Fallbrook Rehabiliation and Care Center

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 4 medication carts (skilled unit MA cart, 300 hall nurse cart, and 200 hall nurse cart) reviewed for medication storage. <BR/>- The 300-hall nurse's cart contained an opened fluticasone propionate nasal spray with no discard date. Cyclosporine ophthalmic emulsion 0.05% was not in the complete original packet. A box of quality choice original eyelid cleansing wipes did not have a visible expiration date.<BR/>-The 200-hall nurse's cart contained a box of quality choice original eyelid cleansing wipes without a visible expiration date.<BR/>These failures could place residents at risk of adverse medication reactions.<BR/>Findings included:<BR/>During observation and interview on 02/07/24 at 4:40 p.m., the 300-hall nursing cart with RN B revealed a bottle of fluticasone propionate nasal spray with an open date of 9/9/23 and no discard date. Cyclosporine ophthalmic emulsion 0.05% was in a white plastic container with a foil cover but did not have the white plastic cover, which had the resident's name, instructions, and expiration date. The plastic contained 28 ampules. A box of quality choice original eyelid cleansing wipes sensitive mild formula had 20 wipes. The box had pink discoloration, and the expiration date was not visible. RN B said she did not know fluticasone propionate nasal spray had a discard date once it was opened. RN B said the bottle had been open for about six months. RN B said Cyclosporine was covered with the plastic cover, which had all the instructions and the resident's name yesterday when she worked, but she did not see it today. RN B checked the eye wipes box and said he could not find the expiration date, and all medications should have an expiration date. The surveyor asked RN B how she ensured she was not administering expired medications to residents, and RN B did not respond. RN B said she had skills checks on medication administration, and it included medication storage.<BR/>During an observation and interview on 02/07/24 at 4:40 p.m., the 200-hall nursing cart with RN A revealed a box of quality choice original eyelid cleansing wipes sensitive mild formula had five wipes, and the expiration date was not visible. RN A said she could not find any expiration date on the eye cleansing wipes box and that all medications should have an expiration date, but she could not find it on the box or the individual packet. RN B said she had not thought about the wipes expiring. RN B said she had skills check off on medication administration and it included medication storage. RN A said she would call the pharmacy, ask about the expiration date, and get back to the surveyor.<BR/>During an interview on 02/09/24 at 9 30 a.m., the DON said all medication that the pharmacy filled should be stored in the original packet it was delivered to the facility because it has all the instructions on how to administer the medication and expiration date, resident's name and the prescriber. The DON said all medication, even over-the-counter medication, should have a use-by date, and she would further investigate the eyelid cleansing wipes. The DON said she would check and see the expiration date on the opened fluticasone propionate nasal spray and get back with the surveyor. The DON and RN A did not get back to the surveyor with the finding on opened expiration date for the opened fluticasone nasal spray.<BR/>Record review of the facility policy on storage of medication dated 2001 MED - PASS, Inc (Revised November 020) read in part . the facility stores all drugs and biologicals in a safe, secure, and orderly manner . policy interpretation and implementation . #2 drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (CR #1) of 6 residents reviewed for resident rights. - Nurse A did not immediately notify CR #1's physician when he had a change in condition and was sent out to the hospital via 911 on 09/14/25. -Nurse A did not notify CR #1's family member/RP/emergency contact when he had a change in condition and was transported to the hospital on [DATE]. The failures could place residents at risk of not receiving appropriate care and required notifications being made when there is a change in their condition. Findings included: Record review of CR #1's admission Record, dated 09/16/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus (high levels of blood sugar in the blood) with chronic kidney disease, degenerative disease of nervous system (conditions that affect the nerve cells in the brain and spinal cord), other chronic pancreatitis (long-standing inflammation of the pancreas), depression, and muscle weakness. Further review revealed resident was listed as RP, family member was listed as RP/emergency contact #1, and another family member was listed as POA-Care/emergency contact #2 (no phone number listed). Record review of CR #1's Quarterly MDS Assessment, dated 08/28/25, revealed a BIMS score of 13, indicating intact cognition. Record review of CR #1's progress notes, dated 09/14/25 at 20:50 (8:50 p.m.), entered by Nurse A, revealed in part CNA called 911 resident complaining of vomiting and chest pain.Blood pressure 143/84, pulse 81, respiration 18, temp 102.2 [degrees Fahrenheit], and O2 sat 99. As nurse was leaving room EMT and police coming in hallway with CNA stating she called them. 2105 [9:05 p.m.] time on stretcher to ambulance. No other documentation/notes were found that indicated doctor or RP was notified. Record review of hospital record, dated 09/14/25, revealed in part .presented from [nursing facility name] with complaints of flu-like symptoms, nausea, vomiting, chest pain associated with vomiting, and abdominal pain. The patient reports the abdominal pain as severe, rated 10/10 [pain scale used for assessing pain intensity, where 0 indicates no pain and 10 represents the worst pain imaginable] and similar to his previous h/o pancreatitis.On exam the patient is AAOx4 [patient is fully aware of their identity, location, time, and situation, reflecting a high level of cognitive function], in no apparent distress. During a telephone interview on 09/16/25 at 7:27 a.m., CNA A said she did not know what time she told Nurse A to check on CR #1 on 09/14/25 but when she told her, she said okay she was going to get to him, but she never checked on him. She said CR #1 was normally grumpy and aggressive but on this day, 09/14/25, he was doubled over, his skin color was grayish, he looked tired and just did not look like himself at all. She said she also heard CNA B, and Residents #2 and #3 tell Nurse A about CR #1 not feeling well while she was helping other residents in the hallway. She said she heard Resident #2 tell Nurse A that CR #1 was asking for her to come to his room because he was not feeling well, but she said she told Resident #2 not to worry about it and that she would take care of it. She said she went back to his room, and CR #1 was on his bed, sitting up but slouched all the way over and throwing up. She said she took his temperature with her personal thermometer, and he had a fever of 103 F. She said CR #1 was saying his chest hurt, and to please call the ambulance. She said he told her his pain level was a 10 out of 10. She said over an hour had passed and she never saw Nurse A go into his room to check on him. She said she called 911 from her cell phone at 8:46 p.m. and yelled out for Nurse A. She said Nurse A went to CR #1's room and asked him how he was feeling. She said the resident could barely talk, and that he just kept saying to call the ambulance. She said she left CR #1's room and went to the hallway to give 911 the address to the facility, and they arrived maybe within 5 minutes. She said Nurse A denied being told that something was wrong with CR #1. During an observation and interview on 09/17/25 at 10:09 a.m., revealed CR #1 was at the hospital lying in bed, watching television. He said he did not remember what time he started feeling bad on Sunday, 09/14/25. He said he was in a lot of pain from his waist down, he was vomiting, his chest was also hurting, and his pain level was at a 10. He said he told the nurse aide he was feeling bad but said he did not remember when he told her. He said he did not get a chance to ask the nurse for anything because she never came and checked on him. He said he pressed his call light, waited for about an hour, but the nurse did not go to his room until about 2-3 minutes before the ambulance got to the facility. He said the nurse aide said she was going to call the ambulance. He said he heard the nurse at the facility tell the ambulance driver he had a fever but did not remember the nurse's name. He said the hospital had yet to tell him what was wrong with him but said they told him they were going to admit him. He said the doctor told him he was not going to be discharged today, 9/17/25. He said the facility did not call his family member/RP/emergency contact #1 and she did not know he was in the hospital. During a telephone interview on 09/17/25 at 11:41 a.m., Nurse A said she called the NP/physician listed on the CR #1's Face Sheet after EMTs took the resident. She said she did not speak to them and probably left them a message. She said she did not contact the resident's RP/emergency contact and that she had no reason for not making the contact. During a telephone interview on 09/17/25 at 1:23 p.m., the NP said he was notified via text (does not know by who) on Monday, 09/15/25, that on Sunday, 09/14/25, CR #1 had nausea, was throwing up, complaining about chest pain, and that the nurse aide had called 911. He said had he been notified when symptoms had been occurring, he could have done some kind of intervention. He said each case was different and he still did not know all the details about what happened on Sunday with the resident. He said he did not know if the on-call service was notified on Sunday. During an interview on 09/18/25 at 9:48 a.m., the DON said the family and physician should be notified immediately once the resident was stable and safe. He said Nurse A did not document that she contacted CR #1's RP/emergency contact #1 in her progress note. He said he gave both emergency contacts a courtesy call on Monday, 09/15/25, to see if they had any concerns or if they needed him to do anything but both of their phones had a message saying they were not taking calls at that time. He said not contacting a resident's RP/emergency contact would not have an ill effect on the resident. During a follow-up telephone interview on 09/18/25 at 11:35 a.m., the NP said he checked with the on-call service and with the physician and the physician said he was not notified and there was no record that the on-call service was called. During a telephone interview on 09/18/25 at 4:03 p.m., with CR #1's family member/RP/emergency contact #1 she said the facility did not call her to tell her CR #1 was sent to the hospital. She said CR #1 called her on 09/16/25 and told her he was in the hospital. Record review of the facility's Notification of Changes policy, date reviewed/revised 12/08/24, revealed in part .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification.2. Significant change in the resident's physical, mental or psychological condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications.Additional considerations: 1. Competent individuals.c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that Resident #1 received treatment and care in accordance with professional standards of practice for one resident (Resident #28) of 5 residents reviewed quality of care and skin .<BR/>The facility failed to assess, report, and obtain new physician orders due to a change in resident #28's skin condition of the perineal (private area of a patient) groin and buttock to the physician.<BR/>This failure affected one resident (Resident #28) out of 4 residents reviewed for skin issues and had the potential to place residents at risk skin break down, infection and discomfort. <BR/>Findings included: <BR/>Record review of the facility face sheet revealed that Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia) You might also hear people use the term acute hypoxemic respiratory failure (AHRF)), morbid obesity with aveolar hypoventilation (Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness), type 2 diabetes (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and lymphedema (build-up of fluid in soft body tissues when the lymph system is damaged or blocked).<BR/>Record review of Resident #28's care plan dated initiated 10/16/2021 revealed a care plan for ADL's and limited physical mobility r/t weakness, confusion, limited mobility with interventions/task Resident #28 requires total assistance with toilet use and personal hygiene. A care plan for bowel and bladder incontinence dated initiated and revised on 1016/2021 r/t activity intolerance, confusion and impaired mobility with a goal target date of 3/29/2024 to refrain free of skin break down due to incontinence and brief use through the target date, interventions and task included use MD's order for Nystatin powder and to check frequently for incontinence. Wash rinse and dry perineum (cleaning the private areas of a patient), change clothing PRN and after incontinence episodes.<BR/>Record review of Resident #28's quarterly MDS assessment dated [DATE]th, 2024, revealed he had a BIM score of 14, indicating he was cognitively intact. Resident #28 was also coded as being impaired on both sides, upper and lower extremities for functional limitation range in motion dependent on 2 or more helpers (staff) to complete the activities of bathing, showering, toileting hygiene, dressing the upper and lower body, putting on and removing footwear, he also required partial to moderate assistance to roll to the left sides and lye back down on the bed. Resident 3 28 was totally dependent on staff to transfer from bed to chair or wheelchair. Resident #28 was frequently incontinent of bladder and bowel. Resident #28 was coded to be a risk for pressure ulcers.<BR/>Record review of physician orders for February 2024 included orders for Nystatin Powder 100000 UNIT/GM ,Apply to inner thighs, scrotum, abd topically everyday shift for Incontinence; Rash.<BR/>May Apply Zinc skin barrier after each incontinent episode to help reduce skin impairments. <BR/>Prior to wound treatment evaluate resident for Pain: everyday shift for Wound Care<BR/>After wound treatment evaluate resident for pain: everyday shift for Wound treatment.<BR/>Record review of Resident #28's weekly wound assessments for January 2024 through February 7, 2024, revealed no wound assessment for his perennial, scrotum and folds areas.<BR/>Record review of Resident #28's Braden Scale assessment dated [DATE] revealed that his skin is constantly moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the patient is moved or turned, chairfast: ability to walk severely limited or non-existent. <BR/>During an observation and on 02/07/24 at 1:30 pm, it was revealed that Resident #28's under abdominal fold, scrotum, left, and right groin were very red, macerated (soften or become softened by soaking in a liquid), and there were tiny opens on all areas. One of the areas on under the abdomen measured about 1.0x1.0 cm. Resident #28 said that it hurts whenever RN A or CNA N cleaned the groin areas, scrotum, and abdominal area. Observation at this time of RN A and CNA N which wiped Resident #28 and the wipes had thick white substance and it had a musty odor. <BR/>During an interview on 02/07/24 at 1:24 pm, RN B said she did Resident #28's skin assessment sometimes and the wound care nurse does it at times. RN B said Resident #28 needed two to three staff assistance for incontinent care. RN B said Resident #28 did not have any redness or open area on his buttocks or peri area when she did his skin assessment two weeks ago. RN B said none of the aides had told her that the resident had any open area on his peri area.<BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated with some openings. LVN H said she had worked with Resident #28 last week on Friday and Saturday and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 she assumed the nurses were aware of the skin condition.<BR/>During an interview on 02/08/24 at 10:42 am, the Wound Care Nurse said she does Resident #28's weekly skin assessment, and she did not see any redness, macerated area, any opening on his groin or abdominal folds. She said she became aware of the area yesterday.<BR/>During an interview on 02/08/24 at 10:54 am, the DON said she became aware of the red macerated area when she came to Resident #28's room. Then DON said she smelled the foul odor and ammonia in the resident room. The DON said the wound care nurse assessments for Resident #28 from January 2024 through February 2024 did not mention Resident #28 had any skin issues on his groin or under his abdomen. The DON said the facility has a new wound care company and the wound care doctor was not notified about the skin condition.<BR/>During an interview on 02/08/24 at 10:57 am, with Resident #28's primary physician, he said he was notified about the change in skin condition yesterday twice. He said Resident #28 was an obese resident and all the folds could cause the areas to stay wet and the intervention of Barrier cream may not prevent the area from being moist and red or open. He said there was no other intervention in place to prevent the area from being moist or red. The physician said the facility also have a wound care doctor who should be taking care of wound and skin issues. <BR/>Record review of the facility policy and procedure entitled Resident Examination and Assessment dated revised February 2014, read in part .physical examination: skin: intactness, moisture, color, texture and presence of bruises, pressure sores, redness, edema, rashes. Activity level: able to perform ADLs; and degree of assistance required . Documentation The following information should be recorded in the resident's medical record: The date and time the procedure was performed, all assessment data obtained during the procedure, how the resident tolerated the procedure .Notify the physician of any abnormalities such as .wounds or rashes on the resident's skin; and report other information in accordance with facility policy and professional standards of practice.<BR/>Record review of the facility policy and procedure entitled Skin Management System no date provided, read in part .head to toe assessments should be completed weekly .skin assessments include the review of all skin areas from the top of the head/scalp to the toes including examination of skin folds .and any crevices that may exist .the Certified Nurse Aide will notify the Treatment Nurse or Charge Nurse of any newly identified skin or pain issues .residents who are incontinent of bladder or bowel will be provided incontinent care every 2 hours as needed .residents who rely on nursing staff for positioning will be turned and repositioned every 2 hours as needed .<BR/>The following Plan of Removal submitted by the facility was accepted on Friday 2/9/2024 at 2:00 pm.<BR/>PLAN OF REMOVAL (POR)<BR/>Name of facility: Fallbrook Rehabilitation and Care Center<BR/>Date: 02/08/2024 <BR/>F-684 - The facility failed to assess, report, and obtain new order due to a change in resident # 28's skin condition of the groin and buttock to the physician.<BR/>The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice.<BR/>Immediate action:<BR/>Resident #28 was promptly assessed once skin issue identified by Director of nurses, Physician and RP was notified; treatment orders were obtained, and resident's care plan updated to reflect change in condition. One on one education provided to CNA N regarding reporting skin issues by DON on 2/7/2024<BR/>The Director of Nurses, Assistant Director of Nurses, Wound Nurse and Nurse Supervisor initiated a head-to-toe skin sweep on all residents that will be completed by 10 pm tonight, 02/08/2024. The primary physician(s) will be notified of any newly identified skin integrity issues and orders will be obtained as appropriate. The resident responsible party will be notified of any findings, and treatment plan(s). <BR/>An audit of all current resident records will be completed by the Director of Nursing, Assistant Director of Nursing, Wound Nurse, and Nurse Supervisor to ensure a weekly head to toe skin assessment order is in place by 11:59pm 02/09/2024. An audit will be completed by the Director of Nursing, Assistant Director of Nursing, Wound Nurse, and Nurse Supervisor to ensure that any residents with an identified skin issue on existing skin assessment has an appropriate treatment order in place by 11:59pm, 02/09/2024. <BR/>Facilities Plan to ensure compliance quickly.<BR/>Education initiated by Director of Nurses, Assistant Director of Nurses, Wound Nurse, and Nurse Supervisor at 9 pm 02/09/2024 for all nurses and certified nurse aids on ADLs, answering call lights, performing timely Peri Care, and Q 2-hour resident rounding. Education will also include what to do when skin issues are identified and what to do if pain occurs during any type of care. Nurses will be educated by the Director of Nurses on Provider and responsible party notifications when a change in condition or treatment plan occurs by 02/09/2024.<BR/>Nursing staff (licensed and certified) will be re-educated on the Skin Management System starting on 02/09/024 by DON and target completion date of 02/09/2024. Nursing staff members will not be allowed to work their oncoming shift until this education is completed. On- going competency of the Skin Management System will be monitored by asking oral/verbal questions, rounding and auditing of documentation and orders in the electronic medical record. <BR/>Nursing staff will be re-educated by Assisted Director of Nurses (ADON), DON, Nurse manager concerning the skin identification form. CNAs will be responsible for completing the skin identification form. CNA will complete skin identification form after every resident's shower on facility skin identification form. CNAs will turn form in to charge nurse before end of shift. The charge nurse will take appropriate action to address any skin issues identified on skin form. DON, ADON & Nurse manager will oversee sheet identification sheet completion by reviewing skin identifications form in morning clinical meeting. Education will be completed prior to nursing staff commencing their next assigned shift. This education will be completed by 02/09/24. Any nursing employee not present will complete the in-service prior to starting their next shift. <BR/>New or readmitted residents will have a head-to-toe skin assessment completed by the on-duty Admitting Nurse upon admission. The physician and responsible party will be notified of any identified skin issues and the treatment plan(s). The Wound Nurse will follow up on all new or readmitted resident skin assessments on her next scheduled shift and alert the Wound Care Physician of her findings, obtaining any treatment order changes at this time. The Director of Nurses will provide education on this process by 02/09/24. Any nursing employee not present will complete the in-service prior to starting their next shift. <BR/>QAPI meeting was held 2/8/2024 by the facility IDT team, which included Administrator, DON, ADON, CNO, Housekeeping supervisor, Social Worker, Human resources to review policy/procedure for ADL care.<BR/>Monitoring:<BR/>Record review on 2/10/2024 of POR binder including CNA skills competencies, the POR for F677, Head to toe assessments for the current residents, IDT rounds and in-services, policies and procedures for: Proper Procedure for Head-to-Toe Assessments, Skin Assessments, Skin Management System, Perineal Care, Activities of Daily Living Supporting, Call System-Resident, Peri-Care/Assisting Meals/Incontinent Care, given to all staff on 2/8/2024-2/9/2024 and the Stop and Watch -QAPI<BR/>Observations on 2/9/2024 through 2/11/2024 at various times in the day revealed that Resident #28 was resting in his room, watching football, he would give a thumbs up when asked how he was feeling.<BR/>Observations on 2/9/2024 through 2/11/2024 at various times of the day of staff making rounds, checking to see if any resident needed anything.<BR/>Interviews: Interviews with staff were conducted between 2/9/2024 through 2/11/2024 on multiple shifts with the Administrator, DON, ADON, VP, DVP, MDS Coordinator,Wound Care Nurse, RN's: A, B,C LVN's:A,B,C,D,E,P,R CNA's:A,B,C,D,E,F,G,H <BR/>Staff were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received.<BR/>Interview answers with CNA's: in-services included assessing skin, notifying nurse/nurse manager, to checking under the skin folds and placing barrier cream on them, documentation in PCC, (the electronic medical file system) the skin assessment and also notifying the nurse, answering the call-lights timely, witnessed staff not answering call-lights if, would report it. <BR/>perineal and incontinence in-services, knocking on door, greeting the resident and telling them what you are going to do, setting up supplies, closing privacy curtains, assessments are from front to back all creases and in between, when you see anything different notify the charge nurse, fill out the stop and watch form for any skin difference, skin checks are performed every time a resident is changed, the treatment nurse comes out daily and to assess different residents. <BR/>Interview answers varied from staff, LVN's said in-services received included skin treatment initiation, being informed by CNA of changes in skin, notification to family and the doctor, performing head to toe assessments including abdominal folds, to initiate care plan for said area, skin swipes, dry skin, skin barrier was to applied daily, prn and after every episode of incontinence, do a change of condition form.<BR/>Interviews with RN's included assessment of the resident when they come from the hospital, charting/documentation, when anyone observes a skin issue, document and make a treatment plan. Call doctor, RP and get an order.<BR/>On 2/10/2024 at 1:02 pm with the Administrator he said the team were aware of a broken system with skin prior to survey when HHSC surveyors came. The QAPI team did the PIP on January 30th, 2024 he added that the responsibility for skin integrity were interdisciplinary in the process, primarily he, the DON, treatment nurse, Social Worker and therapy, each person had their specific role. The team started addressing skin integrity immediately to addressing with skin assessments, they did not have time to follow through Braden timely, assessments basically before HHSC surveyors came in.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she was already aware of break in system with the skin issues and that the team had begun performing skin audits, was training with wound care nurse discussed in QAPI, IDT, physician, PIP, Resident #28, skin assessment was due 2/7/24 and she (the wound care nurse) had not gotten a chance to get to Resident #28, was working the other hall. Resident #28's assessment was due on the 7th of February, If the assessment was due that day and hadn't been conducted that day, she hadn't identified on that day yet because it (the newly identified skin area issue) had not been identified on prior skin assessments it ( the skin issue)was not there in the abdominal fold. They did identify the skin area and put treatment put in place, they are also in process of changing the wound care nurse, they have in-serviced the staff and did a 100 percent skin audit on residents. She said that a care plan was added, and a comprehensive care plan should be in place for specific Resident #28's perineal area to include under the folds. She said that any nurse at the facility is responsible for care plans and said a negative outcome could be skin impairment, infection, and delayed. treatment. Interview and record review on 2/10/2024 at 3:00 pm received and reviewed with VP, including skin sweep 100 percent, in-services/policies and procedures, all staff signatures, question/test/stop and watch. All staff in-serviced. 2 people identified with redness in skin sweep. Treat/care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident has a right to a dignified existence and maintain good grooming at resident request in a timely manner for two out of four residents (Resident#2 and Resident #1) reviewed residents rights. The facility failed to provide timely incontinent care for Resident #2 and Resident #1 and it affected the resident's feelings. This deficient practice could place residents at risk of skin breakdown and reduced feelings of self-worth Record review of Resident #2's face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included morbid (severe) obesity (A BMI of 40 plus), diabetes mellitus (high blood sugar), hypertension (high blood pressure), and need assistance with personal care. Record review of Resident #2's Quarterly MDS assessment, dated 06/28/25, revealed a BIMS score of 14 of 15, which indicated intact cognition. Resident #2 needed extensive to total care with ADL assistance with one staff assist. Record review of Resident #2's care plan, revision dated 09/05/25, read in part . [Resident #2] had incontinent of bladder and bowel. Intervention: clean peri area with each incontinence episode, check on resident every two hours and assist with toileting as needed. resident had self-care performance deficit related to impaired mobility. was on antibiotic therapy for UTI on Cipro 500mg PO BID for 5 days . During an observation on 09/04/325 at 2:15 p.m., the Treatment nurse and CNA M provided a head-to-to-skin assessment for Resident #2. When CNA M opened the resident's incontinent brief, it revealed Resident #1's brief was saturated with urine, and the inside of the brief was brown in color. During an interview on 09/04/25 at 2:07 p.m., Resident #2 said she was provided incontinent once today around 10:15 a.m. or 10:30 a.m., when she had a bowel movement, and nobody had come to ask her if she was wet. Resident #2 said the staff did not change her often, and that contributed to her having UTIs often. Resident #2 stated she told the aide she was wet before lunch, and the aide said she was coming to change her, but she did not come back, and her shift had ended, and she had gone home without changing her. Resident #2 said she felt uncared for because she was left in a dirty incontinent brief for hours. During an interview on 09/04/25 at 2:32 p.m., LVN P said CNA O was Resident #2's aide. LVN P said the aide should check the resident and see if the resident was wet at least every two hours. She said Resident #2's brief was soaked, and the resident would have redness, an open area, and a UTI. LVN P said CNA O did not tell her Resident #2 had not been changed when she asked if she had provided incontinent care for Resident #2. During an interview on 09/04/25 at 2:45 p.m., the Treatment Nurse said Resident #2's incontinent brief was soaking wet with urine, and it appeared Resident #2 was not changed recently. The Treatment Nurse said Resident #2's skin could break down, develop rashes, pressure ulcers, and UTI if the aide did not provide timely incontinent care for the resident. She said the aides were responsible for checking on the resident during rounds at least every two hours. She said the floor nurse was responsible for monitoring the aides throughout the shift to ensure the aides were providing care for the residents. The Treatment Nurse said she had an in-service on incontinence care during the all-staff meeting last week, Thursday (08/28/29), and she educated the staff on the importance of making rounds every two hours, changing the residents' incontinent briefs, and making sure the residents were kept dry to prevent skin breakdown and UTI. During an interview on 09/05/25 at 2:52 p.m., CNA M said Resident #2's incontinent brief was very wet, and the inside of the brief was brown, which showed Resident #2 had not been changed for more than two hours. CNA M said the aides made rounds every two hours and as needed. She said Resident #2 could get a bed sore, redness or infection. CNA M said she had a skills check, and it included ADLs, and the treatment nurse educated aides to make rounds every two hours and change the resident to prevent skin breakdown or UTI. During an interview on 09/08/25 at 10:05 p.m., the Corporate Nurse said the aides were responsible for providing incontinent care and were supposed to make rounds every two hours per standard of care. She said if Resident #2 was not changed promptly, the resident's skin could get red, and there was potential for UTI. The Corporate Nurse stated if she was a resident, she would not feel good if she were left on a wet incontinent brief for hours. During a telephone interview on 09/08/25 at 3:54 p.m., CNA O said she did not work with Resident #2 on 09/04/25 because she no longer worked at the facility. She said she had not worked in the facility at all in September 2025. During an interview on 09/08/25 at 5:10 p.m., the DON stated he would go and verify if he had given CNA O's name in error, because they had another aide with the same first name but a different last name. The DON did not provide the other aide's name before the state surveyor exited. 2. Record review of Resident #1's face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included morbid (severe) obesity (A BMI of 40 plus), diabetes mellitus (high blood sugar), hypertension (high blood pressure), and cerebral infraction (brain attack caused by a blockage in a blood vessel). Record review of Resident #1's Quarterly MDS assessment, dated 07/31/25, revealed a BIMS score of 00 of 13, which indicated severely impaired cognition. Resident #1 needed total care with ADL assistance with two staff assist. Record review of Resident #1's care plan, revision dated 08/11/25, read in part . [Resident #1] was frequently incontinent of bladder and bowel. Intervention: monitor for incontinent often and PRN, change promptly and apply a protective barrier to the skin. During an observation and interview on 09/04/25 at 3:35 p.m., revealed Resident #1 was in bed and covered with a sheet. Resident #1 said the aide from the morning shift had not changed her today, but the night aide changed her before she left, which was early in the morning, and she could not recall the exact time. Resident #1 said she asked LVN P to tell her aide to come and change her between 10:00 a.m. and 11:00 a.m., and the aide had not come to change her up till now. Resident #1 said she felt dirty and upset because the aides did not change her on time because they have to get another staff member because she was on the heavy side. During observation on 09/04/25 at 4:00 p.m., revealed when CNA L and CNA T opened Resident #1's incontinent brief, the resident's incontinent brief was saturated with urine, and the inside of the brief was brown. When CNA L turned Resident #1 to the left, it revealed the two-draw sheets were soaked with urine, and the air mattress was soaked with urine from the resident's lower back to her middle thigh area. During an interview on 09/04/25 at 4:09 p.m., LVN P said Resident #1 told her she wanted her incontinent brief changed at 11:00 a.m., because the morning aide had not changed her incontinent brief today. LVN P said she told the aide to go and change Resident #1 when she came out of Resident #1's room around 11:05 a.m. LVN P said she was not aware the aide did not provide incontinent care for the resident. LVN P said Resident #1 would feel terrible, and it was not accepted. Everybody should be checked and changed, regardless of the resident's size. LVN P said the aides were supposed to make rounds every two hours and as needed for incontinent care. LVN P said Resident #2 could develop UTI and skin breakdown if she was left on incontinent brief for extend time. During an interview on 09/04/25 at 4:49 p.m., CNA L said the aides were supposed to make rounds every two hours to check and change the resident. CNA L stated when she unfastened Resident #1's incontinent brief, it revealed the incontinent brief was very soaked, and when she turned the resident to her left, it revealed the two draw sheets and the air mattress were also soaked with urine. CNA L said Resident #1 could have skin breakdown or an infection because she had not been changed for hours. During an interview on 09/04/25 at 5:21 p.m., CNA T said Resident #1 was her resident. CNA T said Resident #1 was not her original resident. CNA T said when she became aware Resident #1 was assigned to her, she came to provide incontinent care. CNA T said aides were supposed to make rounds for incontinent care every two hours. CNA T said Resident #1's incontinent brief was very wet and soaked with urine, as well as the two draw sheets, and the air mattress. CNA T said Resident #1's skin could break down. During an interview on 09/05/25 at 9:17 a.m., the DON said aides should make rounds for incontinent care at least every two hours. The DON said the residents were not supposed to ask the aide to provide incontinent care because that was part of ADL care. The DON said the aides should make rounds every two hours. The DON said Resident #1 was a heavy wetter, and when she voided, she voided a lot because she drank a lot of water. The DON said if the continent brief was brown, it could mean the urine had been on the incontinent brief for an extended time. The DON said Resident #1 could develop moist-associated skin damage, and the resident would not feel good being left on a wet incontinent brief. During an interview on 09/05/25 at 1:07 p.m., the Administrator said the aides should make rounds for incontinent care every two hours according to the facility's policy. The Administrator said the staff should also make PRN rounds for incontinent care. He said if Resident #1 was left in a wet incontinent brief, it could cause skin breakdown and infection. He said Resident #1 would feel uncomfortable and dirty. Record review of the facility's policy on activities of daily living, dated revised 04/23/25, and implemented 09/01/25, read in part .care and services will be provided for the flowing activities of daily living: 3. Toileting.policy explanation and compliance guideline #2. A resident who is unable to carry out activity of daily living will receive the necessary services to maintain . grooming .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a Resident #28 who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 (Resident #28) of 4 residents reviewed for ADL's and quality of life. <BR/>The facility failed to ensure Resident #28 was provided incontinent care in a timely manner, which resulted in decreased skin integrity.<BR/>This failure affected one resident (Resident #28) and placed residents requiring assistance with incontinent care at risk of not have the assistance with personal care which could cause pain, skin breakdown, lack of dignity and low self-esteem.<BR/>Findings:<BR/>Record review of the facility face sheet revealed that Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia) You might also hear people use the term acute hypoxemic respiratory failure (AHRF)), morbid obesity with aveolar hypoventilation (Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness), type 2 diabetes (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and lymphedema (build-up of fluid in soft body tissues when the lymph system is damaged or blocked).<BR/>Record review of Resident #28's care plan dated initiated 10/16/2021 revealed a care plan for ADL's and limited physical mobility r/t weakness, confusion, limited mobility with interventions/task Resident #28 requires total assistance with toilet use and personal hygiene. A care plan for bowel and bladder incontinence dated initiated and revised on 1016/2021 r/t activity intolerance, confusion and impaired mobility with a goal target date of 3/29/2024 to refrain free of skin break down due to incontinence and brief use through the target date, interventions and task included use MD's order for Nystatin powder and to check frequently for incontinence. Wash rinse and dry perineum (cleaning the private areas of a patient), change clothing PRN and after incontinence episodes.<BR/>Record review of Resident #28's quarterly MDS assessment dated [DATE]th, 2024, revealed he had a BIM score of 14, indicating he was cognitively intact. Resident #28 was also coded as being impaired on both sides, upper and lower extremities for functional limitation range in motion dependent on 2 or more helpers (staff) to complete the activities of bathing, showering, toileting hygiene, dressing the upper and lower body, putting on and removing footwear, he also required partial to moderate assistance to roll to the left sides and lye back down on the bed. Resident 3 28 was totally dependent on staff to transfer from bed to chair or wheelchair. Resident #28 was frequently incontinent of bladder and bowel. Resident #28 was coded to be a risk for pressure ulcers.<BR/>Record review of physician orders for February 2024 included orders for Nystatin Powder 100000 UNIT/GM ,Apply to inner thighs, scrotum, abd topically everyday shift for Incontinence; Rash.<BR/>May Apply Zinc skin barrier after each incontinent episode to help reduce skin impairments. <BR/>Prior to wound treatment evaluate resident for Pain: everyday shift for Wound Care<BR/>After wound treatment evaluate resident for pain: everyday shift for Wound treatment.<BR/>Record review of Resident #28's weekly wound assessments for January 2024 through February 7, 2024, revealed no wound assessment for his perennial, scrotum and folds areas.<BR/>Record review of the facility grievance/complaint form dated 2/7/2024 revealed that Resident #28 filed a grievance that he did not receive care. Resolved by the DON assisting CNA's with providing care and disciplinary action scheduled with CNA assigned Resident #28.<BR/>During an observation and interview on 2/07/2024 at 8:03 am, with Resident #28, laying in his bed, he said that the CNA's do not want to do their job. He said he pushed his call-light at 4:00 pm yesterday and the staff did not come and assist him until 9:00 pm. He said that he has wounds on his bottom and that the staff make him wait and sit in his feces for so long that it dries up on his bottom and they have to scrape the feces off. He said it does not feel good to sit in that at all. He added if he could clean himself, he would but he cannot.<BR/>During an observation and on 02/07/24 at 1:30 pm, it was revealed that Resident #28's under abdominal fold, scrotum, left, and right groin were very red, macerated, and there were tiny opens on all areas. One of the areas on under the abdomen measured about 1.0x1.0 cm. Resident #28 said that it hurts whenever RN A or CNA N cleaned the groin areas, scrotum, and abdominal area. Observation at this time of RN A and CNA N which wiped Resident #28 and the wipes had thick white substance and it had a musty odor. <BR/>During an interview on 02/07/24 at 1:20 pm, CNA N said she had not provided incontinent care for Resident #28 since she came to work today at 6:30 a.m. CNA N said Resident #28 had to call her if he needed to be changed, and she had not gone and checked on Resident #28 for incontinent care. CNA N said she was supposed to make rounds for incontinent care on all residents every two hours. <BR/>During an interview on 02/07/24 at 1:24 pm, RN B said she did Resident #28's skin assessment sometimes and the wound care nurse does it at times. RN B said Resident #28 needed two to three staff assistance for incontinent care. RN B said Resident #28 did not have any redness or open area on his buttocks or peri area when she did his skin assessment two weeks ago. RN B said none of the aides had told her that the resident had any open area on his peri area.<BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated with some openings. LVN H said she had worked with Resident #28 last week on Friday and Saturday and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 she assumed the nurses were aware of the skin condition.<BR/>During an interview on 02/08/24 at 10:42 am, the Wound Care Nurse said she does Resident #28's weekly skin assessment, and she did not see any redness, macerated area, any opening on his groin or abdominal folds. She said she became aware of the area yesterday.<BR/>During an interview on 02/08/24 at 10:54 am, the DON said she became aware of the red macerated area when she came to Resident #28's room. Then DON said she smelled the foul odor and ammonia in the resident room. The DON said the wound care nurse assessments for Resident #28 from January 2024 through February 2024 did not mention Resident #28 had any skin issues on his groin or under his abdomen. The DON said the facility has a new wound care company and the wound care doctor was not notified about the skin condition.<BR/>Interview on 02/08/24 at 10:57 am, with Resident #28's primary physician, he said he was notified about the change in skin condition yesterday twice. He said Resident #28 was an obese resident and all the folds could cause the areas to stay wet and the intervention of Barrier cream may not prevent the area from being moist and red or open. He said there was no other intervention in place to prevent the area from being moist or red. The physician said the facility also have a wound care doctor who should be taking care of wound and skin issues. <BR/>Record review of the facility policy and procedure entitled Perineal Care dated revised February 2018 read in part . Purpose, the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .Preparation: 1.Review the resident's care plan to assess for any special needs of the resident .wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks .dry area thoroughly .document any discharge, odor, bleeding, skin care problems or irritation, complaints of pain or discomfort .report other information in accordance with facility policy and professional standards of practice.<BR/>Record review of the facility policy and procedure entitled Activities of Daily Living (ADL's) Supporting dated revised March 2018 read in part .residents who are unable to carry out activities of daily living independently will receive the services to maintain good nutrition, grooming, personal and oral hygiene .appropriate care and services will be provided for residents who are unable to carry out ADL's independently .in accordance with the plan of care including support and assistance with: hygiene (bathing) .elimination (toileting) .A resident's ability to perform ADL's will be measured using clinical tools including the MDS and the following MDS definitions .totally dependent: full staff performance on an activity with no participation by the resident for any aspect of the ADL activity . <BR/>Record review of the facility policy and procedure entitled Call System, Resident dated September 2022 read in part .residents are provided with the means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation .calls for assistance are answered as soon as possible but no longer than 5 minutes .