5 (normal 5.7 - 8.0). The PT/INR revealed Resident #4 had a high PT 12.4 (normal is 9.0 to 12.0). <BR/>During an interview on 07/12/23 at 5:59 PM, Physician M stated Resident #4 had some anemia by looking at the CBC. Physician M said the protein (on the CMP) was a little off but still good. Physician M stated the INR was normal and the PT was only elevated by 0.4 which was not concerning. Physician M stated he wanted the facility to keep monitoring the bruising and to repeat the CBC in one week because Resident #4 might need a blood transfusion, which could indicate bleeding. Physician M stated he wanted to be notified of any changes. <BR/>During an interview on 07/12/23 at 6:03 PM, CNA N stated he worked 2-10 shift on 07/10/23 and 7/11/23. CNA N stated he helped the treatment nurse with Resident #4's skin assessment on 07/11/23 after the supper meal. CNA N stated during the skin assessment on 07/11/23 was the first time he had noticed bruising on Resident #4, but she did have a history of bruising on and off. CNA N stated he was unsure how Resident #4 received the bruising to her arms and legs. CNA N stated he worked on a different hall on 07/10/23. CNA N stated he would have reported the bruising to the charge nurse if he would have noticed it. CNA N stated the treatment nurse was aware of the bruising, so he did not have to report it. <BR/>During an interview on 07/12/23 at 6:16 PM, LVN E stated she normally worked with Resident #4. LVN E stated the bruising to Resident #4 had been there but was unable to say for how long. LVN E stated the bruising was present on 07/10/23 (Monday) but she believed the bruising had been documented on a skin assessment. LVN E stated it was normal for Resident #4 to bruise easily because she was on a blood thinner. LVN E stated she was unsure how Resident #4 received the bruising on her arms and legs. LVN E stated the physician should have been notified any time a new bruise or skin problem was identified. LVN E stated it was important to notify the physician for signs of bleeding so lab work could have been ordered to check for internal bleeding and medication could have been adjusted as it was needed. <BR/>During an interview on 07/13/23 at 1:39 PM, CNA C stated she worked Resident #4's hall on 07/10/23 and she had discoloration to her upper and lower limbs. CNA C she did not report the discoloration to the charge nurse because it had been reported previously and the charge nurse was aware. CNA C was unsure who reported the discoloration previously. CNA C stated she was unsure how the discoloration to Resident #4's arms and legs occurred. CNA C stated Resident #4 had other signs of bleeding. CNA C stated it was important to document and report new bruising to the charge nurse because it could have been a change of condition and the charge nurse would want to be aware. <BR/>Record review of the Change of Condition Notification policy, revised 06/2020, revealed I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent an acute change of condition (ACOC). The policy further revealed I. The Licensed Nurse will notify the resident's Attending Physician when there is an A. Incident/accident involving the resident; B. an accident involving the resident which results injury and has the potential for requiring physician intervention; C. A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions, or clinical complications; D. A need to alter treatment significantly . <BR/>The Administrator was notified on 07/13/23 at 10:53 AM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 07/13/23 at 10:57 AM and the plan of removal was requested. <BR/>The facility's Plan of Removal was accepted on 07/13/23 at 8:47 PM and included: <BR/>1. Immediate action(s) taken for the resident(s) found to have been affected include:<BR/>1. Resident Notification to Family Treatment nurse at 1:59pm attempted left message and 2:02pm family called back and was notified by ADON, Medical Director/Physician 7-12-23 ADON 1:25pm<BR/>2. SBAR (change in condition) Completed 7-12-23 ADON 1:25pm<BR/>3. Medical Director / Physician Evaluated Resident for changes in condition related to bruises 7-12-23 1:45pm<BR/>4. New orders to monitor bruising, Labs - CBC/INR Orders 7-12-23 1:25pm Labs Drawn at 2:21PM on 7-12-23 and results received at 3:21PM and MD notified 3:25pm and order to repeat CBC in one week received. <BR/>5. Trauma Assessment completed 7-12-23 Charge Nurse LVN A 1:47 PM<BR/>6. Pain Assessment completed 7-12-23 Charge Nurse LVN A 1:45pm<BR/>7. Care Plan Updated 7-12-23 MDS Nurse, Added Skin Care BUE/BLE Bruising- updated with Intervention monitoring skin for the bruising until healed and report abnormality to MD. <BR/>8. Therapy Screening completed 7-12-23 RN DON 3:57pm and Therapy screened completed DOR COTA on 7-12-23 7:15pm, Resident is on services as of 7-13-23 on OT services.<BR/>9. Incident Report ADON LVN 7-12-23 at 6:42pm<BR/>Self-Report Completed 7-12-23 by the Administrator 3:21PM<BR/>10. Skin assessment conducted for all residents that resided in the facility completed 7-12-23 7:30pm completed by Charge Nurse A LVN, Charge Nurse B LVN, all undocumented concerns were reported to MD/Families by LVN ADON, and RN DON completed by 7-13-23 by 4:00pm<BR/>Include actions that were performed toa address to citation: 7-13-23 11:00am <BR/>1. Facility Wide Resident Skin Sweep completed 7-12-23 Charge Nurses A LVN, Charge Nurse LVN B, completed at 7:30pm<BR/>2. Safe Survey with residents that are cognitively intact. 7-13-23 at 1:47pm by Social Worker completed at 4:00pm<BR/>3. Staff Safe Survey completed 7-13-23 Administrator and Regional Director of Operations started at 12:25pm completed at 3:45pm<BR/>4. One on One Inservice with treatment nurse on skin assessment initiated 4:00pm and completed on 7-12-23 conducted by DON RN completed 4:30pm on 7-12-23, Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan and job duties.<BR/>5. One on One Inservice with DON conducted by Regional Nurse Consultant on change in condition/skin assessment and notification. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Initiated 3:00pm 7-12-23 and completed on 7-12-23 3:30pm. Regional Nurse Consultant<BR/>6. In-services for licensed nursing staff on Skin Assessment/Skin initiated on 7/13/2023 at 11:45am by Regional Nurse Consultant. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Completed 7-13-23 5:00pm. <BR/>7. Training for licensed staff was initiated 7-12-23 at 11:45am on Anticoagulant monitoring/documentation timely and accurately 7-13-23 at 5:00pm. Training consisted of how to recognize changed with anticoagulant, monitoring, and orders and care plan in place. <BR/>8. Training for licensed staff was initiated 7-12-23 at 11:45am on Following care plan of anticoagulant completed 7-13-23 at 5:00pm. Training consisted of the following care plan. <BR/>9. Training for Clinical Licensed staff was initiated 7-12-23 at 11:45am on ADL transfers, this Inservice training consisted of transfer safety and how to conduct proper transfers. This Inservice was conducted at a precaution. Training completed on 7-13-23 at 5:00pm.<BR/>10. Training for Clinical Licensed staff was initiated on 7/12/23 at 11:45am, on Notification of Change completed on 7/13/23 at 5:00pm. This training includes what is a change in a condition, proper notification, reported and documentation of change in conditions. <BR/>11. Training with facility staff was initiated on 7/12/23 at 11:45am, by DON on Abuse and Neglect. This training includes what is abuse and neglect, procedures of abuse and neglect, reporting of abuse and the abuse coordinator, completed on 7/13/23 at 5:00pm. <BR/>12. All new hires will be educated on abuse and neglect protocol/change in condition/skin assessment, and anticoagulant ongoing. <BR/>13. The ADON and Director of Nursing will ensure competency through signing of in service, verbalization of understanding. All licensed nurses will notify DON/Administrator/Physician/Family regarding change in conditions. The ADON/DON will audit all skin assessments daily in morning clinical meetings to ensure compliance. <BR/>14. Team members will receive required training prior to their shifted. <BR/>Involvement of Medical Director<BR/>The Medical Director met with the Interdisciplinary team on 7/12/2023 at 4:00pm and conducted an Ad HOC QAPI regarding the change in condition and skin assessment protocol. <BR/>The Medical Director was notified about the immediate Jeopardy on 7/13/2023 at 1:30pm, the Plan of removal was reviewed with IDT Team and Medical Director.<BR/>Involvement of QAPI<BR/>An Ad Hoc QAPI meeting was held with the Medical Director via phone, facility administrator, director of nursing, and social services director to review plan of removal on 7/13/2023 at 2:30pm. <BR/>The Director of Nursing and Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 7/12/2023. Monitoring and reviewing skin assessment during clinical meeting to ensure compliance with facility policy.<BR/>On 07/14/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of the following documents, dated 07/12/23, were as follows:<BR/>1. The SBAR was completed. <BR/>2. A physician progress note was completed and addressed Resident #4's bruising. <BR/>3. The incident report was completed, and the physician, family, DON, and Administrator were notified. <BR/>4. New orders were obtained for labs.<BR/>5. The trauma assessment was completed.<BR/>6. The pain assessment was completed. <BR/>7. The care plan was updated, which included monitoring Resident #4's skin for bruising until healed and report abnormalities to the physician.<BR/>8. The therapy screen was completed. <BR/>9. The provider investigation report was completed. <BR/>10. The skin assessments were reviewed for all residents in the facility. <BR/>11. Skin sweeps were reviewed and completed for all residents in the facility. <BR/>12. Safe surveys for residents and staff were reviewed with no problems identified. <BR/>13. Ad Hoc QAPI plan was reviewed and completed with meeting minutes signed by the medical director, Administrator, DON, ADON, MDS, HR, AD, Maintenance, Social Worker, Dietary Manager, Medical Records, DOR, Housekeeping Supervisor, Business Office Manager, and RDO. <BR/>Interviews with the Treatment Nurse (LVN L) and DON revealed one-on-one in-services were completed. During the interviews the Treatment Nurse and DON were able to correctly identify how to conduct a thorough skin assessment, how to accurately document a weekly skin assessment, changes in the skin, and care plan. <BR/>Interviews of licensed nurses (LVN A, LVN E, LVN R, LVN S, LVN T, LVN U, RN B, RN O, RN P, RN Q, MDS Nurse, and the ADON) were performed. During the interviews all licensed nurses were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, and documenting the change of condition. All licensed nurses were able to correctly identify when skin assessments should be completed and how to conduct a thorough skin assessment, what should be documented on a skin assessment, changes in the skin, and updating the care plan. All licensed nurses were able to correctly identify how to recognize changes for resident's taking an anticoagulant medication, proper monitoring, orders, and following the care plan. All licensed nurses were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All licensed nurses were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. <BR/>Interview of clinical licensed staff (CNA D, CNA K, CNA N, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, CNA CC, CNA DD, CNA EE, CNA FF, MA V, and MA W) were performed. During the interviews all clinical licensed staff were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All clinical licensed staff were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, documenting the change of condition, and who to report a change of condition to. All clinical licensed staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin.<BR/>Interviews of staff (BOM, HR, Receptionist, Maintenance Supervisor, Housekeeping Supervisor, Dietary Manager, Social Worker, AD, Housekeeper GG, Housekeeper HH, Housekeeper KK, LA LL, LA MM, [NAME] NN, [NAME] OO, [NAME] PP, DA QQ, and DA RR) were performed. During the interviews all staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin.<BR/>On 07/14/23 at 11:56 AM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and establish policies and procedures to report and investigate such allegations, for 1 of 6 residents (Resident #3) reviewed for abuse.<BR/>The facility did not implement the policy on investigating an injury of unknown origin to the state agency for Resident #3 when Resident # 3 was found with bruising and a skin tear on 02/11/2025 on the left arm.<BR/>This failure could place the residents at increased risk of abuse and neglect.<BR/>Findings included:<BR/>Record review of Resident #3's face sheet, dated 04/09/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (diseases that affect memory, thinking, and the ability to perform daily activities), diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily living).<BR/>Record review of Resident #3's annual MDS assessment, dated 02/26/25, indicated Resident #3 rarely understood and was rarely understood by others. Resident #3's BIMS score was 00, which meant she was severely cognitively impaired. The MDS indicated Resident #3 required extensive help with toileting, bed mobility, dressing, transfers, personal hygiene, and supervision with eating. The MDS did not indicate Resident #3 had wounds or skin problems. <BR/>Record review of Resident #3's progress note dated 2/11/25 at 6:22 pm, written by LVN A, revealed Resident #3's family member reported 2 open areas to her left arm, both less than 0.25 x 0.25 in diameter. Both showed no signs of infection. The nurse provided first aid to both, and neither area showed signs of infection. The resident denied pain. The call light was in reach.<BR/>Record review of Resident #3's progress note updated 2/11/25 at 6:42 pm, written by LVN A revealed Resident #3 had one open area and one bruise to her left arm. <BR/>Record review of Resident #3's progress note dated 2/12/25 at 2:40 am, written by LVN C revealed to continue to monitor skin tear and bruising to the left arm for Resident #3. No signs or symptoms of infection, pain, or discomfort were noted. <BR/>Record review of Resident #3's physician orders, dated 02/01/25 through 02/28/23, did not reveal any orders for monitoring bruise to the left arm.<BR/>Record review of Resident #3's physician orders, dated 02/01/25 through 02/28/25, did not reveal any orders for treating a skin tear to her left arm. <BR/>Record review of Resident #3's skin assessment dated [DATE] did not indicate a skin assessment was done after the bruise and skin tear were noted. <BR/>Record review of Resident #3's skin assessment dated [DATE] charted by LVN C did not indicate a bruise or skin tear to her left arm.<BR/>Record review of Resident #3's care plan revised on 03/26/25 did not indicate a bruise or skin tear to her left arm on 02/11/25.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN B said she was the treatment nurse. She said if a resident had a skin tear or a bruise, it should be reported to the nurse, the nurse would then report it to her, and she would assess and determine what type of treatment was needed, if any. She said if a skin tear were noted, she would look at it daily and document it in the TAR. If a bruise were noted, she would put in an order to monitor weekly till resolved. LVN B said that Resident #3 had several bruises over time because she would attempt to get up by herself. She said she could not recall this particular bruise or skin tear. She said part of her process was if a bruise or skin tear were reported, she would investigate to see what happened. She said Resident #3 was not normally able to say what happened related to her cognitive status. LVN C said if she could not figure out what happened, she would report it to the Administrator or DON.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN A said she was the charge nurse on duty when a family member reported Resident #3 had a skin tear and bruise on her left arm. LVN C said she was not aware how Resident #3 received the bruise or skin tear. She said she did not ask the staff or the family member who reported the skin tear or bruise if they knew what happened. LVN A said if an unknown skin tear or bruise was reported to her, she was supposed to notify the Administrator, DON, the physician, and the family. LVN A said she reported the bruise and skin tear to the Administrator and the DON. She said she was new to the facility during the incident and was told to do a progress note. She said she did not recall the Administrator or the DON questioning her about the incident once she reported it. She said since this incident, she had been educated to do an incident report and progress note, notify management, the physician, and the family. <BR/>During an interview on 04/09/25 at 6:55 a.m., LVN C said she was the 10 pm-6 am nurse for Resident #3. She said she could not recall the skin tear or bruise from 02/12/25 on Resident #3. LVN C said if she charted it, then it was either given to her in the report or was on the 24-hour report. She said if a bruise or skin tear occurred and staff was unaware of how it occurred, staff would report it to the ADON or DON, and they would investigate it. She said the nurses were supposed to do an incident report, document a progress note, and notify the physician, the family, the Administrator, and the DON of any skin tears or bruises of unknown origin. She said even if the nurses did not report something, it was on the 24-hour report, and management was supposed to review it daily. She said she did not recall being asked about Resident #3's skin tear or bruise by the Administrator or DON. <BR/>During an interview on 4/9/25 at 10:00 a.m., the ADON said if a resident had a bruise or skin tear of an unknown origin, she would investigate to see if she could figure out what happened. She said the nurses should document the incident in the progress notes, do an incident report, and notify the physician, the family, the Administrator, and the DON. She said the nurses were to chart the incident for 72 hours. She said even if a nurse forgot to report the incident, she would see it on the 24-hour report or while reading the nurses' notes. She said she could recall the incident on 02/11/25 but could not remember the details. The ADON reviewed Resident #3's chart and did not see an incident report on 02/11/25.<BR/>During an interview on 04/09/25 at 10:53 a.m., LVN B said she was the treatment nurse, and she had done a skin assessment on Resident #3 earlier on the 6 am-2 pm shift on 02/11/25. She said Resident #3 did not have any skin tears or bruises during her assessment. She said LVN A charted the skin tear and bruise at 6:22 pm after her shift. <BR/>During an interview on 04/09/25 at 11:03 a.m., the DON said he expected if a resident had a bruise or skin tear of an unknown source that staff would report it to him and the Administrator. He said they would do an internal investigation to see if they could see what happened, and if they could not figure out what happened, they would report it to the State of Texas. He said he could not recall the skin tear or bruise for Resident #3 around 02/11/25. He said Resident #3 had often scratched herself, or she could have bumped it on the wall, but since he did not remember investigating it, he could not say what happened. He said they do review the 24-hour reports in the morning meeting, and it must have been overlooked. He said that although he did not feel like abuse occurred, it was important to report and investigate abuse/neglect to prevent further abuse/neglect from occurring.<BR/>During an interview on 04/09/25 at 4:37 p.m., the Administrator said she was unaware of Resident #3's skin tear or bruise; therefore, it was not investigated or reported. She said she was not contacted for all skin tears or bruises, only if suspicion of abuse. She said if there was suspicion of abuse, the nurses should have called and reported it to her, and then they would have investigated and reported if needed. She said, after looking at Resident #3's chart, that LVN A was a new nurse during the incident and did not follow all the necessary steps, such as notification. She said they would educate LVN A. The Administrator said when injuries of unknown origin were not reported promptly, abuse could continue to occur. <BR/>Record review of the facility policy titled Abuse Prohibition Policy, revised 08/2020, indicated, Purpose: To ensure the facility established, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. VI. Investigation: A. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal activity. IX. Reporting: The facility will report allegations of abuse, neglect, exploitation, mistreatment, and injuries of unknown source, etc . immediately but no longer than two hours

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 6 residents (Resident #3) reviewed for abuse and neglect. <BR/>The facility staff did not report to the state agency that Resident #3 had a bruise and a skin tear to the left arm of unknown origin on 02/11/25.<BR/>This failure could place the residents at increased risk for abuse and neglect or further potential abuse due to unreported allegations of abuse and neglect.<BR/>Findings included:<BR/>Record review of Resident #3's face sheet, dated 04/09/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (diseases that affect memory, thinking, and the ability to perform daily activities), diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily living).<BR/>Record review of Resident #3's annual MDS assessment, dated 02/26/25, indicated Resident #3 rarely understood and was rarely understood by others. Resident #3's BIMS score was 00, which meant she was severely cognitively impaired. The MDS indicated Resident #3 required extensive help with toileting, bed mobility, dressing, transfers, personal hygiene, and supervision with eating. The MDS did not indicate Resident #3 had wounds or skin problems. <BR/>Record review of Resident #3's progress note dated 2/11/25 at 6:22 pm, written by LVN A, revealed Resident #3's family member reported 2 open areas to her left arm, both less than 0.25 x 0.25 in diameter. Both showed no signs of infection. The nurse provided first aid to both, and neither area showed signs of infection. The resident denied pain. The call light was in reach.<BR/>Record review of Resident #3's progress note updated 2/11/25 at 6:42 pm, written by LVN A revealed Resident #3 had one open area and one bruise to her left arm. <BR/>Record review of Resident #3's progress note dated 2/12/25 at 2:40 am, written by LVN C, revealed to continue to monitor skin tear and bruising to the left arm for Resident #3. No signs or symptoms of infection, pain, or discomfort were noted. <BR/>Record review of Resident #3's physician orders, dated 02/01/25 through 02/28/23, did not reveal any orders for monitoring bruising to the left arm.<BR/>Record review of Resident #3's physician orders, dated 02/01/25 through 02/28/25, did not reveal any orders for treating a skin tear to her left arm. <BR/>Record review of Resident #3's skin assessment dated [DATE] did not indicate a skin assessment was done after the bruise and skin tear were noted. <BR/>Record review of Resident #3's skin assessment dated [DATE], charted by LVN C, did not indicate a bruise or skin tear to her left arm.<BR/>Record review of Resident #3's care plan, revised on 03/26/25, did not indicate a bruise or skin tear to her left arm on 02/11/25.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN B said she was the treatment nurse. She said if a resident had a skin tear or a bruise, it should be reported to the nurse, the nurse would then report it to her, and she would assess and determine what type of treatment was needed, if any. She said if a skin tear were noted, she would look at it daily and document it in the TAR. If a bruise were noted, she would put in an order to monitor weekly till resolved. LVN B said that Resident #3 had several bruises over time because she would attempt to get up by herself. She said she could not recall this particular bruise or skin tear. She said part of her process was if a bruise or skin tear were reported, she would investigate to see what happened. She said Resident #3 was not normally able to say what happened related to her cognitive status. LVN C said if she could not figure out what happened, she would report it to the Administrator or DON.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN A said she was the charge nurse on duty when a family member reported Resident #3 had a skin tear and bruise on her left arm. LVN C said she was not aware how Resident #3 received the bruise or skin tear. She said she did not ask the staff or the family member who reported the skin tear or bruise if they knew what happened. LVN A said if an unknown skin tear or bruise was reported to her, she was supposed to notify the Administrator, DON, the physician, and the family. LVN A said she reported the bruise and skin tear to the Administrator and the DON. She said she was new to the facility during the incident and was told to do a progress note. She said she did not recall the Administrator or the DON questioning her about the incident once she reported it. She said since this incident, she had been educated to do an incident report and progress note, notify management, the physician, and the family. <BR/>During an interview on 04/09/25 at 6:55 a.m., LVN C said she was the 10 pm-6 am nurse for Resident #3. She said she could not recall the skin tear or bruise from 02/12/25 on Resident #3. LVN C said if she charted it, then it was either given to her in the report or was on the 24-hour report. She said if a bruise or skin tear occurred and staff were unaware of how it occurred, staff would report it to the ADON or DON, and they would investigate it. She said the nurses were supposed to do an incident report, document a progress note, and notify the physician, the family, the Administrator, and the DON of any skin tears or bruises of unknown origin. She said even if the nurses did not report something, it was on the 24-hour report, and management was supposed to review it daily. She said she did not recall being asked about Resident #3's skin tear or bruise by the Administrator or DON. <BR/>During an interview on 4/9/25 at 10:00 a.m., the ADON said if a resident had a bruise or skin tear of an unknown origin, she would investigate to see if she could figure out what happened. She said the nurses should document the incident in the progress notes, do an incident report, and notify the physician, the family, the Administrator, and the DON. She said the nurses were to chart the incident for 72 hours. She said even if a nurse forgot to report the incident, she would see it on the 24-hour report or while reading the nurses' notes. She said she could recall the incident on 02/11/25, but could not remember the details. The ADON reviewed Resident #3's chart and did not see an incident report on 02/11/25.<BR/>During an interview on 04/09/25 at 10:53 a.m., LVN B said she was the treatment nurse, and she had done a skin assessment on Resident #3 earlier on the 6 am-2 pm shift on 02/11/25. She said Resident #3 did not have any skin tears or bruises during her assessment. She said LVN A charted the skin tear and bruise at 6:22 pm after her shift. <BR/>During an interview on 04/09/25 at 11:03 a.m., the DON said he expected if a resident had a bruise or skin tear of an unknown source that staff would report it to him and the Administrator. He said they would do an internal investigation to see if they could figure out what happened, and if they could not figure out what happened, they would report it to the State of Texas. He said he could not recall the skin tear or bruise for Resident #3 around 02/11/25. He said Resident #3 had often scratched herself, or she could have bumped it on the wall, but since he did not remember investigating it, he could not say what happened. He said they do review the 24-hour reports in the morning meeting, and it must have been overlooked. He said that although he did not feel like abuse occurred, it was important to report and investigate abuse/neglect to prevent further abuse/neglect from occurring.<BR/>During an interview on 04/09/25 at 4:37 p.m., the Administrator said she was unaware of Resident #3's skin tear or bruise; therefore, it was not investigated or reported. She said she was not contacted for all skin tears or bruises, only if suspicion of abuse. She said if there was suspicion of abuse, the nurses should have called and reported it to her, and then they would have investigated and reported if needed. She said, after looking at Resident #3's chart, that LVN A was a new nurse during the incident and did not follow all the necessary steps, such as notification. She said they would educate LVN A. The Administrator said when injuries of unknown origin were not reported promptly, abuse could continue to occur. <BR/>Record review of the facility policy titled Abuse Prohibition Policy, revised 08/2020, indicated, Purpose: To ensure the facility established, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. VI. Investigation: A. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal activity. IX. Reporting: The facility will report allegations of abuse, neglect, exploitation, mistreatment, and injuries of unknown source, etc . immediately but no longer than two hours

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #64, and Resident #78) of 24 residents reviewed for accuracy of MDS assessments. <BR/>1) The facility failed to ensure that Resident #64's MDS accurately reflected the resident had received antibiotics during the 7-day look back period. <BR/>2) The facility failed to ensure that Resident's #64's MDS accurately reflected the resident had a MRSA infection to his right hip. <BR/>3) The facility failed to ensure Resident #78's MDS accurately reflected his discharge from the facility.<BR/>These failures could put residents at risk of not receiving the necessary care and services related to inaccurate MDS assessment. <BR/>Findings included: <BR/>1) Record review of Resident #64's face sheet dated 08/20/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of depression (common but serious mood disorder causing sadness), centrilobular emphysema (a form of lung disease in people who smoke that affects the upper lungs), anxiety (a feeling of nervous, restless, or tense), and heart failure (a chronic condition in which the heart does not pump blood as well as it should). <BR/>Record review of Resident #64's quarterly MDS assessment dated [DATE] indicated he made himself understood, he understood others, and he had a BIMS score of 3 which meant he had severely impaired cognition. The MDS also indicated he required maximal assistance from the staff for toileting and dressing and moderate assistance from staff for bed mobility and transfers. The MDS did not indicate Resident #64 had a MRSA diagnosis nor did it indicate he received antibiotics for the 7-day look back period. <BR/>Record review of Resident #64's care plan (that included the resolved plans) revised on 07/29/24 did not include a care plan for the diagnosis of MRSA with interventions to care for the infection to his wound. <BR/>Record review of Resident #64's Order summary reported dated 07/01/24-07/31/24 indicated he had an order for:<BR/>1) Doxycycline Hyclate oral capsule 100mg Give 1 capsule by mouth two times a day for MRSA positive to wound bed for 14 days that had a start date of 07/31/2024 and end date of 08/14/2024.<BR/>Record review of Resident #64's lab report dated 07/26/24 indicated the MRSA infection resulted on 07/28/24. <BR/>During an interview on 08/22/24 at 02:56 PM, the MDS Nurse said that Resident #64 was taking the antibiotics as of 08/22/24 but he was unaware at the time he completed the MDS, dated [DATE]. He said 7 days of antibiotics and the MRSA infection should have been coded on the MDS for accuracy and to ensure the facility was providing the correct care. The MDS Nurse said he was responsible for all the facility MDS's, and the information submitted. <BR/>During an interview on 08/22/24 at 03:23 PM, the DON said he expected the MRSA and the antibiotics to be on the MDS assessment dated [DATE]. He said the failure placed a risk for improper care for Resident #64. The DON said the MDS Nurse was responsible for ensuring accurate information was submitted in the MDS assessments. <BR/>During an interview on 08/22/24 at 03:35 PM, the Administrator said her expectation was for the antibiotics and the MRSA infection to have been included in the MDS assessment dated [DATE]. She said the MDS Nurse was responsible for all the MDS assessments. The Administrator said information about antibiotics and MRSA infection being included in the MDS was important to ensure the resident received proper treatment and to ensure accuracy of the information that was being sent to CMS. <BR/>2.Record review of Resident #78's face sheet, dated 08/22/24 indicated Resident #78 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Metabolic encephalopathy (ME - a group of neurological disorders that affect the brain due to chemical imbalances in the blood), Hepatitis C (a viral infection that causes liver inflammation and can lead to serious liver damage), and high blood pressure.<BR/>Record review of Resident #78's quarterly MDS assessment, dated 07/07/24, indicated Resident #78 was discharged from the facility to the hospital.<BR/>Record review of Resident #78's nurse's note dated 07/16/24 written by the Social Worker indicated Resident #78 was discharged on 07/16/24 with meds. The discharge was initiated per the resident. Resident #78 was transported per medical transport to his residence.<BR/>During an interview on 08/22/24 at 1:42 p.m., the MDS nurse said he was responsible for the completion of the MDS assessments. He looked at section A on Resident # 78 and said he coded his discharge incorrectly. He said he got his information from hearsay instead of the chart. He said it was important to code the MDS assessment correctly because it reflected their care and reimbursement. He said he would update their assessments and resend them to the state.<BR/>During an interview on 08/22/24 at 1:51 p.m., the ADON said the MDS Coordinator was responsible for completing the MDS assessments. The ADON stated she did not know why the MDS indicated Resident # 78 was discharged to the hospital. The ADON stated it was important for the MDS assessments to be accurately coded to make sure they provide the residents with the care they needed. <BR/>During an interview on 08/22/24 at 2:20 p.m., the DON said the MDS Coordinator was responsible for completing the MDS assessments. The DON said it was a mistake in the MDS coding for Resident #78 being discharged to the hospital from the facility. The DON stated the MDS assessment was important to ensure the care was going right, and the bill was correct as well. <BR/>During an interview on 08/22/24 at 3:00 p.m. the Administrator said the MDS Coordinator was responsible for completing the MDS assessments. She said she was his overseer The Administrator said she expected the coding on the MDS assessments to be accurate.<BR/>Record review of the facility policy titled, Minimum Data Set Policy, unknown date, indicated The purpose: to utilize the most current version of the resident assessment instrument manual to guide all IDT members on the proper procedure for coding items on the MSDS assessment, completion of care area assessment, and other instructions related to MSDS procedure.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities based on the comprehensive assessment to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 (08/21/24 and 08/22/24) of 2 days reviewed for quality of life.<BR/>The facility failed to ensure 4 of 8 scheduled activities were provided according to the August 2024 activity schedule on 08/21/2024 and 08/22/2024.<BR/>This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.<BR/>Findings included:<BR/>Record review of the Activity Calendar dated August 2024 indicated the following: <BR/>Wednesday 08/21/2024: 09:30 AM balloon tennis; 10:30 AM Left-Right-Center game; 2:30 PM bean bag toss; 03:30 PM Help Your Neighbor<BR/>Thursday 08/22/2024: 09:30 AM ball toss; 10:30 AM Left-Right-Center game; 02:30 PM Dominoes; 03:30 PM Skip Bo.<BR/>During an observation on 08/21/2024 at 02:35 PM, the bean bag toss activity was not happening in the dining room. <BR/>During an observation and interview on 08/21/2024 at 03:30 PM, an anonymous resident was sitting in the wheelchair looking at the activity calendar and stated there was not much activity in the facility mainly popcorn and bingo on some Fridays even though the calendar had an activity scheduled. <BR/>During an observation on 08/21/2024 at 03:35 PM, the Help your Neighbor activity was not happening in the dining room. <BR/>During an observation on 08/22/2024 at 09:35 AM PM the ball toss activity was not happening in the dining room. <BR/>During an observation on 08/22/2024 at 3:30 PM the Skip Bo activity was not happening in the dining room.<BR/>During an interview on 08/22/2024 at 03:40 PM., the Business Office Manager said the facility activities usually occurred in the dining room. The Business office Manager said the Activity Director was not in the facility at that time. <BR/>During an interview on 08/22/2024 at 4:10 PM, the Activity Director said she had been the Activity Director since 2017. The AD said she left the facility to pick up her grandchildren from school. The Activity Director said she usually picked them up from the school daily during the week. The Activity Director said she probably needed to adjust the scheduled activities because she picked up her grandchildren from school during the scheduled 3:30 PM activity and was not in the facility. The Activity Directory said the residents that were bedridden received one on one activities. The Activity Director said some residents did better in small groups and the larger groups were for the more outgoing residents. The Activity Director said she had done the ball toss activity with a resident in the front lobby area in the morning, but she did not have a lot of time because she had to watch the residents smoke. The Activity Director said she had not done the bean bag toss or the ball toss in the dining hall yesterday (08/21/2024) or today (08/22/2024). The Activity Director said the residents liked for her to take them out to smoke because they trusted her. The Activity Director said she did not mind taking the residents out to smoke because she smoked also. The Activity Director said she was unable to recall any other times when an activity was cancelled or not done. She stated a possible negative outcome for not having new games that were stimulating for the residents could be depression and memory loss. The Activity Director stated a possible negative outcome for not conducting activities that were scheduled could be boredom and depression.<BR/>During an interview on 08/22/2024 at 4:17 PM, the DON said the activities were expected and should be conducted per the scheduled times listed on the activity calendar. The DON said without meaningful activities held per the calendar the residents could become depressed. <BR/>During an interview on 08/22/2024 at 4:22 PM, the Administrator said the activities should be scheduled and conducted per the resident's activity calendar. The Administrator said when activities were not held as scheduled, the residents could become bored, lose interest, and potentially become depressed. The Administrator said she had oversight of the Activity Director. The Administrator said she was aware of the Activity Director being out of the facility but had not realized the activities were scheduled and missed during this time. <BR/>Record review of facility policy titled Activities Program with a revised date of 006/2020 did not address conducting scheduled activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 3 residents (Resident #54 and Resident #75) reviewed for respiratory care.<BR/>1. The facility did not ensure Resident #54 had a physician's order for oxygen that she wore continuously. <BR/>2. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #75.<BR/>These failures could place residents who receive respiratory care at risk for developing respiratory complications.<BR/>The findings included: <BR/>1. Record review of the face sheet, dated 07/11/2023, revealed Resident #54 was an [AGE] year-old female who initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of chronic respiratory failure with hypoxia (not enough oxygen in the blood), shortness of breath, and COPD - chronic obstructive respiratory disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs).<BR/>Record review of the MDS assessment, dated 06/27/2023, revealed Resident #54 had clear speech and was usually understood by staff. The MDS revealed Resident #54 was usually able to understand others. The MDS revealed Resident #54 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #54 had shortness of breath or trouble breathing with exertion (walking, bathing, transferring), when sitting at rest, and when lying flat. The MDS revealed Resident #54 received oxygen while a resident at the facility during the 14-day look-back period. <BR/>Record review of the comprehensive care plan, revised on 04/11/2023, revealed Resident #54 had a diagnosis of COPD. The interventions included Give oxygen therapy as ordered by the physician.<BR/>Record review of the order summary report, dated 07/12/2023, revealed Resident #54 had no physician order for oxygen.<BR/>During an observation and interview on 07/10/2023 at 9:09 AM, Resident #54 was sitting up in her bed with the head of the bed elevated. She was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute. Resident #54 stated she had worn oxygen continuously, since she admitted to the facility, because she had problems breathing. Resident #54 stated the facility staff change her oxygen tubing weekly and checked her oxygen saturations daily.<BR/>During an observation on 07/10/2023 at 2:18 PM, Resident #54 was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute. <BR/>During an observation on 07/11/2023 at 9:33 AM, Resident #54 was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute.<BR/>During an observation on 07/11/2023 at 4:25 PM, Resident #54 was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute.<BR/>During an interview on 07/13/2023 at 2:03 PM, LVN E stated Resident #54 wore oxygen continuously. LVN E stated the charge nurses were responsible for putting orders for oxygen in the electronic charting system. LVN E stated Resident #54 should have a physician's order for oxygen. LVN E stated the order probably did not get put back on when she came back from the hospital. LVN E stated the nurses try to check each other when residents readmit from the hospital. LVN E stated it was important to ensure Resident #54 had a physician's order for oxygen because you need a doctor's order for it. <BR/>During an interview on 07/13/2023 at 3:43 PM, the DON stated nurses were responsible for ensuring physician orders for oxygen were in the computer. The DON stated that was monitored by reconciling with the physician and performing 24-72-hour chart audits and admissions and readmission. The DON stated Resident #54 should have a physician's order for oxygen. The DON stated she expected nursing staff to ensure a physician's order for oxygen was placed in the electronic monitoring system. The DON stated it was important to ensure an order for oxygen was placed in the computer for the safety and well-being of residents and to follow the plan of care. <BR/>During an interview on 07/14/2023 at 12:04 PM, the Administrator stated he expected the nursing staff to ensure an order for oxygen was placed in the computer. The Administrator stated the DON and ADON were responsible for monitoring orders during the clinical morning meeting. The Administrator stated it was important to ensure orders were placed in the computer to ensure the facility staff are following all physician's orders and provide treatment that was required. <BR/>2. Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), acute respiratory failure with hypoxia (not enough oxygen in blood), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (chronic condition that affects the way the body processes blood sugar with progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). <BR/>Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #75 was usually understood and usually understood others. The MDS assessment indicated Resident #75's BIMS was an 8, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #75 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS assessment indicated Resident #75 was receiving oxygen therapy.<BR/>Record review of Resident #75's care plan with date initiated 07/11/2023, indicated he had altered respiratory status/difficulty breathing related to a pulmonary nodule (small growth in the lungs that can be non-cancerous or cancerous) with an intervention to provide oxygen as ordered. <BR/>Record review of Resident #75's order summary report dated 07/11/2023, indicated an order to check oxygen saturation three times a day, as needed, and every shift, and apply oxygen at 2 liters per minute via nasal canula for oxygen saturation less than 90% with a start date of 06/30/2023. <BR/>During an observation on 07/10/2023 at 11:02 AM, Resident #75 was sitting on the side of the bed with oxygen on via nasal canula at 4 liters per minute. <BR/>During an observation on 07/12/2023 at 9:05 AM, Resident #75 was in bed with oxygen via nasal canula on, set between 3-4 liter per minute. <BR/>During an interview on 07/12/2023 at 5:48 PM, RN B said oxygen should be administered per the physician's orders. RN B said Resident #75's oxygen should have been set at 2 liter per minute per the physician's order, and he only used it as needed. RN B said setting the oxygen higher than the prescribed rate could make the residents sicker. <BR/>During an interview on 07/13/2023 at 9:01 AM, the ADON said the nurses were responsible for making sure oxygen was administered per the physician's order. The ADON said the nurses should be checking the oxygen to make sure it was set at the correct prescription. The ADON said if the oxygen was set higher than the prescribed rate it could be counterproductive for certain diseases and could cause more harm than good. <BR/>During an interview on 07/13/2023 at 10:40 AM, the DON said the nurses were responsible for ensuring oxygen was administered per the physician's order. The DON said Resident #75's oxygen via nasal canula was as needed, and he could put it on himself when he felt short of breath. The DON said setting the oxygen higher than the physician's order could cause lightheadedness and dizziness. <BR/>During an interview on 07/13/2023 at 2:34 PM, the Administrator said the charge nurses were responsible for making sure oxygen was administered per the physician's order. The Administrator said he expected the nurses to follow the physicians' orders. The Administrator said it was important that oxygen be administered per the physician's order to avoid respiratory distress. <BR/>Record review of the facility's policy titled, Oxygen Administration, with date revised 06/2020, indicated, . Initiation of oxygen A. A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include: i. Oxygen flow rate ii. Method of administration (e.g., nasal cannula) iii. Usage of therapy (continuous or prn) iv. Titration instructions (if indicated) v. Indication of use . Explain the procedure to the resident II. Check the physician's order . VI. Turn on oxygen at the prescribed rate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 2 residents (Resident #75) reviewed for dialysis. <BR/>The facility failed to have physician's orders for the care of Resident #75's central venous catheter used for dialysis (a long, flexible tube inserted into a vein in your neck, chest, arm, or groin and leads to a large vein that empties into your heart and is used as a dialysis access). <BR/>The facility failed to care plan Resident #75's central venous catheter used for dialysis. <BR/>These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs.<BR/>Findings included:<BR/>Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (chronic condition that affects the way the body processes blood sugar with progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). <BR/>Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #75 was usually understood and usually understood others. The MDS assessment indicated Resident #75's BIMS was 8, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #75 received dialysis while a resident at the facility.<BR/>Record review of Resident #75's care plan with date initiated 06/26/2023 did not indicate his central venous catheter was care planned. <BR/>Record review of Resident #75's order summary report dated 07/11/2023 did not indicate physician orders for his central venous catheter. <BR/>During an observation and interview on 07/10/2023 at 10:15 AM, Resident #75 was in his bed central venous catheter observed to right chest, dressing was not adhered from the bottom, and it had brownish-tinged spots on it. Resident #75 said he was going to dialysis later that day. <BR/>During an interview on 07/12/2023 at 3:34 PM, Dialysis RN G said the Resident #75 should have orders to monitor the central venous catheter due to the risk of infection. Dialysis RN G said if the central venous catheter dressing was not completely adhered the facility needed to contact the dialysis clinic for further instructions.<BR/>During an interview on 07/12/2023 at 6:28 PM, LVN A said she was aware Resident #75 had a central venous catheter to his right chest and it was used for his dialysis. LVN A said she had not noticed on 07/10/2023 that his dressing was soiled and not completely adhered. LVN A said she had been checking Resident #75's catheter. LVN A said she was not aware Resident #75 did not have physician orders for his central venous catheter. LVN A said the admitting nurse should have obtained physician orders for the central venous catheter. LVN A said it was important for Resident #75 to have physician orders for his central venous catheter because of the risk of infection. <BR/>During an interview on 07/13/2023 at 8:45 AM, the ADON said on admission the nurse was supposed to call the doctor to get orders for Resident #75's central venous catheter used for dialysis. The ADON said she was not sure why Resident #75 did not have physician orders for his central venous catheter. The ADON said Resident #75's central venous catheter should have been care planned. The ADON said the MDS Coordinator should have care planned Resident #75's central venous catheter. The ADON said it was important to have physician orders for the central venous catheter for prevention of infection and to prevent dislodgment. The ADON said it was important for Resident #75's central venous catheter to be included in his care plan, so that everybody knew it was there and how staff should take care of it. <BR/>During an interview on 07/13/2023 at 9:16 AM, the DON said Resident #75 should have had orders for his central venous catheter to monitor for signs and symptoms of infection and for dressing changes. The DON said the physician orders should have been obtained on admission. The DON said it was important to have orders for the central venous catheter because of the risk of infection. The DON said Resident #75's central venous catheter should have been included in his care plan. The DON said the MDS Coordinator was responsible for including Resident #75's central venous catheter in the care plan. The DON said it was important for Resident #75's central venous catheter to be included in the care plan for the staff to know how to care for the central venous catheter. <BR/>During an interview on 07/13/2023 at 2:28 PM, the Administrator said the charge nurses were responsible for obtaining physician orders for a central venous catheter. The Administrator said the DON and ADON should make sure the central venous catheter was included in the care plan. The Administrator said he expected the nurses to obtain physician orders for the care of a central venous catheter, and he expected for the care plan to include a central venous catheter. The Administrator said it was important to have physician orders and care plan a central venous catheter to appropriately care for the residents and because of the risk of infection. <BR/>During an interview on 07/13/2023 at 3:58 PM, the MDS Coordinator said a central venous catheter used for dialysis should be included in the resident's care plan. The MDS Coordinator said she was responsible for including a central venous catheter in the care plan. The MDS Coordinator said Resident #75's central venous catheter was not included in his care plan because he had no physician orders for the central venous catheter. The MDS Coordinator said when she created the residents care plans, she used the MDS assessment and the physician orders. The MDS Coordinator said it was important for Resident #75's central venous catheter to be included in his care plan because the staff needed to monitor the site, perform dressing changes, and monitor for signs and symptoms of infection. <BR/>Record review of the facility's policy titled, Dialysis Care, last revised 06/2020, indicated, .The Facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment . The Licensed Nurse will monitor the integrity of the catheter dressing every shift and reinforce the dressing with tape as needed . The Interdisciplinary Team (IDT) will ensure that the resident's Care Plan includes documentation of the resident's renal condition and necessary precautions .