<BR/>Record review of the facility policy and procedure entitled Dignity dated February 2021 read in part . Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem Policy Interpretation and Implementation: Residents are treated with dignity and respect at all times .demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example: promptly responding to a resident's request for toileting assistance.<BR/>The following Plan of Removal submitted by the facility was accepted on Friday 2/9/2024 at 2:00 pm.<BR/>Plan of Removal (POR) <BR/>PLAN OF REMOVAL<BR/>Name of facility: Fallbrook Rehabilitation and Care Center<BR/>Date: 02/08/2024 <BR/>F 677 - <BR/>The facility fail to ensure that residents who are unable to carry out Activities of Daily Living (ADLs) receive the necessary services to maintain nutrition, grooming, and personal and oral hygiene. <BR/>The facility failed to ensure that incontinent care was provided timely <BR/>Immediate action:<BR/>Resident #28 was assessed, and incontinent care provided immediately when identified on 02/07/2024. Nurse aide (CNA N) was provided one on one re-educated in providing peri care at least every 2 hours and as needed on 2/07/2024 at 1:30pm <BR/>The Director of Nurses, Assistant Director of Nurses, Wound Nurse and Nurse Supervisor initiated a sweep on all residents to verify that incontinent care was done on all residents by 10 pm tonight, 02/08/2024. The primary physician(s) will be notified of any newly identified skin integrity issues related to the skin sweep and orders will be obtained as appropriate. The resident responsible party will be notified of any findings, and treatment plan(s). Two new skin areas were found during sweep. One was redden area to a resident's back and other was redden area to a resident's neck along trach collar area secures. Family and provider notified, and orders obtained<BR/>An audit of the skin identification forms for current residents were completed by the Director of Nursing, Assistant Director of Nursing, Wound Nurse and Nurse Supervisor to ensure CNA skin sheets were completed by 10 pm 02/08/2024. Two new skin areas were found during sweep. One was redden area to a resident's back and other was redden area to a resident's neck along trach collar area secures. Family and provider notified, and orders obtained<BR/>Facilities Plan to ensure compliance quickly.<BR/>Education provided and to be completed by Director of Nurses, Assistant Director of Nurses, Wound Nurse, and Nurse Supervisor by 11:59pm 02/09/2024 for all nurses and certified nurse aids on ADLs, shower sheet completion, answering call lights, Peri Care, and Q 2-hour resident rounding. Education also includes what to do when skin issues are identified and what to do if pain occurs during any type of care. IDT will make rounds twice a day and charge nurses will make rounds every 2 hours. Nurse managers will validate randomly throughout day that charge nurses are making rounds to check that Residents' skin is dry and clean to prevent skin breakdown. Specific training on system which includes assessment and treatment of skin folds. CNAs/Nurses will not be allowed to work until they've received the training.<BR/>All CNAs will have skill checks completed by Director of Nurses, Assistant Director of Nurses, and Nurse Supervisor on peri care to validate incontinent care protocol is followed appropriately by 02/09/2024.<BR/>Nursing staff (licensed and certified) will be re-educated on the Skin Management System by Director of Nurses, ADON, Treatment Nurse and Nurse manager with the target completion date of 02/09/2024. Nursing staff members will not be allowed to work their oncoming shift until this education is completed. <BR/>Nursing staff will be re-educated by Assistant Director of Nursing and Wound Nurse on the stop and watch tools and the skin identification form. Education will be completed prior to nursing staff commencing their next assigned shift. This education will be completed by 02/09/24. Any nursing employee not present will complete the in-service prior to starting their next shift. <BR/>The nurse will verify that the skin identification sheets are completed by the CNAs when bathing and/or showering residents and that any identified issue is addressed. The physician and responsible party will be notified of any identified skin issues and the treatment plan(s). The Director of Nurses will provide education on this process to all nursing staff by 02/09/24. Nursing employee will not be allowed to start shift until complete the in-service. <BR/>QAPI meeting was held 2/8/2024 by The facility IDT team, which included Administrator, DON, ADON, CNO, Housekeeping supervisor, Social worker, Human resources to review policy/procedure for ADL care.<BR/>Monitoring:<BR/>Record review on 2/10/2024 of POR binder including CNA skills competencies, the POR for F677, Head to toe assessments for the current residents, IDT rounds and in-services, policies and procedures for: Proper Procedure for Head-to-Toe Assessments, Skin Assessments, Skin Management System, Perineal Care, Activities of Daily Living Supporting, Call System-Resident, Peri-Care/Assisting Meals/Incontinent Care, given to all staff on 2/8/2024-2/9/2024 and the Stop and Watch -QAPI<BR/>Interviews on training: assessments, skin sheets, change of skin, documentation, communication, physician orders.<BR/>Observations on 2/9/2024 through 2/11/2024 at various times in the day revealed that Resident #28 was resting in his room, watching football, he would give a thumbs up when asked how he was feeling.<BR/>Observations on 2/9/2024 through 2/11/2024 at various times of the day of staff making rounds, checking to see if any resident needed anything.<BR/>Interviews: Interviews with staff were conducted between 2/9/2024 through 2/11/2024 on multiple shifts with the Administrator, DON, ADON, VP, DVP, MDS Coordinator,Wound Care Nurse, RN's: A, B,C LVN's:A,B,C,D,E,P,R CNA's:A,B,C,D,E,F,G,H <BR/>Staff were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received.<BR/>Interview answers with CNA's: in-services included assessing skin, notifying nurse/nurse manager, to checking under the skin folds and placing barrier cream on them, documentation in PCC, (the electronic medical file system) the skin assessment and also notifying the nurse, answering the call-lights timely, witnessed staff not answering call-lights if, would report it. <BR/>perineal and incontinence in-services, knocking on door, greeting the resident and telling them what you are going to do, setting up supplies, closing privacy curtains, assessments are from front to back all creases and in between, when you see anything different notify the charge nurse, fill out the stop and watch form for any skin difference, skin checks are performed every time a resident is changed, the treatment nurse comes out daily and to assess different residents. <BR/>Interview answers varied from staff, LVN's said in-services received included skin treatment initiation, being informed by CNA of changes in skin, notification to family and the doctor, performing head to toe assessments including abdominal folds, to initiate care plan for said area, skin swipes, dry skin, skin barrier was to applied daily, prn and after every episode of incontinence, do a change of condition form.<BR/>Interviews with RN's included assessment of the resident when they come from the hospital, charting/documentation, when anyone observes a skin issue, document and make a treatment plan. Call doctor, RP and get an order.<BR/>During an interview on 2/10/2024 at 1:02 pm with the Administrator he said the team were aware of a broken system with skin prior to survey when HHSC surveyors came. The QAPI team did the PIP on January 30th, 2024 he added that the responsibility for skin integrity were interdisciplinary in the process, primarily he, the DON, treatment nurse, Social Worker and therapy, each person had their specific role. The team started addressing skin integrity immediately to addressing with skin assessments, they did not have time to follow through Braden timely, assessments basically before HHSC surveyors came in.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she was already aware of break in system with the skin issues and that the team had begun performing skin audits, was training with wound care nurse discussed in QAPI, IDT, physician, PIP, Resident #28, skin assessment was due 2/7/24 and she (the wound care nurse) had not gotten a chance to get to Resident #28, was working the other hall. Resident #28's assessment was due on the 7th of February, If the assessment was due that day and hadn't been conducted that day, she hadn't identified on that day yet because it (the newly identified skin area issue) had not been identified on prior skin assessments it ( the skin issue)was not there in the abdominal fold. They did identify the skin area and put treatment put in place, they are also in process of changing the wound care nurse, they have in-serviced the staff and did a 100 percent skin audit on residents. She said that a care plan was added, and a comprehensive care plan should be in place for specific Resident #28's perineal area to include under the folds. She said that any nurse at the facility is responsible for care plans and said a negative outcome could be skin impairment, infection, and delayed treatment.<BR/>On 2/10/2024 at 3:00 pm received and reviewed with VP, including skin sweep 100 percent, in-services/policies and procedures, all staff signatures, question/test/stop and watch. All staff in-serviced. 2 people identified with redness in skin sweep. Treat/care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents ( Resident #16 and Resident #89) reviewed for incontinent care, in that:<BR/> CNA B did not separate Resident #16's labia to clean during incontinent, clean arround the buttocks and did not perform appropriate hand hygiene with glove changes throughout the care<BR/> CNA A did not separate Resident # 89's labia to clean during incontinent, clean arround the buttock and did not perform appropriate hand hygiene with glove changes throughout the care.<BR/>This deficient practice could affect residents who received perineal care( the skin in between your genital and your anus) and place them at-risk of increased urinary tract infections due to improper care. <BR/>The findings included:<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/>Review of Resident #16s Care Plan, dated 01/24/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for sign and symptom of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 8:46 AM of Resident #16's incontinent care, revealed C.NA B washed hands before donning (putting) clean gloves and C.NA A was assisting . Resident #16's soiled brief was pulled down in front. C.NA B using the wet wipes cleaned the perineal, groin area. She did not open the labia to be cleaned, did not change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then picked up a clean brief using the same gloves. The resident was rolled to her back, and the brief was secured. CNA B placed a wedge under residents' hip and pulled the blanket up to cover her legs. CNA B used the same gloves throughout while performing incontinent care. <BR/>Resident #89<BR/>Review of Resident #89's face sheet dated 02/07/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 01/27/24 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), pneumonia,(an infection of the lungs that may be caused by bacteria, viruses or fungi ), sacral region stage 4 pressure sore (full thickness tissue loss with exposed bone, tendon or muscle), severe sepsis with septic shock,( a dramatic drop in blood pressure that can damage the lung, kidneys, liver and other organs), anoxic brain damage ( caused by a complete lack of oxygen to the brain).<BR/>Record review of Resident #89's MDS assessment dated [DATE] (admission) reflected BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and continent of bladder was using indwelling catheter.<BR/>Review of Resident #89's Care Plan, dated 01/10/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for s/s of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 5:30 PM of Resident #89's incontinent care, revealed C.NA A washed hands before donning clean gloves and C.NA B was assisting. Resident #89 was lying in bed. C.NA A washed hands don cleaned gloves, and removed the old brief. Using the wet wipes she cleaned the perineal, groin area. She did not open the labia to clean, did not change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then used the same gloves and picked up a clean brief put on the Resident #89.<BR/>In an interview with CNA A and C.NA B on 02/08/24 at 6:10 PM, they both stated they forgot to wipe the buttocks and open the labia. C.NA A and C.NA B stated it was wrong because it could cause an infection. C.NA A and C.NA B stated they had training on infection control in 01/2024.<BR/>Record review for CNA A's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 01/17/2024 done by the DON. <BR/>Record review for CNA B's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 11/5/23 and 01/17/2024 done by the DON. <BR/>During an interview on 02/09/24 at 3:10PM with ADON/ Infection Preventionist, stated that her expectations for staff is to wash hands before all resident care. Staff should knock on the door, introduce themselves, wash hands, and don gloves. Staff should then provide incontinent care, then doff ( removing gloves) gloves. Staff should wash hands, open up female labia and cleaned and don new gloves prior to applying new brief. The ADON was informed of the observation and stated the facility did proficiency checks on hire and quarterly.<BR/>In an interview with the DON on 02/09/24 at 3:30 PM, she stated CNA A was one of the facility's lead aides that monitored other staff during orientation with incontinent care. DON said not washing hands after changing gloves and not opening the labia to clean could cause urinary tract infection. DON said C.NA A and C.NA B knew they should clean around the buttocks before placing a clean brief. DON said she would be performing more in-services for incontinent care. <BR/>In an interview on 02/09/2024 at 3:35 PM, the Administrator stated his expectation was that incontinent care and hand washing were always done to prevent infection.<BR/>Review of the facility's staff skills competencies on incontinent care, dated 02/2022, revealed:<BR/>1. Prepare for process, obtain supplies, and wash hands.<BR/>2. Prepare work area<BR/>3. Wash hands<BR/>4. Remove soiled brief and place in bag.<BR/>5. Doff gloves, wash hands, don new gloves.<BR/>6. Clean the resident, doff gloves and place soiled items in bag.<BR/>7. Wash hands and don new gloves.<BR/>8. Position clean brief under resident, apply barrier cream.<BR/>9. Doff gloves, wash hands, position resident for comfort<BR/>10. lower bed and place call light in reach, wash hands. <BR/>Review of the facility's policy titled; Perineal Care revised on 02/2018. <BR/>Purpose<BR/>The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.<BR/>For a female resident:<BR/>Wet washcloth and apply soap or skin cleansing agent.<BR/>Wash perineal area, wiping from front to back.<BR/>1. <BR/>Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.)<BR/>2. <BR/>Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth.<BR/>3. <BR/>If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.<BR/>4. <BR/>Gently dry perineum.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 2 of 2 residents (Resident #16 and #89) reviewed for infection control.<BR/>1.CNA B failed to perform hand hygiene appropriately while providing incontinent care for Resident #16 by not changing gloves and washing hands.<BR/>2.CNA A failed to perform hand hygiene appropriately while providing incontinent care for Resident #89 by not changing gloves and washing hands.<BR/>These failures could place residents at risk for transmission of diseases and organisms. <BR/>The findings included:<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/>Review of Resident #16s Care Plan, dated 01/24/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for sign and symptom of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 8:46 AM of Resident #16's incontinent care, revealed C.NA B washed hands before donning ( put on) clean gloves and C.NA A was assisting . Resident #16's soiled brief was pulled down in front. C.NA B using the wet wipes cleaned the perineal, groin area. She did not change gloves and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then picked up a clean brief using the same gloves. The resident was rolled to her back, and the brief was secured. CNA B placed a wedge under residents' hip and pulled the blanket up to cover her legs. CNA B used the same gloves throughout while performing incontinent care. <BR/>Resident #89<BR/>Review of Resident #89's face sheet dated 02/07/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 01/27/24 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), pneumonia,(an infection of the lungs that may be caused by bacteria, viruses or fungi ), sacral region stage 4 pressure sore (full thickness tissue loss with exposed bone, tendon or muscle), severe sepsis with septic shock,( a dramatic drop in blood pressure that can damage the lung, kidneys, liver and other organs), anoxic brain damage ( caused by a complete lack of oxygen to the brain).<BR/> Record review of Resident #89's MDS assessment dated [DATE] (admission) reflected BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and continent of bladder using indwelling catheter.<BR/>Review of Resident #89's Care Plan, dated 01/10/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for s/s of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 5:30 PM of Resident #89's incontinent care, revealed C.NA A washed hands before donning clean gloves and C.NA B was assisting. Resident #89 was lying in bed. C.NA A washed hands don cleaned gloves, and removed the old brief. Using the wet wipes she cleaned the perineal, groin area., She did not did change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then used the same gloves and picked up a clean brief put on the Resident #89.<BR/>In an interview with CNA A and C.NA B on 02/08/24 at 6:10 PM, she stated she forgot to change gloves . They both stated it was wrong because it could cause an infection. Both C.NA's stated they had training on infection control in 01/2024.<BR/>During an interview on 02/09/24 at 3:10PM with ADON/ Infection Preventionist, stated that her expectations for staff is to wash hands before all resident care. Staff should knock on the door, introduce themselves, wash hands, and don (putting on) gloves. Staff should then provide incontinent care, then doff (removing) gloves. Staff should wash hands, and don new gloves prior to applying new brief. The ADON was informed of the observation and stated the facility did proficiency checks on hire and quarterly.<BR/>In an interview with the DON on 02/09/24 at 3:30 PM, she stated CNA A was one of the facility's lead aides that monitored other staff during orientation with incontinent care. DON said not washing hands after changing gloves could cause urinary tract infections. DON said C.NA A and C.NA B knew they should clean around the buttocks before placing a clean brief. DON said she would be performing more in-services for incontinent care. <BR/>In an interview on 02/09/2024 at 3:35 PM, the Administrator stated his expectation was that incontinent care and hand washing were always done to prevent infection. <BR/>Record review for CNA A's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 01/17/2024 done by the DON. <BR/>Record review for CNA B's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 11/5/23 and 01/17/2024 done by the DON. <BR/>Review of the facility's policy titled; Handwashing/Hand Hygiene revised on 08/2019. <BR/>Policy Statement<BR/>This facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.<BR/>2. <BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.<BR/>3. <BR/>The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.<BR/>4. <BR/>Single-use disposable gloves should be used:<BR/>1. <BR/>before aseptic procedures;<BR/>2. <BR/>when anticipating contact with blood or body fluids; and<BR/>3. <BR/>when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions.<BR/>Equipment and Supplies<BR/>1. <BR/>The following equipment and supplies are necessary for hand hygiene:<BR/>4. <BR/>Alcohol-based hand rub containing at least 62% alcohol;<BR/>5. <BR/>Running water;<BR/>6. <BR/>Soap (liquid or bar; anti-microbial or non-antimicrobial);<BR/>7. <BR/>Paper towels;<BR/>8. <BR/>Trash can;<BR/>9. <BR/>Lotion; and<BR/>10. <BR/>Non-sterile gloves.<BR/>Washing Hands<BR/>1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands.<BR/>2.Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside, and toilet and bathing facilities for 1 of 5 residents (Resident #1) reviewed for call light systems. The facility failed to ensure Resident #1' s call light was properly functioning. These failures could place residents at risk of not being able to call for assistance when needed. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included morbid (severe) obesity (A BMI of 40 plus), diabetes mellitus (high blood sugar), hypertension (high blood pressure), and cerebral infraction (brain attack caused by a blockage in a blood vessel). Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 13 of 15, which indicated moderately impaired cognition. Resident #1 needed total care with ADL assistance with two staff assist. Record review of Resident #1's care plan, revision date [DATE], read in part . [Resident #1] required assistance with ADL functions: Goal resident would maintain a sense of dignity by being clean, dry odor free and well groomed. There was intervention for call light. During an observation and interview on [DATE] at 3:35 p.m., Resident #1 said her call light was not working, and the State Surveyor asked her to push her call light. When the resident pushed the red button on the call light, the light was not blinking at the insertion site in the room or above the resident's door. Resident #1 said her call light worked sometimes, and sometimes it would not work, and she could not remember how long the call light had not been working correctly. Resident #1 said her aides and the nurses knew about it. Resident #1 said LVN P gave her the call light when she came to her room between 10:00 a.m. and 11:00 a.m. and she did not know if the call was working or not During an observation and interview on [DATE] at 3:39 p.m., LVN P came into Resident #1's room, pushed the call light, and it was not working. LVN P pulled the call light cord out of the wall insertion, and the light came on. She pushed the call light back into the wall insertion and pushed on the red knob on the call light, but the light did not come on in the room or above the door. LVN P said the call light was not working properly, and she was not aware the call light was malfunctioning. LVN P said she was going to notify the maintenance director. During an observation and interview on [DATE] at 3:41 p.m., LVN P came back to Resident #1's room with another call light cord, which she inserted into the wall outlet and pushed the red button on the cord, and the call light lit up in the room at the wall and above the resident's door. LVN P said she would still put the repair order in the log. She said if the call light was not working, Resident #1 would not be able to reach the staff for any assistance until a staff member came into the resident's room. She said Resident #1 would have delayed care, and if the resident tried to get up to call for assistance, the resident could fall and sustain injury. She said she handed the call light to Resident #1, but did not check if the call light was functioning properly. LVN P said she forgot to check if the call light was functioning, before she handed the call light to Resident #1. She stated the maintenance director was responsible for making sure the call light was functioning correctly. During an interview on [DATE] at 9:48 a.m., the DON said the call light connected Resident #1 to the staff to make her needs known when the staff were not in the room. The DON said maintenance was responsible for maintaining the call light, and the nursing staff were supposed to notify maintenance, by writing, that the call light was not functioning in the maintenance log. The DON said the aides were supposed to check and ensure the call light was working before the staff handed the call light to Resident #1. The DON said Resident #1 would not get the assistance she needed until the staff made the next round. The DON said there would be a variable negative outcome for Resident #1 and did not respond to what types of variables. During an interview on [DATE] at 12:58 p.m., the Administrator said the maintenance director was responsible for making sure all the call lights were working. He said he did the audit of all the call lights last night when he became aware Resident #1's was not working. The Administrator said the call light was what Resident #1 used to communicate her needs to the staff. The Administrator said Resident #1 could have delayed care because the resident's call light was not functioning correctly. The Administrator said the staff should have checked and made sure the call light was working before she gave the call light to Resident #1. The Administrator stated he performed a call light audit on [DATE], and the maintenance director should have documented it. During a telephone interview on [DATE] at 3:13 p.m., the Maintenance Director stated the entire maintenance team conducted monthly rounds to ensure the call lights were functioning. However, he was not required to document these monthly checks; instead, he documented the yearly call light checks. He said he did not work yesterday ([DATE]), and he was not aware Resident #1's call light was not working. The Maintenance Director said the staff should have checked if the call light was working before the staff gave the call light to Resident #1. He said it would not be safe for Resident #1 because if she fell, she would not be able to get assistance promptly, because the call light was not working. The Maintenance Director said the nursing staff should document any call light repair in the maintenance log or tell one of the maintenance staff, and one of the maintenance staff would fix the call light. Record review of the facility's maintenance log for hall 100 did not reveal there was any call light order repair for Resident #1 room call light from [DATE] to [DATE]. Record review of the facility's, undated, policy on call lights read in part .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside .2. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include replace 'call light', provide a bell or whistle, increase frequency of rounding, etc.) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that Resident #1 received treatment and care in accordance with professional standards of practice for one resident (Resident #28) of 5 residents reviewed quality of care and skin .<BR/>The facility failed to assess, report, and obtain new physician orders due to a change in resident #28's skin condition of the perineal (private area of a patient) groin and buttock to the physician.<BR/>This failure affected one resident (Resident #28) out of 4 residents reviewed for skin issues and had the potential to place residents at risk skin break down, infection and discomfort. <BR/>Findings included: <BR/>Record review of the facility face sheet revealed that Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia) You might also hear people use the term acute hypoxemic respiratory failure (AHRF)), morbid obesity with aveolar hypoventilation (Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness), type 2 diabetes (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and lymphedema (build-up of fluid in soft body tissues when the lymph system is damaged or blocked).<BR/>Record review of Resident #28's care plan dated initiated 10/16/2021 revealed a care plan for ADL's and limited physical mobility r/t weakness, confusion, limited mobility with interventions/task Resident #28 requires total assistance with toilet use and personal hygiene. A care plan for bowel and bladder incontinence dated initiated and revised on 1016/2021 r/t activity intolerance, confusion and impaired mobility with a goal target date of 3/29/2024 to refrain free of skin break down due to incontinence and brief use through the target date, interventions and task included use MD's order for Nystatin powder and to check frequently for incontinence. Wash rinse and dry perineum (cleaning the private areas of a patient), change clothing PRN and after incontinence episodes.<BR/>Record review of Resident #28's quarterly MDS assessment dated [DATE]th, 2024, revealed he had a BIM score of 14, indicating he was cognitively intact. Resident #28 was also coded as being impaired on both sides, upper and lower extremities for functional limitation range in motion dependent on 2 or more helpers (staff) to complete the activities of bathing, showering, toileting hygiene, dressing the upper and lower body, putting on and removing footwear, he also required partial to moderate assistance to roll to the left sides and lye back down on the bed. Resident 3 28 was totally dependent on staff to transfer from bed to chair or wheelchair. Resident #28 was frequently incontinent of bladder and bowel. Resident #28 was coded to be a risk for pressure ulcers.<BR/>Record review of physician orders for February 2024 included orders for Nystatin Powder 100000 UNIT/GM ,Apply to inner thighs, scrotum, abd topically everyday shift for Incontinence; Rash.<BR/>May Apply Zinc skin barrier after each incontinent episode to help reduce skin impairments. <BR/>Prior to wound treatment evaluate resident for Pain: everyday shift for Wound Care<BR/>After wound treatment evaluate resident for pain: everyday shift for Wound treatment.<BR/>Record review of Resident #28's weekly wound assessments for January 2024 through February 7, 2024, revealed no wound assessment for his perennial, scrotum and folds areas.<BR/>Record review of Resident #28's Braden Scale assessment dated [DATE] revealed that his skin is constantly moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the patient is moved or turned, chairfast: ability to walk severely limited or non-existent. <BR/>During an observation and on 02/07/24 at 1:30 pm, it was revealed that Resident #28's under abdominal fold, scrotum, left, and right groin were very red, macerated (soften or become softened by soaking in a liquid), and there were tiny opens on all areas. One of the areas on under the abdomen measured about 1.0x1.0 cm. Resident #28 said that it hurts whenever RN A or CNA N cleaned the groin areas, scrotum, and abdominal area. Observation at this time of RN A and CNA N which wiped Resident #28 and the wipes had thick white substance and it had a musty odor. <BR/>During an interview on 02/07/24 at 1:24 pm, RN B said she did Resident #28's skin assessment sometimes and the wound care nurse does it at times. RN B said Resident #28 needed two to three staff assistance for incontinent care. RN B said Resident #28 did not have any redness or open area on his buttocks or peri area when she did his skin assessment two weeks ago. RN B said none of the aides had told her that the resident had any open area on his peri area.<BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated with some openings. LVN H said she had worked with Resident #28 last week on Friday and Saturday and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 she assumed the nurses were aware of the skin condition.<BR/>During an interview on 02/08/24 at 10:42 am, the Wound Care Nurse said she does Resident #28's weekly skin assessment, and she did not see any redness, macerated area, any opening on his groin or abdominal folds. She said she became aware of the area yesterday.<BR/>During an interview on 02/08/24 at 10:54 am, the DON said she became aware of the red macerated area when she came to Resident #28's room. Then DON said she smelled the foul odor and ammonia in the resident room. The DON said the wound care nurse assessments for Resident #28 from January 2024 through February 2024 did not mention Resident #28 had any skin issues on his groin or under his abdomen. The DON said the facility has a new wound care company and the wound care doctor was not notified about the skin condition.<BR/>During an interview on 02/08/24 at 10:57 am, with Resident #28's primary physician, he said he was notified about the change in skin condition yesterday twice. He said Resident #28 was an obese resident and all the folds could cause the areas to stay wet and the intervention of Barrier cream may not prevent the area from being moist and red or open. He said there was no other intervention in place to prevent the area from being moist or red. The physician said the facility also have a wound care doctor who should be taking care of wound and skin issues. <BR/>Record review of the facility policy and procedure entitled Resident Examination and Assessment dated revised February 2014, read in part .physical examination: skin: intactness, moisture, color, texture and presence of bruises, pressure sores, redness, edema, rashes. Activity level: able to perform ADLs; and degree of assistance required . Documentation The following information should be recorded in the resident's medical record: The date and time the procedure was performed, all assessment data obtained during the procedure, how the resident tolerated the procedure .Notify the physician of any abnormalities such as .wounds or rashes on the resident's skin; and report other information in accordance with facility policy and professional standards of practice.<BR/>Record review of the facility policy and procedure entitled Skin Management System no date provided, read in part .head to toe assessments should be completed weekly .skin assessments include the review of all skin areas from the top of the head/scalp to the toes including examination of skin folds .and any crevices that may exist .the Certified Nurse Aide will notify the Treatment Nurse or Charge Nurse of any newly identified skin or pain issues .residents who are incontinent of bladder or bowel will be provided incontinent care every 2 hours as needed .residents who rely on nursing staff for positioning will be turned and repositioned every 2 hours as needed .<BR/>The following Plan of Removal submitted by the facility was accepted on Friday 2/9/2024 at 2:00 pm.<BR/>PLAN OF REMOVAL (POR)<BR/>Name of facility: Fallbrook Rehabilitation and Care Center<BR/>Date: 02/08/2024 <BR/>F-684 - The facility failed to assess, report, and obtain new order due to a change in resident # 28's skin condition of the groin and buttock to the physician.<BR/>The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice.<BR/>Immediate action:<BR/>Resident #28 was promptly assessed once skin issue identified by Director of nurses, Physician and RP was notified; treatment orders were obtained, and resident's care plan updated to reflect change in condition. One on one education provided to CNA N regarding reporting skin issues by DON on 2/7/2024<BR/>The Director of Nurses, Assistant Director of Nurses, Wound Nurse and Nurse Supervisor initiated a head-to-toe skin sweep on all residents that will be completed by 10 pm tonight, 02/08/2024. The primary physician(s) will be notified of any newly identified skin integrity issues and orders will be obtained as appropriate. The resident responsible party will be notified of any findings, and treatment plan(s). <BR/>An audit of all current resident records will be completed by the Director of Nursing, Assistant Director of Nursing, Wound Nurse, and Nurse Supervisor to ensure a weekly head to toe skin assessment order is in place by 11:59pm 02/09/2024. An audit will be completed by the Director of Nursing, Assistant Director of Nursing, Wound Nurse, and Nurse Supervisor to ensure that any residents with an identified skin issue on existing skin assessment has an appropriate treatment order in place by 11:59pm, 02/09/2024. <BR/>Facilities Plan to ensure compliance quickly.<BR/>Education initiated by Director of Nurses, Assistant Director of Nurses, Wound Nurse, and Nurse Supervisor at 9 pm 02/09/2024 for all nurses and certified nurse aids on ADLs, answering call lights, performing timely Peri Care, and Q 2-hour resident rounding. Education will also include what to do when skin issues are identified and what to do if pain occurs during any type of care. Nurses will be educated by the Director of Nurses on Provider and responsible party notifications when a change in condition or treatment plan occurs by 02/09/2024.<BR/>Nursing staff (licensed and certified) will be re-educated on the Skin Management System starting on 02/09/024 by DON and target completion date of 02/09/2024. Nursing staff members will not be allowed to work their oncoming shift until this education is completed. On- going competency of the Skin Management System will be monitored by asking oral/verbal questions, rounding and auditing of documentation and orders in the electronic medical record. <BR/>Nursing staff will be re-educated by Assisted Director of Nurses (ADON), DON, Nurse manager concerning the skin identification form. CNAs will be responsible for completing the skin identification form. CNA will complete skin identification form after every resident's shower on facility skin identification form. CNAs will turn form in to charge nurse before end of shift. The charge nurse will take appropriate action to address any skin issues identified on skin form. DON, ADON & Nurse manager will oversee sheet identification sheet completion by reviewing skin identifications form in morning clinical meeting. Education will be completed prior to nursing staff commencing their next assigned shift. This education will be completed by 02/09/24. Any nursing employee not present will complete the in-service prior to starting their next shift. <BR/>New or readmitted residents will have a head-to-toe skin assessment completed by the on-duty Admitting Nurse upon admission. The physician and responsible party will be notified of any identified skin issues and the treatment plan(s). The Wound Nurse will follow up on all new or readmitted resident skin assessments on her next scheduled shift and alert the Wound Care Physician of her findings, obtaining any treatment order changes at this time. The Director of Nurses will provide education on this process by 02/09/24. Any nursing employee not present will complete the in-service prior to starting their next shift. <BR/>QAPI meeting was held 2/8/2024 by the facility IDT team, which included Administrator, DON, ADON, CNO, Housekeeping supervisor, Social Worker, Human resources to review policy/procedure for ADL care.<BR/>Monitoring:<BR/>Record review on 2/10/2024 of POR binder including CNA skills competencies, the POR for F677, Head to toe assessments for the current residents, IDT rounds and in-services, policies and procedures for: Proper Procedure for Head-to-Toe Assessments, Skin Assessments, Skin Management System, Perineal Care, Activities of Daily Living Supporting, Call System-Resident, Peri-Care/Assisting Meals/Incontinent Care, given to all staff on 2/8/2024-2/9/2024 and the Stop and Watch -QAPI<BR/>Observations on 2/9/2024 through 2/11/2024 at various times in the day revealed that Resident #28 was resting in his room, watching football, he would give a thumbs up when asked how he was feeling.<BR/>Observations on 2/9/2024 through 2/11/2024 at various times of the day of staff making rounds, checking to see if any resident needed anything.<BR/>Interviews: Interviews with staff were conducted between 2/9/2024 through 2/11/2024 on multiple shifts with the Administrator, DON, ADON, VP, DVP, MDS Coordinator,Wound Care Nurse, RN's: A, B,C LVN's:A,B,C,D,E,P,R CNA's:A,B,C,D,E,F,G,H <BR/>Staff were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received.<BR/>Interview answers with CNA's: in-services included assessing skin, notifying nurse/nurse manager, to checking under the skin folds and placing barrier cream on them, documentation in PCC, (the electronic medical file system) the skin assessment and also notifying the nurse, answering the call-lights timely, witnessed staff not answering call-lights if, would report it. <BR/>perineal and incontinence in-services, knocking on door, greeting the resident and telling them what you are going to do, setting up supplies, closing privacy curtains, assessments are from front to back all creases and in between, when you see anything different notify the charge nurse, fill out the stop and watch form for any skin difference, skin checks are performed every time a resident is changed, the treatment nurse comes out daily and to assess different residents. <BR/>Interview answers varied from staff, LVN's said in-services received included skin treatment initiation, being informed by CNA of changes in skin, notification to family and the doctor, performing head to toe assessments including abdominal folds, to initiate care plan for said area, skin swipes, dry skin, skin barrier was to applied daily, prn and after every episode of incontinence, do a change of condition form.<BR/>Interviews with RN's included assessment of the resident when they come from the hospital, charting/documentation, when anyone observes a skin issue, document and make a treatment plan. Call doctor, RP and get an order.<BR/>On 2/10/2024 at 1:02 pm with the Administrator he said the team were aware of a broken system with skin prior to survey when HHSC surveyors came. The QAPI team did the PIP on January 30th, 2024 he added that the responsibility for skin integrity were interdisciplinary in the process, primarily he, the DON, treatment nurse, Social Worker and therapy, each person had their specific role. The team started addressing skin integrity immediately to addressing with skin assessments, they did not have time to follow through Braden timely, assessments basically before HHSC surveyors came in.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she was already aware of break in system with the skin issues and that the team had begun performing skin audits, was training with wound care nurse discussed in QAPI, IDT, physician, PIP, Resident #28, skin assessment was due 2/7/24 and she (the wound care nurse) had not gotten a chance to get to Resident #28, was working the other hall. Resident #28's assessment was due on the 7th of February, If the assessment was due that day and hadn't been conducted that day, she hadn't identified on that day yet because it (the newly identified skin area issue) had not been identified on prior skin assessments it ( the skin issue)was not there in the abdominal fold. They did identify the skin area and put treatment put in place, they are also in process of changing the wound care nurse, they have in-serviced the staff and did a 100 percent skin audit on residents. She said that a care plan was added, and a comprehensive care plan should be in place for specific Resident #28's perineal area to include under the folds. She said that any nurse at the facility is responsible for care plans and said a negative outcome could be skin impairment, infection, and delayed. treatment. Interview and record review on 2/10/2024 at 3:00 pm received and reviewed with VP, including skin sweep 100 percent, in-services/policies and procedures, all staff signatures, question/test/stop and watch. All staff in-serviced. 2 people identified with redness in skin sweep. Treat/care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 (CR #1) of 7 residents reviewed for controlled drugs in that:<BR/>-The facility failed to appropriately store CR #1's Norco oral tablet 5-325mg (Hydrocodone -Acetaminophen- medication classified as a schedule II drug (high potential for addiction and abuse) used to treat pain and also used as a cough suppressant) in the DON's office under double lock when CR #1 was discharged to the hospital on [DATE] and returned to the facility 06/21/24. It was discovered on 06/29/24 that the medication was missing after CR #1 requested pain medication.<BR/>-The facility Nursing staff failed to have completed signatures on their Controlled Drugs-Count Record for the month of June 2024 regarding 7am oncoming nurse and 7pm off going nurse for 6/18/24, 6/20/24, 6/24/24, 6/25/24, and 6/28/24. <BR/>This failure could place residents at risk for unwanted discomfort, pain, and further decrease in quality of life.<BR/>Findings include:<BR/>Record review of CR #1's face sheet dated 03/31/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. CR #1's diagnoses included the following: COPD (a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness, lack of coordination, cognitive deficit, spondylosis(age-related wear and tear of the spine) with radiculopathy lumbar region (a condition that affects the nerve roots in the lower back), anxiety, malignant neoplasm of bronchus or lung (a type of cancer that originates in the airways or lung tissue), malignant pleural effusion (cancer causing an abnormal amount of fluid to collect in the thin layers of tissue lining the outside of the lung), and respiratory failure with hypoxia (lack of oxygen in the tissue to sustain bodily functions) . Further review of the face sheet revealed that resident was discharged from the facility on 07/05/24 to the hospital.<BR/>Record review of CR #1's admission MDS dated [DATE] reflected a BIMS score of 15 indicating that resident cognition was intact. Section N (Medication) of CR #1's MDS reflected that CR #1 was receiving and opioid (pain-relieving medicine that work with the brain cells). <BR/>Record review of CR #1's Comprehensive Care Plan dated 06/14/24 reflected CR #1 was being care planned for pain r/t lung cancer with interventions that included to administer analgesics as per ordered. Give &frac12; hour before treatments or care.<BR/>Record review of CR #1's Physician Order Summery Report for the month of June 2024 reflected the following orders:<BR/>-Dated 06/13/24 Norco oral tablet 5-325mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 6 hours as needed for pain.<BR/>-Dated 06/29/24 Tylenol with Codeine #4 tablet 300-60mg (Acetaminophen-Codeine) give 1 tablet by mouth every 6 hours as needed for pain do not give with Norco. <BR/>Record review of CR #1's MAR for the month of June 2024 reflected the medication Norco 5-325mg (Hydrocodone-Acetaminophen) was given twice on the following days: June the 14th and June the 17th by RN B. Further review reflected that Tylenol with Codeine #4 tablet 300-60mg (Acetaminophen-Codeine) was administered to CR #1 on June the 29th. <BR/>Record review of an E-INTERACT (interventions used to improve the identification, evaluation, and management of changes in resident's condition to reduce unnecessary hospital transfer) was done on CR #1 on 06/17/25 for urinary retention with pain (severe pain) uncontrolled with pain medication and CR #1 was sent to the hospital.<BR/>Record review of the facility- self report revealed CR #1's medication Norco oral tablet 5-325mg (Hydrocodone) went missing after resident was discharged to the hospital 06/17/24. CR #1 returned to the facility 06/21/24 and on 06/29/24 CR #1 requested pain medication. The Unit Manager called pharmacy to reorder the medication. The pharmacy informed the facility the medication Norco 5-325mg 120 tablets was delivered to the facility on [DATE] and signed by LVN G. The Police Department was called, and the investigation was ongoing. <BR/>Record review of the facility Pharmacy drug delivery receipt dated 06/16/24 revealed 120 tablets of Norco 5-325mg (Hydrocodone) was delivered to the facility for CR #1 with the Unit Manger signing for the medication. <BR/>Record review of the facility investigation dated 07/01/24 of statement taken from Unit Manger said after he received the medication Norco 5-325mg (Hydrocodone 120 tablets) on 06/16/24 he did not work on the hall after that.<BR/>Record review of the facility's June 2024 Controlled Drugs-Count Record revealed the following: <BR/>-6/18/24 no signature for 7pm off going nurse.<BR/>-6/19/24 no signature for the 7pm off going nurse.<BR/>-6/20/24 no signature for the7am off going nurse.<BR/>-6/24/24 no signature for the 7am oncoming and 7am off going nurses.<BR/>-6/25/24 no signature for the 7am oncoming and 7am off going nurses.<BR/>-6/26/24 7am oncoming and 7am off going was RN B signature.<BR/>-6/26/24 7am oncoming was RN B signature. The off going signature was not legible.<BR/>-6/27/24 7am oncoming nurse was LVN F signature. The off going signature was not legible.<BR/>-6/28/24 7am oncoming nurse had an illegible signature; no signature for the 7am off going nurse.<BR/>-6/29/24 7am oncoming was LVN A signature. <BR/>Record review of statement from LPN D dated 07/01/24 said she was approached by the previous ADON that RN B would be leaving the facility at 2:00PM and that LPN D along with orientee LVN F would be responsible for the floor. LPN D reported that she got report from RN B and while counting the narcotics with RN B she observed there were some medications wrapped on a sheet with a rubber band. LPN D said she enquired about it and RN B told her don't do not worry about those, CR #1 was transferred to the hospital. LPN D said she suggested that the medication should be given to the ADON, but RN B insisted that she should not worry about the wrapped pack of medications and walk away. LPN D said LVN F was given the key to the narcotic cart throughout the shift and handed it to the oncoming nurse. <BR/>Interview on 04/01/25 at 12:08PM via phone with LPN D said she worked at the facility PRN on the morning or evening shift. LPN D said she remembered the incident regarding CR #1 Norco medication missing. LPN D said she did not remember what day it was but that she was orienting a new nurse when around 12PM the previous ADON came to her to tell her another nurse on the hall was going to have to leave at 2pm who name she could not recall. LPN D said she counted the narcotic count with the nurse. LPN D said she remembered counting Norco medication, but did not remember who the medication belonged to. LPN D said when they approached her later about Norco medication missing. She said 120 pills were missing and that was not what she remembered counting. LPN D said when a resident receiving narcotics had to be transferred to the hospital, the narcotic was supposed to be counted and given to the DON. LPN D said she could not remember what medication belonged to who. LPN D said when she finished counting the narcotic with the nurse, she was told by the previous ADON to give the narcotic key to the nurse she was orienting, and she did.<BR/>Record review of statement from RN B dated 07/01/24 indicated on 06/21/24 she was scheduled to work from 7AM-1PM. RN B said CR #1 was scheduled to be re-admitted to the facility on [DATE]. RN B said she counted the narcotic cart with LPN D and gave report. RN B said when she counted the narcotic with LPN D among the narcotics was CR #1 Norco wrapped with 2 count sheets. RN B said she gave the narcotic key to LPN D.<BR/>Interview on 04/01/25 at 9:43AM via phone with RN B said she used to work at the facility full time on the morning shift from 7a-7p. RN B said she stopped working at the facility in August 2024. RN B said she heard there was a problem with the narcotic count on the hall that CR #1 resided on. RN B said she was called to come to the facility to take a drug test which she did. RN B said she tested negative for the drug test. RN B said there was a male nurse that worked on the same hall that refused to take the drug test but did not remember his name. RN B said whenever she counted the narcotic cart, the count was correct.<BR/>Interview on 04/01/25 at 1:00PM RN B said she was not sure if CR #1's narcotics were on the cart when she counted with LPN D. RN B said it was the facility protocol to count the narcotics and give to the DON when the resident was transferred to the hospital to ensure the medication remained secured. RN B said the narcotics could have been left on the cart because the DON was not at the facility and if not in the facility, the medication must stay on the narcotic cart until the medication can be delivered to the DON.<BR/>Record review of statement from LVN F said on 06/21/24 said she was on orientation with LPN D. LVN F said RN B left the facility at 2:00PM after counting the narcotic cart with LPN D. LVN F said she thought everything was okay.<BR/>Interview on 04/01/25 at 3:33PM via phone with LVN F said on 06/21/24 she was in training with nurse LPN D and did not count the narcotic medication cart. LVN F said she was never given the key to the narcotic cart. LVN F said she was one of the nurses that done a drug test and tested negative for drugs in her system.<BR/>Interview on 03/31/25 at 3:05PM via phone with LPN A said she remembered last year of a resident medication gone missing but did not remember CR #1. LPN A said she worked at the facility on a PRN basis 6a-6p but last year the shift time was from 7a-7p. LPN A said she only worked at the facility on the weekends PRN morning shift. LPN A said when a resident that was receiving narcotics and had to be transferred to the hospital on the weekends, the narcotic had to be counted at the end of each shift with the oncoming nurse following up to that following Monday. After counting the narcotic on that Monday ensuring the count was correct, the narcotic would then be given to the DON to lock the medication away until the resident returned to the facility. <BR/>Interview on 03/31/25 at 5:32PM via phone with the Unit Manager worked at the facility PRN on the weekends as a supervisor. The Unit Manager said it was the morning nurse who name he could not remember brought it to his attention that CR #1's narcotic Norco was missing. The Unit Manger said when CR #1's Norco could not be located, he notified DON A and previous Administrator. The Unit Manager said the protocol was when a resident receiving narcotics was transferred to the hospital, the narcotic must be counted at the end of each shift until it was picked up by the DON. The Unit Manager said LVN G no longer worked at the facility and had not worked at the facility for approximately a year. The Unit Manager said after DON A and the previous Administrator was notified, he did not know what happen regarding the missing narcotic for CR #1. <BR/>Interview on 04/01/25 at 10:45AM with the Human Resource Specialist said all the nurses that had access to the narcotic cart on Hall 200 where CR #1 resided done a drug test except RN E who refused. The Human Resource Specialist said all the nurses that tested for drugs were negative. The Human Resource Specialist said RN E no longer worked at the facility after the incident of CR #1's Norco went missing.<BR/>On 04/01/25 at 11:03AM A call was placed to RN E, no answer. left voicemail with a call back number. RN E did not return the call after making several attempts to contact RN E.<BR/> Interview on 04/01/25 at 1:10PM with the present DON, DON B said if a resident was admitted to the hospital and was receiving narcotics, the narcotics had to be counted by 2 nurses and delivered to the DON for best practices. DON B said if the resident was gone from the facility over 3 days, he believed the narcotic would have to be destroyed. DON B said if the resident returned to the facility and on the same medications, the medications would have to be re-ordered by the physician. DON B said this was how it was done at the previous facility he worked at. The DON B said when the resident was discharged , the narcotic (s) needed to be given to the DON within 24-hour period. DON B said if the resident discharged from the facility on the weekend, the staff would have to continue to count the narcotic at the end of each shift and given to the DON on the following Monday. DON B said when this protocol was not being followed it placed the narcotic at risk of being misplaced. Further interview with DON B said it was the responsibility of the DON to be checking the narcotics on each cart to ensure there were no discrepancies detected with the narcotics and the count sheet and that all signatures were completed on the narcotic sheet. DON B said he had been working at the facility since February 10th, 2025. DON B said he checked the narcotic carts each morning looking for any discrepancies. The DON said the facility had a total of 4 medication carts. <BR/>Record review of DON A work schedule when worked at the facility in June 20204 reflected that DON A was at the facility 06/17/24 (Monday) through 06/21/24 (Friday) as well as 06/24/24 (Monday) through 06/28/24 (Friday).<BR/>Interview on 04/01/25 at 3:18PM via phone with the previous DON, DON A said it was reported that CR #1 Norco was missing when he returned from the hospital. DON A said RN B gave CR #1 his Norco. DON A said it was RN E who refused to be drug tested and resigned. DON A said all the other nurses that had access to the narcotic cart on hall 200 done the drug test and was negative for drugs in their system. DON A said she tried to call RN E later and he never answered. DON A said when a resident on narcotics must be taken to the hospital and gone for more than 24 hours, the narcotics needed to be given to the DON and the drugs are double locked until the resident returned to the facility. DON A said CR #1's narcotic Norco was never located. DON A said whoever counts the narcotic cart was responsible for the narcotic cart. DON A said the facility failed to remove CR #1's medication Norco from the cart and give to the DON so the medication could be double lock for safe keeping. DON A said the staff was in-serviced on the handling of controlled medications. <BR/>Record review of the facility investigation revealed that an in-service was done on 07/01/24 with the staff on controlled substances, storge of medications, abuse, neglect, misappropriation protocols/response. Further review revealed that the facility had conducted a pain questionnaire with the residents with no negative outcome identified. The Regional Nurse had done an audit of the medication room and storage room on 07/01/24 with all medications including narcotics were stored safely. The medication rooms were locked, and medication carts were observed locked when nurse was away from the cart. <BR/>Record review of the facility policy on Controlled Substances revised in April of 2019 reflected in part:<BR/> .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications .At the end of each shift: controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together .Controlled medications will be counted every shift change (scheduled or incidental) by an authorized staff member (RN, LVN, CMA) reporting for duty with an authorized staff member reporting off duty . <BR/>Record review of the facility policy on Identifying Exploitation, Theft and Misappropriation of Resident Property dated April 2021 reflected in part:<BR/> .As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to recognize exploitation of residents and misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without resident's consent .Example of misappropriation of resident property include drug diversion (taking the residents medication) . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accommodate the needs and preferences reviewed for accommodation of needs. for one resident (Resident #28) of 15 residents.<BR/>The facility failed to ensure Resident #28's call light was within reach of the resident. <BR/>This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.<BR/>Findings included:<BR/>Observation and interview on 4/8/25 at 10:18 AM revealed Resident #28's call light was under his dresser on the right side of his bed. Resident #28 was observed lying in bed, he said that he just woke up and his leg hurts. The surveyor asked him to press his call-light for assistance and he said he did not even know he had a call-light. Surveyors searched for the call-light which was found under the dresser. The DON came to assist, he removed the call-light from beneath the dresser and attached the call-light to Resident #28's blanket. Resident #28 pressed the call-light to make sure it worked. <BR/>An interview with the DON on 4/8/25 at 10:25 AM, when asked what a negative outcome could have been if the resident could not be able to reach and press his call-light. The DON said he could have fallen and hurt himself by getting up to get what he needed. The DON said that he would address Resident 328's pain and conduct in-services on call-lights with the staff. He said that all staff were responsible for having call-light placement.<BR/>An interview on 4/10/25 at 10:14 am with the Administrator he said that the call-lights being withing reach of the resident were important because the call-light notified staff of the residents needs so they could address them. He said that all staff were responsible for having call-light placement.<BR/>Record review of Resident #28's facility admission record in the facility medical record system revealed that Resident #28 was admitted on [DATE]. Resident #28 was a [AGE] year-old male with diagnoses that included facial weakness following other cerebrovascular (facial weakness can develop following other cerebrovascular diseases, such as stroke, subarachnoid hemorrhage, or cerebral venous thrombosis. These conditions disrupt the normal blood flow to the brain, resulting in damage to the facial nerve disease.) and attention and concentration deficit following cerebral infarction (concentration deficit refers to a person's ability to filter out distractions and maintain their focus on a particular task. Attention and concentration deficits are common following cerebral infarction).<BR/>Record review of Resident #28's admission MDS dated [DATE], revealed a BIM score of 12 out of 15 indicating a moderate cognitive impairment. Resident #28 was documented to have lower extremity impairment and was documented to require total to substantial/maximum assistance from staff for ADL's. He required set-up to or clean-up assistance with eating. He was always continent with bladder and bowel. <BR/>Record review of Resident #28's care plan revealed a care plan to address ADL self-care performance deficit and requires hands on assistance. Date Initiated: 01/29/2025. Revision on: 02/12/2025 Goals included to maintain/improve level of<BR/>Functioning, bed mobility with assist of 1. Date Initiated: 02/12/2025 and a care plan to address a prescribed an anticonvulsant medication for behaviors and is at risk for side effects, abnormal labs, skin reaction<BR/>and falls. Interventions included will be free of side effects/adverse reactions related<BR/>to anticonvulsant use throughout the next review. Date Initiated: 02/12/2025.<BR/>Revision on: 02/24/2025, Monitor for Side effects of headache, fatigue, dizziness, blurred vision, nausea,<BR/>weight changes and mood changes. Date Initiated: 02/12/2025.<BR/>Review of the facility's policy and procedure entitled Answering the Call-light, dated revised September 2022 read in part . The purpose of this procedure is to ensure timely responses to the resident's requests and needs .Explain to the resident that a call system is also located in his/her bathroom .Be sure that the call light is plugged in and functioning at all times .<BR/>Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to respect the resident's right to personal privacy during care, for 1(Resident # 777) of 6 residents reviewed for privacy, in that:<BR/>-LVN F failed to lock her computer during medication pass on 04/09/25, leaving Resident #777's medical records disclosed on the hallway.<BR/>This failure could place resident at risk for economic harm, embarrassment, and not maintaining their individual autonomy and individuality.<BR/>The findings included:<BR/>Record review of Resident # 777's face sheet dated 04/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident # 777 diagnoses included the following: staphylococcal (bacteria) arthritis (swelling or tenderness in one or more joints causing pain or stiffness) of the right knee, chronic pain, anemia (low count of red blood cells {cells that carry oxygen from the lungs to the rest of the body}), hypertension (high blood pressure), heart failure, and kidney disease stage 3 (moderate loss of kidney function).<BR/>Record review of Resident #777's admission MDS dated [DATE] reflected a BIMS score of 15 indicating that resident cognition was intact.<BR/>Record review of Resident #777's Physician Order Summary Report for the month of April 2025 reflected the following order:<BR/>-Dated 03/25/25 Cefazolin (antibiotic) 2gm intravenously every 8 hours for infection until 04/30/25.<BR/>Record review of Resident #777's Comprehensive Care Planned dated 03/26/25 reflected that resident was being care planned for receiving IV antibiotics for infection. The intervention included to monitor for signs and symptoms of infiltration (when a substance move into a space not normally found).<BR/>Record review of Resident #777's MAR for the month of April 2025 revealed that the facility was administering the medication Cefazolin 2gm IV as ordered. <BR/>Observation on 04/09/25 at 7:45AM during medication pass for Resident #777, LVN F retrieved the IV medication Cefazolin 2mg from her medication cart. LVN F left her computer screen open exposing Resident #777's medical records for medication administration and walked away from the cart entering resident room to administer the medication. <BR/>Interview on 04/09/25 at 7:47AM with nurse LVN F said she forgot to close Resident #777 medical record before going into the resident's room. LVN F said this placed the residents medical information at risk of being exposed to anyone and this was a HIPPA violation. LVN F said she had been in-serviced on resident privacy and HIPPA (a federal law designed to protect the privacy and security of patient health information.<BR/>Record review of the facility policy on Resident Rights revised February 2021 reflected in part:<BR/> .Employees shall treat all residents with kindness, respect, and dignity .privacy and confidentiality .<BR/>Record review of the facility policy on Confidentiality of Infection and Personal revised October 2017 reflected in part:<BR/> .The facility will safeguard the personal privacy and confidentiality of all residents personal and medical records .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a person-centered baseline admission care plan for 2 of 6 residents (Resident #45 and Resident #31 ) reviewed for baseline care plans in that: <BR/>-The facility failed to develop a 48-hour baseline care plan with goals, interventions, treatments, and psychosocial needs addressed in a resident specific care plan for Resident #45.<BR/>- The facility failed to develop a 48-hour baseline care plan with goals, interventions, treatments, and psychosocial needs addressed in a resident specific care plan for Resident #31.<BR/>This failure could affect new admissions residents reviewed for 48-hour baseline care plans of not having their individual, medical, functional, and psychosocial needs identified and cause a physical or psychosocial decline in health.<BR/>Findings included:<BR/>Resident #45<BR/>Record review or Resident #45's admission record dated 4/11/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #45's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (both conditions that can occur after a cerebral infarction, or stroke, and are characterized by weakness or paralysis on one side of the body) and brief psychotic disorder (psychiatric condition characterized by sudden and temporary periods of psychotic behavior, such as delusions, hallucinations, and confusion). <BR/>Record review of Resident #45's admissions MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13 out of 15 revealing he was cognitively intact. The MDS assessment revealed that Resident #45 was coded for ranges substantial/maximal assistance to setup or clean-up assistance with ADL's. Resident #43 was coded to be frequently incontinent of bladder and always incontinent of bowel. <BR/>Record review of Resident #45's medical record revealed there was no baseline care plan.<BR/>Record review of Resident #45's comprehensive care plan revealed care plans to address ADL self-care performance deficit and altered cardiovascular status, no date provided.<BR/>During an interview on 4/10/25 at 5:03 pm the DON said that Resident #45 should have had a baseline care plan and comprehensive care plan to provide the continuum of care that the resident needs. The DON said that the negative outcome could be the resident not having the care he needs provided. He said that the MDS Coordinator would be responsible for creating the care plans. <BR/>During an interview on 4/11/25 at 1:15 pm with the MDS Coordinator, she said she was the one responsible for completing the care plans, she said that the care plans were important to help take care of the resident and provide care for the resident. She said that she used the RAI manual for the policy for care plans. The MDS Coordinator added that she had only worked at the facility for 2 weeks and was doing an audit of the care plans. <BR/>Resident #31<BR/>Record review of Resident #31's face sheet dated 04/10/25 revealed a [AGE] year-old male was admitted to the on 03/05/25. Resident #31 diagnosis included: end stage renal disease (kidneys have stopped working well enough to support the body), hypertension (force of blood against the walls of the arteries is consistently too high), atrial fibrillation (an irregular heartbeat) and coronary artery disease (arteries that supply blood to the heart become narrowed or blocked due to build up of plaque).<BR/>Record review of Resident #31's admission assessment dated [DATE] revealed BIMS of 13 indicating intact cognition. Further review revealed Resident #31 was depended on staff with ADL care with one to two staff assist.<BR/>Record review of Resident #31's medical record revealed there was no baseline care plan.<BR/>During an interview on 04/11/25 at 2:42 p.m., the MDS Coordinator said the baseline care plan should be initiated upon admission and completed within 48 hours. The MDS Coordinator said if Resident #31 did not have a baseline care plan, Resident #31 might not get all the appropriate care from the staff.<BR/>During an interview on 04/11/25 at 2:57 p.m., the ADON said a baseline care plan should initiated on admission, and she was not sure how it is done in this facility. The ADON said she would check with the corporate nurse and update the surveyor.<BR/>During an interview on 04/11/25 at 3:05 p.m., the DON said the admitting nurse was responsible for starting the bassline care plan within 24 hours and completed within 72 hours. The DON said he becomes involved with the baseline care plan when he reviews the admission the following day unless the admission is over the weekend, and then he will review it on Monday. The DON did not respond when he was asked why Resident #31 did not have a baseline care plan. The DON said the staff would care for Resident #31 based on the report received from the hospital and the discharge summary report from the hospital. The DON said if Resident #31 had any order that was not in the discharge summary report, then the order and care would not be provided for Resident #31.<BR/>During an interview on 04/11/25 at 4:09 a.m., the Corporate Nurse said the bassline care plan should be started on admission by the admitting nurse and completed within 48 hours.<BR/> During an interview on 04/11/25 at 4:22 p.m., LVN F said the nurse did not initiate the 48-hour care plan, and she thought the MDS was responsible for the 48-hour care plan. LVN F said she was the admitting nurse for Resident #31. She said she reviewed the hospital orders, notified the physician about the resident medications, and carried out the physician's orders. LVN F said she had no skill check-off or training for a baseline care plan. LVN F said the DON and ADON monitored the nurse during rounds and reviewed the admission paperwork for new residents.<BR/>Record review of the facility policy entitled; Care Plans-Baseline dated revised March 2022 read in part . Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a Resident #28 who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 (Resident #28) of 4 residents reviewed for ADL's and quality of life. <BR/>The facility failed to ensure Resident #28 was provided incontinent care in a timely manner, which resulted in decreased skin integrity.<BR/>This failure affected one resident (Resident #28) and placed residents requiring assistance with incontinent care at risk of not have the assistance with personal care which could cause pain, skin breakdown, lack of dignity and low self-esteem.<BR/>Findings:<BR/>Record review of the facility face sheet revealed that Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia) You might also hear people use the term acute hypoxemic respiratory failure (AHRF)), morbid obesity with aveolar hypoventilation (Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness), type 2 diabetes (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and lymphedema (build-up of fluid in soft body tissues when the lymph system is damaged or blocked).<BR/>Record review of Resident #28's care plan dated initiated 10/16/2021 revealed a care plan for ADL's and limited physical mobility r/t weakness, confusion, limited mobility with interventions/task Resident #28 requires total assistance with toilet use and personal hygiene. A care plan for bowel and bladder incontinence dated initiated and revised on 1016/2021 r/t activity intolerance, confusion and impaired mobility with a goal target date of 3/29/2024 to refrain free of skin break down due to incontinence and brief use through the target date, interventions and task included use MD's order for Nystatin powder and to check frequently for incontinence. Wash rinse and dry perineum (cleaning the private areas of a patient), change clothing PRN and after incontinence episodes.<BR/>Record review of Resident #28's quarterly MDS assessment dated [DATE]th, 2024, revealed he had a BIM score of 14, indicating he was cognitively intact. Resident #28 was also coded as being impaired on both sides, upper and lower extremities for functional limitation range in motion dependent on 2 or more helpers (staff) to complete the activities of bathing, showering, toileting hygiene, dressing the upper and lower body, putting on and removing footwear, he also required partial to moderate assistance to roll to the left sides and lye back down on the bed. Resident 3 28 was totally dependent on staff to transfer from bed to chair or wheelchair. Resident #28 was frequently incontinent of bladder and bowel. Resident #28 was coded to be a risk for pressure ulcers.<BR/>Record review of physician orders for February 2024 included orders for Nystatin Powder 100000 UNIT/GM ,Apply to inner thighs, scrotum, abd topically everyday shift for Incontinence; Rash.<BR/>May Apply Zinc skin barrier after each incontinent episode to help reduce skin impairments. <BR/>Prior to wound treatment evaluate resident for Pain: everyday shift for Wound Care<BR/>After wound treatment evaluate resident for pain: everyday shift for Wound treatment.<BR/>Record review of Resident #28's weekly wound assessments for January 2024 through February 7, 2024, revealed no wound assessment for his perennial, scrotum and folds areas.<BR/>Record review of the facility grievance/complaint form dated 2/7/2024 revealed that Resident #28 filed a grievance that he did not receive care. Resolved by the DON assisting CNA's with providing care and disciplinary action scheduled with CNA assigned Resident #28.<BR/>During an observation and interview on 2/07/2024 at 8:03 am, with Resident #28, laying in his bed, he said that the CNA's do not want to do their job. He said he pushed his call-light at 4:00 pm yesterday and the staff did not come and assist him until 9:00 pm. He said that he has wounds on his bottom and that the staff make him wait and sit in his feces for so long that it dries up on his bottom and they have to scrape the feces off. He said it does not feel good to sit in that at all. He added if he could clean himself, he would but he cannot.<BR/>During an observation and on 02/07/24 at 1:30 pm, it was revealed that Resident #28's under abdominal fold, scrotum, left, and right groin were very red, macerated, and there were tiny opens on all areas. One of the areas on under the abdomen measured about 1.0x1.0 cm. Resident #28 said that it hurts whenever RN A or CNA N cleaned the groin areas, scrotum, and abdominal area. Observation at this time of RN A and CNA N which wiped Resident #28 and the wipes had thick white substance and it had a musty odor. <BR/>During an interview on 02/07/24 at 1:20 pm, CNA N said she had not provided incontinent care for Resident #28 since she came to work today at 6:30 a.m. CNA N said Resident #28 had to call her if he needed to be changed, and she had not gone and checked on Resident #28 for incontinent care. CNA N said she was supposed to make rounds for incontinent care on all residents every two hours. <BR/>During an interview on 02/07/24 at 1:24 pm, RN B said she did Resident #28's skin assessment sometimes and the wound care nurse does it at times. RN B said Resident #28 needed two to three staff assistance for incontinent care. RN B said Resident #28 did not have any redness or open area on his buttocks or peri area when she did his skin assessment two weeks ago. RN B said none of the aides had told her that the resident had any open area on his peri area.<BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated with some openings. LVN H said she had worked with Resident #28 last week on Friday and Saturday and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 she assumed the nurses were aware of the skin condition.<BR/>During an interview on 02/08/24 at 10:42 am, the Wound Care Nurse said she does Resident #28's weekly skin assessment, and she did not see any redness, macerated area, any opening on his groin or abdominal folds. She said she became aware of the area yesterday.<BR/>During an interview on 02/08/24 at 10:54 am, the DON said she became aware of the red macerated area when she came to Resident #28's room. Then DON said she smelled the foul odor and ammonia in the resident room. The DON said the wound care nurse assessments for Resident #28 from January 2024 through February 2024 did not mention Resident #28 had any skin issues on his groin or under his abdomen. The DON said the facility has a new wound care company and the wound care doctor was not notified about the skin condition.<BR/>Interview on 02/08/24 at 10:57 am, with Resident #28's primary physician, he said he was notified about the change in skin condition yesterday twice. He said Resident #28 was an obese resident and all the folds could cause the areas to stay wet and the intervention of Barrier cream may not prevent the area from being moist and red or open. He said there was no other intervention in place to prevent the area from being moist or red. The physician said the facility also have a wound care doctor who should be taking care of wound and skin issues. <BR/>Record review of the facility policy and procedure entitled Perineal Care dated revised February 2018 read in part . Purpose, the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .Preparation: 1.Review the resident's care plan to assess for any special needs of the resident .wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks .dry area thoroughly .document any discharge, odor, bleeding, skin care problems or irritation, complaints of pain or discomfort .report other information in accordance with facility policy and professional standards of practice.<BR/>Record review of the facility policy and procedure entitled Activities of Daily Living (ADL's) Supporting dated revised March 2018 read in part .residents who are unable to carry out activities of daily living independently will receive the services to maintain good nutrition, grooming, personal and oral hygiene .appropriate care and services will be provided for residents who are unable to carry out ADL's independently .in accordance with the plan of care including support and assistance with: hygiene (bathing) .elimination (toileting) .A resident's ability to perform ADL's will be measured using clinical tools including the MDS and the following MDS definitions .totally dependent: full staff performance on an activity with no participation by the resident for any aspect of the ADL activity . <BR/>Record review of the facility policy and procedure entitled Call System, Resident dated September 2022 read in part .residents are provided with the means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation .calls for assistance are answered as soon as possible but no longer than 5 minutes .<BR/>Record review of the facility policy and procedure entitled Dignity dated February 2021 read in part . Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem Policy Interpretation and Implementation: Residents are treated with dignity and respect at all times .demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example: promptly responding to a resident's request for toileting assistance.<BR/>The following Plan of Removal submitted by the facility was accepted on Friday 2/9/2024 at 2:00 pm.<BR/>Plan of Removal (POR) <BR/>PLAN OF REMOVAL<BR/>Name of facility: Fallbrook Rehabilitation and Care Center<BR/>Date: 02/08/2024 <BR/>F 677 - <BR/>The facility fail to ensure that residents who are unable to carry out Activities of Daily Living (ADLs) receive the necessary services to maintain nutrition, grooming, and personal and oral hygiene. <BR/>The facility failed to ensure that incontinent care was provided timely <BR/>Immediate action:<BR/>Resident #28 was assessed, and incontinent care provided immediately when identified on 02/07/2024. Nurse aide (CNA N) was provided one on one re-educated in providing peri care at least every 2 hours and as needed on 2/07/2024 at 1:30pm <BR/>The Director of Nurses, Assistant Director of Nurses, Wound Nurse and Nurse Supervisor initiated a sweep on all residents to verify that incontinent care was done on all residents by 10 pm tonight, 02/08/2024. The primary physician(s) will be notified of any newly identified skin integrity issues related to the skin sweep and orders will be obtained as appropriate. The resident responsible party will be notified of any findings, and treatment plan(s). Two new skin areas were found during sweep. One was redden area to a resident's back and other was redden area to a resident's neck along trach collar area secures. Family and provider notified, and orders obtained<BR/>An audit of the skin identification forms for current residents were completed by the Director of Nursing, Assistant Director of Nursing, Wound Nurse and Nurse Supervisor to ensure CNA skin sheets were completed by 10 pm 02/08/2024. Two new skin areas were found during sweep. One was redden area to a resident's back and other was redden area to a resident's neck along trach collar area secures. Family and provider notified, and orders obtained<BR/>Facilities Plan to ensure compliance quickly.<BR/>Education provided and to be completed by Director of Nurses, Assistant Director of Nurses, Wound Nurse, and Nurse Supervisor by 11:59pm 02/09/2024 for all nurses and certified nurse aids on ADLs, shower sheet completion, answering call lights, Peri Care, and Q 2-hour resident rounding. Education also includes what to do when skin issues are identified and what to do if pain occurs during any type of care. IDT will make rounds twice a day and charge nurses will make rounds every 2 hours. Nurse managers will validate randomly throughout day that charge nurses are making rounds to check that Residents' skin is dry and clean to prevent skin breakdown. Specific training on system which includes assessment and treatment of skin folds. CNAs/Nurses will not be allowed to work until they've received the training.<BR/>All CNAs will have skill checks completed by Director of Nurses, Assistant Director of Nurses, and Nurse Supervisor on peri care to validate incontinent care protocol is followed appropriately by 02/09/2024.<BR/>Nursing staff (licensed and certified) will be re-educated on the Skin Management System by Director of Nurses, ADON, Treatment Nurse and Nurse manager with the target completion date of 02/09/2024. Nursing staff members will not be allowed to work their oncoming shift until this education is completed. <BR/>Nursing staff will be re-educated by Assistant Director of Nursing and Wound Nurse on the stop and watch tools and the skin identification form. Education will be completed prior to nursing staff commencing their next assigned shift. This education will be completed by 02/09/24. Any nursing employee not present will complete the in-service prior to starting their next shift. <BR/>The nurse will verify that the skin identification sheets are completed by the CNAs when bathing and/or showering residents and that any identified issue is addressed. The physician and responsible party will be notified of any identified skin issues and the treatment plan(s). The Director of Nurses will provide education on this process to all nursing staff by 02/09/24. Nursing employee will not be allowed to start shift until complete the in-service. <BR/>QAPI meeting was held 2/8/2024 by The facility IDT team, which included Administrator, DON, ADON, CNO, Housekeeping supervisor, Social worker, Human resources to review policy/procedure for ADL care.<BR/>Monitoring:<BR/>Record review on 2/10/2024 of POR binder including CNA skills competencies, the POR for F677, Head to toe assessments for the current residents, IDT rounds and in-services, policies and procedures for: Proper Procedure for Head-to-Toe Assessments, Skin Assessments, Skin Management System, Perineal Care, Activities of Daily Living Supporting, Call System-Resident, Peri-Care/Assisting Meals/Incontinent Care, given to all staff on 2/8/2024-2/9/2024 and the Stop and Watch -QAPI<BR/>Interviews on training: assessments, skin sheets, change of skin, documentation, communication, physician orders.<BR/>Observations on 2/9/2024 through 2/11/2024 at various times in the day revealed that Resident #28 was resting in his room, watching football, he would give a thumbs up when asked how he was feeling.<BR/>Observations on 2/9/2024 through 2/11/2024 at various times of the day of staff making rounds, checking to see if any resident needed anything.<BR/>Interviews: Interviews with staff were conducted between 2/9/2024 through 2/11/2024 on multiple shifts with the Administrator, DON, ADON, VP, DVP, MDS Coordinator,Wound Care Nurse, RN's: A, B,C LVN's:A,B,C,D,E,P,R CNA's:A,B,C,D,E,F,G,H <BR/>Staff were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received.<BR/>Interview answers with CNA's: in-services included assessing skin, notifying nurse/nurse manager, to checking under the skin folds and placing barrier cream on them, documentation in PCC, (the electronic medical file system) the skin assessment and also notifying the nurse, answering the call-lights timely, witnessed staff not answering call-lights if, would report it. <BR/>perineal and incontinence in-services, knocking on door, greeting the resident and telling them what you are going to do, setting up supplies, closing privacy curtains, assessments are from front to back all creases and in between, when you see anything different notify the charge nurse, fill out the stop and watch form for any skin difference, skin checks are performed every time a resident is changed, the treatment nurse comes out daily and to assess different residents. <BR/>Interview answers varied from staff, LVN's said in-services received included skin treatment initiation, being informed by CNA of changes in skin, notification to family and the doctor, performing head to toe assessments including abdominal folds, to initiate care plan for said area, skin swipes, dry skin, skin barrier was to applied daily, prn and after every episode of incontinence, do a change of condition form.<BR/>Interviews with RN's included assessment of the resident when they come from the hospital, charting/documentation, when anyone observes a skin issue, document and make a treatment plan. Call doctor, RP and get an order.<BR/>During an interview on 2/10/2024 at 1:02 pm with the Administrator he said the team were aware of a broken system with skin prior to survey when HHSC surveyors came. The QAPI team did the PIP on January 30th, 2024 he added that the responsibility for skin integrity were interdisciplinary in the process, primarily he, the DON, treatment nurse, Social Worker and therapy, each person had their specific role. The team started addressing skin integrity immediately to addressing with skin assessments, they did not have time to follow through Braden timely, assessments basically before HHSC surveyors came in.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she was already aware of break in system with the skin issues and that the team had begun performing skin audits, was training with wound care nurse discussed in QAPI, IDT, physician, PIP, Resident #28, skin assessment was due 2/7/24 and she (the wound care nurse) had not gotten a chance to get to Resident #28, was working the other hall. Resident #28's assessment was due on the 7th of February, If the assessment was due that day and hadn't been conducted that day, she hadn't identified on that day yet because it (the newly identified skin area issue) had not been identified on prior skin assessments it ( the skin issue)was not there in the abdominal fold. They did identify the skin area and put treatment put in place, they are also in process of changing the wound care nurse, they have in-serviced the staff and did a 100 percent skin audit on residents. She said that a care plan was added, and a comprehensive care plan should be in place for specific Resident #28's perineal area to include under the folds. She said that any nurse at the facility is responsible for care plans and said a negative outcome could be skin impairment, infection, and delayed treatment.<BR/>On 2/10/2024 at 3:00 pm received and reviewed with VP, including skin sweep 100 percent, in-services/policies and procedures, all staff signatures, question/test/stop and watch. All staff in-serviced. 2 people identified with redness in skin sweep. Treat/care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent decrease in range of motion for 1 of 5 residents (Resident #16) reviewed range of motion.<BR/>-The facility failed to ensure Resident #16, with contractures to both hands, was wearing a hand rolls on both hands and off load bilateral heels. as care planned and ordered by the physician.<BR/>- This failure could place resident at risk for further contractures of the hands and fingers, pain, and a decrease in quality of life.<BR/>Findings included:<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck), tachycardia ( a heart rate over 100 beats a Minute), gastrostomy( a surgical procedure used to insert a tube, often referred to as a G-tube).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) reflected BIMS score marked was 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems, and could not recall the current season, She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/> Record review of physician's order dated 10/03/23 reflected Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. <BR/>Review of Resident #16's care plan review on 10/03/23 revealed a focus of Bilateral Hand Roll and off load Bilateral heels, bilateral hand rolls and off load heel up to 24 hours tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. Goal Resident #16 will have hand rolls and to have Bilateral Heels off loaded daily up to 24 hours as tolerated to assist with preventing contractures and injury to bilateral heels with constant monitoring every 4-6 hours by staff. Care plan update of 02/01/24 had intervention for Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours. With an initiated date of 10/03/23<BR/>Record review of Resident # 16's February 2024 MAR and TAR revealed order to Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. <BR/> With a start date of 10/03/23. Treatment was signed as completed daily for 2/6/24, 2/7/24/ and 2/8/24.<BR/>Observation of Resident #16 on 2/6/24 at 10:00 AM, 12:00 PM, and 2:00 PM, revealed her lying in bed with bilateral hands contracted, with no hand rolls, no heel protectors, and her heels were not off the mattress.<BR/>Observation of Resident #16 lying in bed non-responsive on 2/07/24 at 8:47 AM, 10:30 AM, 12:00 PM, 1:30 PM, and 3:30 PM revealed bilateral hands contracted with no hand rolls, no heel protectors, and her heels were not off the mattress.<BR/>Further observation of Resident #16 lying in bed on 2/8/24 at 11:20 AM with Director Respiratory therapy who was at bed side and helped uncover Resident #16's top linen, revealed resident did not have any hand roll to contracted right hand, and feet were not off loaded off the mattress. She had socks on and heels were not floated.<BR/>During an interview with the C.NA A on 2/7/24 at 4:40 PM C.NA A said the nursing staffs were responsible for placing bilateral hand rolls and floating Resident #16's heels. C.NA A said not floating the heels could result in skin break down, she forget to float the heels ( Float heels means that a Resident's heel should be positioned in such a way as to remove all contact between the heel and the bed) and place the handrolls in Resident #16's hands.<BR/>During an interview with the Treatment Nurse and record review on 02/08/24 at 1:00pm she stated she was responsible for making sure that Resident #16 had bilateral hand rolls and floating heels while providing wound care to the resident.