**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 psychotropic drugs (without adequate behavior monitoring or side effects) for 1 (Resident #179) of 5 residents reviewed for unnecessary meds.<BR/>1. The facility failed to ensure Resident #179 had behavior monitoring for Bupropion HCL ER(Wellbutrin) and Sertraline (Zoloft) used for depression.<BR/>2. The facility failed to ensure Resident #179 had side effect monitoring for Clonazepam (Klonopin) used for anxiety. <BR/>These failures could place residents at risk of possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.<BR/>Findings included:<BR/>Record review of Resident #179's face sheet, dated 08/22/24, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses which included Spinal stenosis (pain in the lower back, that can cause cramping in one or both legs), Schizophrenia (a chronic mental illness that affects how a person thinks, feels, and behaves), depression (sadness), and post-traumatic stress disorder also known as PTSD (a mental health condition that's caused by an extremely stressful or terrifying event).<BR/>Record review of Resident #179's admission MDS assessment, dated 08/12/24, indicated Resident #179 understood and was understood by others. Resident #179's BIMS score was 15, which indicated he was cognitively intact. The MDS indicated Resident #179 required extensive help with toileting bed mobility, dressing, transfer, setup for personal hygiene, and being independent with eating. The MDS indicated he took antianxiety and antidepressant medication during the 7-day look-back period.<BR/>Record review of Resident #179's physician's order dated 08/05/24 for Bupropion HCL ER(Wellbutrin) 150mg, give 1 tablet by mouth daily for depression.<BR/>Record review of Resident #179's physician's order dated 08/05/24 for Sertraline (Zoloft) 50mg, give 1 tablet by mouth daily for depression.<BR/>Record review of Resident #179's physician's order dated 08/05/24 for Clonazepam (Klonopin) 1 mg, give 1 tablet by mouth at bedtime for anxiety.<BR/>Review of Resident #179's medication administration record dated 08/05/24 through 08/22/24 revealed Resident #179 took Bupropion HCL ER(Wellbutrin) 1 tab daily for depression, Sertraline (Zoloft) 1 tab daily for depression, and Clonazepam (Klonopin) 1 tab at bedtime for anxiety.<BR/>Review of Resident #179's medication administration record dated 08/05/24 through 08/22/24 did not reveal any behavioral monitoring for Bupropion HCL ER(Wellbutrin) or Sertraline (Zoloft) 1 tab daily for depression.<BR/>Review of Resident #179's medication administration record dated 08/05/24 through 08/22/24 did not reveal any side effect monitoring for Clonazepam (Klonopin) 1 tab at bedtime for anxiety.<BR/>During an interview on 08/21/24 at 4:05 p.m., LVN A said she was Resident #179's nurse. LVN B said she was not aware Resident #179 did not have his monitoring in place for his psychoactive medications. LVN B said the nurses should put monitoring and side effects in place once they received the order for psychotropic meds. She said if the nurse failed to put monitoring in place the resident might not have the proper monitoring to see if the medication was effective or not and may not know which side effects to look for.<BR/>During an interview on 08/22/24 at 1:51 p.m., the ADON said the nurses were responsible for adding the behavior monitoring and the side effects when the resident received an order for psychotropic medication. She said she and the DON were responsible for checking behind the nurses to ensure they added the behavior monitoring and or side effects for psychotropic medications. She said behavior monitoring should be in place to see if the medication was effective. The ADON said side effects monitoring should be in place to see if the resident could be experiencing any side effects from the medication. She said if they did not monitor behavior they would not know if the medication was effective or if they needed to increase or decrease the medication.<BR/>During an interview on 08/22/24 at 2:20 p.m., the DON said the admission nurse or nurse receiving the order was responsible for putting orders in for behavior and side effects monitoring. He said they put a blank statement such as monitor for any side effects or behavior until they got to know the resident better and then they would make it more specific as they learned the resident. He said the IDT was responsible for ensuring side effects or behavior monitoring was in place. He said not documenting could cause a delay in notification to the doctor. He said it was important to document behaviors and side effects of medication to observe for adverse reactions and to know if it was effective. <BR/>During an interview on 08/22/24 at 3:00 PM, the Administrator said behavior and side effect monitoring should be done for psychotropic medications. She said she expected the nurses to document behavior and intervention when the medication was given. She said the ADON/DON were responsible for ensuring side effects and behavior monitoring were done. She said it was important to track to see if the medication was needed and if it worked. <BR/>Record review of the facility policy, Guidelines for Psychotherapeutic Medication unknown date, indicated Antipsychotic medication: residents with a mental health diagnosis may be admitted on psychotropic medications that that the diagnosis shall be noted on the physician order and the physician shall be responsible for obtaining informed consent. II. Antidepressant medication: residents receiving antidepressant drugs shall have behaviors and side effects monitored on the medication administration record. Dose reductions are not required however, monitoring to ensure that residents are improving on the medication is required. III. Anti-anxiety medication: non-drug intervention shall be tried to decrease the resident's anxiety . When a resident displays behavioral symptoms (i.e., crying, hollering, hitting, resisting care, etc.) The facility staff shall assess the behavioral symptoms to determine possible causal factors and implement non-drug interventions to alleviate the behavioral symptoms prior to initiating psychotherapy agents. All assessments, interventions, and outcomes shall be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #1 and Resident #2) reviewed for infection control.<BR/> The facility failed to ensure LVN D wore the proper PPE (gown and gloves) while checking Resident #1's blood sugar or administering insulin on 04/08/25, who was positive for ESBL.<BR/>The facility failed to ensure CNA E wore the proper PPE (gown and gloves) while providing care to Resident #1, who was positive for ESBL on 04/09/25. <BR/>The facility failed to ensure Resident #2 understood contact isolation precautions when the resident was in activities with other residents and positive for MRSA on 04/08/25.<BR/>These failures could place residents and staff at risk for cross-contamination and spread of infection and could potentially affect all others in the building. <BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included urinary tract infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), extended-spectrum beta-lactamase also known as ESBL (occurs when bacteria producing the enzyme ESBL, which renders them resistant to many common antibiotics, causes an infection), diabetes (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), and stroke.<BR/>Record review of Resident 1's quarterly MDS assessment, dated 02/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 03, indicating she was severely cognitively impaired. The MDS indicated Resident #1 required assistance with his transfers, toileting, dressing, hygiene, and supervision for eating. The MDS indicated she was always incontinent of urine and was on an antibiotic.<BR/>Record review of Resident #1's electronic medical records revealed a urinalysis dated 04/05/25 which detected extended-spectrum beta-lactamase, also known as ESBL.<BR/>Record review of Resident #1's comprehensive care plan dated 04/06/25 indicated Resident #1 had a UTI. The intervention was for staff to encourage adequate fluids and monitor side effects. The care plan did not indicate Resident #1 was on contact isolation.<BR/>Record review of Resident #1's physician's order dated 04/07/25 indicated: Doxycycline 100mg, give 1 capsule by mouth two times a day related to Urinary tract infection for 5 days. <BR/>Record review of Resident #1's Physician order dated 04/07/25 indicated contact isolation precautions in place related to the diagnosis of ESBL.<BR/>During an observation on 04/08/25 at 12:09 p.m., a contact isolation sign was noted on Resident #1's door. LVN D walked into Resident #1's room to check her blood sugar without applying a gown. LVN D reached over Resident #1 to check her blood sugar on her left finger. LVN D then left Resident #1's room to gather her insulin, reentered the room without a gown, and administered her insulin.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN A said she was the nurse who received Resident #1's diagnosis of ESBL related to her lab results and the order for Doxycycline. She said she gave the initial dose on 04/07/25 and posted an isolation sign on Resident #1's door. She said she reported it to the oncoming nurse about Resident #1's isolation and new order for Doxycycline. She said she also placed it on the 24-hour report sheet.<BR/>During an interview on 04/09/25 at 9:15 a.m., LVN D said she was the charge nurse for Resident #1 and Resident #2. She said Resident #1 was on contact precautions for ESBL in her urine, and Resident #2 was on contact precautions for MRSA in her urine. LVN D said staff should have on a gown and gloves when entering Resident #1 and Resident #2's rooms. She said she did not wear a gown when she went into Resident #1's room to check her blood sugar or when she administered her insulin. She said she honestly forgot she was in contact isolation. She said Resident #2 had rights, and if she wished to come out of her room, then she could. She said she could not recall if she had personally asked Resident #2 to stay in her room related to her contact isolation orders. She said if staff were not wearing gowns or gloves, they could spread the infection to others.<BR/>During an observation on 04/09/25 at 9:45 a.m., CNA E went into Resident #1's room to provide care. CNA E did not have on her gown or gloves when entering Resident #1's room. <BR/>During an observation and interview on 04/09/25 at 10:09 a.m., CNA E came out of Resident #1's room and disposed of her linen in the laundry barrel without it being in a yellow bag. She said she was aware Resident #1 was on contact precautions for something in her urine. She said she did not see a cart next to her door and did not see any boxes in her room, so she assumed she did not have to wear anything while in the room. She said that in the past, if a resident was on isolation, they would have a cart with equipment next to the door and boxes in the room with red bags for the trash and yellow bags for the linen. She said she worked yesterday (04/08/25) and did not wear a gown while providing care for Resident #1. She said she could spread infection since she did not properly dispose of her linen or wear a gown while in the room. <BR/>During an observation on 04/09/25 at 10:15 a.m., no linen or trash boxes were noted in Resident #1's room. The isolation cart was noted 1 door to the right of Resident#1's room.<BR/>2.Record review of Resident #2's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia(a general term for a group of diseases that cause a decline in memory, thinking, and reasoning abilities, significantly affecting a person's daily life), Urinary Tract Infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), and anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident 2's quarterly MDS assessment, dated 01/30/25, indicated Resident #2 usually understood and was usually understood by others. Resident #2's BIMS score was 15, indicating she was cognitively intact. The MDS indicated Resident #2 required set-up assistance with her dressing and hygiene, independent with toileting and eating. The MDS indicated she was continent of bladder.<BR/>Record review of Resident #2's comprehensive care plan dated 03/29/23 indicated Resident #1 was occasionally incontinent of urine. The intervention was for staff to monitor for signs and symptoms of UTI. The care plan did not indicate a care plan for contact isolation or refusal to comply with contact isolation. <BR/>Record review of Resident #2's electronic medical records revealed a urinalysis dated 04/03/25, which detected MRSA (an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections). <BR/>Record review of Resident #2's physician's order dated 04/06/25 indicated: Rifampin 300mg, give 1 capsule by mouth two times a day related to MRSA in urine until 04/20/25. <BR/>Record review of Resident #2's Physician order dated 04/06/25 indicated Contact isolation precautions in place related to MRSA.<BR/>Record review of Resident #2's comprehensive care plan after surveyor intervention was dated 04/06/25 but updated on 04/09/25, indicating Resident #1 required isolation. The intervention was to follow facility isolation policy and give medication as ordered.<BR/>During an observation on 04/08/25 at 11:00 a.m., Resident #2 was in the dining room attending an activity with 8 other residents while positive for MRSA.<BR/>During an interview on 04/08/25 at 3:30 p.m., Resident #2 said the staff told her she had something in her bladder and to make sure she washed her hands after using the bathroom. She said they did not tell her she had something that someone might catch or to stay in her room.<BR/>During an observation on 04/09/25 at 9:28 a.m., Resident #2 was in the day room sitting on the couch talking to another resident.<BR/>During an interview on 04/09/25 at 10:00 a.m., the ADON said if a resident were in contact isolation, staff would know because of the sign posted on the door. She said staff should wear gowns and gloves when they enter contact-isolated rooms. She said they encourage handwashing before and after care for all residents. She said she was not sure what the policy said on contact isolation for a resident. She said she thought the contact isolated residents could walk the facility. She said she knew they had educated Resident #2 on hand washing.<BR/>During an interview on 04/09/25 at 11:22 a.m., the DON said he expected all staff to follow the guidelines on the sign posted on the door. He said they should be wearing the proper PPE (gown and gloves) to protect themselves and to keep the spread of infection from other residents. He said if the resident were on contact isolation, then staff should be educating the resident on why they need to stay in their room and encouraging them to stay in their rooms. If the resident refuses to stay in their room, then the staff should document the refusal and add it to the resident's care plan.<BR/>During an interview on 04/09/25 at 12:16 p.m., the Administrator said when a resident was on contact isolation, staff should wear gowns and gloves when entering the room. She said the DON oversaw infection control. The Administrator said staff should ensure they had on the proper PPE to protect themselves and the residents and to prevent the spread of infection. She said residents who were on contact isolation should be encouraged to stay in their rooms and practice good hygiene to prevent the spread of infection. <BR/>Record review of the facility's policy titled, Infection Prevention and Control Program, revised 06/2020, indicated, Purpose: Ensure the facility established and maintained an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements. Policy: The facility must establish an infection prevention and control program under which it: #1 identifies, investigates, controls, and prevents infections in the facility .<BR/>Record review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions, revised 6/2020, indicated, To ensure that transmission-based precautions are used when caring for residents with communicable diseases or transmittable infections. III. Contact Precautions A. Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. I. Examples of infections requiring Contact Precautions include, but are not limited to: A. Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-drug resistant organisms (e.g., MRSA). C. Gloves and Handwashing: I. As outlined under Standard Precautions, gloves (clean, non-sterile) are worn when entering the room. D. Gown: I. As outlined under Standard Precautions, a (clean, non-sterile) gown is worn for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. G. Notice: I. The Facility alerts staff to the type of precaution a resident requires. ii. The Facility also ensures that the resident's care plan indicates the type of precautions implemented for the resident. iii. The Facility may utilize a sign requesting visitors to check in at the nursing station before entering a resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents environment remained free of accident hazards for 1 of 26 residents (Residents #11) reviewed for accident hazards. The facility failed to ensure a safe environment to prevent accidents and hazards for Residents #11 by not ensuring 3 razors (1 razor that did not have a cover over the blades and 2 razors in the open package) in his drawer were stored securely. This failure could place residents at risk for injuries. Findings included: Record review of Resident #11's face sheet dated 09/10/25 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses legal blindness, high blood pressure, malignant neoplasm of the prostate (prostate cancer), and depression. Record review of Resident #11's quarterly MDS assessment dated [DATE] indicated he usually understood others and usually made himself understood. The MDS also indicated he had a BIMS score of 15 which meant he was cognitively intact. The MDS also indicated he required total assistance with toileting, transfers, bathing, and bed mobility and required setup assistance for eating and hygiene. Record review of Resident #11's undated care plan indicated he had impaired visual function related to cataracts, poor vision, and macular degeneration and ADL self-care performance deficit with interventions of dependent staff participation in toileting, transfers, bed mobility, bathing, and personal hygiene. During an interview and observation on 09/08/25 at 3:05 PM, Resident #11 said the facility removed items from the residents' rooms in the facility and then returned items back to them. Resident #11 told surveyor to look in his drawer. Resident #11 had 3 razors (1 razor that did not have a cover over the blades and 2 razors in the open package). He said the staff shaved him when needed. During an interview on 09/10/2025 at 4:58 PM, the ADON said Resident #11 should not have had the razors in his room. She said the failure placed a risk for someone getting the razors and cutting themselves. She stated the facility does have wanders that goes all over the facility and open doors. During an interview on 09/10/2025 at 6:08 PM, Tthe DON said Resident #11 should not have had the razors in his room. The DON said the failure placed a risk for other residents getting the razors out of the drawers and cutting themselves, and the risk for Resident #11 using the wrong items related to him being blind. She said Resident #11 could have reached in drawer and cut himself. During an interview on 09/10/2025 at 6:23 PM, the Administrator said Resident #11 should not have had the razors in his drawers. She said the razors were hazardous items and placed a risk for Resident #11 cutting his hands. The Administrator said the department heads were responsible for monitoring each residents' room daily. She said the CNAs should have removed the razors after care. Record review of the facility's policy Resident Rooms and Environment revised 08/2020 indicated:PurposeTo provide residents with a safe, clean, comfortable and homelike environment.PolicyThe Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #1 and Resident #2) reviewed for infection control.<BR/> The facility failed to ensure LVN D wore the proper PPE (gown and gloves) while checking Resident #1's blood sugar or administering insulin on 04/08/25, who was positive for ESBL.<BR/>The facility failed to ensure CNA E wore the proper PPE (gown and gloves) while providing care to Resident #1, who was positive for ESBL on 04/09/25. <BR/>The facility failed to ensure Resident #2 understood contact isolation precautions when the resident was in activities with other residents and positive for MRSA on 04/08/25.<BR/>These failures could place residents and staff at risk for cross-contamination and spread of infection and could potentially affect all others in the building. <BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included urinary tract infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), extended-spectrum beta-lactamase also known as ESBL (occurs when bacteria producing the enzyme ESBL, which renders them resistant to many common antibiotics, causes an infection), diabetes (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), and stroke.<BR/>Record review of Resident 1's quarterly MDS assessment, dated 02/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 03, indicating she was severely cognitively impaired. The MDS indicated Resident #1 required assistance with his transfers, toileting, dressing, hygiene, and supervision for eating. The MDS indicated she was always incontinent of urine and was on an antibiotic.<BR/>Record review of Resident #1's electronic medical records revealed a urinalysis dated 04/05/25 which detected extended-spectrum beta-lactamase, also known as ESBL.<BR/>Record review of Resident #1's comprehensive care plan dated 04/06/25 indicated Resident #1 had a UTI. The intervention was for staff to encourage adequate fluids and monitor side effects. The care plan did not indicate Resident #1 was on contact isolation.<BR/>Record review of Resident #1's physician's order dated 04/07/25 indicated: Doxycycline 100mg, give 1 capsule by mouth two times a day related to Urinary tract infection for 5 days. <BR/>Record review of Resident #1's Physician order dated 04/07/25 indicated contact isolation precautions in place related to the diagnosis of ESBL.<BR/>During an observation on 04/08/25 at 12:09 p.m., a contact isolation sign was noted on Resident #1's door. LVN D walked into Resident #1's room to check her blood sugar without applying a gown. LVN D reached over Resident #1 to check her blood sugar on her left finger. LVN D then left Resident #1's room to gather her insulin, reentered the room without a gown, and administered her insulin.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN A said she was the nurse who received Resident #1's diagnosis of ESBL related to her lab results and the order for Doxycycline. She said she gave the initial dose on 04/07/25 and posted an isolation sign on Resident #1's door. She said she reported it to the oncoming nurse about Resident #1's isolation and new order for Doxycycline. She said she also placed it on the 24-hour report sheet.<BR/>During an interview on 04/09/25 at 9:15 a.m., LVN D said she was the charge nurse for Resident #1 and Resident #2. She said Resident #1 was on contact precautions for ESBL in her urine, and Resident #2 was on contact precautions for MRSA in her urine. LVN D said staff should have on a gown and gloves when entering Resident #1 and Resident #2's rooms. She said she did not wear a gown when she went into Resident #1's room to check her blood sugar or when she administered her insulin. She said she honestly forgot she was in contact isolation. She said Resident #2 had rights, and if she wished to come out of her room, then she could. She said she could not recall if she had personally asked Resident #2 to stay in her room related to her contact isolation orders. She said if staff were not wearing gowns or gloves, they could spread the infection to others.<BR/>During an observation on 04/09/25 at 9:45 a.m., CNA E went into Resident #1's room to provide care. CNA E did not have on her gown or gloves when entering Resident #1's room. <BR/>During an observation and interview on 04/09/25 at 10:09 a.m., CNA E came out of Resident #1's room and disposed of her linen in the laundry barrel without it being in a yellow bag. She said she was aware Resident #1 was on contact precautions for something in her urine. She said she did not see a cart next to her door and did not see any boxes in her room, so she assumed she did not have to wear anything while in the room. She said that in the past, if a resident was on isolation, they would have a cart with equipment next to the door and boxes in the room with red bags for the trash and yellow bags for the linen. She said she worked yesterday (04/08/25) and did not wear a gown while providing care for Resident #1. She said she could spread infection since she did not properly dispose of her linen or wear a gown while in the room. <BR/>During an observation on 04/09/25 at 10:15 a.m., no linen or trash boxes were noted in Resident #1's room. The isolation cart was noted 1 door to the right of Resident#1's room.<BR/>2.Record review of Resident #2's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia(a general term for a group of diseases that cause a decline in memory, thinking, and reasoning abilities, significantly affecting a person's daily life), Urinary Tract Infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), and anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident 2's quarterly MDS assessment, dated 01/30/25, indicated Resident #2 usually understood and was usually understood by others. Resident #2's BIMS score was 15, indicating she was cognitively intact. The MDS indicated Resident #2 required set-up assistance with her dressing and hygiene, independent with toileting and eating. The MDS indicated she was continent of bladder.<BR/>Record review of Resident #2's comprehensive care plan dated 03/29/23 indicated Resident #1 was occasionally incontinent of urine. The intervention was for staff to monitor for signs and symptoms of UTI. The care plan did not indicate a care plan for contact isolation or refusal to comply with contact isolation. <BR/>Record review of Resident #2's electronic medical records revealed a urinalysis dated 04/03/25, which detected MRSA (an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections). <BR/>Record review of Resident #2's physician's order dated 04/06/25 indicated: Rifampin 300mg, give 1 capsule by mouth two times a day related to MRSA in urine until 04/20/25. <BR/>Record review of Resident #2's Physician order dated 04/06/25 indicated Contact isolation precautions in place related to MRSA.<BR/>Record review of Resident #2's comprehensive care plan after surveyor intervention was dated 04/06/25 but updated on 04/09/25, indicating Resident #1 required isolation. The intervention was to follow facility isolation policy and give medication as ordered.<BR/>During an observation on 04/08/25 at 11:00 a.m., Resident #2 was in the dining room attending an activity with 8 other residents while positive for MRSA.<BR/>During an interview on 04/08/25 at 3:30 p.m., Resident #2 said the staff told her she had something in her bladder and to make sure she washed her hands after using the bathroom. She said they did not tell her she had something that someone might catch or to stay in her room.<BR/>During an observation on 04/09/25 at 9:28 a.m., Resident #2 was in the day room sitting on the couch talking to another resident.<BR/>During an interview on 04/09/25 at 10:00 a.m., the ADON said if a resident were in contact isolation, staff would know because of the sign posted on the door. She said staff should wear gowns and gloves when they enter contact-isolated rooms. She said they encourage handwashing before and after care for all residents. She said she was not sure what the policy said on contact isolation for a resident. She said she thought the contact isolated residents could walk the facility. She said she knew they had educated Resident #2 on hand washing.<BR/>During an interview on 04/09/25 at 11:22 a.m., the DON said he expected all staff to follow the guidelines on the sign posted on the door. He said they should be wearing the proper PPE (gown and gloves) to protect themselves and to keep the spread of infection from other residents. He said if the resident were on contact isolation, then staff should be educating the resident on why they need to stay in their room and encouraging them to stay in their rooms. If the resident refuses to stay in their room, then the staff should document the refusal and add it to the resident's care plan.<BR/>During an interview on 04/09/25 at 12:16 p.m., the Administrator said when a resident was on contact isolation, staff should wear gowns and gloves when entering the room. She said the DON oversaw infection control. The Administrator said staff should ensure they had on the proper PPE to protect themselves and the residents and to prevent the spread of infection. She said residents who were on contact isolation should be encouraged to stay in their rooms and practice good hygiene to prevent the spread of infection. <BR/>Record review of the facility's policy titled, Infection Prevention and Control Program, revised 06/2020, indicated, Purpose: Ensure the facility established and maintained an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements. Policy: The facility must establish an infection prevention and control program under which it: #1 identifies, investigates, controls, and prevents infections in the facility .<BR/>Record review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions, revised 6/2020, indicated, To ensure that transmission-based precautions are used when caring for residents with communicable diseases or transmittable infections. III. Contact Precautions A. Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. I. Examples of infections requiring Contact Precautions include, but are not limited to: A. Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-drug resistant organisms (e.g., MRSA). C. Gloves and Handwashing: I. As outlined under Standard Precautions, gloves (clean, non-sterile) are worn when entering the room. D. Gown: I. As outlined under Standard Precautions, a (clean, non-sterile) gown is worn for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. G. Notice: I. The Facility alerts staff to the type of precaution a resident requires. ii. The Facility also ensures that the resident's care plan indicates the type of precautions implemented for the resident. iii. The Facility may utilize a sign requesting visitors to check in at the nursing station before entering a resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately consult the physician when there was a significant change in the resident's physical and mental status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 13 residents (Resident #4) whose records were reviewed for change in condition.<BR/>1. The facility failed to notify Resident #4's physician when Resident #4 had an increase in bruising while taking an anticoagulant medication (blood thinner that works by preventing red blood cells from forming clots), which indicated a change of condition and resulted in a delay of treatment. <BR/>An Immediate Jeopardy (IJ) situation was identified on 07/13/23 at 9:30 AM. While the IJ was removed on 07/14/23 at 11:56 AM, the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk of a delay in medical intervention and puts residents at an increased risk for adverse reaction while taking an anticoagulant medication (blood thinners), such as severe bruising, external or internal bleeding, or death.<BR/>The findings included: <BR/>Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), history of cerebral infarction (stroke), history of a heart attack, hypertension (high blood pressure), mitral (valve) stenosis (narrowing of the mitral valve of the heart that causes tiredness and shortness of breath), and congestive heart failure (progressive heart disease that affects pumping action of the heart muscles). <BR/>Record review of the MDS assessment, dated 05/30/23, revealed Resident #4 had clear speech and was usually understood by staff. The MDS revealed Resident #4 was usually able to understand others. The MDS revealed Resident #4 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #4 had no behaviors or refusal of care. The MDS revealed Resident #4 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene with a one or two staff assistance. <BR/>Record review of the comprehensive care plan, revised on 01/28/23, revealed Resident #4 was on anticoagulant therapy. The interventions included Monitor/document/report to the doctor as needed for signs and symptoms of anticoagulant complications: .bruising .