<BR/>During an interview with the DON on 2/8/24 at 4:00 PM, she stated the staffs were to ensure physician orders are implemented as ordered. DON stated the nursing staffs were responsible for ensuring bilateral hand rolls and floating heels. DON stated not implementing physician orders could cause a delay in treatment and there could be a potential for worsening of the condition or delay in progress.<BR/>During an interview with the Administrator on 2/8/24 at 4:30 PM, he stated the staffs were to ensure physician orders are implemented as ordered. If treatment was not implemented as ordered by the physician, it could cause worsening of the condition.<BR/>Record review of the facility's policy titled, Following Physician Orders with an implementation date of 09/28/21 stated, 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Document the order by entering the order and the time, date, and signature on the physician order sheet. B. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #21) reviewed for free of accidents, hazards, supervision, and devices., in that: <BR/>The facility failed to ensure Resident #21 who the facility staff knew he was at risk for fall and update fall precaution interventions after several falls resulting in injuries to the head.<BR/>An IJ was identified on 02/09/24. The IJ template was provided to the facility on [DATE] at 7:15 p.m. While the IJ was removed on 02/11/24 at 12:50 p.m., with the Administrator, DVP and DVP Clinical. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated due to the facility staff had not been trained on identifying residents at risk for fall, preventions, and interventions, and modification and care plan falls. <BR/>This failure could affect residents who were fall risk and place them at risk for physical harm, pain, mental anguish, or emotional distress. <BR/>Findings included : <BR/>Review of Resident #21's face sheet revealed Resident #21was a [AGE] year-old male who was admitted to the facility on [DATE], re-admission on [DATE] with a diagnosis of Atrial fibrillation, (irregular and often very rapid heartbeat) , cerebral palsy (weakness or problem with using the muscles), history of falls, and epilepsy(unprovoked seizures).<BR/>Record review of Resident #21's quarterly MDS assessment, dated 02/07/2024, revealed a BIMS score of 04 out of 15, which indicated the resident's cognition was severely impaired. Further review of Resident #21's MDS revealed the resident required supervision assistance with one staff for transfer and dependent on one staff assistance with putting and taking off footwear. Further review of Resident #21 MDS revealed the resident had one fall snice admission.<BR/>Record review of Resident # 21 order summary report revealed the following: PT to evaluate and treat under PASRR active date 08/25/23, <BR/>OT to evaluate and treat under PASRR active date 08/25/23, <BR/>ST to evaluate and treat under PASRR active date 08/25/23, <BR/>Fall mat placed next to bed every shift active date 12/18/23.<BR/>Record review of the facility incident report on falls for Resident #21 revealed the following: 7/22/23 - Unwitnessed fall - in resident room, Mental Status: disoriented, Hematoma was on forehead and transported to 911. <BR/>10/22/23 - Unwitnessed fall-in resident room, Mental Status: oriented to time, place and person, abrasion to his forehead, I was sitting on my bed putting my shoes on and fell. <BR/> 12/18/23 - Unwitnessed fall- in resident room, Mental Status: disoriented, large hematoma above left eye trying to get out of bed to wheelchair. <BR/>2/1/24 - Unwitnessed fall - in resident room, and hematoma was on forehead. <BR/>Record review of Resident #21's care plan revealed the care plan was not updated following falls 07/22/23, 10/22/23, 12/18/23.Intervention:be sure call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Further review of Resident #21's care plan revealed resident was at risk for fall related to confusion, deconditioning, gait/balance problem, and history of fall. Intervention: fall mat placed next to bed during all shift was not care planed.<BR/>During an observation on 02/06/24 at 9:57 a.m., Resident #21 was sitting in a wheelchair in his room, and the call light was on the nightstand and was not within reach. Resident #21 had dark red-purple bruises from the middle of his forehead to the left of his nose, left eyes, and cheeks. He also had a black line about 1 inch thick across his forehead. Resident #21 also had a hematoma about the size of a tennis ball. <BR/>During an observation on 02/08/24 at 2:39 p.m., Resident #21 was sitting in his room in his wheelchair, and the call light was not within reach.<BR/>During an interview on 02/09/24 at 12:21 p.m., the DON said Resident #21 had several falls, in which he had some head injuries, and they have done all they could to prevent Resident #21 from falling except for a helmet for the protection of his head. The DON said Resident #21 bed should be at the lowest position whenever he was in bed, and she did not know if his bed was on the lowest position when fell because all his fall were unwitnessed. The DON said all the interventions were care planned.<BR/>During an observation and interview on 02/09/24 at 1:30 p.m., Resident #21 was in his room sitting in his wheelchair, and the call light was not within reach; it was on the nightstand. Resident # 21 said he fell from the bed but could not remember what day it was or if the bed was low.<BR/>During an observation and interview on 02/09/24 at 1:34 p.m., LVN R said Resident #21 falls frequently. LVN R said Resident #21's call light was on the nightstand far from Resident #21, and he could not reach it if he wanted to use it. LVN R said the DON and ADON are responsible for implementing any changes in the care plan.<BR/>During an observation and interview on 02/09/24 at 1:41 p.m., the DON and ADON went into Resident #21's room and the DON said they saw the call light on the nightstand, and Resident #21 could not reach the call light if he wanted to use it. The DON said the call should be within reach whenever the resident was in the room.<BR/>During an interview on 02/09/24 at 1:43 p.m., CNA F said she just picked up the tray from Resident #21's room and did not notice Resident #21's call light was not within reach. CNA F said Resident #21 could fall if he tried to reach for his call light, and he could not call for assistance if he wanted to call because the call light was not within reach.<BR/>During an interview on 02/09/24 at 3:03 p.m., the ADON said she saw that Resident #21's call light was not within reach of the resident. The ADON said Resident #21 was at risk of falling and could fall if he tried to reach for the call light. The ADON said all of Resident #21's falls should have been care planned and intervention modified. The ADON said she did not know why the falls were not care planed, she said the intervention should be modified with each fall, and she was not responsible for care planning the falls and it was the responsibility of MDS coordinator and social worker.<BR/>During an interview on 02/09/24 at 3:23 p.m., The DON said any nurse could update the care plan, and all of Resident # 21's falls should have been care planed and intervention modified as needed. The DON said she would investigate and update the surveyor later.<BR/>During an interview on 02/09/24 at 3:28 p.m., the Corporate Nurse said that all of Resident #21's falls should be care planned and that she would investigate and find out the root cause of his falls so that an intervention could be put in place.<BR/>During an interview on 02/09/24 at 3:36 p.m., the SW said she had not had any care plan meeting with Resident #21's family about his falls. SW said she was aware of the falls because she would see Resident #21 had a knot on his head and bruises.<BR/>During an interview on 02/09/24 at 3:41 p.m., the MDS Coordinator said the DON and ADON updated the care plan, and she only coded the MDS. The MDS coordinator stated that the GG section of MDS did not require any coding for staff assistance for Resident #21's bed mobility. The MDS coordinator said the DON and the ADON were responsible for putting and modifying interventions in the care plan.<BR/>During an interview on 02/09/24 at 3:44 p.m., the Director of Rehabilitation said Resident #21 has been in therapy since March last year, and they are working on his endurance, balance, and memory. The Director of Rehabilitation said he does not work with Resident #21 and would talk to his staff if any recommendation was made for Resident #21. The Director of Rehabilitation said if his department made any recommendations, the nursing department would be responsible for care planning, intervention, and monitoring of Resident #21.<BR/>Record review of facility policy on fall clinical protocol dated 2001 MED PASS, Inc. (Revised March 2018) read in part .cause identification . #3 The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified .treatment/management .#1 Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .monitoring and follow-Up .#1 . the staff, with the physician 's guidance, will follow up on any fall with associated injury . #2 .the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of fall .#4 if the individual continue to fall, the staff and the physician will re- evaluate the situation and reconsider possible reasons for the resident's falling(instead of, or in addition to those that have already been identified) and also reconsider the current interventions .<BR/>This was determined to be an Immediate jeopardy (IJ) on 02/09/24 at 7:15 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 02/09/24 at 7:15p.m.<BR/>The following Plan of Removal submitted by the facility was accepted on 02/10/24 at 9:34 a.m.<BR/>PLAN OF REMOVAL<BR/>Name of facility: Fallbrook Rehabilitation and Care Center<BR/>Date: 02/09/2024 <BR/>F 689 - <BR/>The facility failed to ensure that Resident #21 received adequate supervision and assistive devices to prevent accidents. <BR/>The facility failed to update fall precaution interventions after several falls resulting in injuries to a resident. <BR/>Immediate action:<BR/>The Medical Director was notified of the Immediate Jeopardy status on 02/09/2024 at 7:50 pm.<BR/>Resident #21 promptly had a new fall risk assessment done by ADON 02/09/2024. Resident #21 is currently receiving Physical, Occupational and Speech therapy 5 days a week. Resident's care plan updated to include fall mat, bed to be kept in low position, and verification that call light was in reach 2/9/2024. <BR/>The Director of Nurses, Assistant Director of Nurses will review all fall risk assessment and update care plans to ensure appropriate interventions are in place and this will be completed by 2/10/2024. Regional nurses will review all current resident fall history and verify falls and fall interventions are captured on care plan by 2/10/2024. Therapy will review all residents who have fallen in the last 90 days to ensure residents have been screened and therapy will implement additional interventions as indicated (to be completed by 2/10/2024). Therapy will provide any needed training to nursing staff for interventions. Rehab director attends fall management meeting during stand-up meeting and will provide any screen and therapy plan information related to resident's falls to nursing staff. Nursing management. To include DON, ADON, MDS, will update care plan and CNA guidance in Point click care. Charge nurses will ensure recommended interventions related to resident's falls are followed and DON, ADON will provide oversight by making rounds daily, All nursing staff, which includes all nurses and nurse aides, will be in-service to ensure call bells are within resident's reach by Nursing manager by 2/10/2024; Nurse staff All nursing staff, which includes all nurses and nurse aides, will not be allowed to start shift until completing in-service training.<BR/>Facility Plan to ensure compliance quickly<BR/>Director of Nurses, Assistant Director of Nurses, and Nurse Supervisor will provide education to nursing staff by 2/10/2024 to notify physician and RP and to promptly implement an intervention after fall by updating resident's care plan. The Director of Nurses, Assistant Director of Nurses, and MDS Nurse will review falls in morning meeting and ensure that the nursing staff has updated the care plan, and the physician was notified. IDT team will review the fall intervention implemented by nurses in morning meeting. Education will be completed by the Director of Nurses, Assistant Director of Nurses, and Nurse Supervisor by 02/10/2024 for all nurses and certified nurse aids on importance of ensuring call lights are in resident's reach. CNAs will be educated on ensuring call lights are in resident's reach when doing Q 2-hour rounds. Charge nurses will verify that CNAs have place call bell in reach when their doing rounds. IDT team will do rounds 5 days a week to verify call bells are within resident's reach and document on IDT round sheet. Staff will not be allowed to start shift until completing in-service training.<BR/>Nursing staff (licensed and certified) will be re-educated on call bell system to include call bell placement by 2/10/2024. Administrator, DON, ADON, and Nurse Supervisor will Inservice Nursing staff/aides on falling star program, which includes stars on name room plate and bands on devices. Interventions will be listed in nurse/CNA care plan in Point click care. Inservice to be completed 2/11/2024Staff will not be allowed to start shift until completing in-service training.<BR/>QAPI meeting was held 2/9/2024 by the facility IDT team, which included Administrator, DON, ADON, CNO, Housekeeping supervisor, social worker, Human resources to review policy/procedure Fall management program.<BR/>Surveyor monitored the plan of removal for effectiveness as follows:<BR/>A record review of the facility removal plan revealed the medical director was notified of the IJ on 2/09/24 at 7:50 p.m.<BR/>A record review of the risk assessment revealed all residents were reviewed on 02/10/23 by the corporate nurse for fall risk assessment. <BR/>Record review of the facility in service revealed the DON and ADON in-service the nurses and CNAs on fall prevention, care plans/[NAME] (electronic health record) for personalized interventions, identifying residents at risk for falls, falling star/yellow bands, fall prevention and updating the care plan on 02/10/24.<BR/>A record review of the progress note revealed Residents with falls for the past 90 days were reviewed by the therapy on 02/10/24 and they are currently in therapy. <BR/>A record review of fall risk assessment revealed Resident #21 had a new fall risk assessment done by ADON on 02/09/2024. <BR/>A record review of Resident #21's care plan revision dated 02/09/24 revealed the following up date: with a fall mat, bed in a low position, all the falls were care-planned and currently on PT, OT, ST, under PASRR 5 times a week indefinitely since March 2023. <BR/>During observations on 02/11/24 from 10:00a.m. to 2:00 p.m., revealed residents(Resident #21, Resident #18, and Resident #25) on the fall list had their call lights attached to the bed, and one Resident #24 was in bed, and she could reach her call light.<BR/>During interviews on 02/10/24 between 11:21 a.m. and 8:48 P.m., two CNAs and three nurses from the night shift were interviewed on the facility in service and training on fall precautions, interventions, identification of residents at risk of falls, care plan modification of intervention and who was responsible for updating care plans. <BR/>All staff interviewed were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. <BR/>During an interview on 02/11/24 between 9:00 a.m. and 9:30 a.m., one CNA, one nurse from the day shift, and The MDS coordinator were interviewed on the facility in service and training on fall precautions, interventions, identification of residents at risk of falls, care plan modification of intervention and who was responsible for updating care plans. All staff <BR/>interviewed were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. <BR/>During an interview on 02/11/24 at 9:57 a.m., the DON said she was checking to ensure that all the in-services were done because she did some training, and the Social Worker and the Administrator did some of the in-services. The DON said she provided training for the aides not to move any resident observed on the floor but to call the nurse so the nurse could assess the resident. The DON said she also trained the aides to look at the [NAME] for residents at risk for falls, and the [NAME] also showed the aides the different types of interventions for each resident. The DON said [NAME] told the aides that the resident should have a nonskid stocking, a yellow falling star on the door, and the resident should wear a yellow band. The DON said the nurses were given the same training as the aides, and they were also trained on how to update the care plan if any resident had a fall. The DON said the nurses were in serviced on assessing a resident during a fall, notifying the physician, carrying out the physician's order, and also notifying the responsible party and nurse management. <BR/>During an interview on 02/11/24 between 10:00 a.m. and 11:00 a.m., two CNAs and three nurses from the day shift were interviewed on the facility in service and training on fall precautions, interventions, identification of residents at risk of falls, care plan modification of intervention and who was responsible for updating care plans. All staff <BR/>interviewed were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. <BR/>During an observation on 02/11/24 at 11:17 a.m., it revealed Resident #21 was sitting in his wheelchair in his room close to the foot of the bed close to the door, and the call light was clipped on the linen close to the resident, and he could reach the call light.<BR/>During an interview on 02/11/24 at 12:11 p.m., the Administrator said he was aware of Resident #21 falls, and they discussed them during IDT meets. The Administrator said they had changed Resident #21's fall precautions, and his care plan has been updated. The Administrator said he assisted with the in-service training for the aides and nurses on falls; they have amended the fall program and implemented the falling star and general intervention for falls but did not go into details about the care plan. The Administrator said the DON and the ADON conducted in-service the staff on updating the care plan, and he told the staff to follow up with the DON any time they had any falls.<BR/>On 02/11/24 at 12:50 p.m., the Administrator, the DON, the VP of operation, and DVP Clinical were notified the Immediate Jeopardy was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm that is not immediate Jeopardy and a scope of isolated due to the facility's need to 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 Residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents ( Resident #16 and Resident #89) reviewed for incontinent care, in that:<BR/> CNA B did not separate Resident #16's labia to clean during incontinent, clean arround the buttocks and did not perform appropriate hand hygiene with glove changes throughout the care<BR/> CNA A did not separate Resident # 89's labia to clean during incontinent, clean arround the buttock and did not perform appropriate hand hygiene with glove changes throughout the care.<BR/>This deficient practice could affect residents who received perineal care( the skin in between your genital and your anus) and place them at-risk of increased urinary tract infections due to improper care. <BR/>The findings included:<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/>Review of Resident #16s Care Plan, dated 01/24/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for sign and symptom of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 8:46 AM of Resident #16's incontinent care, revealed C.NA B washed hands before donning (putting) clean gloves and C.NA A was assisting . Resident #16's soiled brief was pulled down in front. C.NA B using the wet wipes cleaned the perineal, groin area. She did not open the labia to be cleaned, did not change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then picked up a clean brief using the same gloves. The resident was rolled to her back, and the brief was secured. CNA B placed a wedge under residents' hip and pulled the blanket up to cover her legs. CNA B used the same gloves throughout while performing incontinent care. <BR/>Resident #89<BR/>Review of Resident #89's face sheet dated 02/07/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 01/27/24 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), pneumonia,(an infection of the lungs that may be caused by bacteria, viruses or fungi ), sacral region stage 4 pressure sore (full thickness tissue loss with exposed bone, tendon or muscle), severe sepsis with septic shock,( a dramatic drop in blood pressure that can damage the lung, kidneys, liver and other organs), anoxic brain damage ( caused by a complete lack of oxygen to the brain).<BR/>Record review of Resident #89's MDS assessment dated [DATE] (admission) reflected BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and continent of bladder was using indwelling catheter.<BR/>Review of Resident #89's Care Plan, dated 01/10/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for s/s of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 5:30 PM of Resident #89's incontinent care, revealed C.NA A washed hands before donning clean gloves and C.NA B was assisting. Resident #89 was lying in bed. C.NA A washed hands don cleaned gloves, and removed the old brief. Using the wet wipes she cleaned the perineal, groin area. She did not open the labia to clean, did not change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then used the same gloves and picked up a clean brief put on the Resident #89.<BR/>In an interview with CNA A and C.NA B on 02/08/24 at 6:10 PM, they both stated they forgot to wipe the buttocks and open the labia. C.NA A and C.NA B stated it was wrong because it could cause an infection. C.NA A and C.NA B stated they had training on infection control in 01/2024.<BR/>Record review for CNA A's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 01/17/2024 done by the DON. <BR/>Record review for CNA B's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 11/5/23 and 01/17/2024 done by the DON. <BR/>During an interview on 02/09/24 at 3:10PM with ADON/ Infection Preventionist, stated that her expectations for staff is to wash hands before all resident care. Staff should knock on the door, introduce themselves, wash hands, and don gloves. Staff should then provide incontinent care, then doff ( removing gloves) gloves. Staff should wash hands, open up female labia and cleaned and don new gloves prior to applying new brief. The ADON was informed of the observation and stated the facility did proficiency checks on hire and quarterly.<BR/>In an interview with the DON on 02/09/24 at 3:30 PM, she stated CNA A was one of the facility's lead aides that monitored other staff during orientation with incontinent care. DON said not washing hands after changing gloves and not opening the labia to clean could cause urinary tract infection. DON said C.NA A and C.NA B knew they should clean around the buttocks before placing a clean brief. DON said she would be performing more in-services for incontinent care. <BR/>In an interview on 02/09/2024 at 3:35 PM, the Administrator stated his expectation was that incontinent care and hand washing were always done to prevent infection.<BR/>Review of the facility's staff skills competencies on incontinent care, dated 02/2022, revealed:<BR/>1. Prepare for process, obtain supplies, and wash hands.<BR/>2. Prepare work area<BR/>3. Wash hands<BR/>4. Remove soiled brief and place in bag.<BR/>5. Doff gloves, wash hands, don new gloves.<BR/>6. Clean the resident, doff gloves and place soiled items in bag.<BR/>7. Wash hands and don new gloves.<BR/>8. Position clean brief under resident, apply barrier cream.<BR/>9. Doff gloves, wash hands, position resident for comfort<BR/>10. lower bed and place call light in reach, wash hands. <BR/>Review of the facility's policy titled; Perineal Care revised on 02/2018. <BR/>Purpose<BR/>The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.<BR/>For a female resident:<BR/>Wet washcloth and apply soap or skin cleansing agent.<BR/>Wash perineal area, wiping from front to back.<BR/>1. <BR/>Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.)<BR/>2. <BR/>Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth.<BR/>3. <BR/>If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.<BR/>4. <BR/>Gently dry perineum.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 (CR #1) of 7 residents reviewed for controlled drugs in that:<BR/>-The facility failed to appropriately store CR #1's Norco oral tablet 5-325mg (Hydrocodone -Acetaminophen- medication classified as a schedule II drug (high potential for addiction and abuse) used to treat pain and also used as a cough suppressant) in the DON's office under double lock when CR #1 was discharged to the hospital on [DATE] and returned to the facility 06/21/24. It was discovered on 06/29/24 that the medication was missing after CR #1 requested pain medication.<BR/>-The facility Nursing staff failed to have completed signatures on their Controlled Drugs-Count Record for the month of June 2024 regarding 7am oncoming nurse and 7pm off going nurse for 6/18/24, 6/20/24, 6/24/24, 6/25/24, and 6/28/24. <BR/>This failure could place residents at risk for unwanted discomfort, pain, and further decrease in quality of life.<BR/>Findings include:<BR/>Record review of CR #1's face sheet dated 03/31/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. CR #1's diagnoses included the following: COPD (a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness, lack of coordination, cognitive deficit, spondylosis(age-related wear and tear of the spine) with radiculopathy lumbar region (a condition that affects the nerve roots in the lower back), anxiety, malignant neoplasm of bronchus or lung (a type of cancer that originates in the airways or lung tissue), malignant pleural effusion (cancer causing an abnormal amount of fluid to collect in the thin layers of tissue lining the outside of the lung), and respiratory failure with hypoxia (lack of oxygen in the tissue to sustain bodily functions) . Further review of the face sheet revealed that resident was discharged from the facility on 07/05/24 to the hospital.<BR/>Record review of CR #1's admission MDS dated [DATE] reflected a BIMS score of 15 indicating that resident cognition was intact. Section N (Medication) of CR #1's MDS reflected that CR #1 was receiving and opioid (pain-relieving medicine that work with the brain cells). <BR/>Record review of CR #1's Comprehensive Care Plan dated 06/14/24 reflected CR #1 was being care planned for pain r/t lung cancer with interventions that included to administer analgesics as per ordered. Give &frac12; hour before treatments or care.<BR/>Record review of CR #1's Physician Order Summery Report for the month of June 2024 reflected the following orders:<BR/>-Dated 06/13/24 Norco oral tablet 5-325mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 6 hours as needed for pain.<BR/>-Dated 06/29/24 Tylenol with Codeine #4 tablet 300-60mg (Acetaminophen-Codeine) give 1 tablet by mouth every 6 hours as needed for pain do not give with Norco. <BR/>Record review of CR #1's MAR for the month of June 2024 reflected the medication Norco 5-325mg (Hydrocodone-Acetaminophen) was given twice on the following days: June the 14th and June the 17th by RN B. Further review reflected that Tylenol with Codeine #4 tablet 300-60mg (Acetaminophen-Codeine) was administered to CR #1 on June the 29th. <BR/>Record review of an E-INTERACT (interventions used to improve the identification, evaluation, and management of changes in resident's condition to reduce unnecessary hospital transfer) was done on CR #1 on 06/17/25 for urinary retention with pain (severe pain) uncontrolled with pain medication and CR #1 was sent to the hospital.<BR/>Record review of the facility- self report revealed CR #1's medication Norco oral tablet 5-325mg (Hydrocodone) went missing after resident was discharged to the hospital 06/17/24. CR #1 returned to the facility 06/21/24 and on 06/29/24 CR #1 requested pain medication. The Unit Manager called pharmacy to reorder the medication. The pharmacy informed the facility the medication Norco 5-325mg 120 tablets was delivered to the facility on [DATE] and signed by LVN G. The Police Department was called, and the investigation was ongoing. <BR/>Record review of the facility Pharmacy drug delivery receipt dated 06/16/24 revealed 120 tablets of Norco 5-325mg (Hydrocodone) was delivered to the facility for CR #1 with the Unit Manger signing for the medication. <BR/>Record review of the facility investigation dated 07/01/24 of statement taken from Unit Manger said after he received the medication Norco 5-325mg (Hydrocodone 120 tablets) on 06/16/24 he did not work on the hall after that.<BR/>Record review of the facility's June 2024 Controlled Drugs-Count Record revealed the following: <BR/>-6/18/24 no signature for 7pm off going nurse.<BR/>-6/19/24 no signature for the 7pm off going nurse.<BR/>-6/20/24 no signature for the7am off going nurse.<BR/>-6/24/24 no signature for the 7am oncoming and 7am off going nurses.<BR/>-6/25/24 no signature for the 7am oncoming and 7am off going nurses.<BR/>-6/26/24 7am oncoming and 7am off going was RN B signature.<BR/>-6/26/24 7am oncoming was RN B signature. The off going signature was not legible.<BR/>-6/27/24 7am oncoming nurse was LVN F signature. The off going signature was not legible.<BR/>-6/28/24 7am oncoming nurse had an illegible signature; no signature for the 7am off going nurse.<BR/>-6/29/24 7am oncoming was LVN A signature. <BR/>Record review of statement from LPN D dated 07/01/24 said she was approached by the previous ADON that RN B would be leaving the facility at 2:00PM and that LPN D along with orientee LVN F would be responsible for the floor. LPN D reported that she got report from RN B and while counting the narcotics with RN B she observed there were some medications wrapped on a sheet with a rubber band. LPN D said she enquired about it and RN B told her don't do not worry about those, CR #1 was transferred to the hospital. LPN D said she suggested that the medication should be given to the ADON, but RN B insisted that she should not worry about the wrapped pack of medications and walk away. LPN D said LVN F was given the key to the narcotic cart throughout the shift and handed it to the oncoming nurse. <BR/>Interview on 04/01/25 at 12:08PM via phone with LPN D said she worked at the facility PRN on the morning or evening shift. LPN D said she remembered the incident regarding CR #1 Norco medication missing. LPN D said she did not remember what day it was but that she was orienting a new nurse when around 12PM the previous ADON came to her to tell her another nurse on the hall was going to have to leave at 2pm who name she could not recall. LPN D said she counted the narcotic count with the nurse. LPN D said she remembered counting Norco medication, but did not remember who the medication belonged to. LPN D said when they approached her later about Norco medication missing. She said 120 pills were missing and that was not what she remembered counting. LPN D said when a resident receiving narcotics had to be transferred to the hospital, the narcotic was supposed to be counted and given to the DON. LPN D said she could not remember what medication belonged to who. LPN D said when she finished counting the narcotic with the nurse, she was told by the previous ADON to give the narcotic key to the nurse she was orienting, and she did.<BR/>Record review of statement from RN B dated 07/01/24 indicated on 06/21/24 she was scheduled to work from 7AM-1PM. RN B said CR #1 was scheduled to be re-admitted to the facility on [DATE]. RN B said she counted the narcotic cart with LPN D and gave report. RN B said when she counted the narcotic with LPN D among the narcotics was CR #1 Norco wrapped with 2 count sheets. RN B said she gave the narcotic key to LPN D.<BR/>Interview on 04/01/25 at 9:43AM via phone with RN B said she used to work at the facility full time on the morning shift from 7a-7p. RN B said she stopped working at the facility in August 2024. RN B said she heard there was a problem with the narcotic count on the hall that CR #1 resided on. RN B said she was called to come to the facility to take a drug test which she did. RN B said she tested negative for the drug test. RN B said there was a male nurse that worked on the same hall that refused to take the drug test but did not remember his name. RN B said whenever she counted the narcotic cart, the count was correct.<BR/>Interview on 04/01/25 at 1:00PM RN B said she was not sure if CR #1's narcotics were on the cart when she counted with LPN D. RN B said it was the facility protocol to count the narcotics and give to the DON when the resident was transferred to the hospital to ensure the medication remained secured. RN B said the narcotics could have been left on the cart because the DON was not at the facility and if not in the facility, the medication must stay on the narcotic cart until the medication can be delivered to the DON.<BR/>Record review of statement from LVN F said on 06/21/24 said she was on orientation with LPN D. LVN F said RN B left the facility at 2:00PM after counting the narcotic cart with LPN D. LVN F said she thought everything was okay.<BR/>Interview on 04/01/25 at 3:33PM via phone with LVN F said on 06/21/24 she was in training with nurse LPN D and did not count the narcotic medication cart. LVN F said she was never given the key to the narcotic cart. LVN F said she was one of the nurses that done a drug test and tested negative for drugs in her system.<BR/>Interview on 03/31/25 at 3:05PM via phone with LPN A said she remembered last year of a resident medication gone missing but did not remember CR #1. LPN A said she worked at the facility on a PRN basis 6a-6p but last year the shift time was from 7a-7p. LPN A said she only worked at the facility on the weekends PRN morning shift. LPN A said when a resident that was receiving narcotics and had to be transferred to the hospital on the weekends, the narcotic had to be counted at the end of each shift with the oncoming nurse following up to that following Monday. After counting the narcotic on that Monday ensuring the count was correct, the narcotic would then be given to the DON to lock the medication away until the resident returned to the facility. <BR/>Interview on 03/31/25 at 5:32PM via phone with the Unit Manager worked at the facility PRN on the weekends as a supervisor. The Unit Manager said it was the morning nurse who name he could not remember brought it to his attention that CR #1's narcotic Norco was missing. The Unit Manger said when CR #1's Norco could not be located, he notified DON A and previous Administrator. The Unit Manager said the protocol was when a resident receiving narcotics was transferred to the hospital, the narcotic must be counted at the end of each shift until it was picked up by the DON. The Unit Manager said LVN G no longer worked at the facility and had not worked at the facility for approximately a year. The Unit Manager said after DON A and the previous Administrator was notified, he did not know what happen regarding the missing narcotic for CR #1. <BR/>Interview on 04/01/25 at 10:45AM with the Human Resource Specialist said all the nurses that had access to the narcotic cart on Hall 200 where CR #1 resided done a drug test except RN E who refused. The Human Resource Specialist said all the nurses that tested for drugs were negative. The Human Resource Specialist said RN E no longer worked at the facility after the incident of CR #1's Norco went missing.<BR/>On 04/01/25 at 11:03AM A call was placed to RN E, no answer. left voicemail with a call back number. RN E did not return the call after making several attempts to contact RN E.<BR/> Interview on 04/01/25 at 1:10PM with the present DON, DON B said if a resident was admitted to the hospital and was receiving narcotics, the narcotics had to be counted by 2 nurses and delivered to the DON for best practices. DON B said if the resident was gone from the facility over 3 days, he believed the narcotic would have to be destroyed. DON B said if the resident returned to the facility and on the same medications, the medications would have to be re-ordered by the physician. DON B said this was how it was done at the previous facility he worked at. The DON B said when the resident was discharged , the narcotic (s) needed to be given to the DON within 24-hour period. DON B said if the resident discharged from the facility on the weekend, the staff would have to continue to count the narcotic at the end of each shift and given to the DON on the following Monday. DON B said when this protocol was not being followed it placed the narcotic at risk of being misplaced. Further interview with DON B said it was the responsibility of the DON to be checking the narcotics on each cart to ensure there were no discrepancies detected with the narcotics and the count sheet and that all signatures were completed on the narcotic sheet. DON B said he had been working at the facility since February 10th, 2025. DON B said he checked the narcotic carts each morning looking for any discrepancies. The DON said the facility had a total of 4 medication carts. <BR/>Record review of DON A work schedule when worked at the facility in June 20204 reflected that DON A was at the facility 06/17/24 (Monday) through 06/21/24 (Friday) as well as 06/24/24 (Monday) through 06/28/24 (Friday).<BR/>Interview on 04/01/25 at 3:18PM via phone with the previous DON, DON A said it was reported that CR #1 Norco was missing when he returned from the hospital. DON A said RN B gave CR #1 his Norco. DON A said it was RN E who refused to be drug tested and resigned. DON A said all the other nurses that had access to the narcotic cart on hall 200 done the drug test and was negative for drugs in their system. DON A said she tried to call RN E later and he never answered. DON A said when a resident on narcotics must be taken to the hospital and gone for more than 24 hours, the narcotics needed to be given to the DON and the drugs are double locked until the resident returned to the facility. DON A said CR #1's narcotic Norco was never located. DON A said whoever counts the narcotic cart was responsible for the narcotic cart. DON A said the facility failed to remove CR #1's medication Norco from the cart and give to the DON so the medication could be double lock for safe keeping. DON A said the staff was in-serviced on the handling of controlled medications. <BR/>Record review of the facility investigation revealed that an in-service was done on 07/01/24 with the staff on controlled substances, storge of medications, abuse, neglect, misappropriation protocols/response. Further review revealed that the facility had conducted a pain questionnaire with the residents with no negative outcome identified. The Regional Nurse had done an audit of the medication room and storage room on 07/01/24 with all medications including narcotics were stored safely. The medication rooms were locked, and medication carts were observed locked when nurse was away from the cart. <BR/>Record review of the facility policy on Controlled Substances revised in April of 2019 reflected in part:<BR/> .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications .At the end of each shift: controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together .Controlled medications will be counted every shift change (scheduled or incidental) by an authorized staff member (RN, LVN, CMA) reporting for duty with an authorized staff member reporting off duty . <BR/>Record review of the facility policy on Identifying Exploitation, Theft and Misappropriation of Resident Property dated April 2021 reflected in part:<BR/> .As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to recognize exploitation of residents and misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without resident's consent .Example of misappropriation of resident property include drug diversion (taking the residents medication) . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 2 of 2 residents (Resident #16 and #89) reviewed for infection control.<BR/>1.CNA B failed to perform hand hygiene appropriately while providing incontinent care for Resident #16 by not changing gloves and washing hands.<BR/>2.CNA A failed to perform hand hygiene appropriately while providing incontinent care for Resident #89 by not changing gloves and washing hands.<BR/>These failures could place residents at risk for transmission of diseases and organisms. <BR/>The findings included:<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/>Review of Resident #16s Care Plan, dated 01/24/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for sign and symptom of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 8:46 AM of Resident #16's incontinent care, revealed C.NA B washed hands before donning ( put on) clean gloves and C.NA A was assisting . Resident #16's soiled brief was pulled down in front. C.NA B using the wet wipes cleaned the perineal, groin area. She did not change gloves and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then picked up a clean brief using the same gloves. The resident was rolled to her back, and the brief was secured. CNA B placed a wedge under residents' hip and pulled the blanket up to cover her legs. CNA B used the same gloves throughout while performing incontinent care. <BR/>Resident #89<BR/>Review of Resident #89's face sheet dated 02/07/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 01/27/24 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), pneumonia,(an infection of the lungs that may be caused by bacteria, viruses or fungi ), sacral region stage 4 pressure sore (full thickness tissue loss with exposed bone, tendon or muscle), severe sepsis with septic shock,( a dramatic drop in blood pressure that can damage the lung, kidneys, liver and other organs), anoxic brain damage ( caused by a complete lack of oxygen to the brain).<BR/> Record review of Resident #89's MDS assessment dated [DATE] (admission) reflected BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and continent of bladder using indwelling catheter.<BR/>Review of Resident #89's Care Plan, dated 01/10/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for s/s of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 5:30 PM of Resident #89's incontinent care, revealed C.NA A washed hands before donning clean gloves and C.NA B was assisting. Resident #89 was lying in bed. C.NA A washed hands don cleaned gloves, and removed the old brief. Using the wet wipes she cleaned the perineal, groin area., She did not did change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then used the same gloves and picked up a clean brief put on the Resident #89.<BR/>In an interview with CNA A and C.NA B on 02/08/24 at 6:10 PM, she stated she forgot to change gloves . They both stated it was wrong because it could cause an infection. Both C.NA's stated they had training on infection control in 01/2024.<BR/>During an interview on 02/09/24 at 3:10PM with ADON/ Infection Preventionist, stated that her expectations for staff is to wash hands before all resident care. Staff should knock on the door, introduce themselves, wash hands, and don (putting on) gloves. Staff should then provide incontinent care, then doff (removing) gloves. Staff should wash hands, and don new gloves prior to applying new brief. The ADON was informed of the observation and stated the facility did proficiency checks on hire and quarterly.<BR/>In an interview with the DON on 02/09/24 at 3:30 PM, she stated CNA A was one of the facility's lead aides that monitored other staff during orientation with incontinent care. DON said not washing hands after changing gloves could cause urinary tract infections. DON said C.NA A and C.NA B knew they should clean around the buttocks before placing a clean brief. DON said she would be performing more in-services for incontinent care. <BR/>In an interview on 02/09/2024 at 3:35 PM, the Administrator stated his expectation was that incontinent care and hand washing were always done to prevent infection. <BR/>Record review for CNA A's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 01/17/2024 done by the DON. <BR/>Record review for CNA B's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 11/5/23 and 01/17/2024 done by the DON. <BR/>Review of the facility's policy titled; Handwashing/Hand Hygiene revised on 08/2019. <BR/>Policy Statement<BR/>This facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.<BR/>2. <BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.<BR/>3. <BR/>The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.<BR/>4. <BR/>Single-use disposable gloves should be used:<BR/>1. <BR/>before aseptic procedures;<BR/>2. <BR/>when anticipating contact with blood or body fluids; and<BR/>3. <BR/>when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions.<BR/>Equipment and Supplies<BR/>1. <BR/>The following equipment and supplies are necessary for hand hygiene:<BR/>4. <BR/>Alcohol-based hand rub containing at least 62% alcohol;<BR/>5. <BR/>Running water;<BR/>6. <BR/>Soap (liquid or bar; anti-microbial or non-antimicrobial);<BR/>7. <BR/>Paper towels;<BR/>8. <BR/>Trash can;<BR/>9. <BR/>Lotion; and<BR/>10. <BR/>Non-sterile gloves.<BR/>Washing Hands<BR/>1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands.<BR/>2.Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a Resident #28 who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 (Resident #28) of 4 residents reviewed for ADL's and quality of life. <BR/>The facility failed to ensure Resident #28 was provided incontinent care in a timely manner, which resulted in decreased skin integrity.<BR/>This failure affected one resident (Resident #28) and placed residents requiring assistance with incontinent care at risk of not have the assistance with personal care which could cause pain, skin breakdown, lack of dignity and low self-esteem.<BR/>Findings:<BR/>Record review of the facility face sheet revealed that Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia) You might also hear people use the term acute hypoxemic respiratory failure (AHRF)), morbid obesity with aveolar hypoventilation (Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness), type 2 diabetes (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and lymphedema (build-up of fluid in soft body tissues when the lymph system is damaged or blocked).<BR/>Record review of Resident #28's care plan dated initiated 10/16/2021 revealed a care plan for ADL's and limited physical mobility r/t weakness, confusion, limited mobility with interventions/task Resident #28 requires total assistance with toilet use and personal hygiene. A care plan for bowel and bladder incontinence dated initiated and revised on 1016/2021 r/t activity intolerance, confusion and impaired mobility with a goal target date of 3/29/2024 to refrain free of skin break down due to incontinence and brief use through the target date, interventions and task included use MD's order for Nystatin powder and to check frequently for incontinence. Wash rinse and dry perineum (cleaning the private areas of a patient), change clothing PRN and after incontinence episodes.<BR/>Record review of Resident #28's quarterly MDS assessment dated [DATE]th, 2024, revealed he had a BIM score of 14, indicating he was cognitively intact. Resident #28 was also coded as being impaired on both sides, upper and lower extremities for functional limitation range in motion dependent on 2 or more helpers (staff) to complete the activities of bathing, showering, toileting hygiene, dressing the upper and lower body, putting on and removing footwear, he also required partial to moderate assistance to roll to the left sides and lye back down on the bed. Resident 3 28 was totally dependent on staff to transfer from bed to chair or wheelchair. Resident #28 was frequently incontinent of bladder and bowel. Resident #28 was coded to be a risk for pressure ulcers.<BR/>Record review of physician orders for February 2024 included orders for Nystatin Powder 100000 UNIT/GM ,Apply to inner thighs, scrotum, abd topically everyday shift for Incontinence; Rash.<BR/>May Apply Zinc skin barrier after each incontinent episode to help reduce skin impairments. <BR/>Prior to wound treatment evaluate resident for Pain: everyday shift for Wound Care<BR/>After wound treatment evaluate resident for pain: everyday shift for Wound treatment.<BR/>Record review of Resident #28's weekly wound assessments for January 2024 through February 7, 2024, revealed no wound assessment for his perennial, scrotum and folds areas.<BR/>Record review of the facility grievance/complaint form dated 2/7/2024 revealed that Resident #28 filed a grievance that he did not receive care. Resolved by the DON assisting CNA's with providing care and disciplinary action scheduled with CNA assigned Resident #28.<BR/>During an observation and interview on 2/07/2024 at 8:03 am, with Resident #28, laying in his bed, he said that the CNA's do not want to do their job. He said he pushed his call-light at 4:00 pm yesterday and the staff did not come and assist him until 9:00 pm. He said that he has wounds on his bottom and that the staff make him wait and sit in his feces for so long that it dries up on his bottom and they have to scrape the feces off. He said it does not feel good to sit in that at all. He added if he could clean himself, he would but he cannot.<BR/>During an observation and on 02/07/24 at 1:30 pm, it was revealed that Resident #28's under abdominal fold, scrotum, left, and right groin were very red, macerated, and there were tiny opens on all areas. One of the areas on under the abdomen measured about 1.0x1.0 cm. Resident #28 said that it hurts whenever RN A or CNA N cleaned the groin areas, scrotum, and abdominal area. Observation at this time of RN A and CNA N which wiped Resident #28 and the wipes had thick white substance and it had a musty odor. <BR/>During an interview on 02/07/24 at 1:20 pm, CNA N said she had not provided incontinent care for Resident #28 since she came to work today at 6:30 a.m. CNA N said Resident #28 had to call her if he needed to be changed, and she had not gone and checked on Resident #28 for incontinent care. CNA N said she was supposed to make rounds for incontinent care on all residents every two hours. <BR/>During an interview on 02/07/24 at 1:24 pm, RN B said she did Resident #28's skin assessment sometimes and the wound care nurse does it at times. RN B said Resident #28 needed two to three staff assistance for incontinent care. RN B said Resident #28 did not have any redness or open area on his buttocks or peri area when she did his skin assessment two weeks ago. RN B said none of the aides had told her that the resident had any open area on his peri area.<BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated with some openings. LVN H said she had worked with Resident #28 last week on Friday and Saturday and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 she assumed the nurses were aware of the skin condition.<BR/>During an interview on 02/08/24 at 10:42 am, the Wound Care Nurse said she does Resident #28's weekly skin assessment, and she did not see any redness, macerated area, any opening on his groin or abdominal folds. She said she became aware of the area yesterday.<BR/>During an interview on 02/08/24 at 10:54 am, the DON said she became aware of the red macerated area when she came to Resident #28's room. Then DON said she smelled the foul odor and ammonia in the resident room. The DON said the wound care nurse assessments for Resident #28 from January 2024 through February 2024 did not mention Resident #28 had any skin issues on his groin or under his abdomen. The DON said the facility has a new wound care company and the wound care doctor was not notified about the skin condition.<BR/>Interview on 02/08/24 at 10:57 am, with Resident #28's primary physician, he said he was notified about the change in skin condition yesterday twice. He said Resident #28 was an obese resident and all the folds could cause the areas to stay wet and the intervention of Barrier cream may not prevent the area from being moist and red or open. He said there was no other intervention in place to prevent the area from being moist or red. The physician said the facility also have a wound care doctor who should be taking care of wound and skin issues. <BR/>Record review of the facility policy and procedure entitled Perineal Care dated revised February 2018 read in part . Purpose, the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .Preparation: 1.Review the resident's care plan to assess for any special needs of the resident .wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks .dry area thoroughly .document any discharge, odor, bleeding, skin care problems or irritation, complaints of pain or discomfort .report other information in accordance with facility policy and professional standards of practice.<BR/>Record review of the facility policy and procedure entitled Activities of Daily Living (ADL's) Supporting dated revised March 2018 read in part .residents who are unable to carry out activities of daily living independently will receive the services to maintain good nutrition, grooming, personal and oral hygiene .appropriate care and services will be provided for residents who are unable to carry out ADL's independently .in accordance with the plan of care including support and assistance with: hygiene (bathing) .elimination (toileting) .A resident's ability to perform ADL's will be measured using clinical tools including the MDS and the following MDS definitions .totally dependent: full staff performance on an activity with no participation by the resident for any aspect of the ADL activity . <BR/>Record review of the facility policy and procedure entitled Call System, Resident dated September 2022 read in part .residents are provided with the means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation .calls for assistance are answered as soon as possible but no longer than 5 minutes .<BR/>Record review of the facility policy and procedure entitled Dignity dated February 2021 read in part . Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem Policy Interpretation and Implementation: Residents are treated with dignity and respect at all times .demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example: promptly responding to a resident's request for toileting assistance.<BR/>The following Plan of Removal submitted by the facility was accepted on Friday 2/9/2024 at 2:00 pm.<BR/>Plan of Removal (POR) <BR/>PLAN OF REMOVAL<BR/>Name of facility: Fallbrook Rehabilitation and Care Center<BR/>Date: 02/08/2024 <BR/>F 677 - <BR/>The facility fail to ensure that residents who are unable to carry out Activities of Daily Living (ADLs) receive the necessary services to maintain nutrition, grooming, and personal and oral hygiene. <BR/>The facility failed to ensure that incontinent care was provided timely <BR/>Immediate action:<BR/>Resident #28 was assessed, and incontinent care provided immediately when identified on 02/07/2024. Nurse aide (CNA N) was provided one on one re-educated in providing peri care at least every 2 hours and as needed on 2/07/2024 at 1:30pm <BR/>The Director of Nurses, Assistant Director of Nurses, Wound Nurse and Nurse Supervisor initiated a sweep on all residents to verify that incontinent care was done on all residents by 10 pm tonight, 02/08/2024. The primary physician(s) will be notified of any newly identified skin integrity issues related to the skin sweep and orders will be obtained as appropriate. The resident responsible party will be notified of any findings, and treatment plan(s). Two new skin areas were found during sweep. One was redden area to a resident's back and other was redden area to a resident's neck along trach collar area secures. Family and provider notified, and orders obtained<BR/>An audit of the skin identification forms for current residents were completed by the Director of Nursing, Assistant Director of Nursing, Wound Nurse and Nurse Supervisor to ensure CNA skin sheets were completed by 10 pm 02/08/2024. Two new skin areas were found during sweep. One was redden area to a resident's back and other was redden area to a resident's neck along trach collar area secures. Family and provider notified, and orders obtained<BR/>Facilities Plan to ensure compliance quickly.<BR/>Education provided and to be completed by Director of Nurses, Assistant Director of Nurses, Wound Nurse, and Nurse Supervisor by 11:59pm 02/09/2024 for all nurses and certified nurse aids on ADLs, shower sheet completion, answering call lights, Peri Care, and Q 2-hour resident rounding. Education also includes what to do when skin issues are identified and what to do if pain occurs during any type of care. IDT will make rounds twice a day and charge nurses will make rounds every 2 hours. Nurse managers will validate randomly throughout day that charge nurses are making rounds to check that Residents' skin is dry and clean to prevent skin breakdown. Specific training on system which includes assessment and treatment of skin folds. CNAs/Nurses will not be allowed to work until they've received the training.<BR/>All CNAs will have skill checks completed by Director of Nurses, Assistant Director of Nurses, and Nurse Supervisor on peri care to validate incontinent care protocol is followed appropriately by 02/09/2024.<BR/>Nursing staff (licensed and certified) will be re-educated on the Skin Management System by Director of Nurses, ADON, Treatment Nurse and Nurse manager with the target completion date of 02/09/2024. Nursing staff members will not be allowed to work their oncoming shift until this education is completed. <BR/>Nursing staff will be re-educated by Assistant Director of Nursing and Wound Nurse on the stop and watch tools and the skin identification form. Education will be completed prior to nursing staff commencing their next assigned shift. This education will be completed by 02/09/24. Any nursing employee not present will complete the in-service prior to starting their next shift. <BR/>The nurse will verify that the skin identification sheets are completed by the CNAs when bathing and/or showering residents and that any identified issue is addressed. The physician and responsible party will be notified of any identified skin issues and the treatment plan(s). The Director of Nurses will provide education on this process to all nursing staff by 02/09/24. Nursing employee will not be allowed to start shift until complete the in-service. <BR/>QAPI meeting was held 2/8/2024 by The facility IDT team, which included Administrator, DON, ADON, CNO, Housekeeping supervisor, Social worker, Human resources to review policy/procedure for ADL care.<BR/>Monitoring:<BR/>Record review on 2/10/2024 of POR binder including CNA skills competencies, the POR for F677, Head to toe assessments for the current residents, IDT rounds and in-services, policies and procedures for: Proper Procedure for Head-to-Toe Assessments, Skin Assessments, Skin Management System, Perineal Care, Activities of Daily Living Supporting, Call System-Resident, Peri-Care/Assisting Meals/Incontinent Care, given to all staff on 2/8/2024-2/9/2024 and the Stop and Watch -QAPI<BR/>Interviews on training: assessments, skin sheets, change of skin, documentation, communication, physician orders.<BR/>Observations on 2/9/2024 through 2/11/2024 at various times in the day revealed that Resident #28 was resting in his room, watching football, he would give a thumbs up when asked how he was feeling.<BR/>Observations on 2/9/2024 through 2/11/2024 at various times of the day of staff making rounds, checking to see if any resident needed anything.<BR/>Interviews: Interviews with staff were conducted between 2/9/2024 through 2/11/2024 on multiple shifts with the Administrator, DON, ADON, VP, DVP, MDS Coordinator,Wound Care Nurse, RN's: A, B,C LVN's:A,B,C,D,E,P,R CNA's:A,B,C,D,E,F,G,H <BR/>Staff were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received.<BR/>Interview answers with CNA's: in-services included assessing skin, notifying nurse/nurse manager, to checking under the skin folds and placing barrier cream on them, documentation in PCC, (the electronic medical file system) the skin assessment and also notifying the nurse, answering the call-lights timely, witnessed staff not answering call-lights if, would report it. <BR/>perineal and incontinence in-services, knocking on door, greeting the resident and telling them what you are going to do, setting up supplies, closing privacy curtains, assessments are from front to back all creases and in between, when you see anything different notify the charge nurse, fill out the stop and watch form for any skin difference, skin checks are performed every time a resident is changed, the treatment nurse comes out daily and to assess different residents. <BR/>Interview answers varied from staff, LVN's said in-services received included skin treatment initiation, being informed by CNA of changes in skin, notification to family and the doctor, performing head to toe assessments including abdominal folds, to initiate care plan for said area, skin swipes, dry skin, skin barrier was to applied daily, prn and after every episode of incontinence, do a change of condition form.<BR/>Interviews with RN's included assessment of the resident when they come from the hospital, charting/documentation, when anyone observes a skin issue, document and make a treatment plan. Call doctor, RP and get an order.<BR/>During an interview on 2/10/2024 at 1:02 pm with the Administrator he said the team were aware of a broken system with skin prior to survey when HHSC surveyors came. The QAPI team did the PIP on January 30th, 2024 he added that the responsibility for skin integrity were interdisciplinary in the process, primarily he, the DON, treatment nurse, Social Worker and therapy, each person had their specific role. The team started addressing skin integrity immediately to addressing with skin assessments, they did not have time to follow through Braden timely, assessments basically before HHSC surveyors came in.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she was already aware of break in system with the skin issues and that the team had begun performing skin audits, was training with wound care nurse discussed in QAPI, IDT, physician, PIP, Resident #28, skin assessment was due 2/7/24 and she (the wound care nurse) had not gotten a chance to get to Resident #28, was working the other hall. Resident #28's assessment was due on the 7th of February, If the assessment was due that day and hadn't been conducted that day, she hadn't identified on that day yet because it (the newly identified skin area issue) had not been identified on prior skin assessments it ( the skin issue)was not there in the abdominal fold. They did identify the skin area and put treatment put in place, they are also in process of changing the wound care nurse, they have in-serviced the staff and did a 100 percent skin audit on residents. She said that a care plan was added, and a comprehensive care plan should be in place for specific Resident #28's perineal area to include under the folds. She said that any nurse at the facility is responsible for care plans and said a negative outcome could be skin impairment, infection, and delayed treatment.<BR/>On 2/10/2024 at 3:00 pm received and reviewed with VP, including skin sweep 100 percent, in-services/policies and procedures, all staff signatures, question/test/stop and watch. All staff in-serviced. 2 people identified with redness in skin sweep. Treat/care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that Resident #1 received treatment and care in accordance with professional standards of practice for one resident (Resident #28) of 5 residents reviewed quality of care and skin .<BR/>The facility failed to assess, report, and obtain new physician orders due to a change in resident #28's skin condition of the perineal (private area of a patient) groin and buttock to the physician.<BR/>This failure affected one resident (Resident #28) out of 4 residents reviewed for skin issues and had the potential to place residents at risk skin break down, infection and discomfort. <BR/>Findings included: <BR/>Record review of the facility face sheet revealed that Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia) You might also hear people use the term acute hypoxemic respiratory failure (AHRF)), morbid obesity with aveolar hypoventilation (Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness), type 2 diabetes (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and lymphedema (build-up of fluid in soft body tissues when the lymph system is damaged or blocked).<BR/>Record review of Resident #28's care plan dated initiated 10/16/2021 revealed a care plan for ADL's and limited physical mobility r/t weakness, confusion, limited mobility with interventions/task Resident #28 requires total assistance with toilet use and personal hygiene. A care plan for bowel and bladder incontinence dated initiated and revised on 1016/2021 r/t activity intolerance, confusion and impaired mobility with a goal target date of 3/29/2024 to refrain free of skin break down due to incontinence and brief use through the target date, interventions and task included use MD's order for Nystatin powder and to check frequently for incontinence. Wash rinse and dry perineum (cleaning the private areas of a patient), change clothing PRN and after incontinence episodes.<BR/>Record review of Resident #28's quarterly MDS assessment dated [DATE]th, 2024, revealed he had a BIM score of 14, indicating he was cognitively intact. Resident #28 was also coded as being impaired on both sides, upper and lower extremities for functional limitation range in motion dependent on 2 or more helpers (staff) to complete the activities of bathing, showering, toileting hygiene, dressing the upper and lower body, putting on and removing footwear, he also required partial to moderate assistance to roll to the left sides and lye back down on the bed. Resident 3 28 was totally dependent on staff to transfer from bed to chair or wheelchair. Resident #28 was frequently incontinent of bladder and bowel. Resident #28 was coded to be a risk for pressure ulcers.<BR/>Record review of physician orders for February 2024 included orders for Nystatin Powder 100000 UNIT/GM ,Apply to inner thighs, scrotum, abd topically everyday shift for Incontinence; Rash.<BR/>May Apply Zinc skin barrier after each incontinent episode to help reduce skin impairments. <BR/>Prior to wound treatment evaluate resident for Pain: everyday shift for Wound Care<BR/>After wound treatment evaluate resident for pain: everyday shift for Wound treatment.<BR/>Record review of Resident #28's weekly wound assessments for January 2024 through February 7, 2024, revealed no wound assessment for his perennial, scrotum and folds areas.<BR/>Record review of Resident #28's Braden Scale assessment dated [DATE] revealed that his skin is constantly moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the patient is moved or turned, chairfast: ability to walk severely limited or non-existent. <BR/>During an observation and on 02/07/24 at 1:30 pm, it was revealed that Resident #28's under abdominal fold, scrotum, left, and right groin were very red, macerated (soften or become softened by soaking in a liquid), and there were tiny opens on all areas. One of the areas on under the abdomen measured about 1.0x1.0 cm. Resident #28 said that it hurts whenever RN A or CNA N cleaned the groin areas, scrotum, and abdominal area. Observation at this time of RN A and CNA N which wiped Resident #28 and the wipes had thick white substance and it had a musty odor. <BR/>During an interview on 02/07/24 at 1:24 pm, RN B said she did Resident #28's skin assessment sometimes and the wound care nurse does it at times. RN B said Resident #28 needed two to three staff assistance for incontinent care. RN B said Resident #28 did not have any redness or open area on his buttocks or peri area when she did his skin assessment two weeks ago. RN B said none of the aides had told her that the resident had any open area on his peri area.<BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated with some openings. LVN H said she had worked with Resident #28 last week on Friday and Saturday and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 she assumed the nurses were aware of the skin condition.<BR/>During an interview on 02/08/24 at 10:42 am, the Wound Care Nurse said she does Resident #28's weekly skin assessment, and she did not see any redness, macerated area, any opening on his groin or abdominal folds. She said she became aware of the area yesterday.<BR/>During an interview on 02/08/24 at 10:54 am, the DON said she became aware of the red macerated area when she came to Resident #28's room. Then DON said she smelled the foul odor and ammonia in the resident room. The DON said the wound care nurse assessments for Resident #28 from January 2024 through February 2024 did not mention Resident #28 had any skin issues on his groin or under his abdomen. The DON said the facility has a new wound care company and the wound care doctor was not notified about the skin condition.<BR/>During an interview on 02/08/24 at 10:57 am, with Resident #28's primary physician, he said he was notified about the change in skin condition yesterday twice. He said Resident #28 was an obese resident and all the folds could cause the areas to stay wet and the intervention of Barrier cream may not prevent the area from being moist and red or open. He said there was no other intervention in place to prevent the area from being moist or red. The physician said the facility also have a wound care doctor who should be taking care of wound and skin issues. <BR/>Record review of the facility policy and procedure entitled Resident Examination and Assessment dated revised February 2014, read in part .physical examination: skin: intactness, moisture, color, texture and presence of bruises, pressure sores, redness, edema, rashes. Activity level: able to perform ADLs; and degree of assistance required . Documentation The following information should be recorded in the resident's medical record: The date and time the procedure was performed, all assessment data obtained during the procedure, how the resident tolerated the procedure .Notify the physician of any abnormalities such as .wounds or rashes on the resident's skin; and report other information in accordance with facility policy and professional standards of practice.<BR/>Record review of the facility policy and procedure entitled Skin Management System no date provided, read in part .head to toe assessments should be completed weekly .skin assessments include the review of all skin areas from the top of the head/scalp to the toes including examination of skin folds .and any crevices that may exist .the Certified Nurse Aide will notify the Treatment Nurse or Charge Nurse of any newly identified skin or pain issues .residents who are incontinent of bladder or bowel will be provided incontinent care every 2 hours as needed .residents who rely on nursing staff for positioning will be turned and repositioned every 2 hours as needed .<BR/>The following Plan of Removal submitted by the facility was accepted on Friday 2/9/2024 at 2:00 pm.<BR/>PLAN OF REMOVAL (POR)<BR/>Name of facility: Fallbrook Rehabilitation and Care Center<BR/>Date: 02/08/2024 <BR/>F-684 - The facility failed to assess, report, and obtain new order due to a change in resident # 28's skin condition of the groin and buttock to the physician.<BR/>The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice.<BR/>Immediate action:<BR/>Resident #28 was promptly assessed once skin issue identified by Director of nurses, Physician and RP was notified; treatment orders were obtained, and resident's care plan updated to reflect change in condition. One on one education provided to CNA N regarding reporting skin issues by DON on 2/7/2024<BR/>The Director of Nurses, Assistant Director of Nurses, Wound Nurse and Nurse Supervisor initiated a head-to-toe skin sweep on all residents that will be completed by 10 pm tonight, 02/08/2024. The primary physician(s) will be notified of any newly identified skin integrity issues and orders will be obtained as appropriate. The resident responsible party will be notified of any findings, and treatment plan(s). <BR/>An audit of all current resident records will be completed by the Director of Nursing, Assistant Director of Nursing, Wound Nurse, and Nurse Supervisor to ensure a weekly head to toe skin assessment order is in place by 11:59pm 02/09/2024. An audit will be completed by the Director of Nursing, Assistant Director of Nursing, Wound Nurse, and Nurse Supervisor to ensure that any residents with an identified skin issue on existing skin assessment has an appropriate treatment order in place by 11:59pm, 02/09/2024. <BR/>Facilities Plan to ensure compliance quickly.<BR/>Education initiated by Director of Nurses, Assistant Director of Nurses, Wound Nurse, and Nurse Supervisor at 9 pm 02/09/2024 for all nurses and certified nurse aids on ADLs, answering call lights, performing timely Peri Care, and Q 2-hour resident rounding. Education will also include what to do when skin issues are identified and what to do if pain occurs during any type of care. Nurses will be educated by the Director of Nurses on Provider and responsible party notifications when a change in condition or treatment plan occurs by 02/09/2024.<BR/>Nursing staff (licensed and certified) will be re-educated on the Skin Management System starting on 02/09/024 by DON and target completion date of 02/09/2024. Nursing staff members will not be allowed to work their oncoming shift until this education is completed. On- going competency of the Skin Management System will be monitored by asking oral/verbal questions, rounding and auditing of documentation and orders in the electronic medical record. <BR/>Nursing staff will be re-educated by Assisted Director of Nurses (ADON), DON, Nurse manager concerning the skin identification form. CNAs will be responsible for completing the skin identification form. CNA will complete skin identification form after every resident's shower on facility skin identification form. CNAs will turn form in to charge nurse before end of shift. The charge nurse will take appropriate action to address any skin issues identified on skin form. DON, ADON & Nurse manager will oversee sheet identification sheet completion by reviewing skin identifications form in morning clinical meeting. Education will be completed prior to nursing staff commencing their next assigned shift. This education will be completed by 02/09/24. Any nursing employee not present will complete the in-service prior to starting their next shift. <BR/>New or readmitted residents will have a head-to-toe skin assessment completed by the on-duty Admitting Nurse upon admission. The physician and responsible party will be notified of any identified skin issues and the treatment plan(s). The Wound Nurse will follow up on all new or readmitted resident skin assessments on her next scheduled shift and alert the Wound Care Physician of her findings, obtaining any treatment order changes at this time. The Director of Nurses will provide education on this process by 02/09/24. Any nursing employee not present will complete the in-service prior to starting their next shift. <BR/>QAPI meeting was held 2/8/2024 by the facility IDT team, which included Administrator, DON, ADON, CNO, Housekeeping supervisor, Social Worker, Human resources to review policy/procedure for ADL care.<BR/>Monitoring:<BR/>Record review on 2/10/2024 of POR binder including CNA skills competencies, the POR for F677, Head to toe assessments for the current residents, IDT rounds and in-services, policies and procedures for: Proper Procedure for Head-to-Toe Assessments, Skin Assessments, Skin Management System, Perineal Care, Activities of Daily Living Supporting, Call System-Resident, Peri-Care/Assisting Meals/Incontinent Care, given to all staff on 2/8/2024-2/9/2024 and the Stop and Watch -QAPI<BR/>Observations on 2/9/2024 through 2/11/2024 at various times in the day revealed that Resident #28 was resting in his room, watching football, he would give a thumbs up when asked how he was feeling.<BR/>Observations on 2/9/2024 through 2/11/2024 at various times of the day of staff making rounds, checking to see if any resident needed anything.<BR/>Interviews: Interviews with staff were conducted between 2/9/2024 through 2/11/2024 on multiple shifts with the Administrator, DON, ADON, VP, DVP, MDS Coordinator,Wound Care Nurse, RN's: A, B,C LVN's:A,B,C,D,E,P,R CNA's:A,B,C,D,E,F,G,H <BR/>Staff were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received.<BR/>Interview answers with CNA's: in-services included assessing skin, notifying nurse/nurse manager, to checking under the skin folds and placing barrier cream on them, documentation in PCC, (the electronic medical file system) the skin assessment and also notifying the nurse, answering the call-lights timely, witnessed staff not answering call-lights if, would report it. <BR/>perineal and incontinence in-services, knocking on door, greeting the resident and telling them what you are going to do, setting up supplies, closing privacy curtains, assessments are from front to back all creases and in between, when you see anything different notify the charge nurse, fill out the stop and watch form for any skin difference, skin checks are performed every time a resident is changed, the treatment nurse comes out daily and to assess different residents. <BR/>Interview answers varied from staff, LVN's said in-services received included skin treatment initiation, being informed by CNA of changes in skin, notification to family and the doctor, performing head to toe assessments including abdominal folds, to initiate care plan for said area, skin swipes, dry skin, skin barrier was to applied daily, prn and after every episode of incontinence, do a change of condition form.<BR/>Interviews with RN's included assessment of the resident when they come from the hospital, charting/documentation, when anyone observes a skin issue, document and make a treatment plan. Call doctor, RP and get an order.<BR/>On 2/10/2024 at 1:02 pm with the Administrator he said the team were aware of a broken system with skin prior to survey when HHSC surveyors came. The QAPI team did the PIP on January 30th, 2024 he added that the responsibility for skin integrity were interdisciplinary in the process, primarily he, the DON, treatment nurse, Social Worker and therapy, each person had their specific role. The team started addressing skin integrity immediately to addressing with skin assessments, they did not have time to follow through Braden timely, assessments basically before HHSC surveyors came in.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she was already aware of break in system with the skin issues and that the team had begun performing skin audits, was training with wound care nurse discussed in QAPI, IDT, physician, PIP, Resident #28, skin assessment was due 2/7/24 and she (the wound care nurse) had not gotten a chance to get to Resident #28, was working the other hall. Resident #28's assessment was due on the 7th of February, If the assessment was due that day and hadn't been conducted that day, she hadn't identified on that day yet because it (the newly identified skin area issue) had not been identified on prior skin assessments it ( the skin issue)was not there in the abdominal fold. They did identify the skin area and put treatment put in place, they are also in process of changing the wound care nurse, they have in-serviced the staff and did a 100 percent skin audit on residents. She said that a care plan was added, and a comprehensive care plan should be in place for specific Resident #28's perineal area to include under the folds. She said that any nurse at the facility is responsible for care plans and said a negative outcome could be skin impairment, infection, and delayed. treatment. Interview and record review on 2/10/2024 at 3:00 pm received and reviewed with VP, including skin sweep 100 percent, in-services/policies and procedures, all staff signatures, question/test/stop and watch. All staff in-serviced. 2 people identified with redness in skin sweep. Treat/care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #21) reviewed for free of accidents, hazards, supervision, and devices., in that: <BR/>The facility failed to ensure Resident #21 who the facility staff knew he was at risk for fall and update fall precaution interventions after several falls resulting in injuries to the head.<BR/>An IJ was identified on 02/09/24. The IJ template was provided to the facility on [DATE] at 7:15 p.m. While the IJ was removed on 02/11/24 at 12:50 p.m., with the Administrator, DVP and DVP Clinical. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated due to the facility staff had not been trained on identifying residents at risk for fall, preventions, and interventions, and modification and care plan falls. <BR/>This failure could affect residents who were fall risk and place them at risk for physical harm, pain, mental anguish, or emotional distress. <BR/>Findings included : <BR/>Review of Resident #21's face sheet revealed Resident #21was a [AGE] year-old male who was admitted to the facility on [DATE], re-admission on [DATE] with a diagnosis of Atrial fibrillation, (irregular and often very rapid heartbeat) , cerebral palsy (weakness or problem with using the muscles), history of falls, and epilepsy(unprovoked seizures).<BR/>Record review of Resident #21's quarterly MDS assessment, dated 02/07/2024, revealed a BIMS score of 04 out of 15, which indicated the resident's cognition was severely impaired. Further review of Resident #21's MDS revealed the resident required supervision assistance with one staff for transfer and dependent on one staff assistance with putting and taking off footwear. Further review of Resident #21 MDS revealed the resident had one fall snice admission.<BR/>Record review of Resident # 21 order summary report revealed the following: PT to evaluate and treat under PASRR active date 08/25/23, <BR/>OT to evaluate and treat under PASRR active date 08/25/23, <BR/>ST to evaluate and treat under PASRR active date 08/25/23, <BR/>Fall mat placed next to bed every shift active date 12/18/23.<BR/>Record review of the facility incident report on falls for Resident #21 revealed the following: 7/22/23 - Unwitnessed fall - in resident room, Mental Status: disoriented, Hematoma was on forehead and transported to 911. <BR/>10/22/23 - Unwitnessed fall-in resident room, Mental Status: oriented to time, place and person, abrasion to his forehead, I was sitting on my bed putting my shoes on and fell. <BR/> 12/18/23 - Unwitnessed fall- in resident room, Mental Status: disoriented, large hematoma above left eye trying to get out of bed to wheelchair. <BR/>2/1/24 - Unwitnessed fall - in resident room, and hematoma was on forehead. <BR/>Record review of Resident #21's care plan revealed the care plan was not updated following falls 07/22/23, 10/22/23, 12/18/23.Intervention:be sure call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Further review of Resident #21's care plan revealed resident was at risk for fall related to confusion, deconditioning, gait/balance problem, and history of fall. Intervention: fall mat placed next to bed during all shift was not care planed.<BR/>During an observation on 02/06/24 at 9:57 a.m., Resident #21 was sitting in a wheelchair in his room, and the call light was on the nightstand and was not within reach. Resident #21 had dark red-purple bruises from the middle of his forehead to the left of his nose, left eyes, and cheeks. He also had a black line about 1 inch thick across his forehead. Resident #21 also had a hematoma about the size of a tennis ball. <BR/>During an observation on 02/08/24 at 2:39 p.m., Resident #21 was sitting in his room in his wheelchair, and the call light was not within reach.<BR/>During an interview on 02/09/24 at 12:21 p.m., the DON said Resident #21 had several falls, in which he had some head injuries, and they have done all they could to prevent Resident #21 from falling except for a helmet for the protection of his head. The DON said Resident #21 bed should be at the lowest position whenever he was in bed, and she did not know if his bed was on the lowest position when fell because all his fall were unwitnessed. The DON said all the interventions were care planned.<BR/>During an observation and interview on 02/09/24 at 1:30 p.m., Resident #21 was in his room sitting in his wheelchair, and the call light was not within reach; it was on the nightstand. Resident # 21 said he fell from the bed but could not remember what day it was or if the bed was low.<BR/>During an observation and interview on 02/09/24 at 1:34 p.m., LVN R said Resident #21 falls frequently. LVN R said Resident #21's call light was on the nightstand far from Resident #21, and he could not reach it if he wanted to use it. LVN R said the DON and ADON are responsible for implementing any changes in the care plan.<BR/>During an observation and interview on 02/09/24 at 1:41 p.m., the DON and ADON went into Resident #21's room and the DON said they saw the call light on the nightstand, and Resident #21 could not reach the call light if he wanted to use it. The DON said the call should be within reach whenever the resident was in the room.<BR/>During an interview on 02/09/24 at 1:43 p.m., CNA F said she just picked up the tray from Resident #21's room and did not notice Resident #21's call light was not within reach. CNA F said Resident #21 could fall if he tried to reach for his call light, and he could not call for assistance if he wanted to call because the call light was not within reach.<BR/>During an interview on 02/09/24 at 3:03 p.m., the ADON said she saw that Resident #21's call light was not within reach of the resident. The ADON said Resident #21 was at risk of falling and could fall if he tried to reach for the call light. The ADON said all of Resident #21's falls should have been care planned and intervention modified. The ADON said she did not know why the falls were not care planed, she said the intervention should be modified with each fall, and she was not responsible for care planning the falls and it was the responsibility of MDS coordinator and social worker.<BR/>During an interview on 02/09/24 at 3:23 p.m., The DON said any nurse could update the care plan, and all of Resident # 21's falls should have been care planed and intervention modified as needed. The DON said she would investigate and update the surveyor later.<BR/>During an interview on 02/09/24 at 3:28 p.m., the Corporate Nurse said that all of Resident #21's falls should be care planned and that she would investigate and find out the root cause of his falls so that an intervention could be put in place.<BR/>During an interview on 02/09/24 at 3:36 p.m., the SW said she had not had any care plan meeting with Resident #21's family about his falls. SW said she was aware of the falls because she would see Resident #21 had a knot on his head and bruises.<BR/>During an interview on 02/09/24 at 3:41 p.m., the MDS Coordinator said the DON and ADON updated the care plan, and she only coded the MDS. The MDS coordinator stated that the GG section of MDS did not require any coding for staff assistance for Resident #21's bed mobility. The MDS coordinator said the DON and the ADON were responsible for putting and modifying interventions in the care plan.<BR/>During an interview on 02/09/24 at 3:44 p.m., the Director of Rehabilitation said Resident #21 has been in therapy since March last year, and they are working on his endurance, balance, and memory. The Director of Rehabilitation said he does not work with Resident #21 and would talk to his staff if any recommendation was made for Resident #21. The Director of Rehabilitation said if his department made any recommendations, the nursing department would be responsible for care planning, intervention, and monitoring of Resident #21.<BR/>Record review of facility policy on fall clinical protocol dated 2001 MED PASS, Inc. (Revised March 2018) read in part .cause identification . #3 The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified .treatment/management .#1 Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .monitoring and follow-Up .#1 . the staff, with the physician 's guidance, will follow up on any fall with associated injury . #2 .the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of fall .#4 if the individual continue to fall, the staff and the physician will re- evaluate the situation and reconsider possible reasons for the resident's falling(instead of, or in addition to those that have already been identified) and also reconsider the current interventions .<BR/>This was determined to be an Immediate jeopardy (IJ) on 02/09/24 at 7:15 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 02/09/24 at 7:15p.m.<BR/>The following Plan of Removal submitted by the facility was accepted on 02/10/24 at 9:34 a.m.<BR/>PLAN OF REMOVAL<BR/>Name of facility: Fallbrook Rehabilitation and Care Center<BR/>Date: 02/09/2024 <BR/>F 689 - <BR/>The facility failed to ensure that Resident #21 received adequate supervision and assistive devices to prevent accidents. <BR/>The facility failed to update fall precaution interventions after several falls resulting in injuries to a resident. <BR/>Immediate action:<BR/>The Medical Director was notified of the Immediate Jeopardy status on 02/09/2024 at 7:50 pm.<BR/>Resident #21 promptly had a new fall risk assessment done by ADON 02/09/2024. Resident #21 is currently receiving Physical, Occupational and Speech therapy 5 days a week. Resident's care plan updated to include fall mat, bed to be kept in low position, and verification that call light was in reach 2/9/2024. <BR/>The Director of Nurses, Assistant Director of Nurses will review all fall risk assessment and update care plans to ensure appropriate interventions are in place and this will be completed by 2/10/2024. Regional nurses will review all current resident fall history and verify falls and fall interventions are captured on care plan by 2/10/2024. Therapy will review all residents who have fallen in the last 90 days to ensure residents have been screened and therapy will implement additional interventions as indicated (to be completed by 2/10/2024). Therapy will provide any needed training to nursing staff for interventions. Rehab director attends fall management meeting during stand-up meeting and will provide any screen and therapy plan information related to resident's falls to nursing staff. Nursing management. To include DON, ADON, MDS, will update care plan and CNA guidance in Point click care. Charge nurses will ensure recommended interventions related to resident's falls are followed and DON, ADON will provide oversight by making rounds daily, All nursing staff, which includes all nurses and nurse aides, will be in-service to ensure call bells are within resident's reach by Nursing manager by 2/10/2024; Nurse staff All nursing staff, which includes all nurses and nurse aides, will not be allowed to start shift until completing in-service training.<BR/>Facility Plan to ensure compliance quickly<BR/>Director of Nurses, Assistant Director of Nurses, and Nurse Supervisor will provide education to nursing staff by 2/10/2024 to notify physician and RP and to promptly implement an intervention after fall by updating resident's care plan. The Director of Nurses, Assistant Director of Nurses, and MDS Nurse will review falls in morning meeting and ensure that the nursing staff has updated the care plan, and the physician was notified. IDT team will review the fall intervention implemented by nurses in morning meeting. Education will be completed by the Director of Nurses, Assistant Director of Nurses, and Nurse Supervisor by 02/10/2024 for all nurses and certified nurse aids on importance of ensuring call lights are in resident's reach. CNAs will be educated on ensuring call lights are in resident's reach when doing Q 2-hour rounds. Charge nurses will verify that CNAs have place call bell in reach when their doing rounds. IDT team will do rounds 5 days a week to verify call bells are within resident's reach and document on IDT round sheet. Staff will not be allowed to start shift until completing in-service training.<BR/>Nursing staff (licensed and certified) will be re-educated on call bell system to include call bell placement by 2/10/2024. Administrator, DON, ADON, and Nurse Supervisor will Inservice Nursing staff/aides on falling star program, which includes stars on name room plate and bands on devices. Interventions will be listed in nurse/CNA care plan in Point click care. Inservice to be completed 2/11/2024Staff will not be allowed to start shift until completing in-service training.<BR/>QAPI meeting was held 2/9/2024 by the facility IDT team, which included Administrator, DON, ADON, CNO, Housekeeping supervisor, social worker, Human resources to review policy/procedure Fall management program.<BR/>Surveyor monitored the plan of removal for effectiveness as follows:<BR/>A record review of the facility removal plan revealed the medical director was notified of the IJ on 2/09/24 at 7:50 p.m.<BR/>A record review of the risk assessment revealed all residents were reviewed on 02/10/23 by the corporate nurse for fall risk assessment. <BR/>Record review of the facility in service revealed the DON and ADON in-service the nurses and CNAs on fall prevention, care plans/[NAME] (electronic health record) for personalized interventions, identifying residents at risk for falls, falling star/yellow bands, fall prevention and updating the care plan on 02/10/24.