<BR/>Record review of the order summary report, dated 07/12/23, revealed Resident #4 had an order, which started on 12/14/21, for Anticoagulant Monitoring - Place letter of symptoms of excess bleeding .every shift .F. bruising. The orders also revealed an order, which started on 12/13/21, for Aggrenox (blood thinner) Capsule 25-200 mg by mouth two times a day for blood thinner.<BR/>Record review of the Nurse Administration Record, dated July 2023, revealed bruising was present on the following dates: 07/01/23, 07/03/23, 07/04/23, 07/05/23, 07/06/23, and 07/11/2023. The Nurse Administration Record did not specify the location of the bruising. <BR/>Record review of the Weekly Skin Check, dated 07/04/23, revealed Resident #4 had no bruising. <BR/>Record review of the CNA Shower Report, dated 07/10/23, revealed Resident #4 had no skin problems. <BR/>Record review of the Weekly Skin Check, snipped on 07/11/2023 at 5:27 PM, revealed Resident #4 had no bruising. <BR/>During an interview on 07/11/23 at 5:55 PM, a copy of Resident #4's Weekly Skin Check dated 07/11/23 was requested from the DON. <BR/>Record review of the Weekly Skin Check provided by the facility, dated 07/11/23, revealed Resident #4 had the following newly documented skin problem areas: reddish, burgundy discoloration to back of left hand, front of right shoulder, left lower leg (below the knee), front of the left leg (above the knee), front of the right leg (above the knee), and the upper inner arm; bright reddish tint to right and left heel; small scabbing to second right toe and small scabbing to first, second, and fifth toes; red linear scratch to left shoulder in the front; and purplish discoloration to right lateral foot below the fifth toe.<BR/>During an observation and attempted interview on 07/10/23 at 9:09 AM, Resident #4 was laying in her bed with her bed sheets pulled up. She was moving her legs up and down and holding the bed sheets in her hands close to her face. Resident #4's arms and legs were visible from the door and several large, reddish-purple bruises were observed to Resident #4's upper legs and arms. Resident #4 was unable to remember how the bruising occurred and stared at the surveyor when questions were asked. <BR/>During an interview on 07/12/23 at 12:02 PM, LVN L stated she was the treatment nurse at the facility and had worked at the facility since March of 2022. LVN L stated Resident #4 had discoloration to several areas on her skin. LVN L stated Resident #4 had the discoloration and skin problems prior to 07/11/23, when they were documented. However, the skin issues did not require a treatment, so they were not documented on the weekly skin assessment. LVN L stated Resident #4 has always had terrible skin and the discoloration came and went frequently. LVN L stated she was unsure if Resident #4 was taking a blood thinning medication. LVN L stated she had not notified anyone of Resident #4's new skin areas of discoloration. LVN L stated the facility staff were aware of Resident #4's skin status because it had been discussed several times, especially regarding transfers. LVN L stated she was unsure how the areas of discoloration occurred on Resident #4's skin. LVN L stated the discoloration had been present since she started working at the facility but had come and went in the same area. LVN L was unable to say if the discoloration was the same or was in the same area. LVN L stated new skin problems or discoloration should have been reported to physician as soon as it was noticed. <BR/>During an interview on 07/12/23 at 12:20 PM, the ADON stated she used to be the treatment nurse at the facility. The ADON stated weekly skin assessments should have been a complete head to toe assessment, to include discoloration or bruising. The ADON stated new bruising or discoloration should have been monitored for 72 hours, initially, then weekly on the skin assessments. The ADON stated new bruising or discoloration should have been reported to the physician. <BR/>During an interview on 07/12/23 at 1:44 PM, the DON stated she was unaware of Resident #4's increased bruising until this week. The DON stated she expected staff to monitor for bruising and other signs of bleeding every shift for residents taking a blood thinning medication. The DON stated an increase in bruising for resident's taking a blood thinning medication should have been reported to the physician, as soon as it was noticed, because it would have been considered a change of condition. The DON stated the increased bruising for Resident #4 was reported to the physician on 07/12/23 and a new order for a STAT CBC and PT/INR was obtained. The DON stated it had not been reported to physician prior to 07/12/23. The DON stated documenting bruising on the weekly skin assessment, anticoagulant monitoring every shift, and reporting increased bruising to the physician were important to monitor and follow up on side effects of blood thinning medications such as bruising, metabolic functions, and fragile skin.<BR/>During an interview on 07/12/23 at 2:32 PM, Physician M stated he had been caring for Resident #4 for the last 15 to 20 years. Physician M stated Resident #4 had a history of minor skin areas such as small areas of bruising and skin tears, because of the tremors and fidgeting caused by Parkinson's disease. Physician M stated Resident #4 was taking a blood thinner called Aggrenox which had aspirin in it. Physician M stated Resident #4 was at an increased risk for GI bleeding, bruising, and bleeding because she was taking a blood thinning medication. Physician M stated he was notified on 07/12/23 for the increased bruising on Resident #4. Physician M stated he looked at it while he was making rounds and stated he believed it was bruising and it was on her left shoulder and elbow and right and left thighs. Physician M stated the bruising was not concerning or suspicious of abuse because there were no shapes or fingerprints. Physician M stated he wanted to be notified of increased bruising for residents who were taking a blood thinning medication as soon as it was noticed so he could have ordered some lab work to rule out acute or worsening medical problems. Physician M stated he ordered some STAT labs, which included a CBC to check for platelets and red blood cells, a CMP to check for protein, and a PT/INR to check for clotting factors. <BR/>Record review of the lab results, dated 07/12/23 at 5:01 PM, revealed on the CBC, Resident #4 had a low red blood cell count 3.2 (normal 3.8 - 5.1), hemoglobin (iron-containing oxygen carrying protein found in red blood cells) 8.8 (normal 11.6 - 15.4), and hematocrit (volume percentage of red blood cells) 28.0 (normal 34-45). The CMP revealed Resident #4 had a low total protein 5.5 (normal 5.7 - 8.0). The PT/INR revealed Resident #4 had a high PT 12.4 (normal is 9.0 to 12.0). <BR/>During an interview on 07/12/23 at 5:59 PM, Physician M stated Resident #4 had some anemia by looking at the CBC. Physician M said the protein (on the CMP) was a little off but still good. Physician M stated the INR was normal and the PT was only elevated by 0.4 which was not concerning. Physician M stated he wanted the facility to keep monitoring the bruising and to repeat the CBC in one week because Resident #4 might need a blood transfusion, which could indicate bleeding. Physician M stated he wanted to be notified of any changes. <BR/>During an interview on 07/12/23 at 6:03 PM, CNA N stated he worked 2-10 shift on 07/10/23 and 7/11/23. CNA N stated he helped the treatment nurse with Resident #4's skin assessment on 07/11/23 after the supper meal. CNA N stated during the skin assessment on 07/11/23 was the first time he had noticed bruising on Resident #4, but she did have a history of bruising on and off. CNA N stated he was unsure how Resident #4 received the bruising to her arms and legs. CNA N stated he worked on a different hall on 07/10/23. CNA N stated he would have reported the bruising to the charge nurse if he would have noticed it. CNA N stated the treatment nurse was aware of the bruising, so he did not have to report it. <BR/>During an interview on 07/12/23 at 6:16 PM, LVN E stated she normally worked with Resident #4. LVN E stated the bruising to Resident #4 had been there but was unable to say for how long. LVN E stated the bruising was present on 07/10/23 (Monday) but she believed the bruising had been documented on a skin assessment. LVN E stated it was normal for Resident #4 to bruise easily because she was on a blood thinner. LVN E stated she was unsure how Resident #4 received the bruising on her arms and legs. LVN E stated the physician should have been notified any time a new bruise or skin problem was identified. LVN E stated it was important to notify the physician for signs of bleeding so lab work could have been ordered to check for internal bleeding and medication could have been adjusted as it was needed. <BR/>During an interview on 07/13/23 at 1:39 PM, CNA C stated she worked Resident #4's hall on 07/10/23 and she had discoloration to her upper and lower limbs. CNA C she did not report the discoloration to the charge nurse because it had been reported previously and the charge nurse was aware. CNA C was unsure who reported the discoloration previously. CNA C stated she was unsure how the discoloration to Resident #4's arms and legs occurred. CNA C stated Resident #4 had other signs of bleeding. CNA C stated it was important to document and report new bruising to the charge nurse because it could have been a change of condition and the charge nurse would want to be aware. <BR/>Record review of the Change of Condition Notification policy, revised 06/2020, revealed I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent an acute change of condition (ACOC). The policy further revealed I. The Licensed Nurse will notify the resident's Attending Physician when there is an A. Incident/accident involving the resident; B. an accident involving the resident which results injury and has the potential for requiring physician intervention; C. A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions, or clinical complications; D. A need to alter treatment significantly . <BR/>The Administrator was notified on 07/13/23 at 10:53 AM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 07/13/23 at 10:57 AM and the plan of removal was requested. <BR/>The facility's Plan of Removal was accepted on 07/13/23 at 8:47 PM and included: <BR/>1. Immediate action(s) taken for the resident(s) found to have been affected include:<BR/>1. Resident Notification to Family Treatment nurse at 1:59pm attempted left message and 2:02pm family called back and was notified by ADON, Medical Director/Physician 7-12-23 ADON 1:25pm<BR/>2. SBAR (change in condition) Completed 7-12-23 ADON 1:25pm<BR/>3. Medical Director / Physician Evaluated Resident for changes in condition related to bruises 7-12-23 1:45pm<BR/>4. New orders to monitor bruising, Labs - CBC/INR Orders 7-12-23 1:25pm Labs Drawn at 2:21PM on 7-12-23 and results received at 3:21PM and MD notified 3:25pm and order to repeat CBC in one week received. <BR/>5. Trauma Assessment completed 7-12-23 Charge Nurse LVN A 1:47 PM<BR/>6. Pain Assessment completed 7-12-23 Charge Nurse LVN A 1:45pm<BR/>7. Care Plan Updated 7-12-23 MDS Nurse, Added Skin Care BUE/BLE Bruising- updated with Intervention monitoring skin for the bruising until healed and report abnormality to MD. <BR/>8. Therapy Screening completed 7-12-23 RN DON 3:57pm and Therapy screened completed DOR COTA on 7-12-23 7:15pm, Resident is on services as of 7-13-23 on OT services.<BR/>9. Incident Report ADON LVN 7-12-23 at 6:42pm<BR/>Self-Report Completed 7-12-23 by the Administrator 3:21PM<BR/>10. Skin assessment conducted for all residents that resided in the facility completed 7-12-23 7:30pm completed by Charge Nurse A LVN, Charge Nurse B LVN, all undocumented concerns were reported to MD/Families by LVN ADON, and RN DON completed by 7-13-23 by 4:00pm<BR/>Include actions that were performed toa address to citation: 7-13-23 11:00am <BR/>1. Facility Wide Resident Skin Sweep completed 7-12-23 Charge Nurses A LVN, Charge Nurse LVN B, completed at 7:30pm<BR/>2. Safe Survey with residents that are cognitively intact. 7-13-23 at 1:47pm by Social Worker completed at 4:00pm<BR/>3. Staff Safe Survey completed 7-13-23 Administrator and Regional Director of Operations started at 12:25pm completed at 3:45pm<BR/>4. One on One Inservice with treatment nurse on skin assessment initiated 4:00pm and completed on 7-12-23 conducted by DON RN completed 4:30pm on 7-12-23, Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan and job duties.<BR/>5. One on One Inservice with DON conducted by Regional Nurse Consultant on change in condition/skin assessment and notification. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Initiated 3:00pm 7-12-23 and completed on 7-12-23 3:30pm. Regional Nurse Consultant<BR/>6. In-services for licensed nursing staff on Skin Assessment/Skin initiated on 7/13/2023 at 11:45am by Regional Nurse Consultant. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Completed 7-13-23 5:00pm. <BR/>7. Training for licensed staff was initiated 7-12-23 at 11:45am on Anticoagulant monitoring/documentation timely and accurately 7-13-23 at 5:00pm. Training consisted of how to recognize changed with anticoagulant, monitoring, and orders and care plan in place. <BR/>8. Training for licensed staff was initiated 7-12-23 at 11:45am on Following care plan of anticoagulant completed 7-13-23 at 5:00pm. Training consisted of the following care plan. <BR/>9. Training for Clinical Licensed staff was initiated 7-12-23 at 11:45am on ADL transfers, this Inservice training consisted of transfer safety and how to conduct proper transfers. This Inservice was conducted at a precaution. Training completed on 7-13-23 at 5:00pm.<BR/>10. Training for Clinical Licensed staff was initiated on 7/12/23 at 11:45am, on Notification of Change completed on 7/13/23 at 5:00pm. This training includes what is a change in a condition, proper notification, reported and documentation of change in conditions. <BR/>11. Training with facility staff was initiated on 7/12/23 at 11:45am, by DON on Abuse and Neglect. This training includes what is abuse and neglect, procedures of abuse and neglect, reporting of abuse and the abuse coordinator, completed on 7/13/23 at 5:00pm. <BR/>12. All new hires will be educated on abuse and neglect protocol/change in condition/skin assessment, and anticoagulant ongoing. <BR/>13. The ADON and Director of Nursing will ensure competency through signing of in service, verbalization of understanding. All licensed nurses will notify DON/Administrator/Physician/Family regarding change in conditions. The ADON/DON will audit all skin assessments daily in morning clinical meetings to ensure compliance. <BR/>14. Team members will receive required training prior to their shifted. <BR/>Involvement of Medical Director<BR/>The Medical Director met with the Interdisciplinary team on 7/12/2023 at 4:00pm and conducted an Ad HOC QAPI regarding the change in condition and skin assessment protocol. <BR/>The Medical Director was notified about the immediate Jeopardy on 7/13/2023 at 1:30pm, the Plan of removal was reviewed with IDT Team and Medical Director.<BR/>Involvement of QAPI<BR/>An Ad Hoc QAPI meeting was held with the Medical Director via phone, facility administrator, director of nursing, and social services director to review plan of removal on 7/13/2023 at 2:30pm. <BR/>The Director of Nursing and Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 7/12/2023. Monitoring and reviewing skin assessment during clinical meeting to ensure compliance with facility policy.<BR/>On 07/14/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of the following documents, dated 07/12/23, were as follows:<BR/>1. The SBAR was completed. <BR/>2. A physician progress note was completed and addressed Resident #4's bruising. <BR/>3. The incident report was completed, and the physician, family, DON, and Administrator were notified. <BR/>4. New orders were obtained for labs.<BR/>5. The trauma assessment was completed.<BR/>6. The pain assessment was completed. <BR/>7. The care plan was updated, which included monitoring Resident #4's skin for bruising until healed and report abnormalities to the physician.<BR/>8. The therapy screen was completed. <BR/>9. The provider investigation report was completed. <BR/>10. The skin assessments were reviewed for all residents in the facility. <BR/>11. Skin sweeps were reviewed and completed for all residents in the facility. <BR/>12. Safe surveys for residents and staff were reviewed with no problems identified. <BR/>13. Ad Hoc QAPI plan was reviewed and completed with meeting minutes signed by the medical director, Administrator, DON, ADON, MDS, HR, AD, Maintenance, Social Worker, Dietary Manager, Medical Records, DOR, Housekeeping Supervisor, Business Office Manager, and RDO. <BR/>Interviews with the Treatment Nurse (LVN L) and DON revealed one-on-one in-services were completed. During the interviews the Treatment Nurse and DON were able to correctly identify how to conduct a thorough skin assessment, how to accurately document a weekly skin assessment, changes in the skin, and care plan. <BR/>Interviews of licensed nurses (LVN A, LVN E, LVN R, LVN S, LVN T, LVN U, RN B, RN O, RN P, RN Q, MDS Nurse, and the ADON) were performed. During the interviews all licensed nurses were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, and documenting the change of condition. All licensed nurses were able to correctly identify when skin assessments should be completed and how to conduct a thorough skin assessment, what should be documented on a skin assessment, changes in the skin, and updating the care plan. All licensed nurses were able to correctly identify how to recognize changes for resident's taking an anticoagulant medication, proper monitoring, orders, and following the care plan. All licensed nurses were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All licensed nurses were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. <BR/>Interview of clinical licensed staff (CNA D, CNA K, CNA N, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, CNA CC, CNA DD, CNA EE, CNA FF, MA V, and MA W) were performed. During the interviews all clinical licensed staff were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All clinical licensed staff were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, documenting the change of condition, and who to report a change of condition to. All clinical licensed staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin.<BR/>Interviews of staff (BOM, HR, Receptionist, Maintenance Supervisor, Housekeeping Supervisor, Dietary Manager, Social Worker, AD, Housekeeper GG, Housekeeper HH, Housekeeper KK, LA LL, LA MM, [NAME] NN, [NAME] OO, [NAME] PP, DA QQ, and DA RR) were performed. During the interviews all staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin.<BR/>On 07/14/23 at 11:56 AM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #9 and #129) reviewed for Medicare/Medicaid coverage. <BR/>The facility failed to ensure Resident #9 and #129 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted.<BR/>This failure could place residents at risk for not being aware of changes to provided services.<BR/>Findings include: <BR/>1. Record review of Resident #9's face sheet, dated 07/12/2023, indicated Resident #9 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (high blood pressure), and heart failure ((chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). <BR/>Record review of Resident #9's annual MDS assessment, dated 04/26/2023, indicated Resident #9 understood others and made herself understood. The assessment indicated Resident #9 was moderately cognitively impaired with a BIMS score of 12.<BR/>Record review of the SNF Beneficiary Protection Notification Review indicated Resident #9 was receiving Medicare Part A services starting on 04/19/2023 and the last covered day of Part A services was 05/08/2023, however it was revealed that a SNF ABN was not completed which would have informed Resident #9 of the option to continue services at the risk of out-of-pocket. <BR/>2. Record review of Resident #129's face sheet, dated 07/12/2023, indicated Resident #129 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included CKD (gradual loss of kidney function over time), dysphagia (difficulty swallowing), and atrial fibrillation (irregular, often rapid heart rate). <BR/>Record review of Resident #129's admission MDS assessment, dated 12/06/2022, indicated Resident #129 understood others and usually made herself understood. The assessment indicated Resident #129 was severely cognitively impaired with a BIMS score of 4. <BR/>Record review of the SNF Beneficiary Protection Notification Review indicated Resident #129 was receiving Medicare Part A services starting on 12/02/2022 and the last covered day of Part A services was 01/02/2023, however it was revealed that a SNF ABN was not completed which would have informed Resident #129 of the option to continue services at the risk of out-of-pocket. <BR/>During an interview on 07/14/2023 at 12:00 p.m., the Administrator stated the previous social worker was responsible for ensuring Resident #9 and #129 were issued a SNF ABN. The Administrator stated the form should have been issued if the resident had skilled benefit days remaining and was being discharged from Part A services and will continue living in the facility. The Administrator stated there was not an effective plan in place to ensure the forms were completed. The Administrator stated it was important for the resident to receive the form just in case they wanted to appeal, and they would know they had days remaining on their benefit. The Administrator stated there was no negative outcome for not receiving a SNF ABN form prior to covered days being exhausted. <BR/>Record review of the facility's' policy titled, NOMNC & ABN's dated 4/20/2023 indicated, .the social service department was responsible for completing and issuing these forms to the resident and/or family to be signed <BR/>Record review of CMS guidelines Beneficiary Notice Guidelines, approved by CMS-10124-DENC December 31, 2011, indicated Scenario Part A stay will end because: SNF (Skilled Nursing Facility) determines the beneficiary no longer requires daily skilled services. Resident has days remaining in the benefit period. Resident will remain in the facility (custodial care) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) CMS-10055 (2018) and Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (12/31/11)) to be completed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for 5 of 19 residents (Resident #16, Resident #19, Resident #21, Resident #40, and Resident #75) reviewed for environment.<BR/>The facility failed to repair deep scrapes that exposed the sheetrock on the wall behind the head of the bed and on the wall next to the bed for Resident #16, Resident #19, Resident #21, and Resident #40.<BR/>The facility failed to ensure Resident #75's bed linens were changed. <BR/>This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 07/14/2023 indicated Resident #16 was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia, unspecified severity, without behavioral (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), unspecified, and cerebral infarction, unspecified (damage to tissues in the brain due to a loss of oxygen to the area). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #16 was rarely/never understood and rarely/never understood others. The MDS assessment indicated Resident #16 had a short and long-term memory problem. The MDS assessment indicated Resident #16's ability to make decisions regarding tasks of daily life was severely impaired (never/rarely made decisions). <BR/>During an observation and attempted interview on 07/10/2023 at 10:09 AM, Resident #16 was non-interviewable and there were scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. <BR/>During an observation on 07/11/2023 at 09:01 AM, Resident #16 had scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. <BR/>2. Record review of a face sheet dated 07/11/2023 indicated Resident #19 was an [AGE] year old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's Disease, unspecified (progressive disease that destroys memory and other important mental functions), anxiety disorders unspecified (mental illness defined by feelings of uneasiness, worry and fear), and major depressive disorder, recurrent, unspecified (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #19 was usually understood and understood others. The MDS assessment indicated Resident #19's BIMS was 0, which indicated severe cognitive impairment. <BR/>During an observation and attempted interview on 07/10/2023 at 10:03 AM, Resident #19 was non-interviewable, and there were scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. <BR/>During an observation on 07/11/2023 at 08:56 AM, Resident #19 had scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. <BR/>3. Record review of a face sheet dated 07/11/2023, indicated Resident #21 was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential (primary) hypertension (high blood pressure), and major depressive disorder, recurrent, unspecified (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #21 was rarely/never understood and rarely/never understood others. The MDS assessment indicated Resident #21 had a short and long-term memory problem. The MDS assessment indicated Resident #21's ability to make decisions regarding tasks of daily life was severely impaired (never/rarely made decisions). <BR/>During an observation and attempted interview on 07/10/2023 at 09:52 AM, Resident #21 was non-interviewable and there were scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. <BR/>During an observation on 07/11/2023 at 08:54 AM, Resident #21 had scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. <BR/>4. Record review of a face sheet dated 07/11/2023, indicated Resident #40 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), cerebral infarction, unspecified (damage to tissues in the brain due to a loss of oxygen to the area), and major depressive disorder, recurrent, unspecified (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). <BR/>Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #40 was sometimes understood and understood others. The MDS assessment indicated Resident #40's BIMS was 0, which indicated severe cognitive impairment.<BR/>During an observation and attempted interview on 07/10/2023 at 9:50 AM, Resident #40 was non-interviewable and there were scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. <BR/>During an observation on 07/11/2023 at 08:52 AM, Resident #40 had scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. <BR/>5. Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (chronic condition that affects the way the body processes blood sugar with progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). <BR/>Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #75 was usually understood and usually understood others. The MDS assessment indicated Resident #75's BIMS was 8, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #75 required supervision for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. <BR/>Record review of the care plan with date initiated of 07/05/2023, indicated Resident #75 had an ADL self-care deficit and required set up staff participation to use the toilet, for transfers, bathing, dressing, and eating, and 1 staff participation to reposition and turn for bed mobility. <BR/>During an observation on 07/10/2023 at 10:15 AM, Resident #75 had several dark yellowish stains at the foot of the bed on his sheet and a reddish stain on his sheet towards the center of the bed. Resident #75 said he was not sure if his sheets had been changed. <BR/>During an observation and interview on 07/11/2023 at 5:11 PM, Resident #75 had <BR/>had several dark yellowish stains at the foot of the bed on his sheet and a reddish stain on his sheet towards the center of the bed. Resident #75 said he was not aware the staff was supposed to be changing his sheets because he was just there for therapy and would be leaving soon. Resident #75 said it would be nice for the sheets to be changed and to have clean sheets. Resident #75 said the reddish stain was probably blood. <BR/>During an observation and interview on 07/12/2023 at 10:59 AM, LVN A observed the damaged walls in Resident #16, Resident #19, Resident #21, and Resident #40's rooms. LVN A said she had verbally reported the damaged walls to the Maintenance Supervisor for him to repair them. LVN A said it was important for damages to the residents' rooms to be fixed because the facility was the residents' home, and it should look neat. LVN A observed Resident #75's sheet with the multiple dark yellowish stains and reddish stain and said the sheets should have been changed by the CNAs. LVN A said the residents bed linens should be changed daily by at least every shift and as needed. LVN A said the CNAs were responsible for changing the residents' bed linens. LVN A said it was important for the residents' bed linens to be changed for them to have a clean environment and she did not want them to have dirty sheets. <BR/>During an observation and interview on 07/12/2023 11:08 AM, the Maintenance Supervisor observed the damaged walls in Resident #16, Resident #19, Resident #21, and Resident #40's rooms. The Maintenance Supervisor said he was aware of the damaged walls to Resident #19, Resident #21, and Resident #40's rooms, but he was not aware of the damaged walls to Resident #16's room. The Maintenance Supervisor said the staff notified him verbally of rooms needing repair, and they could also record it on the maintenance log. The Maintenance Supervisor said he was working on getting the rooms repaired. The Maintenance Supervisor said it was important for the residents' rooms to be free of damages for the residents' dignity and everyone wants a good-looking room.<BR/>During an interview on 07/13/2023 at 8:24 AM, the ADON said the residents' bed linens were supposed to be changed on their shower days. The ADON said the CNAs and the nurses were responsible for changing the residents' bed linens. The ADON said there was currently not a system in place for monitoring to ensure the CNAs changed the residents' bed linens. The ADON said it was important for Resident #75's bed linens to be closed because he had wounds and port and they could get infected. The ADON said it was important for the residents' linens to be changed for good hygiene and because it made the residents feel better when they got in a clean bed. The ADON said the facility did ambassador rounds that management was assigned to certain rooms and were supposed to be looking at the rooms to ensure they were clean, and damages repaired. The ADON said she did not know who was assigned to Resident #16, Resident #19, Resident #21, and Resident #40's rooms. The ADON said the Maintenance Supervisor was responsible for making sure the residents' rooms were repaired. The ADON said it was important for the residents' rooms to be repaired and not have damaged walls so the residents could have a homelike environment, for them to feel better about their home and for visitors to see the residents' home in good repairs. <BR/>During an interview on 07/13/2023 at 09:04 AM the DON said all the staff should be making sure the residents' rooms did not have damages. The DON said if the staff noticed damages to a resident's room, they should report it to the Maintenance Supervisor. The DON said it was important for the residents' rooms to be free of damages for them to have a homelike environment. The DON said the residents having damaged walls could make them feel uncomfortable. The DON said the residents bed linens should be changed on their shower days and as needed. The DON said anybody could change the residents bed linens, but generally the CNAs on the hall were the ones responsible for changing the bed linens. The DON said it was important for the residents to have clean bed linens to make them feel comfortable. <BR/>During an interview on 07/13/2023 at 1:42 PM, CNA C said the CNAs should be changing the residents' sheets on shower days or if they were soiled. CNA C said she was not responsible for changing Resident #75's sheets on his bed. CNA C said CNA D was responsible for changing Resident #75's sheets on his beds. <BR/>During an interview on 07/13/2023 at 2:04 PM, CNA D said the sheets on the residents' beds should be changed on their shower days or if they were dirty. CNA D said she was not assigned to care for Resident #75. CNA D said according to the schedule for the day CNA C was responsible for providing care to Resident #75, and she should have changed Resident #75's bed linens. CNA D said it was important for the residents to have clean linens on their beds because of infection, and she did not want anybody to lay down in dirty sheets. <BR/>During an interview on 7/13/2023 at 2:20 PM, the Administrator said the staff doing daily rounds should report to the Maintenance Supervisor damages to the residents' rooms. The Administrator said the Maintenance Supervisor was responsible for ensuring the residents' rooms were in good repairs. The Administrator said he expected for the Maintenance Supervisor to repair damages to the residents' rooms. The Administrator said the Maintenance Supervisor tried to get to the rooms as he could to fix them. The Administrator said it was important for the residents' rooms to be fixed to make it as much of a homelike environment for them. The Administrator said he wanted to the residents to have a safe and pleasant home. The Administrator said the CNAs were supposed to change the residents bed linens if they were soiled, and the nursing staff was responsible for making sure they did this. The Administrator said he expected the CNAs to change the residents' bed linens. The Administrator said it was important for the residents' bed linens to be changed for their hygiene and for infection control. <BR/>Record review of the facility's document titled, Maintenance Log, dated from 11/16/22 to 07/11/23, indicated an entry dated 6/12 (no year indicated), Room No. 209 paint walls and floor reported and initialed by the Dietary Manager. room [ROOM NUMBER] was Resident #21 and Resident #40s room. Record review of the Maintenance Log did not indicate entries related to Resident #16's and Resident #19's rooms. <BR/>Record review of the facility's policy titled, Resident Rooms and Environment, last revised 08/2020, indicated, Purpose To provide residents with a safe, clean, comfortable and homelike environment. Policy The Facility provides residents with a safe, clean, comfortable, and homelike environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 6 residents (Resident #3) reviewed for abuse and neglect. <BR/>The facility staff did not report to the state agency that Resident #3 had a bruise and a skin tear to the left arm of unknown origin on 02/11/25.<BR/>This failure could place the residents at increased risk for abuse and neglect or further potential abuse due to unreported allegations of abuse and neglect.<BR/>Findings included:<BR/>Record review of Resident #3's face sheet, dated 04/09/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (diseases that affect memory, thinking, and the ability to perform daily activities), diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily living).<BR/>Record review of Resident #3's annual MDS assessment, dated 02/26/25, indicated Resident #3 rarely understood and was rarely understood by others. Resident #3's BIMS score was 00, which meant she was severely cognitively impaired. The MDS indicated Resident #3 required extensive help with toileting, bed mobility, dressing, transfers, personal hygiene, and supervision with eating. The MDS did not indicate Resident #3 had wounds or skin problems. <BR/>Record review of Resident #3's progress note dated 2/11/25 at 6:22 pm, written by LVN A, revealed Resident #3's family member reported 2 open areas to her left arm, both less than 0.25 x 0.25 in diameter. Both showed no signs of infection. The nurse provided first aid to both, and neither area showed signs of infection. The resident denied pain. The call light was in reach.<BR/>Record review of Resident #3's progress note updated 2/11/25 at 6:42 pm, written by LVN A revealed Resident #3 had one open area and one bruise to her left arm. <BR/>Record review of Resident #3's progress note dated 2/12/25 at 2:40 am, written by LVN C, revealed to continue to monitor skin tear and bruising to the left arm for Resident #3. No signs or symptoms of infection, pain, or discomfort were noted. <BR/>Record review of Resident #3's physician orders, dated 02/01/25 through 02/28/23, did not reveal any orders for monitoring bruising to the left arm.<BR/>Record review of Resident #3's physician orders, dated 02/01/25 through 02/28/25, did not reveal any orders for treating a skin tear to her left arm. <BR/>Record review of Resident #3's skin assessment dated [DATE] did not indicate a skin assessment was done after the bruise and skin tear were noted. <BR/>Record review of Resident #3's skin assessment dated [DATE], charted by LVN C, did not indicate a bruise or skin tear to her left arm.<BR/>Record review of Resident #3's care plan, revised on 03/26/25, did not indicate a bruise or skin tear to her left arm on 02/11/25.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN B said she was the treatment nurse. She said if a resident had a skin tear or a bruise, it should be reported to the nurse, the nurse would then report it to her, and she would assess and determine what type of treatment was needed, if any. She said if a skin tear were noted, she would look at it daily and document it in the TAR. If a bruise were noted, she would put in an order to monitor weekly till resolved. LVN B said that Resident #3 had several bruises over time because she would attempt to get up by herself. She said she could not recall this particular bruise or skin tear. She said part of her process was if a bruise or skin tear were reported, she would investigate to see what happened. She said Resident #3 was not normally able to say what happened related to her cognitive status. LVN C said if she could not figure out what happened, she would report it to the Administrator or DON.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN A said she was the charge nurse on duty when a family member reported Resident #3 had a skin tear and bruise on her left arm. LVN C said she was not aware how Resident #3 received the bruise or skin tear. She said she did not ask the staff or the family member who reported the skin tear or bruise if they knew what happened. LVN A said if an unknown skin tear or bruise was reported to her, she was supposed to notify the Administrator, DON, the physician, and the family. LVN A said she reported the bruise and skin tear to the Administrator and the DON. She said she was new to the facility during the incident and was told to do a progress note. She said she did not recall the Administrator or the DON questioning her about the incident once she reported it. She said since this incident, she had been educated to do an incident report and progress note, notify management, the physician, and the family. <BR/>During an interview on 04/09/25 at 6:55 a.m., LVN C said she was the 10 pm-6 am nurse for Resident #3. She said she could not recall the skin tear or bruise from 02/12/25 on Resident #3. LVN C said if she charted it, then it was either given to her in the report or was on the 24-hour report. She said if a bruise or skin tear occurred and staff were unaware of how it occurred, staff would report it to the ADON or DON, and they would investigate it. She said the nurses were supposed to do an incident report, document a progress note, and notify the physician, the family, the Administrator, and the DON of any skin tears or bruises of unknown origin. She said even if the nurses did not report something, it was on the 24-hour report, and management was supposed to review it daily. She said she did not recall being asked about Resident #3's skin tear or bruise by the Administrator or DON. <BR/>During an interview on 4/9/25 at 10:00 a.m., the ADON said if a resident had a bruise or skin tear of an unknown origin, she would investigate to see if she could figure out what happened. She said the nurses should document the incident in the progress notes, do an incident report, and notify the physician, the family, the Administrator, and the DON. She said the nurses were to chart the incident for 72 hours. She said even if a nurse forgot to report the incident, she would see it on the 24-hour report or while reading the nurses' notes. She said she could recall the incident on 02/11/25, but could not remember the details. The ADON reviewed Resident #3's chart and did not see an incident report on 02/11/25.<BR/>During an interview on 04/09/25 at 10:53 a.m., LVN B said she was the treatment nurse, and she had done a skin assessment on Resident #3 earlier on the 6 am-2 pm shift on 02/11/25. She said Resident #3 did not have any skin tears or bruises during her assessment. She said LVN A charted the skin tear and bruise at 6:22 pm after her shift. <BR/>During an interview on 04/09/25 at 11:03 a.m., the DON said he expected if a resident had a bruise or skin tear of an unknown source that staff would report it to him and the Administrator. He said they would do an internal investigation to see if they could figure out what happened, and if they could not figure out what happened, they would report it to the State of Texas. He said he could not recall the skin tear or bruise for Resident #3 around 02/11/25. He said Resident #3 had often scratched herself, or she could have bumped it on the wall, but since he did not remember investigating it, he could not say what happened. He said they do review the 24-hour reports in the morning meeting, and it must have been overlooked. He said that although he did not feel like abuse occurred, it was important to report and investigate abuse/neglect to prevent further abuse/neglect from occurring.<BR/>During an interview on 04/09/25 at 4:37 p.m., the Administrator said she was unaware of Resident #3's skin tear or bruise; therefore, it was not investigated or reported. She said she was not contacted for all skin tears or bruises, only if suspicion of abuse. She said if there was suspicion of abuse, the nurses should have called and reported it to her, and then they would have investigated and reported if needed. She said, after looking at Resident #3's chart, that LVN A was a new nurse during the incident and did not follow all the necessary steps, such as notification. She said they would educate LVN A. The Administrator said when injuries of unknown origin were not reported promptly, abuse could continue to occur. <BR/>Record review of the facility policy titled Abuse Prohibition Policy, revised 08/2020, indicated, Purpose: To ensure the facility established, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. VI. Investigation: A. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal activity. IX. Reporting: The facility will report allegations of abuse, neglect, exploitation, mistreatment, and injuries of unknown source, etc . immediately but no longer than two hours

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 3 residents (Resident #75) reviewed for baseline care plans.<BR/>The facility failed to ensure Resident #75 had a baseline care plan completed within 48 hours of admission<BR/>This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome.<BR/>Findings included: <BR/>Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (chronic condition that affects the way the body processes blood sugar with progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). <BR/>Record review of the Baseline Plan of Care-V2 indicated an admission date of 06/30/2022 and it was signed completed on 06/26/2023 by LVN A. <BR/>Record review of another Baseline Plan of Care-V2 indicated an admission date of 06/30/2022 and it was signed completed on 07/03/2023 by LVN A. <BR/>During an interview on 07/12/2023 at 11:02 AM, LVN A said the baseline care plan should be completed within 24 hours after admission. LVN A said the baseline care plan signed completed 06/26/2023 corresponded to Resident #75's initial admission date of 06/22/2023. LVN A said it was completed late. LVN A said the baseline care plan signed completed on 07/03/2023 corresponded to the admission date of 06/30/2023, and it was note completed on time. LVN A said she did not know why she had completed Resident #75's baseline care plans late. LVN A said it was important to complete the baseline care plan within 24 hours after admission, so the CNAs knew what the residents required for their care and the level of assistance they needed. <BR/>During an interview on 07/13/2023 at 8:32 AM, the ADON said the baseline care plan was supposed to be completed by the nurse on admission, if the admitting nurse was not able to complete it, the next shift nurse was responsible for completing it. The ADON said the DON and herself tried to make sure the nurses were completing the baseline care plans timely. The ADON said the baseline care plans should be completed by the next day after admission. The ADON said Resident #75's baseline care plan for his admission on [DATE] was completed on 06/26/2023, which indicated it was 3 days late. The ADON said Resident #75's baseline care plan for his admission on [DATE] was completed on 07/03/2023, which indicated it was completed 3 days late. The ADON said she did not know why Resident #75's baseline care plans were completed late. The ADON said it was important to complete the baseline care plan on time because it let the staff know what the residents needed and how to take care of the residents<BR/>During an interview on 07/13/2023 at 9:09 AM, the DON said the baseline care plan should be completed 72 hours after admission. The DON said the charge nurses were responsible for completing the baseline care plans. The DON said she monitored the completion of the baseline care plans. The DON said it was important for the baseline care plan to be completed timely, so that the staff knew how to accurately take care of the residents. Regarding Resident #75's baseline care plans the DON said the nurses had 72 hours to complete them. <BR/>During an interview on 07/13/2023 at 2:22 PM, the Administrator said the Social Worker, DON, and MDS Coordinator worked together to ensure the baseline care plan was completed timely. The Administrator said the baseline care plan should be completed within 48 hours of admission. The Administrator said he expected the residents' baseline care plans to be completed within 48 hours of admission. The Administrator said it was important for the baseline care plans to be completed timely, so the staff would know how to take care of the residents. <BR/>Record review of the facility's policy titled, Care Planning, last revised October 24, 2022, indicated, . The facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 13 (Resident #4) residents reviewed for quality of care.<BR/>1. The facility failed to intervene when Resident #4, who was taking an anticoagulant medication (blood thinner that works by preventing red blood cells from forming clots), had increased bruising, which indicated a change of condition. <BR/>2. The facility did not ensure LVN L, who was the treatment nurse, accurately performed weekly skin assessments. <BR/>An Immediate Jeopardy (IJ) situation was identified on 07/13/23 at 9:30 AM. While the IJ was removed on 07/14/23 at 11:56 AM, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. <BR/>These failures could place residents at an increased risk for adverse reactions while taking an anticoagulant medication (blood thinners), such as severe bruising, external or internal bleeding, or death. <BR/>The findings included: <BR/>Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), history of cerebral infarction (stroke), history of a heart attack, hypertension (high blood pressure), mitral (valve) stenosis (narrowing of the mitral valve of the heart that causes tiredness and shortness of breath), and congestive heart failure (progressive heart disease that affects pumping action of the heart muscles). <BR/>Record review of the MDS assessment, dated 05/30/23, revealed Resident #4 had clear speech and was usually understood by staff. The MDS revealed Resident #4 was usually able to understand others. The MDS revealed Resident #4 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #4 had no behaviors or refusal of care. The MDS revealed Resident #4 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene with a one or two staff assistance. <BR/>Record review of the comprehensive care plan, revised on 01/28/23, revealed Resident #4 was on anticoagulant therapy. The interventions included Monitor/document/report to the doctor as needed for signs and symptoms of anticoagulant complications: .bruising .<BR/>Record review of the order summary report, dated 07/12/23, revealed Resident #4 had an order, which started on 12/14/21, for Anticoagulant Monitoring - Place letter of symptoms of excess bleeding .every shift .F. bruising. The orders also revealed an order, which started on 12/13/21, for Aggrenox (blood thinner) Capsule 25-200 mg by mouth two times a day for blood thinner.<BR/>Record review of the Nurse Administration Record, dated July 2023, revealed bruising was present on the following dates: 07/01/23, 07/03/23, 07/04/23, 07/05/23, 07/06/23, and 07/11/2023. The Nurse Administration Record did not specify the location of the bruising. <BR/>Record review of the Weekly Skin Check, dated 07/04/23, revealed Resident #4 had no bruising. <BR/>Record review of the CNA Shower Report, dated 07/10/23, revealed Resident #4 had no skin problems. <BR/>Record review of the Weekly Skin Check, snipped on 07/11/2023 at 5:27 PM, revealed Resident #4 had no bruising. <BR/>During an interview on 07/11/23 at 5:55 PM, a copy of Resident #4's Weekly Skin Check dated 07/11/23 was requested from the DON. <BR/>Record review of the Weekly Skin Check provided by the facility, dated 07/11/23, revealed Resident #4 had the following newly documented skin problem areas: reddish, burgundy discoloration to back of left hand, front of right shoulder, left lower leg (below the knee), front of the left leg (above the knee), front of the right leg (above the knee), and the upper inner arm; bright reddish tint to right and left heel; small scabbing to second right toe and small scabbing to first, second, and fifth toes; red linear scratch to left shoulder in the front; and purplish discoloration to right lateral foot below the fifth toe.<BR/>Record review of the Weekly Wound Progress, dated 07/12/23, revealed scabbing to toes that measured pinpoint; multiple areas or discoloration to left leg below that knee that measured scattered; discoloration to bottom of right foot 5th toe that measured 2.5 cm x 1.5 cm; linear scratch to left front of shoulder that measured 3.5 cm x 0.1 cm; dicoloration to right upper arm that measured 6 cm x 5.5 cm; discoloration to left anterior leg above the knee that measured 16 cm x 18.5 cm; disocloration to right anterior leg above the knee with scabbing that measured 11.5 cm x 9 cm; discoloration to right front shoulder that measured 4 cm x 3 cm; discoloration to back of left hand that measured 2 cm x 3 cm. <BR/>During an observation and attempted interview on 07/10/23 at 9:09 AM, Resident #4 was laying in her bed with her bed sheets pulled up. She was moving her legs up and down and holding the bed sheets in her hands close to her face. Resident #4's arms and legs were visible from the door and several large, reddish-purple bruises were observed to Resident #4's upper legs and arms. Resident #4 was unable to remember how the bruising occurred and stared at the surveyor when questions were asked. <BR/>During an interview on 07/12/23 at 12:02 PM, LVN L stated she was the treatment nurse at the facility and had worked at the facility since March of 2022. LVN L stated Resident #4 had discoloration to several areas on her skin. LVN L said she was unable to call the discoloration a bruise because bruising was usually blue, green, or reddish-purple and the discoloration on Resident #4 was reddish burgundy. LVN L stated when she completed the weekly skin assessments, she was only documenting skin impairments on the form. LVN L stated skin impairments were areas on the skin that required a treatment. LVN L stated she did not document areas on the skin that did not require a treatment, such as bruising. LVN L stated she was asked by the DON to reopen her skin assessment and document a complete head to toe assessment because the state agency wanted them to. LVN L stated Resident #4 had the discoloration and skin problems prior to 07/11/23, when they were documented. However, the skin issues did not require a treatment, so they were not documented on the weekly skin assessment. LVN L stated Resident #4 has always had terrible skin and the discoloration came and went frequently. LVN L stated she was unsure if Resident #4 was taking a blood thinning medication. LVN L stated she had not notified anyone of Resident #4's new skin areas of discoloration. LVN L stated the facility staff were aware of Resident #4's skin status because it had been discussed several times, especially regarding transfers. LVN L stated if Resident #4 had a history of discoloration and skin problems that should have been addressed on the care plan. LVN L stated she was unsure how the areas of discoloration occurred on Resident #4's skin. LVN L stated the discoloration had been present since she started working at the facility but had come and went in the same area. LVN L was unable to say if the discoloration was the same or was in the same area. <BR/>During an interview on 07/12/23 at 12:20 PM, the ADON stated she used to be the treatment nurse at the facility. The ADON stated weekly skin assessments should have been a complete head to toe assessment, to include discoloration or bruising. The ADON stated new bruising or discoloration should have been monitored for 72 hours, initially, then weekly on the skin assessments. The ADON stated new bruising or discoloration should have been reported to the physician. <BR/>During an interview on 07/12/23 at 1:44 PM, the DON stated the treatment nurse was responsible for ensuring weekly skin assessments were completed. The DON stated she expected all skin integrity issues to be documented, which included bruising or areas or discoloration. The DON stated she did not ask the treatment nurse to reopen her skin assessment. The DON stated it was a miscommunication because she thought it was requested by the state agency. The DON stated a one-on-one in-service on accurately completing and documented skin assessments was given to the treatment nurse on 07/12/23 and prior to that she was provided training by the ADON on how to perform skin assessments when she was hired at the facility. The DON stated Resident #4 had long-term, recurring bruising and discoloration. The DON stated Resident #4 should have had a care plan in place to address recurrent bruising. The DON was unsure why Resident #4 did not have a care plan in place to address recurrent bruising. The DON was unsure if Resident #4 was taking a blood thinning medication. The DON stated she was unaware of Resident #4's increased bruising until this week. The DON stated she expected staff to monitor for increased bruising, especially if a resident was taking a blood thinning medication. The DON stated she expected staff to monitor for bruising and other signs of bleeding every shift for residents taking a blood thinning medication. The DON stated an increase in bruising for resident's taking a blood thinning medication should have been reported to the physician, as soon as it was noticed, because it would have been considered a change of condition. The DON stated the increased bruising for Resident #4 was reported to the physician on 07/12/23 and a new order for a STAT CBC and PT/INR was obtained. The DON stated it had not been reported to physician prior to 07/12/23. The DON stated documenting bruising on the weekly skin assessment, anticoagulant monitoring every shift, and reporting increased bruising to the physician were important to monitor and follow up on side effects of blood thinning medications such as bruising, metabolic functions, and fragile skin.<BR/>During an interview on 07/12/23 at 2:32 PM, Physician M stated he had been caring for Resident #4 for the last 15 to 20 years. Physician M stated Resident #4 had a history of minor skin areas such as small areas of bruising and skin tears, because of the tremors and fidgeting caused by Parkinson's disease. Physician M stated Resident #4 was taking a blood thinner called Aggrenox which had aspirin in it. Physician M stated Resident #4 was at an increased risk for GI bleeding, bruising, and bleeding because she was taking a blood thinning medication. Physician M stated he was notified on 07/12/23 for the increased bruising on Resident #4. Physician M stated he looked at it while he was making rounds and stated he believed it was bruising and it was on her left shoulder and elbow and right and left thighs. Physician M stated the bruising was not concerning or suspicious of abuse because there were no shapes or fingerprints. Physician M stated he wanted to be notified of increased bruising for residents who were taking a blood thinning medication as soon as it was noticed so he could have ordered some lab work to rule out acute or worsening medical problems. Physician M stated he ordered some STAT labs, which included a CBC to check for platelets and red blood cells, a CMP to check for protein, and a PT/INR to check for clotting factors. <BR/>Record review of the lab results, dated 07/12/23 at 5:01 PM, revealed on the CBC, Resident #4 had a low red blood cell count 3.2 (normal 3.8 - 5.1), hemoglobin (iron-containing oxygen carrying protein found in red blood cells) 8.8 (normal 11.6 - 15.4), and hematocrit (volume percentage of red blood cells) 28.0 (normal 34-45). The CMP revealed Resident #4 had a low total protein 5.5 (normal 5.7 - 8.0). The PT/INR revealed Resident #4 had a high PT 12.4 (normal is 9.0 to 12.0). <BR/>During an interview on 07/12/23 at 5:59 PM, Physician M stated Resident #4 had some anemia by looking at the CBC. Physician M said the protein (on the CMP) was a little off but still good. Physician M stated the INR was normal and the PT was only elevated by 0.4 which was not concerning. Physician M stated he wanted the facility to keep monitoring the bruising and to repeat the CBC in one week because Resident #4 might need a blood transfusion, which could indicate bleeding. Physician M stated he wanted to be notified of any changes. <BR/>During an interview on 07/12/23 at 6:03 PM, CNA N stated he worked 2-10 shift on 07/10/23 and 7/11/23. CNA N stated he helped the treatment nurse with Resident #4's skin assessment on 07/11/23 after the supper meal. CNA N stated during the skin assessment on 07/11/23 was the first time he had noticed bruising on Resident #4, but she did have a history of bruising on and off. CNA N stated he was unsure how Resident #4 received the bruising to her arms and legs. CNA N stated he worked on a different hall on 07/10/23. CNA N stated he would have reported the bruising to the charge nurse if he would have noticed it. CNA N stated the treatment nurse was aware of the bruising, so he did not have to report it. <BR/>During an interview on 07/12/23 at 6:16 PM, LVN E stated she normally worked with Resident #4. LVN E stated the bruising to Resident #4 had been there but was unable to say for how long. LVN E stated the bruising was present on 07/10/23 (Monday) but she believed the bruising had been documented on a skin assessment. LVN E stated it was normal for Resident #4 to bruise easily because she was on a blood thinner. LVN E stated she was unsure how Resident #4 received the bruising on her arms and legs. LVN E stated she monitored for signs and symptoms of bleeding on the anticoagulant monitoring form that was on the Nurse Administration Record. LVN E stated the bruising was normal for Resident #4 and she did not document on the anticoagulant monitoring form. LVN E stated the physician should have been notified any time a new bruise or skin problem was identified. LVN E stated it was important to notify the physician for signs of bleeding so lab work could have been ordered to check for internal bleeding and medication could have been adjusted as it was needed. LVN E stated it was important to monitor and follow up with Resident #4 for signs and symptoms of bleeding, which included increased bruising because she could have had internal bleeding. LVN E stated it was important to document bruising so it could have been monitored and followed up on. <BR/>During an interview on 07/13/23 at 1:39 PM, CNA C stated she worked Resident #4's hall on 07/10/23 and she had discoloration to her upper and lower limbs. CNA C she did not report the discoloration to the charge nurse because it had been reported previously and the charge nurse was aware. CNA C was unsure who reported the discoloration previously. CNA C stated she was unsure how the discoloration to Resident #4's arms and legs occurred. CNA C stated Resident #4 had other signs of bleeding. CNA C stated it was important to document and report new bruising to the charge nurse because it could have been a change of condition and the charge nurse would want to be aware. <BR/>Record review of the Change of Condition Notification policy, revised 06/2020, revealed I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent an acute change of condition (ACOC). The policy further revealed I. The Licensed Nurse will notify the resident's Attending Physician when there is an A. Incident/accident involving the resident; B. an accident involving the resident which results injury and has the potential for requiring physician intervention; C. A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions, or clinical complications; D. A need to alter treatment significantly . <BR/>Record review of the Anticoagulant Therapy policy, revised 06/2020, revealed VI. Complete a head-to-toe assessment of the resident. Document any pre-existing bruising. VII. Initiate the care plan following initiation of anticoagulant therapy. The policy further revealed XI. Educate the resident and family regarding the side effects and adverse drug effects of anticoagulant therapy. The policy did not address monitoring for signs and symptoms of bleeding or bruising. <BR/>The Administrator was notified on 07/13/23 at 10:53 AM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 07/13/23 at 10:57 AM and the plan of removal was requested. <BR/>The facility's Plan of Removal was accepted on 07/13/23 at 8:47 PM and included: <BR/>1. Immediate action(s) taken for the resident(s) found to have been affected include:<BR/>1. Resident Notification to Family Treatment nurse at 1:59pm attempted left message and 2:02pm family called back and was notified by ADON, Medical Director/Physician 7-12-23 ADON 1:25pm<BR/>2. SBAR (change in condition) Completed 7-12-23 ADON 1:25pm<BR/>3. Medical Director / Physician Evaluated Resident for changes in condition related to bruises 7-12-23 1:45pm<BR/>4. New orders to monitor bruising, Labs - CBC/INR Orders 7-12-23 1:25pm Labs Drawn at 2:21PM on 7-12-23 and results received at 3:21PM and MD notified 3:25pm and order to repeat CBC in one week received. <BR/>5. Trauma Assessment completed 7-12-23 Charge Nurse LVN A 1:47 PM<BR/>6. Pain Assessment completed 7-12-23 Charge Nurse LVN A 1:45pm<BR/>7. Care Plan Updated 7-12-23 MDS Nurse, Added Skin Care BUE/BLE Bruising- updated with Intervention monitoring skin for the bruising until healed and report abnormality to MD. <BR/>8. Therapy Screening completed 7-12-23 RN DON 3:57pm and Therapy screened completed DOR COTA on 7-12-23 7:15pm, Resident is on services as of 7-13-23 on OT services.<BR/>9. Incident Report ADON LVN 7-12-23 at 6:42pm<BR/>Self-Report Completed 7-12-23 by the Administrator 3:21PM<BR/>10. Skin assessment conducted for all residents that resided in the facility completed 7-12-23 7:30pm completed by Charge Nurse A LVN, Charge Nurse B LVN, all undocumented concerns were reported to MD/Families by LVN ADON, and RN DON completed by 7-13-23 by 4:00pm<BR/>Include actions that were performed toa address to citation: 7-13-23 11:00am <BR/>1. Facility Wide Resident Skin Sweep completed 7-12-23 Charge Nurses A LVN, Charge Nurse LVN B, completed at 7:30pm<BR/>2. Safe Survey with residents that are cognitively intact. 