<BR/>A record review of the progress note revealed Residents with falls for the past 90 days were reviewed by the therapy on 02/10/24 and they are currently in therapy. <BR/>A record review of fall risk assessment revealed Resident #21 had a new fall risk assessment done by ADON on 02/09/2024. <BR/>A record review of Resident #21's care plan revision dated 02/09/24 revealed the following up date: with a fall mat, bed in a low position, all the falls were care-planned and currently on PT, OT, ST, under PASRR 5 times a week indefinitely since March 2023. <BR/>During observations on 02/11/24 from 10:00a.m. to 2:00 p.m., revealed residents(Resident #21, Resident #18, and Resident #25) on the fall list had their call lights attached to the bed, and one Resident #24 was in bed, and she could reach her call light.<BR/>During interviews on 02/10/24 between 11:21 a.m. and 8:48 P.m., two CNAs and three nurses from the night shift were interviewed on the facility in service and training on fall precautions, interventions, identification of residents at risk of falls, care plan modification of intervention and who was responsible for updating care plans. <BR/>All staff interviewed were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. <BR/>During an interview on 02/11/24 between 9:00 a.m. and 9:30 a.m., one CNA, one nurse from the day shift, and The MDS coordinator were interviewed on the facility in service and training on fall precautions, interventions, identification of residents at risk of falls, care plan modification of intervention and who was responsible for updating care plans. All staff <BR/>interviewed were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. <BR/>During an interview on 02/11/24 at 9:57 a.m., the DON said she was checking to ensure that all the in-services were done because she did some training, and the Social Worker and the Administrator did some of the in-services. The DON said she provided training for the aides not to move any resident observed on the floor but to call the nurse so the nurse could assess the resident. The DON said she also trained the aides to look at the [NAME] for residents at risk for falls, and the [NAME] also showed the aides the different types of interventions for each resident. The DON said [NAME] told the aides that the resident should have a nonskid stocking, a yellow falling star on the door, and the resident should wear a yellow band. The DON said the nurses were given the same training as the aides, and they were also trained on how to update the care plan if any resident had a fall. The DON said the nurses were in serviced on assessing a resident during a fall, notifying the physician, carrying out the physician's order, and also notifying the responsible party and nurse management. <BR/>During an interview on 02/11/24 between 10:00 a.m. and 11:00 a.m., two CNAs and three nurses from the day shift were interviewed on the facility in service and training on fall precautions, interventions, identification of residents at risk of falls, care plan modification of intervention and who was responsible for updating care plans. All staff <BR/>interviewed were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. <BR/>During an observation on 02/11/24 at 11:17 a.m., it revealed Resident #21 was sitting in his wheelchair in his room close to the foot of the bed close to the door, and the call light was clipped on the linen close to the resident, and he could reach the call light.<BR/>During an interview on 02/11/24 at 12:11 p.m., the Administrator said he was aware of Resident #21 falls, and they discussed them during IDT meets. The Administrator said they had changed Resident #21's fall precautions, and his care plan has been updated. The Administrator said he assisted with the in-service training for the aides and nurses on falls; they have amended the fall program and implemented the falling star and general intervention for falls but did not go into details about the care plan. The Administrator said the DON and the ADON conducted in-service the staff on updating the care plan, and he told the staff to follow up with the DON any time they had any falls.<BR/>On 02/11/24 at 12:50 p.m., the Administrator, the DON, the VP of operation, and DVP Clinical were notified the Immediate Jeopardy was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm that is not immediate Jeopardy and a scope of isolated due to the facility's need to 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 Residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents ( Resident #16 and Resident #89) reviewed for incontinent care, in that:<BR/> CNA B did not separate Resident #16's labia to clean during incontinent, clean arround the buttocks and did not perform appropriate hand hygiene with glove changes throughout the care<BR/> CNA A did not separate Resident # 89's labia to clean during incontinent, clean arround the buttock and did not perform appropriate hand hygiene with glove changes throughout the care.<BR/>This deficient practice could affect residents who received perineal care( the skin in between your genital and your anus) and place them at-risk of increased urinary tract infections due to improper care. <BR/>The findings included:<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/>Review of Resident #16s Care Plan, dated 01/24/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for sign and symptom of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 8:46 AM of Resident #16's incontinent care, revealed C.NA B washed hands before donning (putting) clean gloves and C.NA A was assisting . Resident #16's soiled brief was pulled down in front. C.NA B using the wet wipes cleaned the perineal, groin area. She did not open the labia to be cleaned, did not change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then picked up a clean brief using the same gloves. The resident was rolled to her back, and the brief was secured. CNA B placed a wedge under residents' hip and pulled the blanket up to cover her legs. CNA B used the same gloves throughout while performing incontinent care. <BR/>Resident #89<BR/>Review of Resident #89's face sheet dated 02/07/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 01/27/24 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), pneumonia,(an infection of the lungs that may be caused by bacteria, viruses or fungi ), sacral region stage 4 pressure sore (full thickness tissue loss with exposed bone, tendon or muscle), severe sepsis with septic shock,( a dramatic drop in blood pressure that can damage the lung, kidneys, liver and other organs), anoxic brain damage ( caused by a complete lack of oxygen to the brain).<BR/>Record review of Resident #89's MDS assessment dated [DATE] (admission) reflected BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and continent of bladder was using indwelling catheter.<BR/>Review of Resident #89's Care Plan, dated 01/10/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for s/s of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 5:30 PM of Resident #89's incontinent care, revealed C.NA A washed hands before donning clean gloves and C.NA B was assisting. Resident #89 was lying in bed. C.NA A washed hands don cleaned gloves, and removed the old brief. Using the wet wipes she cleaned the perineal, groin area. She did not open the labia to clean, did not change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then used the same gloves and picked up a clean brief put on the Resident #89.<BR/>In an interview with CNA A and C.NA B on 02/08/24 at 6:10 PM, they both stated they forgot to wipe the buttocks and open the labia. C.NA A and C.NA B stated it was wrong because it could cause an infection. C.NA A and C.NA B stated they had training on infection control in 01/2024.<BR/>Record review for CNA A's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 01/17/2024 done by the DON. <BR/>Record review for CNA B's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 11/5/23 and 01/17/2024 done by the DON. <BR/>During an interview on 02/09/24 at 3:10PM with ADON/ Infection Preventionist, stated that her expectations for staff is to wash hands before all resident care. Staff should knock on the door, introduce themselves, wash hands, and don gloves. Staff should then provide incontinent care, then doff ( removing gloves) gloves. Staff should wash hands, open up female labia and cleaned and don new gloves prior to applying new brief. The ADON was informed of the observation and stated the facility did proficiency checks on hire and quarterly.<BR/>In an interview with the DON on 02/09/24 at 3:30 PM, she stated CNA A was one of the facility's lead aides that monitored other staff during orientation with incontinent care. DON said not washing hands after changing gloves and not opening the labia to clean could cause urinary tract infection. DON said C.NA A and C.NA B knew they should clean around the buttocks before placing a clean brief. DON said she would be performing more in-services for incontinent care. <BR/>In an interview on 02/09/2024 at 3:35 PM, the Administrator stated his expectation was that incontinent care and hand washing were always done to prevent infection.<BR/>Review of the facility's staff skills competencies on incontinent care, dated 02/2022, revealed:<BR/>1. Prepare for process, obtain supplies, and wash hands.<BR/>2. Prepare work area<BR/>3. Wash hands<BR/>4. Remove soiled brief and place in bag.<BR/>5. Doff gloves, wash hands, don new gloves.<BR/>6. Clean the resident, doff gloves and place soiled items in bag.<BR/>7. Wash hands and don new gloves.<BR/>8. Position clean brief under resident, apply barrier cream.<BR/>9. Doff gloves, wash hands, position resident for comfort<BR/>10. lower bed and place call light in reach, wash hands. <BR/>Review of the facility's policy titled; Perineal Care revised on 02/2018. <BR/>Purpose<BR/>The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.<BR/>For a female resident:<BR/>Wet washcloth and apply soap or skin cleansing agent.<BR/>Wash perineal area, wiping from front to back.<BR/>1. <BR/>Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.)<BR/>2. <BR/>Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth.<BR/>3. <BR/>If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.<BR/>4. <BR/>Gently dry perineum.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 2 of 2 residents (Resident #16 and #89) reviewed for infection control.<BR/>1.CNA B failed to perform hand hygiene appropriately while providing incontinent care for Resident #16 by not changing gloves and washing hands.<BR/>2.CNA A failed to perform hand hygiene appropriately while providing incontinent care for Resident #89 by not changing gloves and washing hands.<BR/>These failures could place residents at risk for transmission of diseases and organisms. <BR/>The findings included:<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/>Review of Resident #16s Care Plan, dated 01/24/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for sign and symptom of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 8:46 AM of Resident #16's incontinent care, revealed C.NA B washed hands before donning ( put on) clean gloves and C.NA A was assisting . Resident #16's soiled brief was pulled down in front. C.NA B using the wet wipes cleaned the perineal, groin area. She did not change gloves and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then picked up a clean brief using the same gloves. The resident was rolled to her back, and the brief was secured. CNA B placed a wedge under residents' hip and pulled the blanket up to cover her legs. CNA B used the same gloves throughout while performing incontinent care. <BR/>Resident #89<BR/>Review of Resident #89's face sheet dated 02/07/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 01/27/24 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), pneumonia,(an infection of the lungs that may be caused by bacteria, viruses or fungi ), sacral region stage 4 pressure sore (full thickness tissue loss with exposed bone, tendon or muscle), severe sepsis with septic shock,( a dramatic drop in blood pressure that can damage the lung, kidneys, liver and other organs), anoxic brain damage ( caused by a complete lack of oxygen to the brain).<BR/> Record review of Resident #89's MDS assessment dated [DATE] (admission) reflected BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and continent of bladder using indwelling catheter.<BR/>Review of Resident #89's Care Plan, dated 01/10/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for s/s of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 5:30 PM of Resident #89's incontinent care, revealed C.NA A washed hands before donning clean gloves and C.NA B was assisting. Resident #89 was lying in bed. C.NA A washed hands don cleaned gloves, and removed the old brief. Using the wet wipes she cleaned the perineal, groin area., She did not did change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then used the same gloves and picked up a clean brief put on the Resident #89.<BR/>In an interview with CNA A and C.NA B on 02/08/24 at 6:10 PM, she stated she forgot to change gloves . They both stated it was wrong because it could cause an infection. Both C.NA's stated they had training on infection control in 01/2024.<BR/>During an interview on 02/09/24 at 3:10PM with ADON/ Infection Preventionist, stated that her expectations for staff is to wash hands before all resident care. Staff should knock on the door, introduce themselves, wash hands, and don (putting on) gloves. Staff should then provide incontinent care, then doff (removing) gloves. Staff should wash hands, and don new gloves prior to applying new brief. The ADON was informed of the observation and stated the facility did proficiency checks on hire and quarterly.<BR/>In an interview with the DON on 02/09/24 at 3:30 PM, she stated CNA A was one of the facility's lead aides that monitored other staff during orientation with incontinent care. DON said not washing hands after changing gloves could cause urinary tract infections. DON said C.NA A and C.NA B knew they should clean around the buttocks before placing a clean brief. DON said she would be performing more in-services for incontinent care. <BR/>In an interview on 02/09/2024 at 3:35 PM, the Administrator stated his expectation was that incontinent care and hand washing were always done to prevent infection. <BR/>Record review for CNA A's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 01/17/2024 done by the DON. <BR/>Record review for CNA B's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 11/5/23 and 01/17/2024 done by the DON. <BR/>Review of the facility's policy titled; Handwashing/Hand Hygiene revised on 08/2019. <BR/>Policy Statement<BR/>This facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.<BR/>2. <BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.<BR/>3. <BR/>The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.<BR/>4. <BR/>Single-use disposable gloves should be used:<BR/>1. <BR/>before aseptic procedures;<BR/>2. <BR/>when anticipating contact with blood or body fluids; and<BR/>3. <BR/>when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions.<BR/>Equipment and Supplies<BR/>1. <BR/>The following equipment and supplies are necessary for hand hygiene:<BR/>4. <BR/>Alcohol-based hand rub containing at least 62% alcohol;<BR/>5. <BR/>Running water;<BR/>6. <BR/>Soap (liquid or bar; anti-microbial or non-antimicrobial);<BR/>7. <BR/>Paper towels;<BR/>8. <BR/>Trash can;<BR/>9. <BR/>Lotion; and<BR/>10. <BR/>Non-sterile gloves.<BR/>Washing Hands<BR/>1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands.<BR/>2.Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately assess each resident's status for 1 of 5 Residents (Resident #1) reviewed for assessment accuracy in that: <BR/>1. <BR/>Resident #1's quarterly MDS assessment dated [DATE] did not correctly assess his diagnoses.<BR/>This failure could place residents at risk of not receiving the proper care treatments, and interventions due to inaccurate records.<BR/>Findings include:<BR/>Record review of Resident #1 admission record revealed he was a [AGE] year-old male. He was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included cerebral infarction (disrupted blood flow to the brain), unspecified, acute respiratory failure (impairment exchange between gas and lungs) with hypoxia (insufficient amount of oxygen), type 2 diabetes (body not producing enough insulin) mellitus (excess amount of sugar passing through blood and urine) without complications, essential (primary) hypertension (elevated blood pressure), hypothyroidism (not enough thyroid hormone released into the bloodstream), dysphagia following cerebral infarction (brain swelling from stroke), hyperlipidemia (hardening of arteries), tracheostomy (opening in the front of the neck to assist with breathing) status, gastrostomy (artificial external opening into the stomach for nutritional support and/or gastric decompression) status, and neuromuscular dysfunction (muscle weakness) of bladder.<BR/>Record review of Resident #1's MDS assessment dated [DATE] revealed no C. auris diagnosis.<BR/>Record review of undated list of residents on isolation precaution reflected Resident #1 was listed as 1 of 5 residents on isolation precaution and 1 of 4 residents isolated for C-auris (an emerging multidrug-resistant fungus/yeast causing infections in different parts of the body such as in the bloodstream, open wounds, and ears). <BR/>Interview on 08/18/2023 at 04:23 PM the ADON stated that Resident #1 had a diagnosis of C. auris of the blood and had been on the isolation unit since she began working at the facility in December of 2022. The ADON stated that could not locate where the resident's C. auris diagnosis was listed on his MDS assessment. She stated his diagnosis would have transferred with him to the hospital and transferred back with him when he was readmitted to the facility. She stated that she and the current staff know that the resident was on isolation precautions so when he returned from the hospital, he was automatically placed on the isolation unit and room. She stated the importance of listing resident's diagnosis was to ensure residents received the proper care to meet their diagnoses. <BR/>Interview on 08/18/2023 at 05:06 PM the ADON stated that Resident #1's hospital records dated 7/28/2023 revealed that he had a diagnosis of C. auris. She stated since Resident #1 was a readmitting resident, his diagnosis were already listed in the system. She stated she does not know why or when the resident readmitted the C. auris diagnosis was omitted from his MDS assessment. She stated that she would take responsibility for the diagnosis omission and ensure that the resident's MDS assessment was corrected to reflect his C. auris diagnosis. <BR/>Interview on 08/18/2023 at 05:16 PM the Administrator stated it should be the admitting nurse's responsibility to enter a resident's diagnosis when the resident admits or readmits. She stated the importance of having a resident's diagnosis listed on his MDS assessment was so that staff know if a resident should be placed on isolation, how to take care of that resident, what precautions should be taken, and so residents receive the proper medication that went with the diagnosis. <BR/>Interview on 08/18/2023 at 06:12 PM the ADON stated it should have been the admitting nurse and/or MDS's responsibility to ensure that resident's diagnosis was added to his MDS assessment. She stated that she cannot locate in the client profile system where the lapse occurred, and his diagnosis was removed or how it came off. She stated that she does not know who admitted . She stated that the diagnosis would be in his records moving forward. She stated if the resident was discharged out of the facility again, he would return and forever return to the isolation hall. She stated she would do an in-service to correct the readmission/diagnosis error. <BR/>Record review of Resident #1's hospital records dated 07/28/2023 page 3 of 13 revealed . present upon admission multidrug-resistant bacteria multidrug-resistant bacteria (MDRO)/contact precautions: Candida auris, MDRO specimen type: urine, date cultured: 06/17/2023. <BR/>Record review of Resident #1's Progress Notes dated 8/16/2023 All-Inclusive readmission revealed under section G. Health Condition 1a. Specific type of isolation: candida auris was Log in by LPN.<BR/>No record of Resident #1's diagnosis or test results revealing onset of his C. auris diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #16<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck), tachycardia ( a heart rate over 100 beats a Minute), gastrostomy( a surgical procedure used to insert a tube, often referred to as a G-tube).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) reflected BIMS score marked was 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems, and could not recall the current season, She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/> Record review of physician's order dated 10/03/23 reflected Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. <BR/>Review of Resident #16's care plan review on 10/03/23 revealed a focus of Bilateral Hand Roll and off load Bilateral heels, bilateral hand rolls and off load heel up to 24 hours tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. Goal Resident #16 will have hand rolls and to have Bilateral Heels off loaded daily up to 24 hours as tolerated to assist with preventing contractures and injury to bilateral heels with constant monitoring every 4-6 hours by staff. Care plan update of 02/01/24 had intervention for Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours. With an initiated date of 10/03/23<BR/>Record review of Resident # 16's February 2024 MAR and TAR revealed order to Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. <BR/> With a start date of 10/03/23. Treatment was signed as completed daily for 2/6/24, 2/7/24/ and 2/8/24.<BR/>Observation of Resident #16 on 2/6/24 at 10:00 AM, 12:00 PM, and 2:00 PM, revealed her lying in bed with bilateral hands contracted, with no hand rolls, no heel protectors, and her heels were not off the mattress.<BR/>Observation of Resident #16 lying in bed non-responsive on 2/07/24 at 8:47 AM, 10:30 AM, 12:00 PM, 1:30 PM, and 3:30 PM revealed bilateral hands contracted with no hand rolls, no heel protectors, and her heels were not off the mattress.<BR/>Further observation of Resident #16 lying in bed on 2/8/24 at 11:20 AM with Director Respiratory therapy who was at bed side and helped uncover Resident #16's top linen, revealed resident did not have any hand roll to contracted right hand, and feet were not off loaded off the mattress. She had socks on and heels were not floated.<BR/>During an interview with the C.NA A on 2/7/24 at 4:40 PM C.NA A said the nursing staffs were responsible for placing bilateral hand rolls and floating Resident #16's heels. C.NA A said not floating the heels could result in skin break down, she forget to float the heels ( Float heels means that a Resident's heel should be positioned in such a way as to remove all contact between the heel and the bed) and place the handrolls in Resident #16's hands.<BR/>During an interview with the Treatment Nurse and record review on 02/08/24 at 1:00pm she stated she was responsible for making sure that Resident #16 had bilateral hand rolls and floating heels while providing wound care to the resident.<BR/>During an interview with the DON on 2/8/24 at 4:00 PM, she stated the staffs were to ensure physician orders are implemented as ordered. DON stated the nursing staffs were responsible for ensuring bilateral hand rolls and floating heels. DON stated not implementing physician orders could cause a delay in treatment and there could be a potential for worsening of the condition or delay in progress.<BR/>During an interview with the Administrator on 2/8/24 at 4:30 PM, he stated the staffs were to ensure physician orders are implemented as ordered. If treatment was not implemented as ordered by the physician, it could cause worsening of the condition.<BR/>Record review of the facility's policy titled, Following Physician Orders with an implementation date of 09/28/21 stated, 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Document the order by entering the order and the time, date, and signature on the physician order sheet. B. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record<BR/>Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment plan of care for 2 of 4 residents (Resident #16, Resident#28) reviewed for comprehensive care plans. <BR/>Resident #28's comprehensive care plan did not have measures to address and provide care for his skin care under the folds and crevices in his perennial (private part) area to include assessing and monitoring these areas daily for skin breakdown and infection.<BR/>The facility failed to implement Resident #16's physician's order for treatment of her bilateral hand roll and off load bilateral heels and as care plan.<BR/>This failure could place residents at the facility at risk of not having their care needs met, which could cause a decline in physical and psychosocial health.<BR/>Findings included:<BR/>Record review of the facility face sheet revealed that Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia) You might also hear people use the term acute hypoxemic respiratory failure (AHRF)), morbid obesity with aveolar hypoventilation (Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness), type 2 diabetes (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and lymphedema (build-up of fluid in soft body tissues when the lymph system is damaged or blocked).<BR/>Record review of Resident #28's care plan dated initiated 10/16/2021 revealed a care plan for ADL's and limited physical mobility r/t weakness, confusion, limited mobility with interventions/task Resident #28 requires total assistance with toilet use and personal hygiene. A care plan for bowel and bladder incontinence dated initiated and revised on 1016/2021 r/t activity intolerance, confusion and impaired mobility with a goal target date of 3/29/2024 to refrain free of skin break down due to incontinence and brief use through the target date, interventions and task included use MD's order for Nystatin powder and to check frequently for incontinence. Wash rinse and dry perineum (cleaning the private areas of a patient), change clothing PRN and after incontinence episodes.<BR/>Record review of Resident #28's quarterly MDS assessment dated [DATE]th, 2024, revealed he had a BIM score of 14, indicating he was cognitively intact. Resident #28 was also coded as being impaired on both sides, upper and lower extremities for functional limitation range in motion dependent on 2 or more helpers (staff) to complete the activities of bathing, showering, toileting hygiene, dressing the upper and lower body, putting on and removing footwear, he also required partial to moderate assistance to roll to the left sides and lye back down on the bed. Resident 3 28 was totally dependent on staff to transfer from bed to chair or wheelchair. Resident #28 was frequently incontinent of bladder and bowel. Resident #28 was coded to be a risk for pressure ulcers.<BR/>Record review of physician orders for February 2024 included orders for Nystatin Powder 100000 UNIT/GM ,Apply to inner thighs, scrotum, abd topically everyday shift for Incontinence; Rash.<BR/>May Apply Zinc skin barrier after each incontinent episode to help reduce skin impairments. <BR/>Prior to wound treatment evaluate resident for Pain: everyday shift for Wound Care<BR/>After wound treatment evaluate resident for pain: everyday shift for Wound treatment.<BR/>Record review of Resident #28's weekly wound assessments for January 2024 through February 7, 2024 revealed no wound assessment for his perennial, scrotum and folds areas.<BR/>Record review of the facility grievance/complaint form dated 2/7/2024 revealed that Resident #28 filed a grievance that he did not receive care. Resolved by the DON assisting CNA's with providing care and disciplinary action scheduled with CNA assigned Resident #28.<BR/>During an observation and interview on 2/07/2024 at 8:03 am, with Resident #28, laying in his bed, he said that the CNA's do not want to do their job. He said he pushed his call-light at 4:00 pm yesterday and the staff did not come and assist him until 9:00 pm. He said that he has wounds on his bottom and that the staff make him wait and sit in his feces for so long that it dries up on his bottom and they have to scrape the feces off. He said it does not feel good to sit in that at all. He added if he could clean himself, he would but he cannot.<BR/>During an observation on 02/07/24 at 1:30 pm revealed Resident #28's air mattress was wet with urine, and the bed frame towards the foot of the bed was wet and puddles of urine on the floor from the bed to chest by the foot of the bed.<BR/>During an interview on 02/07/24 at 1:20 p.m. CNA N said she had not provided incontinent care for Resident #28 since she came to work today at 6:30 a.m. CNA N said Resident #28 had to call her if he needed to be changed, and she had not gone and checked on Resident #28 for incontinent care. CNA N said she was supposed to make rounds for incontinent care on all residents every two hours. <BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated (to wear off the skin of) with some openings. LVN H said she had worked with Resident #28 last week Friday and Saturday 2/2/24 and 2/3/24, and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 and she assumed the nurses were aware of the skin condition.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she scheduled a disciplinary action for CNA N not providing care for Resident #28, and in-serviced all staff.<BR/>On 2/07/2024 at 8:03 am, an observation and interview with Resident #28, laying in his bed, he said that the CNA's do not want to do their job. He said he pushed his call-light at 4:00 pm yesterday and the staff did not come and assist him until 9:00 pm. He said that he has wounds on his bottom and that the staff make him wait and sit in his feces for so long that it dries up on his bottom and they have to scrape the feces off. He said it does not feel good to sit in that at all. He added if he could clean himself, he would but he cannot.<BR/>During an observation and interview on 02/07/24 at 1:30 pm, it was revealed that Resident #28's under abdominal fold, scrotum, left, and right groin were very red, macerated , and there were tiny openings on all areas. One of the areas on under the abdomen measured about 1.0x1.0 cm. Resident #28 said that it hurts whenever RN A or CNA N cleaned the groin areas, scrotum, and abdominal area. Observation at this time of RN A and CNA N wiping Resident #28 and revealed the wipes had thick white substance and it had a musty odor. <BR/>During an interview on 02/07/24 at 1:20 pm, CNA N said she had not provided incontinent care for Resident #28 since she came to work today at 6:30 a.m. CNA N said Resident #28 had to call her if he needed to be changed, and she had not gone and checked on Resident #28 for incontinent care. CNA N said she was supposed to make rounds for incontinent care on all residents every two hours. <BR/>During an interview on 02/07/24 at 1:24 pm, RN B said she did Resident #28's skin assessment sometimes and the wound care nurse does it at times. RN B said Resident #28 needed two to three staff assistance for incontinent care. RN B said Resident #28 did not have any redness or open area on his buttocks or peri area when she did his skin assessment two weeks ago. RN B said none of the aides had told her that the resident had any open area on his peri area.<BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated with some openings. LVN H said she had worked with Resident #28 last week on Friday and Saturday (2/2/24 and 2/3/24) and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 and she assumed the nurses were aware of the skin condition.<BR/>During an interview on 02/08/24 at 10:42 am, the Wound Care Nurse said she does Resident #28's weekly skin assessment, and she did not see any redness, macerated area, any opening on his groin or abdominal folds. She said she became aware of the area yesterday .<BR/>During an interview on 02/08/24 at 10:54 am, the DON said she became aware of the red macerated area when she came to Resident #28's room. Then DON said she smelled the foul odor and ammonia in the resident room. The DON said the wound care nurse assessments for Resident #28 from January 2024 through February 2024 did not mention Resident #28 had any skin issues on his groin or under his abdomen. The DON said the facility has a new wound care company and the wound care doctor was not notified about the skin condition.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she was already aware of the break in their system with the skin issues and that the team had begun performing skin audits, was training with wound care nurse discussed in QAPI, IDT, physician, PIP, Resident #28, skin assessment was due 2/7/24 and she (the wound care nurse) had not gotten a chance to get to Resident #28, was working the other hall. Resident #28's assessment was due on the 7th of February, If the assessment was due that day and hadn't been conducted that day, she hadn't identified on that day yet because it (the newly identified skin area issue) had not been identified on prior skin assessments it ( the skin issue)was not there in the abdominal fold. They did identify the skin area and put treatment put in place, they are also in process of changing the wound care nurse, they have in-serviced the staff and did a 100 percent skin audit on residents. She said that a care plan was added, and comprehensive care plan should be in place specific for Resident #28's perineal area to include under the folds. She said that any nurse at the facility is responsible for care plans and said a negative outcome could be skin impairment, infection, and delayed treatment. <BR/>Record review of the facility policy and procedure entitled Care Plans, Comprehensive Person-Centered dated revised March 2022 read in part . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . reflects currently recognized standards of practice for problem areas and conditions .assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately assess each resident's status for 1 of 5 Residents (Resident #1) reviewed for assessment accuracy in that: <BR/>1. <BR/>Resident #1's Facesheet dated 08/18/2023 did not correctly assess his diagnoses.<BR/>2. <BR/>Resident #1's Diagnosis dated 08/18/2023 did not correctly assess his diagnoses.<BR/>This failure could place residents at risk of not receiving the proper care treatments, and interventions due to inaccurate records.<BR/>Finding include:<BR/>Record review of Resident #1's admission record revealed he was a [AGE] year-old male. He was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included cerebral infarction (disrupted blood flow to the brain), unspecified, acute respiratory failure (impairment exchange between gas and lungs) with hypoxia (insufficient amount of oxygen), type 2 diabetes (body not producing enough insulin) mellitus (excess amount of sugar passing through blood and urine) without complications, essential (primary) hypertension (elevated blood pressure), hypothyroidism (not enough thyroid hormone released into the bloodstream), dysphagia following cerebral infarction (brain swelling from stroke), hyperlipidemia (hardening of arteries), tracheostomy (opening in the front of the neck to assist with breathing) status, gastrostomy (artificial external opening into the stomach for nutritional support and/or gastric decompression) status, and neuromuscular dysfunction (muscle weakness) of bladder.<BR/>Interview on 08/18/2023 at 04:23 PM ADON stated could not locate where the resident's C. auris diagnosis was listed on his Facesheet and diagnosis. She stated the importance of listing resident's diagnosis on his Facesheet and diagnosis is to ensure residents received the proper care to meet their diagnoses. <BR/>Interview on 08/18/2023 at 05:06 PM the ADON stated that Resident #1's hospital records dated 7/28/2023 revealed that he had a diagnosis of C. auris. She stated that she does not know why or when the resident readmitted the C. auris diagnosis was omitted from his Facesheet and Diagnosis. She stated that she would take responsibility for the diagnosis omission and ensure that the resident's Facesheet and Diagnosis was corrected to reflect his C. auris diagnosis. <BR/>Record review Resident #1's hospital records dated 7/28/23 page 3 of 13.present upon admission multidrug-resistant bacteria multidrug-resistant bacteria (MDRO)/contact precautions: Candida auris, MDRO specimen type: urine, date cultured: 06/17/2023.<BR/>Record review of Resident #1's Facesheet dated 08/18/23 revealed no C. auris diagnosis.<BR/>Record review of Resident #1's Diagnosis dated 08/18/23 revealed no C. auris diagnosis.<BR/>Record review of undated Infection Control Program. a. When/of isolation is initiated, document must include.: b. Type and duration of the isolation; a. When and how isolation should be used for the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 2 of 2 residents (Resident #16 and #89) reviewed for infection control.<BR/>1.CNA B failed to perform hand hygiene appropriately while providing incontinent care for Resident #16 by not changing gloves and washing hands.<BR/>2.CNA A failed to perform hand hygiene appropriately while providing incontinent care for Resident #89 by not changing gloves and washing hands.<BR/>These failures could place residents at risk for transmission of diseases and organisms. <BR/>The findings included:<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/>Review of Resident #16s Care Plan, dated 01/24/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for sign and symptom of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 8:46 AM of Resident #16's incontinent care, revealed C.NA B washed hands before donning ( put on) clean gloves and C.NA A was assisting . Resident #16's soiled brief was pulled down in front. C.NA B using the wet wipes cleaned the perineal, groin area. She did not change gloves and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then picked up a clean brief using the same gloves. The resident was rolled to her back, and the brief was secured. CNA B placed a wedge under residents' hip and pulled the blanket up to cover her legs. CNA B used the same gloves throughout while performing incontinent care. <BR/>Resident #89<BR/>Review of Resident #89's face sheet dated 02/07/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 01/27/24 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), pneumonia,(an infection of the lungs that may be caused by bacteria, viruses or fungi ), sacral region stage 4 pressure sore (full thickness tissue loss with exposed bone, tendon or muscle), severe sepsis with septic shock,( a dramatic drop in blood pressure that can damage the lung, kidneys, liver and other organs), anoxic brain damage ( caused by a complete lack of oxygen to the brain).<BR/> Record review of Resident #89's MDS assessment dated [DATE] (admission) reflected BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and continent of bladder using indwelling catheter.<BR/>Review of Resident #89's Care Plan, dated 01/10/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for s/s of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 5:30 PM of Resident #89's incontinent care, revealed C.NA A washed hands before donning clean gloves and C.NA B was assisting. Resident #89 was lying in bed. C.NA A washed hands don cleaned gloves, and removed the old brief. Using the wet wipes she cleaned the perineal, groin area., She did not did change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then used the same gloves and picked up a clean brief put on the Resident #89.<BR/>In an interview with CNA A and C.NA B on 02/08/24 at 6:10 PM, she stated she forgot to change gloves . They both stated it was wrong because it could cause an infection. Both C.NA's stated they had training on infection control in 01/2024.<BR/>During an interview on 02/09/24 at 3:10PM with ADON/ Infection Preventionist, stated that her expectations for staff is to wash hands before all resident care. Staff should knock on the door, introduce themselves, wash hands, and don (putting on) gloves. Staff should then provide incontinent care, then doff (removing) gloves. Staff should wash hands, and don new gloves prior to applying new brief. The ADON was informed of the observation and stated the facility did proficiency checks on hire and quarterly.<BR/>In an interview with the DON on 02/09/24 at 3:30 PM, she stated CNA A was one of the facility's lead aides that monitored other staff during orientation with incontinent care. DON said not washing hands after changing gloves could cause urinary tract infections. DON said C.NA A and C.NA B knew they should clean around the buttocks before placing a clean brief. DON said she would be performing more in-services for incontinent care. <BR/>In an interview on 02/09/2024 at 3:35 PM, the Administrator stated his expectation was that incontinent care and hand washing were always done to prevent infection. <BR/>Record review for CNA A's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 01/17/2024 done by the DON. <BR/>Record review for CNA B's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 11/5/23 and 01/17/2024 done by the DON. <BR/>Review of the facility's policy titled; Handwashing/Hand Hygiene revised on 08/2019. <BR/>Policy Statement<BR/>This facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.<BR/>2. <BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.<BR/>3. <BR/>The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.<BR/>4. <BR/>Single-use disposable gloves should be used:<BR/>1. <BR/>before aseptic procedures;<BR/>2. <BR/>when anticipating contact with blood or body fluids; and<BR/>3. <BR/>when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions.<BR/>Equipment and Supplies<BR/>1. <BR/>The following equipment and supplies are necessary for hand hygiene:<BR/>4. <BR/>Alcohol-based hand rub containing at least 62% alcohol;<BR/>5. <BR/>Running water;<BR/>6. <BR/>Soap (liquid or bar; anti-microbial or non-antimicrobial);<BR/>7. <BR/>Paper towels;<BR/>8. <BR/>Trash can;<BR/>9. <BR/>Lotion; and<BR/>10. <BR/>Non-sterile gloves.<BR/>Washing Hands<BR/>1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands.<BR/>2.Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 (CR #1) of 7 residents reviewed for controlled drugs in that:<BR/>-The facility failed to appropriately store CR #1's Norco oral tablet 5-325mg (Hydrocodone -Acetaminophen- medication classified as a schedule II drug (high potential for addiction and abuse) used to treat pain and also used as a cough suppressant) in the DON's office under double lock when CR #1 was discharged to the hospital on [DATE] and returned to the facility 06/21/24. It was discovered on 06/29/24 that the medication was missing after CR #1 requested pain medication.<BR/>-The facility Nursing staff failed to have completed signatures on their Controlled Drugs-Count Record for the month of June 2024 regarding 7am oncoming nurse and 7pm off going nurse for 6/18/24, 6/20/24, 6/24/24, 6/25/24, and 6/28/24. <BR/>This failure could place residents at risk for unwanted discomfort, pain, and further decrease in quality of life.<BR/>Findings include:<BR/>Record review of CR #1's face sheet dated 03/31/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. CR #1's diagnoses included the following: COPD (a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness, lack of coordination, cognitive deficit, spondylosis(age-related wear and tear of the spine) with radiculopathy lumbar region (a condition that affects the nerve roots in the lower back), anxiety, malignant neoplasm of bronchus or lung (a type of cancer that originates in the airways or lung tissue), malignant pleural effusion (cancer causing an abnormal amount of fluid to collect in the thin layers of tissue lining the outside of the lung), and respiratory failure with hypoxia (lack of oxygen in the tissue to sustain bodily functions) . Further review of the face sheet revealed that resident was discharged from the facility on 07/05/24 to the hospital.<BR/>Record review of CR #1's admission MDS dated [DATE] reflected a BIMS score of 15 indicating that resident cognition was intact. Section N (Medication) of CR #1's MDS reflected that CR #1 was receiving and opioid (pain-relieving medicine that work with the brain cells). <BR/>Record review of CR #1's Comprehensive Care Plan dated 06/14/24 reflected CR #1 was being care planned for pain r/t lung cancer with interventions that included to administer analgesics as per ordered. Give &frac12; hour before treatments or care.<BR/>Record review of CR #1's Physician Order Summery Report for the month of June 2024 reflected the following orders:<BR/>-Dated 06/13/24 Norco oral tablet 5-325mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 6 hours as needed for pain.<BR/>-Dated 06/29/24 Tylenol with Codeine #4 tablet 300-60mg (Acetaminophen-Codeine) give 1 tablet by mouth every 6 hours as needed for pain do not give with Norco. <BR/>Record review of CR #1's MAR for the month of June 2024 reflected the medication Norco 5-325mg (Hydrocodone-Acetaminophen) was given twice on the following days: June the 14th and June the 17th by RN B. Further review reflected that Tylenol with Codeine #4 tablet 300-60mg (Acetaminophen-Codeine) was administered to CR #1 on June the 29th. <BR/>Record review of an E-INTERACT (interventions used to improve the identification, evaluation, and management of changes in resident's condition to reduce unnecessary hospital transfer) was done on CR #1 on 06/17/25 for urinary retention with pain (severe pain) uncontrolled with pain medication and CR #1 was sent to the hospital.<BR/>Record review of the facility- self report revealed CR #1's medication Norco oral tablet 5-325mg (Hydrocodone) went missing after resident was discharged to the hospital 06/17/24. CR #1 returned to the facility 06/21/24 and on 06/29/24 CR #1 requested pain medication. The Unit Manager called pharmacy to reorder the medication. The pharmacy informed the facility the medication Norco 5-325mg 120 tablets was delivered to the facility on [DATE] and signed by LVN G. The Police Department was called, and the investigation was ongoing. <BR/>Record review of the facility Pharmacy drug delivery receipt dated 06/16/24 revealed 120 tablets of Norco 5-325mg (Hydrocodone) was delivered to the facility for CR #1 with the Unit Manger signing for the medication. <BR/>Record review of the facility investigation dated 07/01/24 of statement taken from Unit Manger said after he received the medication Norco 5-325mg (Hydrocodone 120 tablets) on 06/16/24 he did not work on the hall after that.