7-13-23 at 1:47pm by Social Worker completed at 4:00pm<BR/>3. Staff Safe Survey completed 7-13-23 Administrator and Regional Director of Operations started at 12:25pm completed at 3:45pm<BR/>4. One on One Inservice with treatment nurse on skin assessment initiated 4:00pm and completed on 7-12-23 conducted by DON RN completed 4:30pm on 7-12-23, Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan and job duties.<BR/>5. One on One Inservice with DON conducted by Regional Nurse Consultant on change in condition/skin assessment and notification. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Initiated 3:00pm 7-12-23 and completed on 7-12-23 3:30pm. Regional Nurse Consultant<BR/>6. In-services for licensed nursing staff on Skin Assessment/Skin initiated on 7/13/2023 at 11:45am by Regional Nurse Consultant. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Completed 7-13-23 5:00pm. <BR/>7. Training for licensed staff was initiated 7-12-23 at 11:45am on Anticoagulant monitoring/documentation timely and accurately 7-13-23 at 5:00pm. Training consisted of how to recognize changed with anticoagulant, monitoring, and orders and care plan in place. <BR/>8. Training for licensed staff was initiated 7-12-23 at 11:45am on Following care plan of anticoagulant completed 7-13-23 at 5:00pm. Training consisted of the following care plan. <BR/>9. Training for Clinical Licensed staff was initiated 7-12-23 at 11:45am on ADL transfers, this Inservice training consisted of transfer safety and how to conduct proper transfers. This Inservice was conducted at a precaution. Training completed on 7-13-23 at 5:00pm.<BR/>10. Training for Clinical Licensed staff was initiated on 7/12/23 at 11:45am, on Notification of Change completed on 7/13/23 at 5:00pm. This training includes what is a change in a condition, proper notification, reported and documentation of change in conditions. <BR/>11. Training with facility staff was initiated on 7/12/23 at 11:45am, by DON on Abuse and Neglect. This training includes what is abuse and neglect, procedures of abuse and neglect, reporting of abuse and the abuse coordinator, completed on 7/13/23 at 5:00pm. <BR/>12. All new hires will be educated on abuse and neglect protocol/change in condition/skin assessment, and anticoagulant ongoing. <BR/>13. The ADON and Director of Nursing will ensure competency through signing of in service, verbalization of understanding. All licensed nurses will notify DON/Administrator/Physician/Family regarding change in conditions. The ADON/DON will audit all skin assessments daily in morning clinical meetings to ensure compliance. <BR/>14. Team members will receive required training prior to their shifted. <BR/>Involvement of Medical Director<BR/>The Medical Director met with the Interdisciplinary team on 7/12/2023 at 4:00pm and conducted an Ad HOC QAPI regarding the change in condition and skin assessment protocol. <BR/>The Medical Director was notified about the immediate Jeopardy on 7/13/2023 at 1:30pm, the Plan of removal was reviewed with IDT Team and Medical Director.<BR/>Involvement of QAPI<BR/>An Ad Hoc QAPI meeting was held with the Medical Director via phone, facility administrator, director of nursing, and social services director to review plan of removal on 7/13/2023 at 2:30pm. <BR/>The Director of Nursing and Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 7/12/2023. Monitoring and reviewing skin assessment during clinical meeting to ensure compliance with facility policy.<BR/>On 07/14/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of the following documents, dated 07/12/23, were as follows:<BR/>1. The SBAR was completed. <BR/>2. A physician progress note was completed and addressed Resident #4's bruising. <BR/>3. The incident report was completed, and the physician, family, DON, and Administrator were notified. <BR/>4. New orders were obtained for labs.<BR/>5. The trauma assessment was completed.<BR/>6. The pain assessment was completed. <BR/>7. The care plan was updated, which included monitoring Resident #4's skin for bruising until healed and report abnormalities to the physician.<BR/>8. The therapy screen was completed. <BR/>9. The provider investigation report was completed. <BR/>10. The skin assessments were reviewed for all residents in the facility. <BR/>11. Skin sweeps were reviewed and completed for all residents in the facility. <BR/>12. Safe surveys for residents and staff were reviewed with no problems identified. <BR/>13. Ad Hoc QAPI plan was reviewed and completed with meeting minutes signed by the medical director, Administrator, DON, ADON, MDS, HR, AD, Maintenance, Social Worker, Dietary Manager, Medical Records, DOR, Housekeeping Supervisor, Business Office Manager, and RDO. <BR/>Interviews with the Treatment Nurse (LVN L) and DON revealed one-on-one in-services were completed. During the interviews the Treatment Nurse and DON were able to correctly identify how to conduct a thorough skin assessment, how to accurately document a weekly skin assessment, changes in the skin, and care plan. <BR/>Interviews of licensed nurses (LVN A, LVN E, LVN R, LVN S, LVN T, LVN U, RN B, RN O, RN P, RN Q, MDS Nurse, and the ADON) were performed. During the interviews all licensed nurses were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, and documenting the change of condition. All licensed nurses were able to correctly identify when skin assessments should be completed and how to conduct a thorough skin assessment, what should be documented on a skin assessment, changes in the skin, and updating the care plan. All licensed nurses were able to correctly identify how to recognize changes for resident's taking an anticoagulant medication, proper monitoring, orders, and following the care plan. All licensed nurses were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All licensed nurses were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. <BR/>Interview of clinical licensed staff (CNA D, CNA K, CNA N, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, CNA CC, CNA DD, CNA EE, CNA FF, MA V, and MA W) were performed. During the interviews all clinical licensed staff were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All clinical licensed staff were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, documenting the change of condition, and who to report a change of condition to. All clinical licensed staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin.<BR/>Interviews of staff (BOM, HR, Receptionist, Maintenance Supervisor, Housekeeping Supervisor, Dietary Manager, Social Worker, AD, Housekeeper GG, Housekeeper HH, Housekeeper KK, LA LL, LA MM, [NAME] NN, [NAME] OO, [NAME] PP, DA QQ, and DA RR) were performed. During the interviews all staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin.<BR/>On 07/14/23 at 11:56 AM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 3 residents (Resident #54 and Resident #75) reviewed for respiratory care.<BR/>1. The facility did not ensure Resident #54 had a physician's order for oxygen that she wore continuously. <BR/>2. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #75.<BR/>These failures could place residents who receive respiratory care at risk for developing respiratory complications.<BR/>The findings included: <BR/>1. Record review of the face sheet, dated 07/11/2023, revealed Resident #54 was an [AGE] year-old female who initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of chronic respiratory failure with hypoxia (not enough oxygen in the blood), shortness of breath, and COPD - chronic obstructive respiratory disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs).<BR/>Record review of the MDS assessment, dated 06/27/2023, revealed Resident #54 had clear speech and was usually understood by staff. The MDS revealed Resident #54 was usually able to understand others. The MDS revealed Resident #54 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #54 had shortness of breath or trouble breathing with exertion (walking, bathing, transferring), when sitting at rest, and when lying flat. The MDS revealed Resident #54 received oxygen while a resident at the facility during the 14-day look-back period. <BR/>Record review of the comprehensive care plan, revised on 04/11/2023, revealed Resident #54 had a diagnosis of COPD. The interventions included Give oxygen therapy as ordered by the physician.<BR/>Record review of the order summary report, dated 07/12/2023, revealed Resident #54 had no physician order for oxygen.<BR/>During an observation and interview on 07/10/2023 at 9:09 AM, Resident #54 was sitting up in her bed with the head of the bed elevated. She was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute. Resident #54 stated she had worn oxygen continuously, since she admitted to the facility, because she had problems breathing. Resident #54 stated the facility staff change her oxygen tubing weekly and checked her oxygen saturations daily.<BR/>During an observation on 07/10/2023 at 2:18 PM, Resident #54 was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute. <BR/>During an observation on 07/11/2023 at 9:33 AM, Resident #54 was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute.<BR/>During an observation on 07/11/2023 at 4:25 PM, Resident #54 was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute.<BR/>During an interview on 07/13/2023 at 2:03 PM, LVN E stated Resident #54 wore oxygen continuously. LVN E stated the charge nurses were responsible for putting orders for oxygen in the electronic charting system. LVN E stated Resident #54 should have a physician's order for oxygen. LVN E stated the order probably did not get put back on when she came back from the hospital. LVN E stated the nurses try to check each other when residents readmit from the hospital. LVN E stated it was important to ensure Resident #54 had a physician's order for oxygen because you need a doctor's order for it. <BR/>During an interview on 07/13/2023 at 3:43 PM, the DON stated nurses were responsible for ensuring physician orders for oxygen were in the computer. The DON stated that was monitored by reconciling with the physician and performing 24-72-hour chart audits and admissions and readmission. The DON stated Resident #54 should have a physician's order for oxygen. The DON stated she expected nursing staff to ensure a physician's order for oxygen was placed in the electronic monitoring system. The DON stated it was important to ensure an order for oxygen was placed in the computer for the safety and well-being of residents and to follow the plan of care. <BR/>During an interview on 07/14/2023 at 12:04 PM, the Administrator stated he expected the nursing staff to ensure an order for oxygen was placed in the computer. The Administrator stated the DON and ADON were responsible for monitoring orders during the clinical morning meeting. The Administrator stated it was important to ensure orders were placed in the computer to ensure the facility staff are following all physician's orders and provide treatment that was required. <BR/>2. Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), acute respiratory failure with hypoxia (not enough oxygen in blood), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (chronic condition that affects the way the body processes blood sugar with progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). <BR/>Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #75 was usually understood and usually understood others. The MDS assessment indicated Resident #75's BIMS was an 8, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #75 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS assessment indicated Resident #75 was receiving oxygen therapy.<BR/>Record review of Resident #75's care plan with date initiated 07/11/2023, indicated he had altered respiratory status/difficulty breathing related to a pulmonary nodule (small growth in the lungs that can be non-cancerous or cancerous) with an intervention to provide oxygen as ordered. <BR/>Record review of Resident #75's order summary report dated 07/11/2023, indicated an order to check oxygen saturation three times a day, as needed, and every shift, and apply oxygen at 2 liters per minute via nasal canula for oxygen saturation less than 90% with a start date of 06/30/2023. <BR/>During an observation on 07/10/2023 at 11:02 AM, Resident #75 was sitting on the side of the bed with oxygen on via nasal canula at 4 liters per minute. <BR/>During an observation on 07/12/2023 at 9:05 AM, Resident #75 was in bed with oxygen via nasal canula on, set between 3-4 liter per minute. <BR/>During an interview on 07/12/2023 at 5:48 PM, RN B said oxygen should be administered per the physician's orders. RN B said Resident #75's oxygen should have been set at 2 liter per minute per the physician's order, and he only used it as needed. RN B said setting the oxygen higher than the prescribed rate could make the residents sicker. <BR/>During an interview on 07/13/2023 at 9:01 AM, the ADON said the nurses were responsible for making sure oxygen was administered per the physician's order. The ADON said the nurses should be checking the oxygen to make sure it was set at the correct prescription. The ADON said if the oxygen was set higher than the prescribed rate it could be counterproductive for certain diseases and could cause more harm than good. <BR/>During an interview on 07/13/2023 at 10:40 AM, the DON said the nurses were responsible for ensuring oxygen was administered per the physician's order. The DON said Resident #75's oxygen via nasal canula was as needed, and he could put it on himself when he felt short of breath. The DON said setting the oxygen higher than the physician's order could cause lightheadedness and dizziness. <BR/>During an interview on 07/13/2023 at 2:34 PM, the Administrator said the charge nurses were responsible for making sure oxygen was administered per the physician's order. The Administrator said he expected the nurses to follow the physicians' orders. The Administrator said it was important that oxygen be administered per the physician's order to avoid respiratory distress. <BR/>Record review of the facility's policy titled, Oxygen Administration, with date revised 06/2020, indicated, . Initiation of oxygen A. A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include: i. Oxygen flow rate ii. Method of administration (e.g., nasal cannula) iii. Usage of therapy (continuous or prn) iv. Titration instructions (if indicated) v. Indication of use . Explain the procedure to the resident II. Check the physician's order . VI. Turn on oxygen at the prescribed rate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 2 residents (Resident #75) reviewed for dialysis. <BR/>The facility failed to have physician's orders for the care of Resident #75's central venous catheter used for dialysis (a long, flexible tube inserted into a vein in your neck, chest, arm, or groin and leads to a large vein that empties into your heart and is used as a dialysis access). <BR/>The facility failed to care plan Resident #75's central venous catheter used for dialysis. <BR/>These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs.<BR/>Findings included:<BR/>Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (chronic condition that affects the way the body processes blood sugar with progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). <BR/>Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #75 was usually understood and usually understood others. The MDS assessment indicated Resident #75's BIMS was 8, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #75 received dialysis while a resident at the facility.<BR/>Record review of Resident #75's care plan with date initiated 06/26/2023 did not indicate his central venous catheter was care planned. <BR/>Record review of Resident #75's order summary report dated 07/11/2023 did not indicate physician orders for his central venous catheter. <BR/>During an observation and interview on 07/10/2023 at 10:15 AM, Resident #75 was in his bed central venous catheter observed to right chest, dressing was not adhered from the bottom, and it had brownish-tinged spots on it. Resident #75 said he was going to dialysis later that day. <BR/>During an interview on 07/12/2023 at 3:34 PM, Dialysis RN G said the Resident #75 should have orders to monitor the central venous catheter due to the risk of infection. Dialysis RN G said if the central venous catheter dressing was not completely adhered the facility needed to contact the dialysis clinic for further instructions.<BR/>During an interview on 07/12/2023 at 6:28 PM, LVN A said she was aware Resident #75 had a central venous catheter to his right chest and it was used for his dialysis. LVN A said she had not noticed on 07/10/2023 that his dressing was soiled and not completely adhered. LVN A said she had been checking Resident #75's catheter. LVN A said she was not aware Resident #75 did not have physician orders for his central venous catheter. LVN A said the admitting nurse should have obtained physician orders for the central venous catheter. LVN A said it was important for Resident #75 to have physician orders for his central venous catheter because of the risk of infection. <BR/>During an interview on 07/13/2023 at 8:45 AM, the ADON said on admission the nurse was supposed to call the doctor to get orders for Resident #75's central venous catheter used for dialysis. The ADON said she was not sure why Resident #75 did not have physician orders for his central venous catheter. The ADON said Resident #75's central venous catheter should have been care planned. The ADON said the MDS Coordinator should have care planned Resident #75's central venous catheter. The ADON said it was important to have physician orders for the central venous catheter for prevention of infection and to prevent dislodgment. The ADON said it was important for Resident #75's central venous catheter to be included in his care plan, so that everybody knew it was there and how staff should take care of it. <BR/>During an interview on 07/13/2023 at 9:16 AM, the DON said Resident #75 should have had orders for his central venous catheter to monitor for signs and symptoms of infection and for dressing changes. The DON said the physician orders should have been obtained on admission. The DON said it was important to have orders for the central venous catheter because of the risk of infection. The DON said Resident #75's central venous catheter should have been included in his care plan. The DON said the MDS Coordinator was responsible for including Resident #75's central venous catheter in the care plan. The DON said it was important for Resident #75's central venous catheter to be included in the care plan for the staff to know how to care for the central venous catheter. <BR/>During an interview on 07/13/2023 at 2:28 PM, the Administrator said the charge nurses were responsible for obtaining physician orders for a central venous catheter. The Administrator said the DON and ADON should make sure the central venous catheter was included in the care plan. The Administrator said he expected the nurses to obtain physician orders for the care of a central venous catheter, and he expected for the care plan to include a central venous catheter. The Administrator said it was important to have physician orders and care plan a central venous catheter to appropriately care for the residents and because of the risk of infection. <BR/>During an interview on 07/13/2023 at 3:58 PM, the MDS Coordinator said a central venous catheter used for dialysis should be included in the resident's care plan. The MDS Coordinator said she was responsible for including a central venous catheter in the care plan. The MDS Coordinator said Resident #75's central venous catheter was not included in his care plan because he had no physician orders for the central venous catheter. The MDS Coordinator said when she created the residents care plans, she used the MDS assessment and the physician orders. The MDS Coordinator said it was important for Resident #75's central venous catheter to be included in his care plan because the staff needed to monitor the site, perform dressing changes, and monitor for signs and symptoms of infection. <BR/>Record review of the facility's policy titled, Dialysis Care, last revised 06/2020, indicated, .The Facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment . The Licensed Nurse will monitor the integrity of the catheter dressing every shift and reinforce the dressing with tape as needed . The Interdisciplinary Team (IDT) will ensure that the resident's Care Plan includes documentation of the resident's renal condition and necessary precautions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 13 residents reviewed (Resident #4) for anticoagulant monitoring and skin assessments.<BR/>1. The facility did not ensure the physician orders for anticoagulant monitoring on Resident #4 were adequately followed, when Resident #4 had an increase in bruising while taking an anticoagulant medication (blood thinner that works by preventing red blood cells from forming clots). <BR/>2. The facility did not ensure LVN L, who was the treatment nurse, accurately performed weekly skin assessment's resulting in no documentation of Resident #4's bruising.<BR/>These failures could place residents at an increased risk for bleeding, bruising, and not receiving the care and services to meet their individual needs.<BR/>The findings included: <BR/>Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), history of cerebral infarction (stroke), history of a heart attack, hypertension (high blood pressure), mitral (valve) stenosis (narrowing of the mitral valve of the heart that causes tiredness and shortness of breath), and congestive heart failure (progressive heart disease that affects pumping action of the heart muscles). <BR/>Record review of the MDS assessment, dated 05/30/23, revealed Resident #4 had clear speech and was usually understood by staff. The MDS revealed Resident #4 was usually able to understand others. The MDS revealed Resident #4 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #4 had no behaviors or refusal of care. The MDS revealed Resident #4 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene with a one or two staff assistance. <BR/>Record review of the comprehensive care plan, revised on 01/28/23, revealed Resident #4 was on anticoagulant therapy. The interventions included Monitor/document/report to the doctor as needed for signs and symptoms of anticoagulant complications: .bruising .<BR/>Record review of the order summary report, dated 07/12/23, revealed Resident #4 had an order, which started on 12/14/21, for Anticoagulant Monitoring - Place letter of symptoms of excess bleeding .every shift .F. bruising. The orders also revealed an order, which started on 12/13/21, for Aggrenox (blood thinner) Capsule 25-200 mg by mouth two times a day for blood thinner.<BR/>Record review of the Nurse Administration Record, dated July 2023, revealed bruising was present on the following dates: 07/01/23, 07/03/23, 07/04/23, 07/05/23, 07/06/23, and 07/11/2023. The Nurse Administration Record did not specify the location of the bruising.<BR/>Record review of the Weekly Skin Check, dated 07/04/23, revealed Resident #4 had no bruising. <BR/>Record review of the CNA Shower Report, dated 07/10/23, revealed Resident #4 had no skin problems. <BR/>Record review of the Weekly Skin Check, snipped on 07/11/2023 at 5:27 PM, revealed Resident #4 had no bruising. <BR/>During an interview on 07/11/23 at 5:55 PM, a copy of Resident #4's Weekly Skin Check dated 07/11/23 was requested from the DON. <BR/>Record review of the Weekly Skin Check provided by the facility, dated 07/11/23, revealed Resident #4 had the following newly documented skin problem areas: reddish, burgundy discoloration to back of left hand, front of right shoulder, left lower leg (below the knee), front of the left leg (above the knee), front of the right leg (above the knee), and the upper inner arm; bright reddish tint to right and left heel; small scabbing to second right toe and small scabbing to first, second, and fifth toes; red linear scratch to left shoulder in the front; and purplish discoloration to right lateral foot below the fifth toe.<BR/>During an observation and attempted interview on 07/10/23 at 9:09 AM, Resident #4 was laying in her bed with her bed sheets pulled up. She was moving her legs up and down and holding the bed sheets in her hands close to her face. Resident #4's arms and legs were visible from the door and several large, reddish-purple bruises were observed to Resident #4's upper legs and arms. Resident #4 was unable to remember how the bruising occurred and stared at the surveyor when questions were asked. <BR/>During an interview on 07/12/23 at 12:02 PM, LVN L stated she was the treatment nurse at the facility and had worked at the facility since March of 2022. LVN L stated Resident #4 had discoloration to several areas on her skin. LVN L said she was unable to call the discoloration a bruise because bruising is usually blue, green, or reddish-purple and the discoloration on Resident #4 was reddish burgundy. LVN L stated when she completed the weekly skin assessments, she was only documenting skin impairments on the form. LVN L stated a skin impairment was areas on the skin that required a treatment. LVN L stated she did not document areas on the skin that did not require a treatment, such as bruising. LVN L stated she was asked by the DON to reopen her skin assessment and document a complete head to toe assessment because the state agency wanted them to. LVN L stated Resident #4 had the discoloration and skin problems prior to 07/11/23, when they were documented. However, the skin issues did not require a treatment, so they were not documented on the weekly skin assessment. LVN L stated Resident #4 has always had terrible skin and the discoloration comes and goes frequently. LVN L stated she was unsure if Resident #4 was taking a blood thinning medication. LVN L stated she had not notified anyone of Resident #4's new skin areas of discoloration. LVN L stated the facility staff was aware of Resident #4's skin status because it has been discussed several times, especially regarding transfers. LVN L stated the discoloration had been present since she started working there but had come and gone in the same area. LVN L was unable to say if the discoloration were the same ones or were in the same area. <BR/>During an interview on 07/12/23 at 12:20 PM, the ADON stated she used to be the treatment nurse at the facility. The ADON stated weekly skin assessments should have been a complete head to toe assessment, to include discoloration or bruising. The ADON stated new bruising or discoloration should have been monitored for 72 hours, initially, then weekly on the skin assessments. <BR/>During an interview on 07/12/23 at 1:44 PM, the DON stated the treatment nurse was responsible for ensuring weekly skin assessments were completed. The DON stated she expected all skin integrity issues to be documented, which included bruising or areas or discoloration. The DON stated she did not ask the treatment nurse to reopen her skin assessment. The DON stated it was a miscommunication because she thought it was requested by the state agency. The DON stated a one-on-one in-service on accurately completing and documented skin assessments was given to the treatment nurse on 07/12/23 and prior to that she was provided training by the ADON on how to perform skin assessments when she was hired at the facility. The DON stated Resident #4 had long-term, recurring bruising and discoloration. The DON was unsure if Resident #4 was taking a blood thinning medication. The DON stated she was unaware of Resident #4's increased bruising until this week. The DON stated she expected staff to monitor for increased bruising, especially if a resident was taking a blood thinning medication. The DON stated she expected staff to monitor for bruising and other signs of bleeding every shift for residents taking a blood thinning medication. The DON stated an increase in bruising for resident's taking a blood thinning medication should have been reported to the physician, as soon as it was noticed, because it would have been considered a change of condition. The DON stated documenting bruising on the weekly skin assessment, anticoagulant monitoring every shift, and reporting increased bruising to the physician were important to monitor and follow up on side effects of blood thinning medications such as bruising, metabolic functions, and fragile skin.<BR/>During an interview on 07/12/23 at 6:03 PM, CNA N stated he worked 2-10 shift on 07/10/23 and 7/11/23. CNA N stated he helped the treatment nurse with Resident #4's skin assessment on 07/11/23 after the supper meal. CNA N stated during the skin assessment on 07/11/23 was the first time he had noticed bruising on Resident #4, but she did have a history of bruising on and off. CNA N stated he was unsure how Resident #4 received the bruising to her arms and legs. CNA N stated he worked on a different hall on 07/10/23. CNA N stated he would have reported the bruising to the charge nurse if he would have noticed it. CNA N stated the treatment nurse was aware of the bruising, so he did not have to report it. <BR/>During an interview on 07/12/23 at 6:16 PM, LVN E stated she normally worked with Resident #4. LVN E stated the bruising to Resident #4 had been there but was unable to say for how long. LVN E stated the bruising was present on 07/10/23 (Monday) but she believed the bruising had been documented on a skin assessment. LVN E stated it was normal for Resident #4 to bruise easily because she was on a blood thinner. LVN E stated she was unsure how Resident #4 received the bruising on her arms and legs. LVN E stated she monitored for signs and symptoms of bleeding on the anticoagulant monitoring form that was on the Nurse Administration Record. LVN E stated the bruising was normal for Resident #4 and she did not document on the anticoagulant monitoring form. LVN E stated the physician should have been notified any time a new bruise or skin problem was identified. LVN E stated it was important to notify the physician for signs of bleeding so lab work could have been ordered to check for internal bleeding and medication could have been adjusted as it was needed. LVN E stated it was important to monitor and follow up with Resident #4 for signs and symptoms of bleeding, which included increased bruising because she could have had internal bleeding. LVN E stated it was important to document bruising so it could have been monitored and followed up on. <BR/>During an interview on 07/13/23 at 1:39 PM, CNA C stated she worked Resident #4's hall on 07/10/23 and she had discoloration to her upper and lower limbs. CNA C she did not report the discoloration to the charge nurse because it had been reported previously and the charge nurse was aware. CNA C was unsure who reported the discoloration previously. CNA C stated she was unsure how the discoloration to Resident #4's arms and legs occurred. CNA C stated Resident #4 had other signs of bleeding. CNA C stated it was important to document and report new bruising to the charge nurse because it could have been a change of condition and the charge nurse would want to be aware. <BR/>During an interview on 07/13/23 at 2:18 PM, LVN L stated she had been trained and checked off on skin assessments. LVN L said the last check off, before the one-on-one in-service provided 07/12/23, was during the mock survey performed by the corporate staff in the earlier part of the year. LVN L stated she had been trained on monitoring for residents taking a blood thinning medication and change of condition. LVN L stated bruising was normal for residents taking a blood thinning medication. LVN L stated the smallest touch to a resident taking a blood thinning medication could have left a bruise. LVN L stated when monitoring resident's taking a blood thinning medication, bruising should have been documented and reported. LVN L stated it was important to perform complete skin assessments to monitor skin problems and address any new skin issues. <BR/>During an interview on 07/13/23 at 3:43 PM, the DON stated anticoagulant monitoring training was upon hire while going over orders in the electronic charting system. The DON stated what to monitor for was learned in nursing school and all nurses should have been aware. The DON stated adequately monitoring residents that took a blood thinning medication was important for the safety and wellbeing of the residents. <BR/>During an interview on 07/14/23 at 12:04 PM, the Administrator stated bruising was normal for a resident who was taking a blood thinning medication. The Administrator stated he expected clinical staff to monitor for signs of bleeding, which included bruising, and report any changes to the physician. The Administrator stated the nursing management was responsible for monitoring clinical staff. The Administrator stated it was important to ensure residents taking a blood thinning medication were monitored and adequately assessed to ensure residents received the care they required. <BR/>Record review of the Inservice Schedule, undated, revealed no in-service training was scheduled regarding skin assessments or anticoagulant monitoring. <BR/>Record review of the Anticoagulant Therapy policy, revised 06/2020, revealed VI. Complete a head-to-toe assessment of the resident. Document any pre-existing bruising. VII. Initiate the care plan following initiation of anticoagulant therapy. The policy further revealed XI. Educate the resident and family regarding the side effects and adverse drug effects of anticoagulant therapy. The policy did not address monitoring for signs and symptoms of bleeding or bruising.<BR/>Record review of the Care Standards policy, revised 06/2020, revealed I. The Director of Nursing Services (DON) ensures care and services are delivered according to accepted standards of clinical practice. Unless specifically addressed in an individual facility policy, the Facility defers to the accepted national standards of clinical practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 2 residents (Resident #68) reviewed for hospice services.<BR/>The facility did not ensure Resident #68's hospice records were a part of their records in the facility<BR/>This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. <BR/>The findings were: <BR/>Record review of a face sheet dated 07/11/2023, indicated Resident #68 was a [AGE] year-old female initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included severe protein-calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets can lead to muscle loss, fat loss, and your body not working as it usually would), cerebral infarction unspecified (damage to tissues in the brain due to a loss of oxygen to the area), and atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). <BR/>Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #68 was understood and understood others. The MDS assessment indicated Resident #68 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #68 received hospice services while a resident at the facility. <BR/>Record review of the care plan with date initiated 03/21/2023, indicated Resident #68 had a terminal prognosis related to severe protein calorie malnutrition with a goal of dignity and autonomy will be maintained at the highest level through the review date. Interventions included to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. <BR/>Record review of the order summary report dated 07/11/2023 indicated Resident #68 had an order to admit to hospice under the diagnosis of severe protein calorie malnutrition with start date of 03/10/2023. <BR/>Record review of Resident #68's electronic health record did not reveal any hospice related records to include: (a) the most recent hospice plan of care; (b) the hospice election form; (c) physician certification and recertification of the terminal illness; (d) hospice medication information; (e) hospice physician orders; and (f) any progress notes from any hospice visits. <BR/>During an interview on 07/12/2023 at 9:39 AM, LVN E said the residents hospice records were kept in a binder at the nurse's station. LVN E said Resident #68 did not have a binder with her hospice records in it. LVN E said she would call the hospice to have them bring the hospice records to the facility. <BR/>During an interview on 07/12/2023 9:43 AM, Hospice RN F said she was Resident #68's hospice case manager. Hospice RN F said she thought she had sent them by e-mail to someone at the facility, but she must have sent it to the wrong email (she was unable to specify to who she had sent them). Hospice RN F said the facility had not requested that she take Resident #68's hospice records to the facility. Hospice RN F said she should have made sure the hospice records were taken to the facility. Hospice RN F said it was important for the facility to have the hospice records so the staff could refer to them and reference back to the nurses' visits, aide visits, the medication list and have the hospice diagnosis and hospice orders. <BR/>During an interview on 07/13/2023 at 08:56 AM, the ADON said the resident's hospice records were kept in a hospice binder. The ADON said the nurses should be making sure the hospice records were in the facility. The ADON said that she was aware there was no system in placed to ensure the hospice records were in the facility. The ADON said she was not aware Resident #68's hospice records were not in the facility. The ADON said it was important for the hospice records to be in the facility to make sure the care was matching, the medications were correct, the facility knew of the hospice scheduled visits, and to ensure any new orders given by the hospice were implemented. <BR/>During an interview on 07/13/2023 at 10:02 AM, the DON said the hospice residents had hospice binders containing all the hospice records. The DON said the charge nurses were responsible for making sure the hospice records were in the facility. The DON said she did not know why Resident #68's hospice records were not in the facility. The DON said it was important for the residents' hospice records to be in the facility to be able to work in collaboration with the hospice and so all the staff would be on the same page with the residents' plan of care. <BR/>During an interview on 07/13/2023 at 1:54 PM, LVN A said the residents' hospice records were kept in binders. LVN A said she did not know who was responsible for making sure the residents' hospice records were in the facility. LVN A said she had not noticed Resident #68 did not have a hospice binder with her hospice records. LVN A said it was important to have the residents' hospice records, so the facility staff knew what was going on and the hospice staff knew what was going on. <BR/>During an interview on 07/13/2023 at 2:32 PM, the Administrator said nursing management was responsible for making sure the residents hospice records were in the facility. The Administrator said the nurses should have requested the hospice records from the hospice provider. The Administrator said it was important for the facility to have the residents' hospice records for coordination of care.<BR/>Record review of the Hospice and Long Term Care Facility Agreement, with an effective date of September 20, 2021, indicated, . Each Party shall allow reasonable access to the records of the other party in order to carry out their respective rights, duties, and obligations under this agreement. Insofar as Plans of Care, clinical records notes, meeting minutes IDG/IDT records, orders, reassessments and updates to the Plans of Care and similar documents have been integrated by Hospice and Provider, each party shall retain a copy of such records . <BR/>Record review of the facility's Nursing Policy and Procedure, Palliative Care, with an effective date of 05/2017, did not address obtaining the residents hospice records.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #1 and Resident #2) reviewed for infection control.<BR/> The facility failed to ensure LVN D wore the proper PPE (gown and gloves) while checking Resident #1's blood sugar or administering insulin on 04/08/25, who was positive for ESBL.<BR/>The facility failed to ensure CNA E wore the proper PPE (gown and gloves) while providing care to Resident #1, who was positive for ESBL on 04/09/25. <BR/>The facility failed to ensure Resident #2 understood contact isolation precautions when the resident was in activities with other residents and positive for MRSA on 04/08/25.<BR/>These failures could place residents and staff at risk for cross-contamination and spread of infection and could potentially affect all others in the building. <BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included urinary tract infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), extended-spectrum beta-lactamase also known as ESBL (occurs when bacteria producing the enzyme ESBL, which renders them resistant to many common antibiotics, causes an infection), diabetes (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), and stroke.<BR/>Record review of Resident 1's quarterly MDS assessment, dated 02/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 03, indicating she was severely cognitively impaired. The MDS indicated Resident #1 required assistance with his transfers, toileting, dressing, hygiene, and supervision for eating. The MDS indicated she was always incontinent of urine and was on an antibiotic.<BR/>Record review of Resident #1's electronic medical records revealed a urinalysis dated 04/05/25 which detected extended-spectrum beta-lactamase, also known as ESBL.<BR/>Record review of Resident #1's comprehensive care plan dated 04/06/25 indicated Resident #1 had a UTI. The intervention was for staff to encourage adequate fluids and monitor side effects. The care plan did not indicate Resident #1 was on contact isolation.<BR/>Record review of Resident #1's physician's order dated 04/07/25 indicated: Doxycycline 100mg, give 1 capsule by mouth two times a day related to Urinary tract infection for 5 days. <BR/>Record review of Resident #1's Physician order dated 04/07/25 indicated contact isolation precautions in place related to the diagnosis of ESBL.<BR/>During an observation on 04/08/25 at 12:09 p.m., a contact isolation sign was noted on Resident #1's door. LVN D walked into Resident #1's room to check her blood sugar without applying a gown. LVN D reached over Resident #1 to check her blood sugar on her left finger. LVN D then left Resident #1's room to gather her insulin, reentered the room without a gown, and administered her insulin.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN A said she was the nurse who received Resident #1's diagnosis of ESBL related to her lab results and the order for Doxycycline. She said she gave the initial dose on 04/07/25 and posted an isolation sign on Resident #1's door. She said she reported it to the oncoming nurse about Resident #1's isolation and new order for Doxycycline. She said she also placed it on the 24-hour report sheet.<BR/>During an interview on 04/09/25 at 9:15 a.m., LVN D said she was the charge nurse for Resident #1 and Resident #2. She said Resident #1 was on contact precautions for ESBL in her urine, and Resident #2 was on contact precautions for MRSA in her urine. LVN D said staff should have on a gown and gloves when entering Resident #1 and Resident #2's rooms. She said she did not wear a gown when she went into Resident #1's room to check her blood sugar or when she administered her insulin. She said she honestly forgot she was in contact isolation. She said Resident #2 had rights, and if she wished to come out of her room, then she could. She said she could not recall if she had personally asked Resident #2 to stay in her room related to her contact isolation orders. She said if staff were not wearing gowns or gloves, they could spread the infection to others.<BR/>During an observation on 04/09/25 at 9:45 a.m., CNA E went into Resident #1's room to provide care. CNA E did not have on her gown or gloves when entering Resident #1's room. <BR/>During an observation and interview on 04/09/25 at 10:09 a.m., CNA E came out of Resident #1's room and disposed of her linen in the laundry barrel without it being in a yellow bag. She said she was aware Resident #1 was on contact precautions for something in her urine. She said she did not see a cart next to her door and did not see any boxes in her room, so she assumed she did not have to wear anything while in the room. She said that in the past, if a resident was on isolation, they would have a cart with equipment next to the door and boxes in the room with red bags for the trash and yellow bags for the linen. She said she worked yesterday (04/08/25) and did not wear a gown while providing care for Resident #1. She said she could spread infection since she did not properly dispose of her linen or wear a gown while in the room. <BR/>During an observation on 04/09/25 at 10:15 a.m., no linen or trash boxes were noted in Resident #1's room. The isolation cart was noted 1 door to the right of Resident#1's room.<BR/>2.Record review of Resident #2's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia(a general term for a group of diseases that cause a decline in memory, thinking, and reasoning abilities, significantly affecting a person's daily life), Urinary Tract Infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), and anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident 2's quarterly MDS assessment, dated 01/30/25, indicated Resident #2 usually understood and was usually understood by others. Resident #2's BIMS score was 15, indicating she was cognitively intact. The MDS indicated Resident #2 required set-up assistance with her dressing and hygiene, independent with toileting and eating. The MDS indicated she was continent of bladder.<BR/>Record review of Resident #2's comprehensive care plan dated 03/29/23 indicated Resident #1 was occasionally incontinent of urine. The intervention was for staff to monitor for signs and symptoms of UTI. The care plan did not indicate a care plan for contact isolation or refusal to comply with contact isolation. <BR/>Record review of Resident #2's electronic medical records revealed a urinalysis dated 04/03/25, which detected MRSA (an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections). <BR/>Record review of Resident #2's physician's order dated 04/06/25 indicated: Rifampin 300mg, give 1 capsule by mouth two times a day related to MRSA in urine until 04/20/25. <BR/>Record review of Resident #2's Physician order dated 04/06/25 indicated Contact isolation precautions in place related to MRSA.<BR/>Record review of Resident #2's comprehensive care plan after surveyor intervention was dated 04/06/25 but updated on 04/09/25, indicating Resident #1 required isolation. The intervention was to follow facility isolation policy and give medication as ordered.<BR/>During an observation on 04/08/25 at 11:00 a.m., Resident #2 was in the dining room attending an activity with 8 other residents while positive for MRSA.<BR/>During an interview on 04/08/25 at 3:30 p.m., Resident #2 said the staff told her she had something in her bladder and to make sure she washed her hands after using the bathroom. She said they did not tell her she had something that someone might catch or to stay in her room.<BR/>During an observation on 04/09/25 at 9:28 a.m., Resident #2 was in the day room sitting on the couch talking to another resident.<BR/>During an interview on 04/09/25 at 10:00 a.m., the ADON said if a resident were in contact isolation, staff would know because of the sign posted on the door. She said staff should wear gowns and gloves when they enter contact-isolated rooms. She said they encourage handwashing before and after care for all residents. She said she was not sure what the policy said on contact isolation for a resident. She said she thought the contact isolated residents could walk the facility. She said she knew they had educated Resident #2 on hand washing.<BR/>During an interview on 04/09/25 at 11:22 a.m., the DON said he expected all staff to follow the guidelines on the sign posted on the door. He said they should be wearing the proper PPE (gown and gloves) to protect themselves and to keep the spread of infection from other residents. He said if the resident were on contact isolation, then staff should be educating the resident on why they need to stay in their room and encouraging them to stay in their rooms. If the resident refuses to stay in their room, then the staff should document the refusal and add it to the resident's care plan.<BR/>During an interview on 04/09/25 at 12:16 p.m., the Administrator said when a resident was on contact isolation, staff should wear gowns and gloves when entering the room. She said the DON oversaw infection control. The Administrator said staff should ensure they had on the proper PPE to protect themselves and the residents and to prevent the spread of infection. She said residents who were on contact isolation should be encouraged to stay in their rooms and practice good hygiene to prevent the spread of infection. <BR/>Record review of the facility's policy titled, Infection Prevention and Control Program, revised 06/2020, indicated, Purpose: Ensure the facility established and maintained an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements. Policy: The facility must establish an infection prevention and control program under which it: #1 identifies, investigates, controls, and prevents infections in the facility .<BR/>Record review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions, revised 6/2020, indicated, To ensure that transmission-based precautions are used when caring for residents with communicable diseases or transmittable infections. III. Contact Precautions A. Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. I. Examples of infections requiring Contact Precautions include, but are not limited to: A. Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-drug resistant organisms (e.g., MRSA). C. Gloves and Handwashing: I. As outlined under Standard Precautions, gloves (clean, non-sterile) are worn when entering the room. D. Gown: I. As outlined under Standard Precautions, a (clean, non-sterile) gown is worn for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. G. Notice: I. The Facility alerts staff to the type of precaution a resident requires. ii. The Facility also ensures that the resident's care plan indicates the type of precautions implemented for the resident. iii. The Facility may utilize a sign requesting visitors to check in at the nursing station before entering a resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 2 of 4 (Resident #1 and Resident #2) residents reviewed for the care plan.<BR/>1. The facility failed to ensure urinalysis results on 04/05/2025 for Resident #1's contact isolation was care planned on 04/06/2025 for a diagnosis of Extended-Spectrum Beta-Lactamase, also known as ESBL (a bacteria that can be spread from person to person on contaminated hands of both patients and healthcare workers.<BR/>2. The facility failed on 04/03/2025 to ensure Resident #2's contact isolation was care planned for methicillin-resistant Staphylococcus aureus also known as MRSA (an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections) and for her refusal to stay in her room related to her being on isolation.<BR/>These failures could affect residents by placing them at risk of not receiving appropriate care and interventions to meet their needs.<BR/>Findings included:<BR/>1.Record review of Resident #1's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included urinary tract infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), extended-spectrum beta-lactamase also known as ESBL (occurs when bacteria producing the enzyme ESBL, which renders them resistant to many common antibiotics, causes an infection), diabetes (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), and stroke.<BR/>Record review of Resident 1's quarterly MDS assessment, dated 02/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 03, indicating she was severely cognitively impaired. The MDS indicated Resident #1 required assistance with her transfers, toileting, dressing, hygiene, and supervision for eating. The MDS indicated she was always incontinent of urine and was on an antibiotic. <BR/>Record review of Resident #1's electronic medical records revealed a urinalysis dated 04/05/25 which detected extended-spectrum beta-lactamase, also known as ESBL.<BR/>Record review of Resident #1's comprehensive care plan dated 04/06/25 indicated Resident #1 had a UTI. The intervention was for staff to encourage adequate fluids and monitor side effects. The care plan did not mention anything about being on contact isolation for ESBL.<BR/>Record review of Resident #1's physician's order dated 04/07/25 indicated: Doxycycline 100mg, give 1 capsule by mouth two times a day related to Urinary tract infection for 5 days. <BR/>Record review of Resident #1's Physician order dated 04/07/25 indicated Contact isolation precautions in place related to ESBL.<BR/>During an observation on 04/08/25 at 12:09 p.m., a contact isolation sign was noted on Resident #1's door. The isolation cart was noted 1 door to the right of Resident #1's room.<BR/>2.Record review of Resident #2's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia(a general term for a group of diseases that cause a decline in memory, thinking, and reasoning abilities, significantly affecting a person's daily life), Urinary Tract Infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), and anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident 2's quarterly MDS assessment, dated 01/30/25, indicated Resident #2 usually understood and was usually understood by others. Resident #2's BIMS score was 15, indicating she was cognitively intact. The MDS indicated Resident #2 required set-up assistance with her dressing and hygiene, independent with toileting and eating. The MDS indicated she was continent of bladder.<BR/>Record review of Resident #2's comprehensive care plan dated 03/29/23 indicated Resident #2 was occasionally incontinent of urine. The intervention was for staff to monitor for signs and symptoms of UTI. The care plan did not indicate a care plan for contact isolation or refusal to comply with contact isolation for MRSA. <BR/>Record review of Resident #2's electronic medical records revealed a urinalysis dated 04/03/25, which detected MRSA. <BR/>Record review of Resident #2's physician's order dated 04/06/25 indicated: Rifampin 300mg, give 1 capsule by mouth two times a day related to MRSA in urine until 04/20/25. <BR/>Record review of Resident #2's Physician order dated 04/06/25 indicated contact isolation precautions in place related to the diagnosis of MRSA.<BR/>Record review of Resident #2's comprehensive care plan after surveyor intervention was dated 04/06/25 but updated on 04/09/25, indicating Resident #1 required isolation. The intervention was to follow the facility's isolation policy and give medication as ordered.<BR/>During an observation on 04/08/25 at 11:00 a.m., Resident #2 was in the dining room attending an activity with 8 other residents while positive for MRSA. Resident #2 had a contact isolation sign on her door and an isolation cart outside her room door.<BR/>During an interview on 04/09/25 at 10:00 a.m., the ADON said the MDS nurses were responsible for the care plans. She said she and the DON were responsible for updating the acute care plans. She looked at Resident #1's and Resident #2's care plan and said she did not see their contact isolation care plan, nor Resident #2's refusal to stay in her room. She said she was aware they were on contact precautions but had not had a chance to update the care plan. She said she was aware of all new orders or changes a resident might have because they discussed the residents in the morning meeting, and she read the 24-hour reports. She said care plans were updated so staff would be aware of the care the residents needed.<BR/>During an interview on 04/09/25 at 11:08 a.m., the Regional MDS nurse said the MDS nurse was responsible for the comprehensive care plan, and the management team was responsible for updating the acute care plans. She said any changes about new orders should be updated within 24-48 hours, depending on when the order was received. She said care plans were done to direct the care of the resident.<BR/>During an interview on 04/09/25 at 11:22 a.m., the DON said the MDS nurses were responsible for the care plans. He said he and the ADON were responsible for the acute care plans. He said he was not aware that Resident #1 or Resident #2's care plan had not been updated related to contact isolation and the refusal of Resident #2 to stay in her room. He said care plans were done to ensure staff conducted the plan of care for each resident.<BR/>During an interview on 04/09/25 at 12:16 p.m., the Administrator said care plans were a team effort with the interdisciplinary team, but the MDS nurses were the overseers. She said the MDS nurse last day at the facility was last week; therefore, the DON/ADON was responsible for updating Resident #1 and #2's care plan. She said care plans were generated to provide each resident with the best care.<BR/>Record review of the facility's policy, Care Plan (Comprehensive), revised 10/24/22, indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. V. The IDT will revise the Comprehensive Care Plan as needed at the following intervals: A. Per RAI schedules; B. As dictated by changes in the resident's condition, C. In preparation for discharge, D. To address changes in behavior and care, and E. Other times as appropriate or necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 2 of 4 (Resident #1 and Resident #2) residents reviewed for the care plan.<BR/>1. The facility failed to ensure urinalysis results on 04/05/2025 for Resident #1's contact isolation was care planned on 04/06/2025 for a diagnosis of Extended-Spectrum Beta-Lactamase, also known as ESBL (a bacteria that can be spread from person to person on contaminated hands of both patients and healthcare workers.<BR/>2. The facility failed on 04/03/2025 to ensure Resident #2's contact isolation was care planned for methicillin-resistant Staphylococcus aureus also known as MRSA (an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections) and for her refusal to stay in her room related to her being on isolation.<BR/>These failures could affect residents by placing them at risk of not receiving appropriate care and interventions to meet their needs.<BR/>Findings included:<BR/>1.Record review of Resident #1's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included urinary tract infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), extended-spectrum beta-lactamase also known as ESBL (occurs when bacteria producing the enzyme ESBL, which renders them resistant to many common antibiotics, causes an infection), diabetes (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), and stroke.<BR/>Record review of Resident 1's quarterly MDS assessment, dated 02/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 03, indicating she was severely cognitively impaired. The MDS indicated Resident #1 required assistance with her transfers, toileting, dressing, hygiene, and supervision for eating. The MDS indicated she was always incontinent of urine and was on an antibiotic. <BR/>Record review of Resident #1's electronic medical records revealed a urinalysis dated 04/05/25 which detected extended-spectrum beta-lactamase, also known as ESBL.<BR/>Record review of Resident #1's comprehensive care plan dated 04/06/25 indicated Resident #1 had a UTI. The intervention was for staff to encourage adequate fluids and monitor side effects. The care plan did not mention anything about being on contact isolation for ESBL.<BR/>Record review of Resident #1's physician's order dated 04/07/25 indicated: Doxycycline 100mg, give 1 capsule by mouth two times a day related to Urinary tract infection for 5 days. <BR/>Record review of Resident #1's Physician order dated 04/07/25 indicated Contact isolation precautions in place related to ESBL.<BR/>During an observation on 04/08/25 at 12:09 p.m., a contact isolation sign was noted on Resident #1's door. The isolation cart was noted 1 door to the right of Resident #1's room.<BR/>2.Record review of Resident #2's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia(a general term for a group of diseases that cause a decline in memory, thinking, and reasoning abilities, significantly affecting a person's daily life), Urinary Tract Infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), and anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident 2's quarterly MDS assessment, dated 01/30/25, indicated Resident #2 usually understood and was usually understood by others. Resident #2's BIMS score was 15, indicating she was cognitively intact. The MDS indicated Resident #2 required set-up assistance with her dressing and hygiene, independent with toileting and eating. The MDS indicated she was continent of bladder.<BR/>Record review of Resident #2's comprehensive care plan dated 03/29/23 indicated Resident #2 was occasionally incontinent of urine. The intervention was for staff to monitor for signs and symptoms of UTI. The care plan did not indicate a care plan for contact isolation or refusal to comply with contact isolation for MRSA. <BR/>Record review of Resident #2's electronic medical records revealed a urinalysis dated 04/03/25, which detected MRSA. <BR/>Record review of Resident #2's physician's order dated 04/06/25 indicated: Rifampin 300mg, give 1 capsule by mouth two times a day related to MRSA in urine until 04/20/25. <BR/>Record review of Resident #2's Physician order dated 04/06/25 indicated contact isolation precautions in place related to the diagnosis of MRSA.<BR/>Record review of Resident #2's comprehensive care plan after surveyor intervention was dated 04/06/25 but updated on 04/09/25, indicating Resident #1 required isolation. The intervention was to follow the facility's isolation policy and give medication as ordered.<BR/>During an observation on 04/08/25 at 11:00 a.m., Resident #2 was in the dining room attending an activity with 8 other residents while positive for MRSA. Resident #2 had a contact isolation sign on her door and an isolation cart outside her room door.<BR/>During an interview on 04/09/25 at 10:00 a.m., the ADON said the MDS nurses were responsible for the care plans. She said she and the DON were responsible for updating the acute care plans. She looked at Resident #1's and Resident #2's care plan and said she did not see their contact isolation care plan, nor Resident #2's refusal to stay in her room. She said she was aware they were on contact precautions but had not had a chance to update the care plan. She said she was aware of all new orders or changes a resident might have because they discussed the residents in the morning meeting, and she read the 24-hour reports. She said care plans were updated so staff would be aware of the care the residents needed.<BR/>During an interview on 04/09/25 at 11:08 a.m., the Regional MDS nurse said the MDS nurse was responsible for the comprehensive care plan, and the management team was responsible for updating the acute care plans. She said any changes about new orders should be updated within 24-48 hours, depending on when the order was received. She said care plans were done to direct the care of the resident.<BR/>During an interview on 04/09/25 at 11:22 a.m., the DON said the MDS nurses were responsible for the care plans. He said he and the ADON were responsible for the acute care plans. He said he was not aware that Resident #1 or Resident #2's care plan had not been updated related to contact isolation and the refusal of Resident #2 to stay in her room. He said care plans were done to ensure staff conducted the plan of care for each resident.<BR/>During an interview on 04/09/25 at 12:16 p.m., the Administrator said care plans were a team effort with the interdisciplinary team, but the MDS nurses were the overseers. She said the MDS nurse last day at the facility was last week; therefore, the DON/ADON was responsible for updating Resident #1 and #2's care plan. She said care plans were generated to provide each resident with the best care.<BR/>Record review of the facility's policy, Care Plan (Comprehensive), revised 10/24/22, indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. V. The IDT will revise the Comprehensive Care Plan as needed at the following intervals: A. Per RAI schedules; B. As dictated by changes in the resident's condition, C. In preparation for discharge, D. To address changes in behavior and care, and E. Other times as appropriate or necessary.

Based on observation and interview the facility failed to ensure all drugs were only accessible by authorized personnel for 1 of 4 medication carts (hall 100). <BR/>The facility did not ensure the 100 hall medication cart was secured and unable to be accessed by unauthorized personnel. <BR/>This failure could place residents at risk of not receiving drugs and biologicals as needed and a drug diversion.<BR/>Findings included:<BR/>During an observation and interview on 08/20/24 at 12:10 p.m., the 100-hall medication cart was left unlocked, and staff, residents, and visitors were observed walking by the unlocked medication cart. The ADON exited a resident's room and said she was responsible for leaving the cart unlocked. She said she was in a hurry and forgot to lock her cart. The ADON said it was her responsibility to lock the cart when unattended. The ADON said by leaving the cart unlocked and unattended, anyone could open the cart and take medications. <BR/>During an interview on 08/22/24 at 12:15 p.m., LVN B said the medication cart should never be left open when unattended. She said the medication cart should be locked to prevent anyone except who was authorized to be in the cart. She said if the medication cart were left open it could lead to someone stealing medication or a resident opening the cart and taking the wrong medication.<BR/>During an interview on 08/22/24 at 2:20 p.m., the DON said he expected the medication cart to be locked when unattended. He said the nurse or med aide who was working on the medication cart should have ensured it was closed when unattended. He said if the medication cart were left open a staff member or a confused resident could take medication out of the cart. <BR/>During an interview on 08/22/24 at 3:00 p.m., the Administrator said nurse management was the overseer of the nursing staff for ensuring the medication carts were locked. She said if carts were left open anyone could obtain anything off the carts without authorization. The Administrator said she expects the medication carts to be locked to ensure the safety of others.<BR/>Record review of the facility's policy titled, Storage of Medications, revision date of 08/20 indicated: The policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. General Guidelines: #2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and establish policies and procedures to report and investigate such allegations, for 1 of 6 residents (Resident #3) reviewed for abuse.<BR/>The facility did not implement the policy on investigating an injury of unknown origin to the state agency for Resident #3 when Resident # 3 was found with bruising and a skin tear on 02/11/2025 on the left arm.<BR/>This failure could place the residents at increased risk of abuse and neglect.<BR/>Findings included:<BR/>Record review of Resident #3's face sheet, dated 04/09/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (diseases that affect memory, thinking, and the ability to perform daily activities), diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily living).<BR/>Record review of Resident #3's annual MDS assessment, dated 02/26/25, indicated Resident #3 rarely understood and was rarely understood by others. Resident #3's BIMS score was 00, which meant she was severely cognitively impaired. The MDS indicated Resident #3 required extensive help with toileting, bed mobility, dressing, transfers, personal hygiene, and supervision with eating. The MDS did not indicate Resident #3 had wounds or skin problems. <BR/>Record review of Resident #3's progress note dated 2/11/25 at 6:22 pm, written by LVN A, revealed Resident #3's family member reported 2 open areas to her left arm, both less than 0.25 x 0.25 in diameter. Both showed no signs of infection. The nurse provided first aid to both, and neither area showed signs of infection. The resident denied pain. The call light was in reach.<BR/>Record review of Resident #3's progress note updated 2/11/25 at 6:42 pm, written by LVN A revealed Resident #3 had one open area and one bruise to her left arm. <BR/>Record review of Resident #3's progress note dated 2/12/25 at 2:40 am, written by LVN C revealed to continue to monitor skin tear and bruising to the left arm for Resident #3. No signs or symptoms of infection, pain, or discomfort were noted. <BR/>Record review of Resident #3's physician orders, dated 02/01/25 through 02/28/23, did not reveal any orders for monitoring bruise to the left arm.<BR/>Record review of Resident #3's physician orders, dated 02/01/25 through 02/28/25, did not reveal any orders for treating a skin tear to her left arm. <BR/>Record review of Resident #3's skin assessment dated [DATE] did not indicate a skin assessment was done after the bruise and skin tear were noted. <BR/>Record review of Resident #3's skin assessment dated [DATE] charted by LVN C did not indicate a bruise or skin tear to her left arm.<BR/>Record review of Resident #3's care plan revised on 03/26/25 did not indicate a bruise or skin tear to her left arm on 02/11/25.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN B said she was the treatment nurse. She said if a resident had a skin tear or a bruise, it should be reported to the nurse, the nurse would then report it to her, and she would assess and determine what type of treatment was needed, if any. She said if a skin tear were noted, she would look at it daily and document it in the TAR. If a bruise were noted, she would put in an order to monitor weekly till resolved. LVN B said that Resident #3 had several bruises over time because she would attempt to get up by herself. She said she could not recall this particular bruise or skin tear. She said part of her process was if a bruise or skin tear were reported, she would investigate to see what happened. She said Resident #3 was not normally able to say what happened related to her cognitive status. LVN C said if she could not figure out what happened, she would report it to the Administrator or DON.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN A said she was the charge nurse on duty when a family member reported Resident #3 had a skin tear and bruise on her left arm. LVN C said she was not aware how Resident #3 received the bruise or skin tear. She said she did not ask the staff or the family member who reported the skin tear or bruise if they knew what happened. LVN A said if an unknown skin tear or bruise was reported to her, she was supposed to notify the Administrator, DON, the physician, and the family. LVN A said she reported the bruise and skin tear to the Administrator and the DON. She said she was new to the facility during the incident and was told to do a progress note. She said she did not recall the Administrator or the DON questioning her about the incident once she reported it. She said since this incident, she had been educated to do an incident report and progress note, notify management, the physician, and the family. <BR/>During an interview on 04/09/25 at 6:55 a.m., LVN C said she was the 10 pm-6 am nurse for Resident #3. She said she could not recall the skin tear or bruise from 02/12/25 on Resident #3. LVN C said if she charted it, then it was either given to her in the report or was on the 24-hour report. She said if a bruise or skin tear occurred and staff was unaware of how it occurred, staff would report it to the ADON or DON, and they would investigate it. She said the nurses were supposed to do an incident report, document a progress note, and notify the physician, the family, the Administrator, and the DON of any skin tears or bruises of unknown origin. She said even if the nurses did not report something, it was on the 24-hour report, and management was supposed to review it daily. She said she did not recall being asked about Resident #3's skin tear or bruise by the Administrator or DON. <BR/>During an interview on 4/9/25 at 10:00 a.m., the ADON said if a resident had a bruise or skin tear of an unknown origin, she would investigate to see if she could figure out what happened. She said the nurses should document the incident in the progress notes, do an incident report, and notify the physician, the family, the Administrator, and the DON. She said the nurses were to chart the incident for 72 hours. She said even if a nurse forgot to report the incident, she would see it on the 24-hour report or while reading the nurses' notes. She said she could recall the incident on 02/11/25 but could not remember the details. The ADON reviewed Resident #3's chart and did not see an incident report on 02/11/25.<BR/>During an interview on 04/09/25 at 10:53 a.m., LVN B said she was the treatment nurse, and she had done a skin assessment on Resident #3 earlier on the 6 am-2 pm shift on 02/11/25. She said Resident #3 did not have any skin tears or bruises during her assessment. She said LVN A charted the skin tear and bruise at 6:22 pm after her shift. <BR/>During an interview on 04/09/25 at 11:03 a.m., the DON said he expected if a resident had a bruise or skin tear of an unknown source that staff would report it to him and the Administrator. He said they would do an internal investigation to see if they could see what happened, and if they could not figure out what happened, they would report it to the State of Texas. He said he could not recall the skin tear or bruise for Resident #3 around 02/11/25. He said Resident #3 had often scratched herself, or she could have bumped it on the wall, but since he did not remember investigating it, he could not say what happened. He said they do review the 24-hour reports in the morning meeting, and it must have been overlooked. He said that although he did not feel like abuse occurred, it was important to report and investigate abuse/neglect to prevent further abuse/neglect from occurring.<BR/>During an interview on 04/09/25 at 4:37 p.m., the Administrator said she was unaware of Resident #3's skin tear or bruise; therefore, it was not investigated or reported. She said she was not contacted for all skin tears or bruises, only if suspicion of abuse. She said if there was suspicion of abuse, the nurses should have called and reported it to her, and then they would have investigated and reported if needed. She said, after looking at Resident #3's chart, that LVN A was a new nurse during the incident and did not follow all the necessary steps, such as notification. She said they would educate LVN A. The Administrator said when injuries of unknown origin were not reported promptly, abuse could continue to occur. <BR/>Record review of the facility policy titled Abuse Prohibition Policy, revised 08/2020, indicated, Purpose: To ensure the facility established, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. VI. Investigation: A. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal activity. IX. Reporting: The facility will report allegations of abuse, neglect, exploitation, mistreatment, and injuries of unknown source, etc . immediately but no longer than two hours

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed by the interdisciplinary team and that the resident was invited to participate in developing the care plan and making decisions about his or her care for 1 of 19 residents (Resident #75) reviewed for care plan timing and revision.<BR/>The facility failed to ensure Resident #75 was invited to participate in the development and review of his care plan. <BR/>This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. <BR/>Findings included:<BR/>Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (chronic condition that affects the way the body processes blood sugar with progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). <BR/>Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #75 was usually understood and usually understood others. The MDS assessment indicated Resident #75's BIMS was 8, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #75 required supervision for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. <BR/>Record review of Resident #75's care plan with a date initiated of 06/26/2023, did not address inviting Resident #75 to participate in the development and reviewing of his care plan. <BR/>During an interview on 07/10/2023 at 10:50 AM, Resident #75 said he had not had a care plan meeting with the IDT. Resident #75 said the facility staff had not discussed his care plan with him or provided him his care plan. <BR/>During an interview on 07/12/2023 at 2:17 PM, the Social Worker said she was responsible for setting up the care plan meetings. The Social Worker said when the care plan meeting took place, the information was entered into the electronic health record under the assessment tabs as an assessment form. The Social Worker said care plan meetings were done with the 48-hour care plan for new admissions, quarterly, and as needed. The Social Worker said she was not sure if a care plan meeting had been done with Resident #75 that she would have to ask the DON. <BR/>Record review of Resident #75's electronic health record on 07/12/2023 did not reveal a care plan meeting had been completed. <BR/>During an interview on 07/13/2023 at 8:24 AM, the ADON said the Social Worker was responsible for setting up the care plan meetings. The ADON said care plan meetings took place upon admission and quarterly, but she was unsure how long after admission the care plan meeting was done. The ADON said after having a care plan meeting it was entered as a care plan conference form in the assessments in the electronic health record. The ADON checked Resident #75's electronic health record and did not find a care plan conference assessment for Resident #75. The ADON said that she recalled there had not been a care plan meeting with Resident #75. The ADON said it was important to have care plan meetings with the resident and/or resident representative so the facility could adjust their plan of care to the residents' needs. <BR/>During an interview on 07/13/2023 at 9:11 AM, the DON said care plan meetings were scheduled by the Social Worker. The DON said for the care plan meetings the IDT team gathered along with the resident and family to discuss the plan of care and discharge planning, if applicable. The DON said the care plan meeting was documented in the electronic health record as a care plan assessment. The DON said she did not recall if they had a care plan meeting for Resident #75. The DON said it was important to have care plan meetings with the residents, so the staff knew how to accurately care for the residents and the residents' preferences. <BR/>During an interview on 07/13/2023 at 2:24 PM, the Administrator said the Social Worker was responsible for setting up the care plan meetings. The Administrator said he expected the residents to have care plan meetings. The Administrator said the initial care plan meeting was done within 48 hours of admission for newly admitted residents. The Administrator said it was important for the care plan meetings to be done with the residents so the staff knew if the residents may have special needs and to make sure all the residents' needs were met. <BR/>During an interview on 07/14/2023 at 10:02 AM, the Social Worker said it was important for the care plan meetings to be done because the facility needed to establish the plan of care and the goals for the residents. The Social Worker said she did not know why the care plan meeting with Resident #75 was not done. <BR/>Record review of the facility's policy titled, Care Planning, last revised October 24, 2022, indicated, . Resident Rights- Care Planning A. The resident has a right to be informed, in advance, of changes to the plan of care. B. The resident has the right to receive the services and/or items included in the plan of care. C. The resident has the right to see the care plan, including the right to sign after significant changes are made to the plan of care. IV. IDT Meetings A. The Facility will invite the resident, if capable, and their family to care planning meetings .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #1 and Resident #2) reviewed for infection control.<BR/> The facility failed to ensure LVN D wore the proper PPE (gown and gloves) while checking Resident #1's blood sugar or administering insulin on 04/08/25, who was positive for ESBL.<BR/>The facility failed to ensure CNA E wore the proper PPE (gown and gloves) while providing care to Resident #1, who was positive for ESBL on 04/09/25. <BR/>The facility failed to ensure Resident #2 understood contact isolation precautions when the resident was in activities with other residents and positive for MRSA on 04/08/25.<BR/>These failures could place residents and staff at risk for cross-contamination and spread of infection and could potentially affect all others in the building. <BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included urinary tract infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), extended-spectrum beta-lactamase also known as ESBL (occurs when bacteria producing the enzyme ESBL, which renders them resistant to many common antibiotics, causes an infection), diabetes (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), and stroke.<BR/>Record review of Resident 1's quarterly MDS assessment, dated 02/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 03, indicating she was severely cognitively impaired. The MDS indicated Resident #1 required assistance with his transfers, toileting, dressing, hygiene, and supervision for eating. The MDS indicated she was always incontinent of urine and was on an antibiotic.<BR/>Record review of Resident #1's electronic medical records revealed a urinalysis dated 04/05/25 which detected extended-spectrum beta-lactamase, also known as ESBL.<BR/>Record review of Resident #1's comprehensive care plan dated 04/06/25 indicated Resident #1 had a UTI. The intervention was for staff to encourage adequate fluids and monitor side effects. The care plan did not indicate Resident #1 was on contact isolation.<BR/>Record review of Resident #1's physician's order dated 04/07/25 indicated: Doxycycline 100mg, give 1 capsule by mouth two times a day related to Urinary tract infection for 5 days. <BR/>Record review of Resident #1's Physician order dated 04/07/25 indicated contact isolation precautions in place related to the diagnosis of ESBL.<BR/>During an observation on 04/08/25 at 12:09 p.m., a contact isolation sign was noted on Resident #1's door. LVN D walked into Resident #1's room to check her blood sugar without applying a gown. LVN D reached over Resident #1 to check her blood sugar on her left finger. LVN D then left Resident #1's room to gather her insulin, reentered the room without a gown, and administered her insulin.<BR/>During an interview on 04/08/25 at 1:44 p.m., LVN A said she was the nurse who received Resident #1's diagnosis of ESBL related to her lab results and the order for Doxycycline. She said she gave the initial dose on 04/07/25 and posted an isolation sign on Resident #1's door. She said she reported it to the oncoming nurse about Resident #1's isolation and new order for Doxycycline. She said she also placed it on the 24-hour report sheet.<BR/>During an interview on 04/09/25 at 9:15 a.m., LVN D said she was the charge nurse for Resident #1 and Resident #2. She said Resident #1 was on contact precautions for ESBL in her urine, and Resident #2 was on contact precautions for MRSA in her urine. LVN D said staff should have on a gown and gloves when entering Resident #1 and Resident #2's rooms. She said she did not wear a gown when she went into Resident #1's room to check her blood sugar or when she administered her insulin. She said she honestly forgot she was in contact isolation. She said Resident #2 had rights, and if she wished to come out of her room, then she could. She said she could not recall if she had personally asked Resident #2 to stay in her room related to her contact isolation orders. She said if staff were not wearing gowns or gloves, they could spread the infection to others.<BR/>During an observation on 04/09/25 at 9:45 a.m., CNA E went into Resident #1's room to provide care. CNA E did not have on her gown or gloves when entering Resident #1's room. <BR/>During an observation and interview on 04/09/25 at 10:09 a.m., CNA E came out of Resident #1's room and disposed of her linen in the laundry barrel without it being in a yellow bag. She said she was aware Resident #1 was on contact precautions for something in her urine. She said she did not see a cart next to her door and did not see any boxes in her room, so she assumed she did not have to wear anything while in the room. She said that in the past, if a resident was on isolation, they would have a cart with equipment next to the door and boxes in the room with red bags for the trash and yellow bags for the linen. She said she worked yesterday (04/08/25) and did not wear a gown while providing care for Resident #1. She said she could spread infection since she did not properly dispose of her linen or wear a gown while in the room. <BR/>During an observation on 04/09/25 at 10:15 a.m., no linen or trash boxes were noted in Resident #1's room. The isolation cart was noted 1 door to the right of Resident#1's room.<BR/>2.Record review of Resident #2's face sheet, dated 04/09/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia(a general term for a group of diseases that cause a decline in memory, thinking, and reasoning abilities, significantly affecting a person's daily life), Urinary Tract Infection also known as UTI (is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra), and anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident 2's quarterly MDS assessment, dated 01/30/25, indicated Resident #2 usually understood and was usually understood by others. Resident #2's BIMS score was 15, indicating she was cognitively intact. The MDS indicated Resident #2 required set-up assistance with her dressing and hygiene, independent with toileting and eating. The MDS indicated she was continent of bladder.<BR/>Record review of Resident #2's comprehensive care plan dated 03/29/23 indicated Resident #1 was occasionally incontinent of urine. The intervention was for staff to monitor for signs and symptoms of UTI. The care plan did not indicate a care plan for contact isolation or refusal to comply with contact isolation. <BR/>Record review of Resident #2's electronic medical records revealed a urinalysis dated 04/03/25, which detected MRSA (an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections). <BR/>Record review of Resident #2's physician's order dated 04/06/25 indicated: Rifampin 300mg, give 1 capsule by mouth two times a day related to MRSA in urine until 04/20/25. <BR/>Record review of Resident #2's Physician order dated 04/06/25 indicated Contact isolation precautions in place related to MRSA.<BR/>Record review of Resident #2's comprehensive care plan after surveyor intervention was dated 04/06/25 but updated on 04/09/25, indicating Resident #1 required isolation. The intervention was to follow facility isolation policy and give medication as ordered.<BR/>During an observation on 04/08/25 at 11:00 a.m., Resident #2 was in the dining room attending an activity with 8 other residents while positive for MRSA.<BR/>During an interview on 04/08/25 at 3:30 p.m., Resident #2 said the staff told her she had something in her bladder and to make sure she washed her hands after using the bathroom. She said they did not tell her she had something that someone might catch or to stay in her room.<BR/>During an observation on 04/09/25 at 9:28 a.m., Resident #2 was in the day room sitting on the couch talking to another resident.<BR/>During an interview on 04/09/25 at 10:00 a.m., the ADON said if a resident were in contact isolation, staff would know because of the sign posted on the door. She said staff should wear gowns and gloves when they enter contact-isolated rooms. She said they encourage handwashing before and after care for all residents. She said she was not sure what the policy said on contact isolation for a resident. She said she thought the contact isolated residents could walk the facility. She said she knew they had educated Resident #2 on hand washing.<BR/>During an interview on 04/09/25 at 11:22 a.m., the DON said he expected all staff to follow the guidelines on the sign posted on the door. He said they should be wearing the proper PPE (gown and gloves) to protect themselves and to keep the spread of infection from other residents. He said if the resident were on contact isolation, then staff should be educating the resident on why they need to stay in their room and encouraging them to stay in their rooms. If the resident refuses to stay in their room, then the staff should document the refusal and add it to the resident's care plan.<BR/>During an interview on 04/09/25 at 12:16 p.m., the Administrator said when a resident was on contact isolation, staff should wear gowns and gloves when entering the room. She said the DON oversaw infection control. The Administrator said staff should ensure they had on the proper PPE to protect themselves and the residents and to prevent the spread of infection. She said residents who were on contact isolation should be encouraged to stay in their rooms and practice good hygiene to prevent the spread of infection. <BR/>Record review of the facility's policy titled, Infection Prevention and Control Program, revised 06/2020, indicated, Purpose: Ensure the facility established and maintained an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements. Policy: The facility must establish an infection prevention and control program under which it: #1 identifies, investigates, controls, and prevents infections in the facility .<BR/>Record review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions, revised 6/2020, indicated, To ensure that transmission-based precautions are used when caring for residents with communicable diseases or transmittable infections. III. Contact Precautions A. Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. I. Examples of infections requiring Contact Precautions include, but are not limited to: A. Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-drug resistant organisms (e.g., MRSA). C. Gloves and Handwashing: I. As outlined under Standard Precautions, gloves (clean, non-sterile) are worn when entering the room. D. Gown: I. As outlined under Standard Precautions, a (clean, non-sterile) gown is worn for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. G. Notice: I. The Facility alerts staff to the type of precaution a resident requires. ii. The Facility also ensures that the resident's care plan indicates the type of precautions implemented for the resident. iii. The Facility may utilize a sign requesting visitors to check in at the nursing station before entering a resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 1 (Resident #57) of 4 residents reviewed for resident rights<BR/>The facility failed to ensure the ADON logged out of her computer and protected the privacy of Resident #57's Medication Administration Record. <BR/>This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others.<BR/>Findings included:<BR/>Record review of Resident #57's face sheet, dated 08/22/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included stroke, diabetes, and high blood pressure.<BR/>Record review of Resident #57's quarterly MDS assessment, dated 06/13/24, indicated Resident #57 understood and was understood by others. Resident #57's BIMS score was 10, which meant she was moderately cognitively impaired. The MDS indicated Resident #57 required extensive help with toileting bed mobility, dressing, transfers, and set up for personal hygiene and eating. The MDS indicated she took insulin medication during the 7-day look-back period. <BR/>During an observation and interview on 08/20/24 at 12:00 PM, the ADON stepped away from the medication cart, and entered Resident #57's room to check her blood sugar The ADON left the computer screen (on top of the medication cart) unlocked where the medication administration record of Resident #57 was clearly displayed. While the ADON was in the room staff, residents, and visitors were observed walking by the unlocked computer screen. The ADON said she left the computer screen open for Resident #57 because she was in a hurry and had other things on her mind. She said she should have closed the MAR before entering Resident #57's room. She said it was a HIPPA violation to keep the MAR open where others could see Resident #57's personal information.<BR/>During an interview on 08/22/24 at 2:20 p.m., the DON stated he expected the nurses and med aides to provide full visual privacy and confidentiality of information for all residents. The DON said staff had been educated on HIPPA violations. The DON said failure not to protect the resident's information could cause poor self-esteem and embarrassment for the resident. <BR/>During an interview on 08/22/24 at 3:00 p.m., the Administrator said she expected the MAR to be always closed when unattended because of resident information and privacy.<BR/>Record review of the facility's policy titled Notice of Privacy Practices, revised August 2020 revealed Purpose: the facility adopts this policy requiring that the facility provide notice of the facilities privacy practices to facility residents and the public. Policy: the facility has adopted a notice of privacy practice that describes the facility's private practice, the use and disclosure of protected health information at the facility, and the resident's rights regarding protected health information. The policy did not indicate anything about protecting the residents' health information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 4 residents (Resident #9) reviewed for smoking.<BR/>The facility failed to follow the policy on smoking by not completing a smoking screen assessment quarterly on Resident #9. <BR/>This failure could place residents at risk of unsafe smoking and injury.<BR/>Findings included:<BR/>Record review of Resident #9's face sheet, dated 8/22/24 indicated Resident #9 was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included stroke and high blood pressure.<BR/>Record review of Resident #9's quarterly MDS assessment, dated 07/04/24, indicated Resident #9 was usually understood and usually understood by others. Resident #9's BIMs score was 15, which indicated he was cognitively intact. Resident #9 required limited assistance with bathing and set-up assistance with toileting, personal hygiene, transfer, eating, and bed mobility. <BR/>Record review of Resident #9's comprehensive care plan, dated 10/31/22 indicated Resident #9 was a smoker. The interventions of the care plan were for staff to provide Resident #9 with a smoking assessment according to facility policy. <BR/>Record review of Resident #9's last completed Smoking Screen Assessment, dated 07/12/23, revealed he required supervision for smoking. <BR/>During an observation on 08/21/24 at 10:12 p.m., revealed Resident #9 was outside smoking with staff. <BR/>During an observation and interview on 08/22/24 at 1:51 p.m., the ADON said the nurses were responsible for completing the smoking assessments. She said the smoking assessment was supposed to be done on admission and quarterly. She said the smoking assessment should have been generated in the resident's electronic medical records. when they were due to be done. The ADON looked in Resident #9's electronic medical records and said his last smoking assessment was done on 07/12/23. She said since the smoking assessments were not being done, residents were at risk of being burned. <BR/>During an interview on 08/22/24 at 2:20 p.m., the DON said the nurses were responsible for doing the smoking assessments. He said they had a system in place for checking on smoking assessments but since some of the smoking assessments did not trigger, they were not aware they were not being done. He said since the smoking assessment was not being done it could place the residents at risk for burns. <BR/>During an interview on 08/22/24 at 3:00 p.m., the Administrator said the nurses should be completing the smoking assessment. She said she had only been at the facility for 4 weeks and was not sure about the time frame of the smoking assessments. She said the DON was the overseer of the smoking process. She said if the smoking assessment were not being done then it could potentially place a resident at risk for injury. <BR/>Record review of the facility Policy titled Smoking by Residents, revised date of November 2023, indicated, The purpose: To respect residents' choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers. Procedure: I. Smokers shall be identified at the time of admission. 2. Residents will be provided with a copy of this policy during the admission process A. All smokers shall be assessed related to smoking safety at the time of admission and then at least quarterly as outlined by the OBRA (Omnibus Budget Reconciliation Act of 1987) assessment timeframe.

Based on observation and interview the facility failed to ensure all drugs were only accessible by authorized personnel for 1 of 4 medication carts (hall 100). <BR/>The facility did not ensure the 100 hall medication cart was secured and unable to be accessed by unauthorized personnel. <BR/>This failure could place residents at risk of not receiving drugs and biologicals as needed and a drug diversion.<BR/>Findings included:<BR/>During an observation and interview on 08/20/24 at 12:10 p.m., the 100-hall medication cart was left unlocked, and staff, residents, and visitors were observed walking by the unlocked medication cart. The ADON exited a resident's room and said she was responsible for leaving the cart unlocked. She said she was in a hurry and forgot to lock her cart. The ADON said it was her responsibility to lock the cart when unattended. The ADON said by leaving the cart unlocked and unattended, anyone could open the cart and take medications. <BR/>During an interview on 08/22/24 at 12:15 p.m., LVN B said the medication cart should never be left open when unattended. She said the medication cart should be locked to prevent anyone except who was authorized to be in the cart. She said if the medication cart were left open it could lead to someone stealing medication or a resident opening the cart and taking the wrong medication.<BR/>During an interview on 08/22/24 at 2:20 p.m., the DON said he expected the medication cart to be locked when unattended. He said the nurse or med aide who was working on the medication cart should have ensured it was closed when unattended. He said if the medication cart were left open a staff member or a confused resident could take medication out of the cart. <BR/>During an interview on 08/22/24 at 3:00 p.m., the Administrator said nurse management was the overseer of the nursing staff for ensuring the medication carts were locked. She said if carts were left open anyone could obtain anything off the carts without authorization. The Administrator said she expects the medication carts to be locked to ensure the safety of others.<BR/>Record review of the facility's policy titled, Storage of Medications, revision date of 08/20 indicated: The policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. General Guidelines: #2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access.