<BR/>Record review of the facility's June 2024 Controlled Drugs-Count Record revealed the following: <BR/>-6/18/24 no signature for 7pm off going nurse.<BR/>-6/19/24 no signature for the 7pm off going nurse.<BR/>-6/20/24 no signature for the7am off going nurse.<BR/>-6/24/24 no signature for the 7am oncoming and 7am off going nurses.<BR/>-6/25/24 no signature for the 7am oncoming and 7am off going nurses.<BR/>-6/26/24 7am oncoming and 7am off going was RN B signature.<BR/>-6/26/24 7am oncoming was RN B signature. The off going signature was not legible.<BR/>-6/27/24 7am oncoming nurse was LVN F signature. The off going signature was not legible.<BR/>-6/28/24 7am oncoming nurse had an illegible signature; no signature for the 7am off going nurse.<BR/>-6/29/24 7am oncoming was LVN A signature. <BR/>Record review of statement from LPN D dated 07/01/24 said she was approached by the previous ADON that RN B would be leaving the facility at 2:00PM and that LPN D along with orientee LVN F would be responsible for the floor. LPN D reported that she got report from RN B and while counting the narcotics with RN B she observed there were some medications wrapped on a sheet with a rubber band. LPN D said she enquired about it and RN B told her don't do not worry about those, CR #1 was transferred to the hospital. LPN D said she suggested that the medication should be given to the ADON, but RN B insisted that she should not worry about the wrapped pack of medications and walk away. LPN D said LVN F was given the key to the narcotic cart throughout the shift and handed it to the oncoming nurse. <BR/>Interview on 04/01/25 at 12:08PM via phone with LPN D said she worked at the facility PRN on the morning or evening shift. LPN D said she remembered the incident regarding CR #1 Norco medication missing. LPN D said she did not remember what day it was but that she was orienting a new nurse when around 12PM the previous ADON came to her to tell her another nurse on the hall was going to have to leave at 2pm who name she could not recall. LPN D said she counted the narcotic count with the nurse. LPN D said she remembered counting Norco medication, but did not remember who the medication belonged to. LPN D said when they approached her later about Norco medication missing. She said 120 pills were missing and that was not what she remembered counting. LPN D said when a resident receiving narcotics had to be transferred to the hospital, the narcotic was supposed to be counted and given to the DON. LPN D said she could not remember what medication belonged to who. LPN D said when she finished counting the narcotic with the nurse, she was told by the previous ADON to give the narcotic key to the nurse she was orienting, and she did.<BR/>Record review of statement from RN B dated 07/01/24 indicated on 06/21/24 she was scheduled to work from 7AM-1PM. RN B said CR #1 was scheduled to be re-admitted to the facility on [DATE]. RN B said she counted the narcotic cart with LPN D and gave report. RN B said when she counted the narcotic with LPN D among the narcotics was CR #1 Norco wrapped with 2 count sheets. RN B said she gave the narcotic key to LPN D.<BR/>Interview on 04/01/25 at 9:43AM via phone with RN B said she used to work at the facility full time on the morning shift from 7a-7p. RN B said she stopped working at the facility in August 2024. RN B said she heard there was a problem with the narcotic count on the hall that CR #1 resided on. RN B said she was called to come to the facility to take a drug test which she did. RN B said she tested negative for the drug test. RN B said there was a male nurse that worked on the same hall that refused to take the drug test but did not remember his name. RN B said whenever she counted the narcotic cart, the count was correct.<BR/>Interview on 04/01/25 at 1:00PM RN B said she was not sure if CR #1's narcotics were on the cart when she counted with LPN D. RN B said it was the facility protocol to count the narcotics and give to the DON when the resident was transferred to the hospital to ensure the medication remained secured. RN B said the narcotics could have been left on the cart because the DON was not at the facility and if not in the facility, the medication must stay on the narcotic cart until the medication can be delivered to the DON.<BR/>Record review of statement from LVN F said on 06/21/24 said she was on orientation with LPN D. LVN F said RN B left the facility at 2:00PM after counting the narcotic cart with LPN D. LVN F said she thought everything was okay.<BR/>Interview on 04/01/25 at 3:33PM via phone with LVN F said on 06/21/24 she was in training with nurse LPN D and did not count the narcotic medication cart. LVN F said she was never given the key to the narcotic cart. LVN F said she was one of the nurses that done a drug test and tested negative for drugs in her system.<BR/>Interview on 03/31/25 at 3:05PM via phone with LPN A said she remembered last year of a resident medication gone missing but did not remember CR #1. LPN A said she worked at the facility on a PRN basis 6a-6p but last year the shift time was from 7a-7p. LPN A said she only worked at the facility on the weekends PRN morning shift. LPN A said when a resident that was receiving narcotics and had to be transferred to the hospital on the weekends, the narcotic had to be counted at the end of each shift with the oncoming nurse following up to that following Monday. After counting the narcotic on that Monday ensuring the count was correct, the narcotic would then be given to the DON to lock the medication away until the resident returned to the facility. <BR/>Interview on 03/31/25 at 5:32PM via phone with the Unit Manager worked at the facility PRN on the weekends as a supervisor. The Unit Manager said it was the morning nurse who name he could not remember brought it to his attention that CR #1's narcotic Norco was missing. The Unit Manger said when CR #1's Norco could not be located, he notified DON A and previous Administrator. The Unit Manager said the protocol was when a resident receiving narcotics was transferred to the hospital, the narcotic must be counted at the end of each shift until it was picked up by the DON. The Unit Manager said LVN G no longer worked at the facility and had not worked at the facility for approximately a year. The Unit Manager said after DON A and the previous Administrator was notified, he did not know what happen regarding the missing narcotic for CR #1. <BR/>Interview on 04/01/25 at 10:45AM with the Human Resource Specialist said all the nurses that had access to the narcotic cart on Hall 200 where CR #1 resided done a drug test except RN E who refused. The Human Resource Specialist said all the nurses that tested for drugs were negative. The Human Resource Specialist said RN E no longer worked at the facility after the incident of CR #1's Norco went missing.<BR/>On 04/01/25 at 11:03AM A call was placed to RN E, no answer. left voicemail with a call back number. RN E did not return the call after making several attempts to contact RN E.<BR/> Interview on 04/01/25 at 1:10PM with the present DON, DON B said if a resident was admitted to the hospital and was receiving narcotics, the narcotics had to be counted by 2 nurses and delivered to the DON for best practices. DON B said if the resident was gone from the facility over 3 days, he believed the narcotic would have to be destroyed. DON B said if the resident returned to the facility and on the same medications, the medications would have to be re-ordered by the physician. DON B said this was how it was done at the previous facility he worked at. The DON B said when the resident was discharged , the narcotic (s) needed to be given to the DON within 24-hour period. DON B said if the resident discharged from the facility on the weekend, the staff would have to continue to count the narcotic at the end of each shift and given to the DON on the following Monday. DON B said when this protocol was not being followed it placed the narcotic at risk of being misplaced. Further interview with DON B said it was the responsibility of the DON to be checking the narcotics on each cart to ensure there were no discrepancies detected with the narcotics and the count sheet and that all signatures were completed on the narcotic sheet. DON B said he had been working at the facility since February 10th, 2025. DON B said he checked the narcotic carts each morning looking for any discrepancies. The DON said the facility had a total of 4 medication carts. <BR/>Record review of DON A work schedule when worked at the facility in June 20204 reflected that DON A was at the facility 06/17/24 (Monday) through 06/21/24 (Friday) as well as 06/24/24 (Monday) through 06/28/24 (Friday).<BR/>Interview on 04/01/25 at 3:18PM via phone with the previous DON, DON A said it was reported that CR #1 Norco was missing when he returned from the hospital. DON A said RN B gave CR #1 his Norco. DON A said it was RN E who refused to be drug tested and resigned. DON A said all the other nurses that had access to the narcotic cart on hall 200 done the drug test and was negative for drugs in their system. DON A said she tried to call RN E later and he never answered. DON A said when a resident on narcotics must be taken to the hospital and gone for more than 24 hours, the narcotics needed to be given to the DON and the drugs are double locked until the resident returned to the facility. DON A said CR #1's narcotic Norco was never located. DON A said whoever counts the narcotic cart was responsible for the narcotic cart. DON A said the facility failed to remove CR #1's medication Norco from the cart and give to the DON so the medication could be double lock for safe keeping. DON A said the staff was in-serviced on the handling of controlled medications. <BR/>Record review of the facility investigation revealed that an in-service was done on 07/01/24 with the staff on controlled substances, storge of medications, abuse, neglect, misappropriation protocols/response. Further review revealed that the facility had conducted a pain questionnaire with the residents with no negative outcome identified. The Regional Nurse had done an audit of the medication room and storage room on 07/01/24 with all medications including narcotics were stored safely. The medication rooms were locked, and medication carts were observed locked when nurse was away from the cart. <BR/>Record review of the facility policy on Controlled Substances revised in April of 2019 reflected in part:<BR/> .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications .At the end of each shift: controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together .Controlled medications will be counted every shift change (scheduled or incidental) by an authorized staff member (RN, LVN, CMA) reporting for duty with an authorized staff member reporting off duty . <BR/>Record review of the facility policy on Identifying Exploitation, Theft and Misappropriation of Resident Property dated April 2021 reflected in part:<BR/> .As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to recognize exploitation of residents and misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without resident's consent .Example of misappropriation of resident property include drug diversion (taking the residents medication) . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three (CR#9, CR#10, and CR#11) of four residents reviewed for treatment/services of pressure ulcers. <BR/>1. Facility failed to fully assess CR #9's wound to establish baseline for treatment and obtain treatment orders.<BR/>2. Facility failed to ensure CR#9 received wound care for six (6) days during his admission to the facility on <BR/>04/12/2023 through 04/17/2023.<BR/>3. Facility failed to provide daily wound care to CR#9, CR#10, and CR#11 having multiple days of missed wound care, resulting in CR#11's wound deterioration.<BR/>An Immediate Jeopardy (IJ) was identified on 06/09/2023. The IJ template was provided to the facility on 6/9/23 at 12:58 p.m. While the IJ was removed on 06/13/2023, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to failure occurred to multiple residents over multiple days and the facility's need to evaluate the effectiveness of the corrective systems.<BR/>These deficiencies could expose residents to wound deterioration, worsening of condition, infection, sepsis, and hospitalization.<BR/>Findings include:<BR/>Review of face sheet revealed CR#9 was a [AGE] year-old male who was admitted to the facility on [DATE]. CR #9's diagnoses included metabolic encephalopathy, anemia, heart failure, type 2 diabetes mellitus, respiratory failure, tracheostomy, osteomyelitis, and muscle wasting.<BR/>Record review of the progress note dated 04/12/2023 during admission revealed CR #9 had wounds identified as unstageable wound to sacrum and DTI (deep tissue injury) to right stump. <BR/>Record review of CR #9's Physician Orders revealed there was no wound care orders for CR #9 the day of his admission on [DATE] through 04/17/2023.<BR/>Record review of CR#9's Progress Note dated 4/12/2023 during admission revealed Sacrum wound stage 4 noted to scrum. Coccyx wound noted, DTI to right hell, right toes are amputated, multiple bruises to upper and lower extremities, old healed wounds and scars to lower and upper extremities. <BR/>Review of facility admission assessment dated [DATE] did not reveal detail about CR #9's wound. The admission Assessment only revealed the following:<BR/>- <BR/>Turgor: good<BR/>- <BR/>Skin color: normal for ethnic group<BR/>- <BR/>Temperature: warm<BR/>- <BR/>Moisture: normal<BR/>- <BR/>Condition: normal<BR/>- <BR/>New wounds: 5<BR/>Record review of Wound Care Doctor's assessment dated [DATE] revealed the following detail regarding CR #9's wound:<BR/>- <BR/>wound size as length = 7cm, width = 7cm, and depth = 1.3cm. <BR/>- <BR/>Surface Area: 49.00 cm2<BR/>- <BR/>Exudate Moderate Sero - sanguinous<BR/>- <BR/>Thick adherent black necrotic tissue (eschar) 20 %<BR/>- <BR/>Thick adherent devitalized necrotic tissue 30 %<BR/>- <BR/>Slough 20 %<BR/>- <BR/>Granulation tissue 10 %<BR/>Record review of the careplan dated 04/18/2023 revealed CR#9 had impairment to skin integrity with stage 4 pressure wound (severely damaged skin) to the sacrum.<BR/>Record review of MDS (Minimum Data Safety) dated 04/17/2023 section M0100 through section M0300 revealed CR#9 has pressure injury.<BR/>Review of TAR (Treatment Administration Record) for the month of April 2023 revealed there was no wound care treatment performed for CR#9 during his admission on [DATE] through 04/17/2023<BR/>Record review of progress note dated 04/18/2023 revealed resident (CR#9) was sent to hospital on [DATE] for change in condition.<BR/>Record review of hospital emergency room note dated 04/20/2023 revealed CR #9 was brought to ER (Emergency Room) on 4/18/2023 due to Cardiac arrest.<BR/>Review of face sheet showed CR #10 was a [AGE] year-old female who was initially admitted to the facility on [DATE]. CR #10's current re-admission to the facility was on 04/26/2023, her diagnoses included type 2 diabetes mellitus, diabetic neuropathy, Peripheral Vascular disease, cerebral infarction, and metabolic encephalopathy. <BR/>Record review of CR #10's Progress Note dated 10/04/2022 during initial admission to the facility revealed CR #10 have a stage 3 wound on her sacrum and left leg<BR/>Record review of a careplan dated 03/21/2023 revealed CR#10 has a pressure ulcer to the sacrum and left thigh with potential for further skin breakdown related to disease process and immobility.<BR/>Record review of the MDS (Minimum Data Safety) dated 03/13/2023 section M0100 revealed CR#10 has pressure injury.<BR/>Review of the TAR (Treatment Administration Record) for the months of January 2023 through April 2023 revealed there was no wound care provided for CR #10 on the following dates:<BR/>- <BR/>4/13/23.<BR/>- <BR/>3/18/23, 3/26/23.<BR/>- <BR/>2/7/23, 2/8/23, 2/10/23, 2/12/23, 2/24/23, 2/25/23.<BR/>- <BR/>1/9/23, 1/14/23, 1/30/23.<BR/>Record review of physician order dated 04/08/2023 revealed CR #10's order for sacrum wound as Cleanse stage 4 pressure wound to the sacrum with ns/wc. pat dry. apply collagen powder and alginate calcium w/silvercover w/bdr foam dressing daily and prn and order for left lateral thigh as Cleanse stage 4 pressurewound to the left lateral thigh with ns/wc. pat dry apply collagen powder cover w/bdr foam dressing daily and prn.<BR/>Record review of physician order revealed, on 1/7/23 - 1/13/23 patient received Ceftaroline Fosamil Intravenous Solution Reconstituted (Ceftaroline Fosamil) Use 200 mg intravenously every 12 hours for Wound Infection for 5 Weeks. On 4/26/23 CR #10 received APTOmycin Intravenous Solution Reconstituted 500 MG (Daptomycin) intravenously every 48 hours for Wound Infection for 5 Weeks.<BR/>Record review of CR#10 hospital records revealed CR#10 was hospitalized on [DATE] to 1/13/23- patient received prophylaxis Cefdinir Oral Capsule 300 MG (Cefdinir). <BR/>Review of CR#11 face sheet revealed CR#11 was admitted to the facility on [DATE]. CR#11's diagnoses included anxiety disorder, osteomyelitis, hypertension, respiratory failure, stage 3 pressure ulcer of the left heel, pressure ulcer of left ankle, pressure ulcer of sacral region, and tracheostomy status. <BR/>Record review of a careplan revision dated 02/10/2023 revealed CR#11 has a stage 4 sacral pressure ulcer and was at risk for wound becoming infected, worsening with poor response to treatment, and other complications to include at risk for additional pressure ulcers and skin breakdown related to contractures and muscle atrophy (decrease in size and wasting of muscle tissue) with impaired mobility and dependent on staff for turning and repositioning and all areas of mobility.<BR/>Record review of MDS (Minimum Data Safety) dated 03/24/2023 section M0100 through section M0300 revealed CR#11 has a pressure injury. <BR/>Review of TAR for the months of March 2023 and April 2023 revealed there were no wound care on 03/23/2023, 03/26/2023, and 4/16/2023.<BR/>Review of Wound Care Doctors note revealed the following:<BR/>- <BR/>0n 3/21/23 the following wounds deteriorated:<BR/>Wound site #2 Stage 4 pressure wound of left, lateral ankle<BR/>Wound site #9 stage 4 pressure wound sacrum<BR/>Wound site #23 stage 4 pressure wound of the left, posterior elbow<BR/>- <BR/>On 3/7/23 the Wound site #9 stage 4 pressure wound sacrum deteriorated<BR/>- <BR/>On 2/14/23 Wound site #2 Stage 4 pressure wound of left; lateral ankle deteriorated<BR/>- <BR/>On 1/10/23 Wound site #9 stage 4 pressure wound sacrum deteriorated<BR/>On 5/25/23 at 1:59PM during interview with the DON, she stated she started working at the facility since May 1st, 2023. She stated she did not know what happened to all these residents' wound care. She also stated there was a wound care nurse who was let go at the time she started working with the facility. She stated they got a new wound care nurse who just started this Monday (05/22/2023). She stated her expectation was for nurses to assess resident during admission, document everything that they assessed, and notify doctor for all necessary orders including wound care order, and that this deficient practice place resident at risk for infection. When Surveyor asked how this could affect the resident, DON stated oh you know it, don't test my intelligence<BR/>On 05/24/2023 at 3:55PM, in an interview with RN C on the floor regarding wound care and who would be responsible for wound/skin assessment during admission and when the wound care nurse not in the building. RN C stated he started working at the facility about two months ago. He said he was not so familiar with the three residents (CR#9, CR#10, and CR#11). He stated if they had any admission the nurses on the floor would do skin assessment on all admissions, and if any resident was admitted with a wound, they would also do wound the assessment and contact the doctor for the order. He stated these three resident's wounds was being cared for by the wound care nurse and he was not familiar with their wound. <BR/>On 05/25/2023 at 4:02PM Surveyor requested the contact number of 4 nurses, including CR#9's admitting nurse, for interview. The DON stated she would provide the contacts information. <BR/>On 05/24/2023 at 4:14PM on the 200 hall, with LVN F, who was one of the nurses on the floor. She stated the floor nurses would do the skin assessment during admission. She also said they had a wound care nurse who was doing all resident's wound care. She stated nurses only did wound care when the wound care nurse was not in the building. Surveyor observed LVN F was in a hurry, she entered into a resident's room.<BR/>On 05/25/2023 at 4:32PM during interview with the New Wound Care Nurse, she stated she had been working at the facility for almost 2 years as a floor nurse, but she started as a wound care nurse on Monday 05/22 2023. The Wound Care Nurse stated when she was working as the floor nurse, the expectation for the Floor nurses was to do patient assessment during admission, document, and notify physician for orders. She stated when wound care nurse comes, she would also do wound /skin assessment on all new admission. She stated, now that she became the wound care nurse, she also did the same thing - she stated she would always do skin assessment on all new admission. She said if resident did not get wound care, it could affect them by causing infection and the wound could get progressively worse.<BR/>On 05/25/2023 at 4:52PM, Surveyor followed-up with the DON regarding the nurses' contact numbers, at this time she stated the HR was pulling the contacts. However, contact numbers were not provided. <BR/>On 06/08/2023 at between 11:03AM through 11:50AM, Surveyor called the Wound Care Doctor multiple times, but his line was breaking up and did not go through. Surveyor asked the DON if the Wound Care Doctor had another contact number, the DON stated she did not know of any other number, she said the contact given to the Surveyor was the same number the facility used to contact the Wound Care Doctor. The DON stated further that the wound care Doctor would be in the building soon and Surveyor would be able to speak with him.<BR/>On 06/08/2023 at 11:52AM, attempt made to interview LVN G, who was the admitting nurse of CR #9. LVN G stated she just lost her younger brother yesterday (06/07/2023), she stated she only came to the facility today (06/08/2023) to take time off. She said she was unable to concentrate to answer any question. <BR/>On 06/08/2023 at 11:54AM, the DON notified the Surveyor that the Wound care Doctor just came in. Surveyor stepped out to talk to the Wound Care Doctor, but he stated he did not have time at the moment, he said, I have not been here in two weeks and that he needed to do rounds right away. He stated he would call surveyor today (06/08/2023) or tomorrow (06/09/2023). Surveyor requested Doctor to kindly try to call today (06/08/2023) and gave a business card to the Wound Care Doctor. <BR/>On 06/08/2023 at 12:08PM Surveyor called the Former Wound Care Nurse, but there was no response, Surveyor left message on the voicemail.<BR/>On 06/08/2023 at 12:27PM Surveyor called LVN H, a nurse on 300 hall, CR#10's hall. LVN H answered the phone but after few seconds, the line cut off. Surveyor called back but there was no response. Surveyor left voice message.<BR/>On 06/08/2023 at 12:42PM Surveyor called LVN J, the nurse who cared for CR#9. Surveyor spoke with a lady who said she was a family member of LVN J and told Surveyor that LVN J would be around in about an hour and a half. <BR/>On 06/08/2023 at 12:50PM Surveyor called DNP the call went straight to voicemail. Surveyor left a voice message.<BR/>On 06/08/2023 at 12:53PM Surveyor attempted to called Respiratory Therapist who cared for CR#9 on the day CR #9 was sent to hospital. There was no response.<BR/>On 6/8/2023 at 3:11PM, in an interview with the DNP, she stated she was not a DNP for state of Texas, she was a DNP for the state of Illinois. She said she only had RN license for Texas and not DNP for Texas. She said she was consulting at the facility as a regional consultant at that time. She stated she was told to sit for the position of DON at the facility because there was no DON at that time. The DNP said she was not aware of any of the residents having their wound care not done. She stated her area of specialization was ventilation., She said she was a consult at the facility to train/ in-service the nurses on ventilation. She stated her expectation as the DON while she was at the facility was that the wound care should be done according to the order.<BR/>On 06/08/2023 at 3:18PM. Surveyor made another attempt to call the Respiratory Therapist who cared for CR#9 on the day CR #9 was sent to hospital. There was no response.<BR/>On 06/08/2023 at 6:21PM. Surveyor attempted call to the Wound Care Doctor again, but the call did not get through.<BR/>On 06/08/2023 at 6:28 PM, another attempt was made to call LVN J back but there was no response.<BR/>On 06/08/2023 at 6:29PM, another attempt was made to reach out to the Former Wound Care Nurse again, but there was no response.<BR/>On 07/05/2023 at 10:10AM Surveyor called the Former Wound Care Nurse in an attempt to interview her. There was no response, message was left on voice mail. <BR/>On 07/05/2023 at 10:53AM in an interview with RN B, she said she had been working at the facility about 2 years and she worked 12 hours day shift. She stated CR#9's names was vague, she said she was not familiar with the resident probably because she did not work on the CR #9's hall - she said she worked 200 hall most of the time. She stated she was not sure if she worked with CR #9 once - she said she might have cared for the CR #9 maybe once in the past, but she can't recall. She stated she did not recall CR #9's wounds as well. RN B said she knew CR #11, and she could remember him on 200 hall where she usually worked. She stated they had a wound care nurse, who usually did wound assessment and wound care on all residents. She said she did not perform wound care for CR #11, and floor nurses did not usually perform wound care - she stated they always had wound care or treatment nurse who was responsible for that. She stated if she ever did wound care on any resident, it was very rare.<BR/>RN B said when the treatment nurse was not there in the building, nurses would be responsible to do treatment. She stated if any resident was a re-admit, they still looked at wound and made documentation. She said if they admitted a new patient, they looked at the wound as well. She said usually they got orders from the hospital or wherever the resident was coming from and wound bring them over into the resident's record. She stated if they admitted a resident without wound care orders, they would call the doctor., She said they could call the residents PCP and get orders in place before the wound care nurse would take over. She stated she believed the deficient practice happened maybe because some of the new nurses were not really following the process. She stated they facility had done series of training for the nurses, and for the past month, they have been very strict about that. <BR/>RN B stated they have wound care/ treatment nurses everyday in the facility. She stated if any of the nurses on schedule, or the treatment nurse did not come in, the ADON would step in to do wounds, even on weekends as well. She said Nurse 1, a PRN nurse also would come some weekends to do wounds too. She stated she never saw any wound dressing outdated. However, she said in the past, she heard some people talked about wound being outdated - she did not recall who she heard from, or which specific resident. She said they had a former wound care nurse who no longer worked at the facility. She said the former wound care nurse had an assistant/treatment Aide who used to work with the former wound care nurse, but both of them were no longer working at the facility anymore. RN B said the only time when nurses would have to look at wounds was during admission. She said the nurses did weekly skin assessment on all residents, and the treatment nurse would do weekly skin assessment on all residents with wound of stage II and above. She also stated each hall has each day of the week assigned when the residents would get skin assessments. <BR/>On 07/05/2023 at 11:07AM, during an interview with LVN H, she stated she always worked day shift on the 300 hall. She said she recalled CR #10 had wounds. LVN H stated one time in the past, they said the resident had sepsis LVN H was not sure what was the cause. Nurse also said CR #10 got an antibiotic sometime in the past when she came back from the hospital, but she could not recall details. LVN H stated she did CR #10's wound one time when there was no wound care nurse in the building. She said CR #10's wound was not bad when she looked at it. LVN H stated if treatment nurse was not in the building and they admitted any resident with wound, the nurse on duty would be responsible to contact doctor for wound care order, and then treatment nurse would take over the wound care from there. She stated they would call the resident's doctor for orders. <BR/>On 07/05/2023 at 11:13AM, Surveyor called LVN J, there was no response, Surveyor left Voice Message and send text message.<BR/>On 07/05/2023 at 11:30AM, Surveyor called LVN G, the admitting nurse of CR #9 Phone did not ring. Surveyor called again, someone picked up but did not speak. Surveyor sent text message.<BR/>On 07/05/2023 at 12:02PM, in an interview with the Wound Care Doctor. He stated he came to the building today (7/5/2023) for rounding because of the July 4th holiday, He stated he normally comes to the building on Tuesdays. He said he remembered the residents, CR#10 and CR#11. He stated he always did comprehensive notes with orders given for every patient. He also stated daily dressing for wounds should be done daily according to the order. He stated wounds are not expected to remain the same, he said wounds changes - drainage changes week to week, same thing with color and size. The Wound Care Doctor said he did not see any concern regarding residents wound in the building. He stated facility had low hospital admission rate for wounds, given the complexity of wounds they have. He stated resident CR#11's wound might have deteriorated at some point, but he would not expect the wound to keep deteriorating week after week for maybe 4 to 5 weeks, he said that would be a concern for him. He stated CR #11 had many wounds and he could recall each time CR #11 went to hospital he would come back with either more wounds or existing wounds deteriorating. The Wound Care Doctor stated CR #11 was frail, had multiple wounds and many co-morbidities, he said his wound care would take them about 30 - 40 minutes to do.<BR/>The Wound Care Doctor stated he remembered CR#10. He said CR #10's wound was not bad. He said the resident was a dialysis patient and she would go to the hospital mostly for non-wound related issues. He said when these residents go to hospital, there were usually high probability that they would come back with deteriorating wounds. <BR/>The Wound Care Doctor stated he did not recall CR #9. Surveyor reminded the Wound Care Doctor he had one visit with CR #9 on 04/18/2023 which was initial wound evaluation, and he gave orders for daily wound care for CR#9. Surveyor also inquired if the Wound Care Doctor, in his expertise, believed the resident could have benefited from daily wound care from the time/day of resident's admission, and what could have happened to these residents if their wounds was not cared for, and what his expectation was regarding wound care. The Wound Care Doctor stated he would not answer what could happen if residents missed some wound care days. He stated further that he did not want to go hypotheticals on what could have happened. He stated he would rather focus on what actually happened and the intervention they were giving to the residents. He stated in the case of CR #11 that, deterioration was probably because of resident's co-morbidities, he said but generally, wound deterioration is not expected to be seen week after week. He said wounds could deteriorate this week, remain the same next week and improve the week after.<BR/>The Wound Care Doctor stated further that the new wound care nurse was a great nurse, he said he could see the passion in the nurse for her job. He said he had been working pretty well with the new wound care nurse. He stated however, that the former wound care nurse was not on the same pedestal with the new wound care nurse. He said he had some issues with the former wound care nurse - He did not say further what the issues were.<BR/>On 07/05/2023 at 12:18PM Surveyor called Aide 1 who used to work with the former wound care nurse. There was no response, Surveyor left voice message and text. Surveyor called Nurse 1 - the PRN nurse who sometimes did wound care on weekends. There was no response. Surveyor left voice and text messages.<BR/>On 07/05/2023 at 1:12PM in an interview with the New Wound Care Nurse. She stated she was initially employed as a floor nurse and, she usually worked on the 200 hall. She stated she did not know CR#9, she knew CR#10 but she did not usually work on CR#10's hall. She stated she knew CR#11, she stated when she was the floor nurse, she mostly worked opposite end of CR#11's room. She stated she did not care for CR#11's wounds. The New Wound Care Nurse said she sometimes would fill in for the treatment nurse if the treatment nurse was not in the building. She stated she became the treatment nurse May 22nd, 2023. She stated when she assumed the position, it was hard to say if any wound deteriorated or not because she did not know all of the residents wound condition before that time. She stated she could remember that wound documentation was all over the place. She stated documentation was not being done. She stated now that she became the treatment nurse, corporate looked behind her to make sure documentations were being done. The New Wound Care Nurse stated if she was not in the building, the floor nurse who admitted the resident would be responsible to get orders for wound and perform wound care whenever she was not in the building. She said most of the residents came in with wounds and were sick. She said if wound care was supposed to be done daily and not done, the wounds could deteriorate, get infected, and resident could even get sepsis. <BR/>On 07/05/2023 at1:32PM in an interview with the ADON. She stated she would sometimes do wound care because she was a Certified wound care nurse. She stated she had done wound care in the past when the former wound care nurse was not in the building, and at that time the wounds she cared for looked good, and she had no concerns - The ADON did not recall the specific resident's wound she cared for at that time. She said they had a weekend wound care nurse (Nurse 2) who usually did wound care for residents in the facility. She stated the Nurse 2 did not work at the facility anymore. The ADON stated further that at the time the residents (CR#9, CR #10, CR #11) were in the building, she was not really looking into wounds at that time, because she had a lot of administrative duties to do. The ADON said CR #9 was in the building briefly and was admitted with wounds as she could see it in the record. She said the admitting nurses were responsible to make sure they get orders for new admission's wound. The ADON said she did not know the full detail/status of CR #9's wound. The ADON said she could vaguely recall CR#10. She said she did not know about resident's wound infection, she stated but she would look in the record. The ADON stated if the treatment nurse not in the building, and nobody else was designated to do wound care, the nurse on the floor would be responsible to do wound care. The Surveyor asked if the ADON thought there would be enough time for nurses to do all wounds on their floor coupled with the responsibility of giving meds and other nursing duties. The ADON stated yes she said because sometimes they only have about 6 to 7 residents on a hall and that would not be too much for the nurses to handle. The ADON stated if residents' daily wound care were not done daily as stated in physician order, the wound could deteriorate and get worse and cause harm to the patient. <BR/>On 07/05/2023 at 2:07PM Surveyor called Nurse 2, the former weekend wound care nurse. There was no response, voice mail not set up. Surveyor sent text message. <BR/>On 07/05/2023 at 3:01PM, the ADON said she went through recent notes and did not see anything about CR#10's wound infection, she said she had to dig deeper to find out about that. She stated CR #10 went out to hospital, during the last hospitalization, for other reason not wound related. The ADON said regarding the missed wound care days shown on the TAR, she stated she understood the Number one rule of nursing is, if it is not documented, it is not done.<BR/>Record review of facility policy titled 'Skin System' no date, revealed in part, .skin assessment will be completed on day of admission and documented by the admitting nurse or treatment nurse upon admission (including re-admission) the admitting nurse will notify the physician and resident representative of any identified areas, implement treatment/ interventions and document<BR/>An Immediate Jeopardy (IJ) was identified on 06/09/2023. The IJ template was provided to the facility on 6/9/23 at 12:58 p.m. While the IJ was removed on 06/13/2023, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to failure occurred to multiple residents over multiple days and the facility's need to evaluate the effectiveness of the corrective systems.<BR/>The plan of removal was accepted on 06/10/2023.<BR/>The plan of removal reflected the following:<BR/>Immediate Jeopardy<BR/>PLAN OF REMOVAL<BR/>Immediate Action:<BR/>Immediate Jeopardy called for Treatment/ Services to Prevent/ Heal Pressure Ulcers.<BR/>The facility will conduct a head-to-toe skin assessment on each resident in the facility to ensure all residents with Non-Pressure and/or Pressure Ulcers are identified. The nurses to complete this task include the ADON, and the Treatment Nurse. This audit will be completed by 06/09/23 at midnight. <BR/>Treatment orders will be audited to ensure that all existing wounds have a wound order in place. This audit will be completed by 06/09/23 at midnight. Nurses, Regional Nurse and Chief Nursing Officer will conduct this audit. <BR/>The Medical Director, primary care physician, and resident responsible parties will be notified regarding any residents with new non pressure and/or pressure areas identified. Treatment Orders will be obtained and initiated for any newly identified areas. Nurses to complete this task will include the ADON, and the Treatment Nurse. This audit and notifications will be completed by 06/10/23 at 12 noon.<BR/>The facility will provide the status of previously identified wounds to the PCP and Medical Director, noting any deterioration or healing progress. Nurses to complete this task will include the ADON, and the Treatment nurse. This audit will be completed by 06/10/23 at 12 noon.<BR/>Facility Plan to Ensure Compliance Quickly (and Ongoing):<BR/>Nursing staff (licensed and certified) will be re-educated on the Skin Management System starting on 06/10/23 by the Regional Nurse and the Chief Nursing Officer with the target completion date of 06/11/23. Nursing staff members will not be allowed to work their oncoming shift until this education is completed. On- going competency of the Skin Management System will be monitored by asking oral/verbal questions, rounding and auditing of documentation and orders in the electronic medical record. This in servicing will occur upon hire, and quarterly moving forward. This will be tracked by the Administrator and the DON monthly to ensure said standards are met. <BR/>Nursing staff will be re-educated on the stop and watch tool and the skin identification form. Education will be completed prior to nursing staff commencing their next assigned shift. Nurses to complete this task will include the ADON, and the Treatment Nurse. This education will be completed by 06/11/23. Any nursing employee not present will complete the in-service prior to starting their next shift. <BR/>The facility will conduct an audit to ensure that all residents have current Braden scores in place to reflect risk for Pressure Ulcer development and to ensure interventions are in place. Nurses completing this task include the Regional Nurse and the Chief Nursing Officer. This audit will be completed by 06/09/23 at midnight.<BR/>New or readmitted residents with wounds will have a head-to-toe skin assessment completed by the Treatment Nurse. If the Treatment nurse is off, the Admitting Charge Nurse will complete the Head to Toe for Skin. The Nurse Managers, ADON, and Infection Preventionist, will do a follow up skin review no later than 24 hours post admission to confirm initial findings and to ensure the treatment order is in place, and that the physician and responsible party are aware of any identified wounds as well as the plan of care. Education on this process will be provided by the DON, and will be completed by Sunday, 06/11/23 at midnight. Any nursing employee not present will complete the in-service prior to starting their next shift. <BR/>Surveyor confirmed the POR for the IJ by monitoring from 06/10/2023 through 06/13/2023 as follows: <BR/>Record review of the in-services dated 06/08/23 to 6/12/23 revealed no concerns and nursing staff were trained on the following:<BR/>Admission/readmission skin assessments, Braden Scales, Skin Management Program, POC Kardex Compliance, Off-loading Devices, Nutritional Guidelines for Pressure Ulcers, Showers, Weekly Skin Assessments, Notification of Medical Director/Responsible Party/Registered Dietician Change in Condition, Contracture Management, Care Plans, Un[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 2 of 2 residents (Resident #16 and #89) reviewed for infection control.<BR/>1.CNA B failed to perform hand hygiene appropriately while providing incontinent care for Resident #16 by not changing gloves and washing hands.<BR/>2.CNA A failed to perform hand hygiene appropriately while providing incontinent care for Resident #89 by not changing gloves and washing hands.<BR/>These failures could place residents at risk for transmission of diseases and organisms. <BR/>The findings included:<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/>Review of Resident #16s Care Plan, dated 01/24/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for sign and symptom of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 8:46 AM of Resident #16's incontinent care, revealed C.NA B washed hands before donning ( put on) clean gloves and C.NA A was assisting . Resident #16's soiled brief was pulled down in front. C.NA B using the wet wipes cleaned the perineal, groin area. She did not change gloves and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then picked up a clean brief using the same gloves. The resident was rolled to her back, and the brief was secured. CNA B placed a wedge under residents' hip and pulled the blanket up to cover her legs. CNA B used the same gloves throughout while performing incontinent care. <BR/>Resident #89<BR/>Review of Resident #89's face sheet dated 02/07/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 01/27/24 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), pneumonia,(an infection of the lungs that may be caused by bacteria, viruses or fungi ), sacral region stage 4 pressure sore (full thickness tissue loss with exposed bone, tendon or muscle), severe sepsis with septic shock,( a dramatic drop in blood pressure that can damage the lung, kidneys, liver and other organs), anoxic brain damage ( caused by a complete lack of oxygen to the brain).<BR/> Record review of Resident #89's MDS assessment dated [DATE] (admission) reflected BIMS score was marked 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and continent of bladder using indwelling catheter.<BR/>Review of Resident #89's Care Plan, dated 01/10/24, revealed:<BR/>Problem: resident is incontinent and at risk for skin breakdown related to quadriplegia (paralysis of all four limbs), Fragile Skin, Immobility, Incontinence, Physical Impairment<BR/>Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for s/s of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician.<BR/>Observation on 02/07/24 at 5:30 PM of Resident #89's incontinent care, revealed C.NA A washed hands before donning clean gloves and C.NA B was assisting. Resident #89 was lying in bed. C.NA A washed hands don cleaned gloves, and removed the old brief. Using the wet wipes she cleaned the perineal, groin area., She did not did change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks twice, did not clean around the buttocks then used the same gloves and picked up a clean brief put on the Resident #89.<BR/>In an interview with CNA A and C.NA B on 02/08/24 at 6:10 PM, she stated she forgot to change gloves . They both stated it was wrong because it could cause an infection. Both C.NA's stated they had training on infection control in 01/2024.<BR/>During an interview on 02/09/24 at 3:10PM with ADON/ Infection Preventionist, stated that her expectations for staff is to wash hands before all resident care. Staff should knock on the door, introduce themselves, wash hands, and don (putting on) gloves. Staff should then provide incontinent care, then doff (removing) gloves. Staff should wash hands, and don new gloves prior to applying new brief. The ADON was informed of the observation and stated the facility did proficiency checks on hire and quarterly.<BR/>In an interview with the DON on 02/09/24 at 3:30 PM, she stated CNA A was one of the facility's lead aides that monitored other staff during orientation with incontinent care. DON said not washing hands after changing gloves could cause urinary tract infections. DON said C.NA A and C.NA B knew they should clean around the buttocks before placing a clean brief. DON said she would be performing more in-services for incontinent care. <BR/>In an interview on 02/09/2024 at 3:35 PM, the Administrator stated his expectation was that incontinent care and hand washing were always done to prevent infection. <BR/>Record review for CNA A's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 01/17/2024 done by the DON. <BR/>Record review for CNA B's skilled checkoff list for incontinent care and hand washing care revealed, she had an in-service on 11/5/23 and 01/17/2024 done by the DON. <BR/>Review of the facility's policy titled; Handwashing/Hand Hygiene revised on 08/2019. <BR/>Policy Statement<BR/>This facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.<BR/>2. <BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.<BR/>3. <BR/>The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.<BR/>4. <BR/>Single-use disposable gloves should be used:<BR/>1. <BR/>before aseptic procedures;<BR/>2. <BR/>when anticipating contact with blood or body fluids; and<BR/>3. <BR/>when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions.<BR/>Equipment and Supplies<BR/>1. <BR/>The following equipment and supplies are necessary for hand hygiene:<BR/>4. <BR/>Alcohol-based hand rub containing at least 62% alcohol;<BR/>5. <BR/>Running water;<BR/>6. <BR/>Soap (liquid or bar; anti-microbial or non-antimicrobial);<BR/>7. <BR/>Paper towels;<BR/>8. <BR/>Trash can;<BR/>9. <BR/>Lotion; and<BR/>10. <BR/>Non-sterile gloves.<BR/>Washing Hands<BR/>1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands.<BR/>2.Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.

Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a safer and sanitary enteral feeding process for seven (Resident #2, #3, #4, #5, #6, #7, #8) of sixteen residents reviewed for receiving enteral feeding via a pump. <BR/>The facility failed to clean enteral feeding pump and pole, which was dirty on 04/19/23 for Residents #2, #3, #4, #5, #6, #7, #8.<BR/>This failure could affect the residents who received their nutritional needs via an enteral feeding pump, by placing them at risk for spreading disease-causing organisms, cross-contamination, and possible infection.<BR/>Findings included:<BR/>Observations on 04/19/23 at 10:03 AM of Resident #2 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; top and bottom of the pump.<BR/>Observations on 04/19/23 at 10:10 AM of Resident #3 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; top and bottom of the pump.<BR/>Observations on 04/19/23 at 10:15 AM of Resident #4 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; top and bottom of the pump.<BR/>Observations on 04/19/23 at 10:20 AM of Resident #5 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; top and bottom of the pump.<BR/>Observations on 04/19/23 at 10:25 AM of Resident #6 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; top and bottom of the pump.<BR/>Observations on 04/19/23 at 10:29 AM of Resident #7 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; top and bottom of the pump.<BR/>Observations on 04/19/23 at 10:34 AM of Resident #8 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; top and bottom of the pump.<BR/>Record review on 05/25/23 revealed Resident #2 had a physician's order for continuous enteral feeding, Glucerna 1.5, Rate: 55 ml/hour x 22 hours daily.<BR/>Record review on 05/25/23 revealed Resident #3 had a physician's order for continuous enteral feeding, every shift may use feeding Nepro 1.8 at 50 ml/hour x 22 hours daily.<BR/>Record review on 05/25/23 revealed Resident #4 had a physician's order for continuous enteral feeding, every shift Jevity 1.5 at 60 ml/hour x 22 hours daily. <BR/>Record review on 05/25/23 revealed Resident #5 had a physician's order for continuous enteral feeding, Formula: 2 Cal, rate at 40ml/hour x 22 hours daily.<BR/>Record review on 05/25/23 revealed Resident #6 had a physician's order for continuous enteral feeding, every shift continuous enteral feeding formula Isosourse rate at 55 ml/hr x 22 hours daily.<BR/>Record review on 05/25/23 revealed Resident #7 had a physician's order for continuous enteral feeding, every shift start continuous enteral feeding formula Osmolite 1.5 at rate 55 cc/hour with 30 cc of water every hour x 22 hours daily.<BR/>Record review on 05/25/23 revealed Resident #8 had a physician's order for continuous enteral feeding, every shift continuous formula Isosourse 1.5 at rate 60 cc/hour x 22 hours daily.<BR/>Interview and observation on 04/19/23 at 10:45 AM with RN A, of the condition of the enteral feeding pump of Residents #2, #3, #4, and #5, RN A stated he had not noticed the pump and pole being dirty and did not know how long Resident #2, #3, #4, and #5's pump and pole had been that way. He also stated the responsibility of cleaning the pole and pump is for anyone who notices it. RN A stated if feeding pumps and poles are not cleaned it can potentially cause an infection for the residents. <BR/>Interview and observation on 04/19/23 at 11:12 AM with LVN B, of the condition of the enteral feeding pump of Residents #6, #7, and #8, LVN B stated she had not noticed the pump and pole being dirty and did not know how long Resident #6, #7, and #8's pump and pole had been that way. She stated nurses keep them clean, but anyone can really clean them. LVN B stated she would get them cleaned up. RN A stated if feeding pumps and poles are not cleaned it can cause infection or illness for the residents. <BR/>Interview on 5/25/2023 at 1:35 PM with the DON revealed, nursing cleans the enteral feeding pumps and anything below the pumb housekeeping should be cleaning. DON stated she was not sure if housekeeping was aware of that but would make sure they are made aware. DON stated she is responsible for letting the nursing staff know they are to clean the pumps. DON also stated her expectation is for the enteral feeding pumps and poles to be clean and to stay clean. DON stated if enteral feeding pumps are not clean it could cause infection in residents. DON also stated it is a dignity issue. <BR/>Review of facility policy titled Cleaning of Durable Medical Equipment revised March 2022, revealed Purpose: Durable medical equipment (DME) used for patient care (IV poles, pumps, other devices, etc.) is cleaned and disinfected before and after each resident use. General Guidelines: 1. Clean and disinfect durable medical equipment: a. between residents, b. when visibly soiled, c. at least weekly when in use for a single resident, and d. at established intervals when not in use. 2. Utilize germicides that are Environmental Protection Agency (EPA) registered and use in accordance with manufacturers' labeled use and directions, 3. Do not use disinfection solutions that could alter the integrity or performance of the equipment. 4. Use standard precautions when handling durable medical equipment., 5. Separate clean and soiled equipment to prevent cross-contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, comfortable, and homelike environment for 4 residents of 20 residents (Resident #10, #49, #19 and #7), reviewed for environment, in that:<BR/>The facility failed to maintain an ambient air temperature range of 71 degrees to 81 degrees Fahrenheit in the 300 hallway, the dining room and in resident rooms.<BR/>The failure could place residents at risk of loss of body heat and of a decrease in quality of life.<BR/>Findings included:<BR/>Resident #10<BR/>Record review of Resident #10's admission Record revealed a [AGE] year-old-male admitted on [DATE] and originally admitted on [DATE]. His diagnoses included: stroke, muscle weakness, bipolar disorder, thyroid disorder, hypertension, obesity, psychosis, manic episode, mood disorder, paralysis of limbs, nerve damage, edema, diabetes, GERD and BPH.<BR/>Record review of Resident #10's annual MDS dated [DATE] revealed a BIMS score of 15 indicating he was cognitively intact. He required extensive assistance of one person assist for most ADLs. He required only set up help for eating. He used a wheelchair for mobility. He was always incontinent of bowel and bladder.<BR/>Resident #49<BR/>Record review of Resident #49's admission Record revealed a [AGE] year-old-male admitted on [DATE] and initially admitted on [DATE]. His diagnoses included: brain bleed, nutritional deficiencies, mood disorder, hepatitis B, major depressive disorder, epilepsy, hypertension, pressure ulcer of the sacral region and colostomy status.<BR/>Record review of Resident #49's annual MDS dated [DATE] revealed a BIMS score of 9 out of 15 indicating moderate cognitive impairment. He required extensive assistance with one person physical assist dressing and toilet use. He required limited assistance with one person physical assist for bed mobility and personal hygiene. He required supervision for transfers. He was always incontinent of urine and had a colostomy for his bowels. He used a wheelchair for mobility.<BR/>Resident #19<BR/>Record review of Resident #19's admission Record revealed a [AGE] year-old-male admitted on [DATE]. His diagnoses included: stroke, paralysis affecting one side of the body, hypertension, major depressive disorder, GERD and BPH.<BR/>Record review of Resident #19's annual MDS dated [DATE] revealed a BIMS score of 15 indicating he was cognitively intact. He required supervision with one person physical assistance for all ADLs. He was always continent of bowel and bladder. He used a wheelchair for mobility.<BR/>Resident #7<BR/>Record review of Resident #7's admission Record revealed a [AGE] year-old male admitted on [DATE] and originally admitted on [DATE]. His diagnoses included: paralysis of the lower body, amputation of the right leg, hypertension, chronic pain syndrome, muscle contractures, paranoid schizophrenia and major depressive disorder.<BR/>Record review of Resident #7's annual MDS dated [DATE] revealed a BIMS score of 14 out of 15 indicating he was cognitively intact. He required extensive two person assistance for bed mobility, transfers and dressing. He required extensive one person assistance for personal hygiene. He required total dependence of two person assistance for toilet use. He was always incontinent of bowel and bladder. He used a wheelchair for mobility.<BR/>In an observation and interview on 12/13/2022 at 7:15 AM, Resident #49 came out of his room and was self-propelling in his wheelchair in the 300 hallway. He stated he was not getting any sleep because it was so cold in his room and that it was also cold in the hallway. He was wearing a long sleeve sweater and long pants. He stated he had told the nurses about being cold. He did not mention names. <BR/>In an observation and interview on 12/13/2022 at 1:58 PM, Resident #19 was in his room. He was laying in the bed. He was wearing a long sleeve sweater, long pants and a thick blanket partially covering his lower body. He had stockings on his feet. He stated that there had not been heat in the 300 wing for 3 years now and it gets very cold. He stated from the nurse station on down the hall, it was cold. He stated during the freeze last time, it was very cold. He stated he had made complaints to the staff. He did not mention names.<BR/>During an observation on 12/14/2022 at 8:00 AM, the air was very cold in the 300 hallway from the nurse station to the end of the hall where rooms [ROOM NUMBERS] were located.<BR/>In an observation and interview on 12/14/2022 at 8:20 AM, the Maintenance Director checked the air temperature with an infrared temperature sensor. The air in 300 hallway and rooms [ROOM NUMBERS] were very cold. The temperature sensor read 64 degrees Fahrenheit in the hallway outside of rooms 318, 320 and 321. room [ROOM NUMBER] was 59 degrees Fahrenheit. room [ROOM NUMBER] was 67 degrees Fahrenheit and the double hung window was open by approximately 4 inches. room [ROOM NUMBER] shared a wall with room [ROOM NUMBER]. room [ROOM NUMBER] was not checked for ambient air temperature. Resident #19, said he liked the fresh air, and this was why he opened the window. Resident #7's bed was by the window. Resident #7 was lying in bed with multiple layers of blankets and thick comforter covering his body from the neck on down. Resident #7 stated it was cold but was ok as long as he had lots of covers. Resident #10 stated it was colder than hell at night and that he would like it if the temperature was normal. Resident #10, stated he had told the staff. He did not mention any staff names. Resident #10 had multiple layers of blankets and a thick comforter. The Maintenance Director stated he did not know what the temperature of the rooms should be but was going to find out why it was cold. The Maintenance Director stated he had never received any complaints about temperature and that he started working at the facility three weeks ago.<BR/>In an observation and interview on 12/15/2022 at 10:00 AM while walking through the dining room with LPN Z, it was cold and drafty in the dining room. LPN Z stated that the building had always been like this, hot in the summer and cold in other areas during other times of the year. LPN Z stated she would give a resident extra blankets if they complained of feeling cold.<BR/>In an observation and interview on 12/14/2022 at 12:25 PM the Maintenance Director measured the air temperature of the dining room and the sensor read 66 degrees. The thermostat on the wall read 66 degrees. The Maintenance Director looked at the switch on the thermostat and stated someone put the air on, that was why it was cold. <BR/>In an interview on 12/15/2022 at 7:15 AM, the Administrator stated she did not know what the facility temperature should be and referred this surveyor to ask the Maintenance Director.<BR/>In an interview on 12/15/2022 at 10:50 AM, the Maintenance Director stated he thought the temperature in the building should be about 71 degrees to keep the residents comfortable. The Maintenance Director stated his assistant was supposed to monitor the temperatures and log the results.<BR/>Record review of the facility's log for weekly room temperature checks revealed on 12/14/2022, the temperatures in rooms [ROOM NUMBERS] were 72 degrees Fahrenheit. room [ROOM NUMBER] was not listed as being checked. There were no times listed on the log. The log indicated there were no complaints received between 09/13/2022 and 12/15/2022.<BR/>In an interview on 12/15/2022 at 4:40 PM the Maintenance Assistant was asked what time did he check temperatures in rooms [ROOM NUMBERS] on 12/14/2022, he stated at 8:00 AM. He stated when he checked temperatures he would choose random resident rooms and that was why not all rooms were listed as being checked.<BR/>In an interview on 12/16/2022 at 9:25 AM, the Maintenance Director was asked how the temperatures documented on 12/14/2022 for rooms [ROOM NUMBERS] were different than what was measured with the infrared temperature sensor on 12/14/2022 at 8:20 AM. The Maintenance Director stated the Assistant could not have been in the building at 8:00 AM because he started work at 8:30 AM. The Maintenance Director stated he had already corrected the thermostat in 300 Hall by 8:30 AM on 12/14/2022 and the Assistant would then have checked temperatures afterwards. <BR/>In an interview on 12/16/2022 at 9:59 AM, the DON stated she would have to ask Environmental Services about what safe building temperatures should be. The DON stated the temperature would also depend on the resident.<BR/>Record review of the facility's policy and procedure titled Safe and Homelike Environment, copyright date 2022 read in part: .In accordance with resident's rights, the facility will provide safe, clean, comfortable and homelike environment, .Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/ hyperthermia and is comfortable for the residents The facility will maintain comfortable and safe temperature levels .the facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit .if and when a resident prefers his or her room temperature be kept below 71 degrees Fahrenheit, or above 81 degrees Fahrenheit, the facility will assess the safety of this practice on the resident and the resident's roommate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately assess each resident's status for 1 of 5 Residents (Resident #1) reviewed for assessment accuracy in that: <BR/>1. <BR/>Resident #1's quarterly MDS assessment dated [DATE] did not correctly assess his diagnoses.<BR/>This failure could place residents at risk of not receiving the proper care treatments, and interventions due to inaccurate records.<BR/>Findings include:<BR/>Record review of Resident #1 admission record revealed he was a [AGE] year-old male. He was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included cerebral infarction (disrupted blood flow to the brain), unspecified, acute respiratory failure (impairment exchange between gas and lungs) with hypoxia (insufficient amount of oxygen), type 2 diabetes (body not producing enough insulin) mellitus (excess amount of sugar passing through blood and urine) without complications, essential (primary) hypertension (elevated blood pressure), hypothyroidism (not enough thyroid hormone released into the bloodstream), dysphagia following cerebral infarction (brain swelling from stroke), hyperlipidemia (hardening of arteries), tracheostomy (opening in the front of the neck to assist with breathing) status, gastrostomy (artificial external opening into the stomach for nutritional support and/or gastric decompression) status, and neuromuscular dysfunction (muscle weakness) of bladder.<BR/>Record review of Resident #1's MDS assessment dated [DATE] revealed no C. auris diagnosis.<BR/>Record review of undated list of residents on isolation precaution reflected Resident #1 was listed as 1 of 5 residents on isolation precaution and 1 of 4 residents isolated for C-auris (an emerging multidrug-resistant fungus/yeast causing infections in different parts of the body such as in the bloodstream, open wounds, and ears). <BR/>Interview on 08/18/2023 at 04:23 PM the ADON stated that Resident #1 had a diagnosis of C. auris of the blood and had been on the isolation unit since she began working at the facility in December of 2022. The ADON stated that could not locate where the resident's C. auris diagnosis was listed on his MDS assessment. She stated his diagnosis would have transferred with him to the hospital and transferred back with him when he was readmitted to the facility. She stated that she and the current staff know that the resident was on isolation precautions so when he returned from the hospital, he was automatically placed on the isolation unit and room. She stated the importance of listing resident's diagnosis was to ensure residents received the proper care to meet their diagnoses. <BR/>Interview on 08/18/2023 at 05:06 PM the ADON stated that Resident #1's hospital records dated 7/28/2023 revealed that he had a diagnosis of C. auris. She stated since Resident #1 was a readmitting resident, his diagnosis were already listed in the system. She stated she does not know why or when the resident readmitted the C. auris diagnosis was omitted from his MDS assessment. She stated that she would take responsibility for the diagnosis omission and ensure that the resident's MDS assessment was corrected to reflect his C. auris diagnosis. <BR/>Interview on 08/18/2023 at 05:16 PM the Administrator stated it should be the admitting nurse's responsibility to enter a resident's diagnosis when the resident admits or readmits. She stated the importance of having a resident's diagnosis listed on his MDS assessment was so that staff know if a resident should be placed on isolation, how to take care of that resident, what precautions should be taken, and so residents receive the proper medication that went with the diagnosis. <BR/>Interview on 08/18/2023 at 06:12 PM the ADON stated it should have been the admitting nurse and/or MDS's responsibility to ensure that resident's diagnosis was added to his MDS assessment. She stated that she cannot locate in the client profile system where the lapse occurred, and his diagnosis was removed or how it came off. She stated that she does not know who admitted . She stated that the diagnosis would be in his records moving forward. She stated if the resident was discharged out of the facility again, he would return and forever return to the isolation hall. She stated she would do an in-service to correct the readmission/diagnosis error. <BR/>Record review of Resident #1's hospital records dated 07/28/2023 page 3 of 13 revealed . present upon admission multidrug-resistant bacteria multidrug-resistant bacteria (MDRO)/contact precautions: Candida auris, MDRO specimen type: urine, date cultured: 06/17/2023. <BR/>Record review of Resident #1's Progress Notes dated 8/16/2023 All-Inclusive readmission revealed under section G. Health Condition 1a. Specific type of isolation: candida auris was Log in by LPN.<BR/>No record of Resident #1's diagnosis or test results revealing onset of his C. auris diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure they coordinated with the appropriate, State-designated authority, to ensure that individuals with a newly diagnosed mental disorder received care and services in the most integrated setting appropriate to their needs for 1 (Resident #10) of 2 residents reviewed for PASSR. <BR/>The facility failed to complete and submit an accurate PASRR Level 1 for Resident #10 when he was newly diagnosed with a mental illness. <BR/>This failure could place residents who had a positive PASRR Level 1 or residents with a diagnosis of mental illness at risk for not receiving care and services to meet their needs.<BR/>Findings included:<BR/>Record review of Resident #10's admission Record revealed a [AGE] year-old-male admitted on [DATE] and originally admitted on [DATE]. <BR/>Record review of Resident #10's PASRR Level 1 Screening dated 01/14/2020 completed by the facility revealed Section C was answered No for mental illness, intellectual disability and developmental disability. <BR/>Record review of Resident #10's admission Record included the following diagnoses and onset dates: bipolar disorder(11/06/2020), manic episode(03/01/2017), psychosis (03/01/2017) mood disorder(03/01/2017), stroke(03/15/2019) and muscle weakness(04/01/2021). There was no diagnosis of dementia.<BR/>Record review of Resident #10's annual MDS dated [DATE] revealed a BIMS score of 15 indicating he was cognitively intact. Section E of the MDS revealed the resident was coded for verbal behavioral symptoms directed toward others. Section N of the MDs revealed the resident received antidepressants during the last 7 days. <BR/>Record review of Resident #10's active physician orders dated revealed the following orders: <BR/>*Divalproex Sodium 125 mg, 2 capsules for psychosis with the order date 03/31/2022. *observations for side effects of antidepressant medications with the order date 08/09/2022.<BR/>Record review of Resident #10's care plan last reviewed on date 11/03/2022, revealed he used antidepressant medications r/t Bipolar Disorder, date initiated and revised on 07/08/2022. Interventions included to give antidepressant medications ordered by the physician. Monitor/document side effects. The resident had impaired cognitive function or impaired thought processes r/t Psychosis, AEB BIMS = 10, date initiated and revised on 09/13/2018.<BR/>Record review of Resident #10's Form 3713: Consent for Antipsychotic or Neuroleptic Medication Treatment dated and signed on 3/30/2022 by the Nurse Practitioner and Physician, revealed the prescribing physician had been treating Resident #10 since 05/29/2021. Further review revealed the resident was believed to have the following psychiatric condition and/or maladaptive behavior: F 25.0 and that the diagnosis was based on the following dominant characteristics exhibited by the resident: diagnoses of psychoses, manic depression, psychiatric hospitalization in late teens followed up by psychiatrists and types of medication prescribed by psychiatrist such as Depakote and Geodon. <BR/>Record review of Resident #10's Form 1012: Mental Illness/Dementia Resident Review, revealed the form was incomplete. The Form 1012 was completed on 12/14/2022, during survey, marking it as complete 23 months after the diagnosis of bipolar disorder and 9 months after the physician wrote the resident was hospitalized for psychiatric diagnoses in his late teen years. <BR/>In an interview on 12/15/2022 at 7:21 AM, the MDS Nurse stated Resident #10 had symptoms that began probably from dementia when he had a stroke in 2014. The MDS Nurse stated she just submitted in the Simple portal for the PASRR evaluation. The MDS Nurse stated the resident had not been hospitalized for psychiatric issues and knew that this would be one of the questions that would be asked. MDS Nurse stated Resident #10 will probably not be confirmed as having MI, ID, or DD.<BR/>In an interview on 12/15/2022 at 3:55 PM, the MDS Nurse stated she did not see a note from the doctor, then checked again and saw the consent letter for Resident #10. When asked what prompted her to file the form 1012, she stated that it was the diagnosis of Bipolar disorder. She stated if she received that letter, she would have filed the 1012 right away. She stated it was the responsibility of the other MDS Nurse who was in charge of Medicaid residents and that nurse no longer worked at the facility.<BR/>In an interview on 12/16/2022 at 9:59 AM, the DON stated that she did not know about PASRR screening and that was the responsibility of the MDS Nurse or SW. The DON stated if they needed a nurse she would then be involved.<BR/>Record review of the facility policy and procedure, not dated, titled Resident Assessment - Coordination with PASARR Program read in part: .This facility coordinates assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include .b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #16<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck), tachycardia ( a heart rate over 100 beats a Minute), gastrostomy( a surgical procedure used to insert a tube, often referred to as a G-tube).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) reflected BIMS score marked was 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems, and could not recall the current season, She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/> Record review of physician's order dated 10/03/23 reflected Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. <BR/>Review of Resident #16's care plan review on 10/03/23 revealed a focus of Bilateral Hand Roll and off load Bilateral heels, bilateral hand rolls and off load heel up to 24 hours tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. Goal Resident #16 will have hand rolls and to have Bilateral Heels off loaded daily up to 24 hours as tolerated to assist with preventing contractures and injury to bilateral heels with constant monitoring every 4-6 hours by staff. Care plan update of 02/01/24 had intervention for Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours. With an initiated date of 10/03/23<BR/>Record review of Resident # 16's February 2024 MAR and TAR revealed order to Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. <BR/> With a start date of 10/03/23. Treatment was signed as completed daily for 2/6/24, 2/7/24/ and 2/8/24.<BR/>Observation of Resident #16 on 2/6/24 at 10:00 AM, 12:00 PM, and 2:00 PM, revealed her lying in bed with bilateral hands contracted, with no hand rolls, no heel protectors, and her heels were not off the mattress.<BR/>Observation of Resident #16 lying in bed non-responsive on 2/07/24 at 8:47 AM, 10:30 AM, 12:00 PM, 1:30 PM, and 3:30 PM revealed bilateral hands contracted with no hand rolls, no heel protectors, and her heels were not off the mattress.<BR/>Further observation of Resident #16 lying in bed on 2/8/24 at 11:20 AM with Director Respiratory therapy who was at bed side and helped uncover Resident #16's top linen, revealed resident did not have any hand roll to contracted right hand, and feet were not off loaded off the mattress. She had socks on and heels were not floated.<BR/>During an interview with the C.NA A on 2/7/24 at 4:40 PM C.NA A said the nursing staffs were responsible for placing bilateral hand rolls and floating Resident #16's heels. C.NA A said not floating the heels could result in skin break down, she forget to float the heels ( Float heels means that a Resident's heel should be positioned in such a way as to remove all contact between the heel and the bed) and place the handrolls in Resident #16's hands.<BR/>During an interview with the Treatment Nurse and record review on 02/08/24 at 1:00pm she stated she was responsible for making sure that Resident #16 had bilateral hand rolls and floating heels while providing wound care to the resident.<BR/>During an interview with the DON on 2/8/24 at 4:00 PM, she stated the staffs were to ensure physician orders are implemented as ordered. DON stated the nursing staffs were responsible for ensuring bilateral hand rolls and floating heels. DON stated not implementing physician orders could cause a delay in treatment and there could be a potential for worsening of the condition or delay in progress.<BR/>During an interview with the Administrator on 2/8/24 at 4:30 PM, he stated the staffs were to ensure physician orders are implemented as ordered. If treatment was not implemented as ordered by the physician, it could cause worsening of the condition.<BR/>Record review of the facility's policy titled, Following Physician Orders with an implementation date of 09/28/21 stated, 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Document the order by entering the order and the time, date, and signature on the physician order sheet. B. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record<BR/>Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment plan of care for 2 of 4 residents (Resident #16, Resident#28) reviewed for comprehensive care plans. <BR/>Resident #28's comprehensive care plan did not have measures to address and provide care for his skin care under the folds and crevices in his perennial (private part) area to include assessing and monitoring these areas daily for skin breakdown and infection.<BR/>The facility failed to implement Resident #16's physician's order for treatment of her bilateral hand roll and off load bilateral heels and as care plan.<BR/>This failure could place residents at the facility at risk of not having their care needs met, which could cause a decline in physical and psychosocial health.<BR/>Findings included:<BR/>Record review of the facility face sheet revealed that Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia) You might also hear people use the term acute hypoxemic respiratory failure (AHRF)), morbid obesity with aveolar hypoventilation (Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness), type 2 diabetes (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and lymphedema (build-up of fluid in soft body tissues when the lymph system is damaged or blocked).<BR/>Record review of Resident #28's care plan dated initiated 10/16/2021 revealed a care plan for ADL's and limited physical mobility r/t weakness, confusion, limited mobility with interventions/task Resident #28 requires total assistance with toilet use and personal hygiene. A care plan for bowel and bladder incontinence dated initiated and revised on 1016/2021 r/t activity intolerance, confusion and impaired mobility with a goal target date of 3/29/2024 to refrain free of skin break down due to incontinence and brief use through the target date, interventions and task included use MD's order for Nystatin powder and to check frequently for incontinence. Wash rinse and dry perineum (cleaning the private areas of a patient), change clothing PRN and after incontinence episodes.<BR/>Record review of Resident #28's quarterly MDS assessment dated [DATE]th, 2024, revealed he had a BIM score of 14, indicating he was cognitively intact. Resident #28 was also coded as being impaired on both sides, upper and lower extremities for functional limitation range in motion dependent on 2 or more helpers (staff) to complete the activities of bathing, showering, toileting hygiene, dressing the upper and lower body, putting on and removing footwear, he also required partial to moderate assistance to roll to the left sides and lye back down on the bed. Resident 3 28 was totally dependent on staff to transfer from bed to chair or wheelchair. Resident #28 was frequently incontinent of bladder and bowel. Resident #28 was coded to be a risk for pressure ulcers.<BR/>Record review of physician orders for February 2024 included orders for Nystatin Powder 100000 UNIT/GM ,Apply to inner thighs, scrotum, abd topically everyday shift for Incontinence; Rash.<BR/>May Apply Zinc skin barrier after each incontinent episode to help reduce skin impairments. <BR/>Prior to wound treatment evaluate resident for Pain: everyday shift for Wound Care<BR/>After wound treatment evaluate resident for pain: everyday shift for Wound treatment.<BR/>Record review of Resident #28's weekly wound assessments for January 2024 through February 7, 2024 revealed no wound assessment for his perennial, scrotum and folds areas.<BR/>Record review of the facility grievance/complaint form dated 2/7/2024 revealed that Resident #28 filed a grievance that he did not receive care. Resolved by the DON assisting CNA's with providing care and disciplinary action scheduled with CNA assigned Resident #28.<BR/>During an observation and interview on 2/07/2024 at 8:03 am, with Resident #28, laying in his bed, he said that the CNA's do not want to do their job. He said he pushed his call-light at 4:00 pm yesterday and the staff did not come and assist him until 9:00 pm. He said that he has wounds on his bottom and that the staff make him wait and sit in his feces for so long that it dries up on his bottom and they have to scrape the feces off. He said it does not feel good to sit in that at all. He added if he could clean himself, he would but he cannot.<BR/>During an observation on 02/07/24 at 1:30 pm revealed Resident #28's air mattress was wet with urine, and the bed frame towards the foot of the bed was wet and puddles of urine on the floor from the bed to chest by the foot of the bed.<BR/>During an interview on 02/07/24 at 1:20 p.m. CNA N said she had not provided incontinent care for Resident #28 since she came to work today at 6:30 a.m. CNA N said Resident #28 had to call her if he needed to be changed, and she had not gone and checked on Resident #28 for incontinent care. CNA N said she was supposed to make rounds for incontinent care on all residents every two hours. <BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated (to wear off the skin of) with some openings. LVN H said she had worked with Resident #28 last week Friday and Saturday 2/2/24 and 2/3/24, and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 and she assumed the nurses were aware of the skin condition.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she scheduled a disciplinary action for CNA N not providing care for Resident #28, and in-serviced all staff.<BR/>On 2/07/2024 at 8:03 am, an observation and interview with Resident #28, laying in his bed, he said that the CNA's do not want to do their job. He said he pushed his call-light at 4:00 pm yesterday and the staff did not come and assist him until 9:00 pm. He said that he has wounds on his bottom and that the staff make him wait and sit in his feces for so long that it dries up on his bottom and they have to scrape the feces off. He said it does not feel good to sit in that at all. He added if he could clean himself, he would but he cannot.<BR/>During an observation and interview on 02/07/24 at 1:30 pm, it was revealed that Resident #28's under abdominal fold, scrotum, left, and right groin were very red, macerated , and there were tiny openings on all areas. One of the areas on under the abdomen measured about 1.0x1.0 cm. Resident #28 said that it hurts whenever RN A or CNA N cleaned the groin areas, scrotum, and abdominal area. Observation at this time of RN A and CNA N wiping Resident #28 and revealed the wipes had thick white substance and it had a musty odor. <BR/>During an interview on 02/07/24 at 1:20 pm, CNA N said she had not provided incontinent care for Resident #28 since she came to work today at 6:30 a.m. CNA N said Resident #28 had to call her if he needed to be changed, and she had not gone and checked on Resident #28 for incontinent care. CNA N said she was supposed to make rounds for incontinent care on all residents every two hours. <BR/>During an interview on 02/07/24 at 1:24 pm, RN B said she did Resident #28's skin assessment sometimes and the wound care nurse does it at times. RN B said Resident #28 needed two to three staff assistance for incontinent care. RN B said Resident #28 did not have any redness or open area on his buttocks or peri area when she did his skin assessment two weeks ago. RN B said none of the aides had told her that the resident had any open area on his peri area.<BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated with some openings. LVN H said she had worked with Resident #28 last week on Friday and Saturday (2/2/24 and 2/3/24) and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 and she assumed the nurses were aware of the skin condition.<BR/>During an interview on 02/08/24 at 10:42 am, the Wound Care Nurse said she does Resident #28's weekly skin assessment, and she did not see any redness, macerated area, any opening on his groin or abdominal folds. She said she became aware of the area yesterday .<BR/>During an interview on 02/08/24 at 10:54 am, the DON said she became aware of the red macerated area when she came to Resident #28's room. Then DON said she smelled the foul odor and ammonia in the resident room. The DON said the wound care nurse assessments for Resident #28 from January 2024 through February 2024 did not mention Resident #28 had any skin issues on his groin or under his abdomen. The DON said the facility has a new wound care company and the wound care doctor was not notified about the skin condition.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she was already aware of the break in their system with the skin issues and that the team had begun performing skin audits, was training with wound care nurse discussed in QAPI, IDT, physician, PIP, Resident #28, skin assessment was due 2/7/24 and she (the wound care nurse) had not gotten a chance to get to Resident #28, was working the other hall. Resident #28's assessment was due on the 7th of February, If the assessment was due that day and hadn't been conducted that day, she hadn't identified on that day yet because it (the newly identified skin area issue) had not been identified on prior skin assessments it ( the skin issue)was not there in the abdominal fold. They did identify the skin area and put treatment put in place, they are also in process of changing the wound care nurse, they have in-serviced the staff and did a 100 percent skin audit on residents. She said that a care plan was added, and comprehensive care plan should be in place specific for Resident #28's perineal area to include under the folds. She said that any nurse at the facility is responsible for care plans and said a negative outcome could be skin impairment, infection, and delayed treatment. <BR/>Record review of the facility policy and procedure entitled Care Plans, Comprehensive Person-Centered dated revised March 2022 read in part . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . reflects currently recognized standards of practice for problem areas and conditions .assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 residents clinical condition demonstrated that it was not possible, or the resident's preferences indicated otherwise for one of six residents (Resident #36) reviewed for weight loss and nutrition. <BR/>The facility failed to identify early, assess and modify interventions consistent with Resident #36's significant weight loss on 12/06/2022.<BR/>The facility failed to notify the physician as appropriate in evaluating and managing Resident #36's significant weight loss on 12/06/2022.<BR/>These failures could place the residents at risk of health complication related to nutritional and hydration. <BR/>Findings included:<BR/>Record review of Resident #36's admission Record revealed a [AGE] year-old female admitted on [DATE] and originally admitted on [DATE]. Her diagnoses included: difficulty swallowing, diabetes, unstageable pressure ulcer to the sacrum, pneumonia, urinary tract infection, hypertension, muscle wasting, acute kidney failure, acute liver failure, encephalopathy (brain disorder), fluid in the lungs, irregular heartbeat, shingles, and urine retention. Further review of the admission Record revealed Anasarca (generalized edema) was not listed as one of the diagnoses.<BR/>Record review of Resident #36's admission MDS dated [DATE] revealed the resident had adequate hearing, had no speech, rarely/never made herself understood, rarely/never understood others and had impaired vision. The resident was totally dependent on one to two staff assistance for all ADLs. The resident had an indwelling urinary catheter and was always incontinent of bowel. Section K of the MDS revealed a weight of 132 lbs., and a height of 69 inches. The resident had a feeding tube both while not a resident and while a resident at the facility. Further review of the MDS revealed Anasarca was not listed in Section 1, Active Diagnoses.<BR/>Record review of Resident #36's electronic care plan, date initiated 10/15/2022 and revised on 12/13/2022, revealed the resident required tube feeding due to Dysphagia (difficulty swallowing). The goals were for the resident to maintain adequate nutritional and hydration status AEB weight stable, no s/sx of malnutrition or dehydration. Interventions were for the RD to evaluate quarterly and PRN, Monitor caloric intake, estimate needs, and make recommendations for changes to tube feeding as needed, date initiated on 10/15/2022. Further review of the care plan revealed there was no plan for potential weight loss r/t diuretic use or Anasarca.<BR/>Record review of Resident #36's active physician orders as of 12/16/2022 revealed the following orders:<BR/>*continuous enteral feeding formula Isosource 1.5 at a rate of 50cc/hour x 22 hours and every shift water to be set at 30cc/hour to run concurrently with enteral feeding. <BR/>*Furosemide 20mg tablet to be given enterally two times a day to be given as a diuretic, order date 10/29/2022; <BR/>*Multiple Vitamins-Minerals 5 ml in the morning for supplement, order date 11/02/2022, *Vitamin C 5ml in the morning for supplement, order date 11/02/2022 and <BR/>*Zinc 220mg once a day for wound healing, order date 11/02/2022.<BR/>Record review of Resident #36's October 2022 and November 2022 MAR revealed the following: <BR/>*10/14/2022 through 10/25/2022, the resident was receiving enteral feeding of Nepro 1.8 at a rate of 50ml/hour. <BR/>*10/30/2022 through 11/06/2022 the resident was receiving Peptamen 1.5 at 30ml/hour and water at 50ml/hour. <BR/>Record review of Resident #36's October 2022 MAR revealed an order in October for weekly weights x 4 weeks from admission every Monday then monthly weights. There were no documented weights except on 10/31/2022. <BR/>Record review of Resident #36's November 2022 MAR there were no documented weights except on 11/28/2022. <BR/>Record review of Resident #36's December 2022 MAR did not have an order for weights.<BR/>Record review of Resident #36's November 2022 and December 2022 MAR revealed on 11/07/2022 through 12/15/2022, the resident was receiving enteral feeding of Isosource 1.5 at a rate of 30ml/hour and 50ml/hour of water. Further review of the MAR revealed a new order for Isosource 1.5 at 50ml/hour was started on 12/15/2022.<BR/>Record review of Resident #36's hospital records dated 10/10/2022 revealed on 10/14/2022 her weight was 123.2 lbs., and height was 62.5 inches. On 10/26/2022 her weight was 120 lbs., and her height was 62 inches. Further review of the resident's hospital records revealed a diagnosis to include Anasarca.<BR/>Record review of Resident #36's weight log from October 2022 to December 2022 revealed the following: <BR/>*12/15/2022 at 9:02 AM, 97 lbs. (Mechanical Lift), recorded by Unit Manager A,-7.5% change (comparison Weight 10/31/2022, 119.0 lbs., -18.5%, -22lbs) *12/06/2022 at 4:17PM (no device was listed), 97.8 lbs., recorded by Corporate Nurse, -7.5% change (Comparison weight 10/31/2022, 119.0 lbs., -17.8%, -21.2 lbs.) *11/28/2022 at 9:35 AM, 119 lbs. (Mechanical Lift) *11/01/2022 at 11:20 AM, 119 lbs. (Mechanical Lift) *10/31/2022 at 1:39 PM, 119 lbs. (Mechanical Lift) *10/31/2022 at 1:38 PM, 119 lbs. (Mechanical Lift) <BR/>Further review revealed there was no recorded admission weight on 10/14/2022 or a weekly weight prior to hospital discharge on [DATE]. There was no recorded readmission weight on 10/29/2022. <BR/>Record review of Resident #36's Dietician Comprehensive assessment dated [DATE] 12:55PM written by the RD, read in part: . Physical Information .Ideal Body Weight 130-160#, percent of ideal body weight 83% . Plan/Recommendations/Additional Comments - [AGE] year-old female admitted with dx of dysphagia. Wt. 132.4# Ht. 69 in. BMI= 19.5 diet - NPO receiving enteral feeding - Nepro 1.8 @ 50 ml.hr x 22 hours, off 5-7pm provides 1100 ml., 1980 kcal's, 89.1 grams protein, 799.7 ml free water, water flushes 50 ml flush every 4 hours + 30 ml before and after each medication., tolerating TF well current TF meeting calorie needs. Receiving Furosemide-there is an expected weight change. PES = increased calorie and protein needs r/t healing process AEB unstageable pressure ulcer to sacrum <BR/>Observation on 12/13/2022 at 8:04 AM, resident #36 was in bed laying on her left side with a wedge under her back. The HOB was raised. Tube feeding of Isosource 1.5 was infusing continuously at 30ml/hour and water at 50ml/hour. The resident had a tracheostomy connected to the ventilator. The resident's eyes were closed, and she did not respond to verbal greeting. The resident's lips were dry, her face thin with sagging facial skin. Her wrists and forearms were thin. Here limbs were severely contracted.<BR/>In an interview on 12/15/2022 at 11:29 AM, RN G stated she had been working at the facility for a year and started working with Resident #36 when she was in the 100 hall. RN G stated that she believed the Restorative Aides perform the weekly weights for the resident. Typically, the restorative aide weighs and then tells the nurse what the weight was. The nurse would be responsible for checking the weight and if needed, would consult the RD. The dietician would come twice a week and if there was a weight change, the dietician would switch the feedings and nurses would make adjustments on the order. RN G stated she did not notice any physical changes with Resident #36. She recalled Resident #36 was sent to the hospital for critical lab results. The restorative aide would enter the weights into the system and everyone including the RD would be notified of changes. The nurses are responsible for checking trends in weights. Both nurses and restorative aides would see the weight trends. A weight gain or weight loss of 5 lbs. in one week would grab her attention and she would notify the RD, MD and family member. RN G stated she was unaware of any weight loss or known conditions causing fluid retention for Resident #36. RN G stated she made skilled nurse assessment notes on her residents at least every shift. She said someone was always assessing Resident #36 physically especially when skin assessments were done weekly and when working with the Gtube.<BR/>In an interview on 12/15/22 at 12:42PM, Unit Manager A stated she did not work closely with Resident #36 or any resident unless there was a clinical issue and there was no issue brought to her attention regarding this resident. She stated she did not weigh residents, but the RNA gave her a weight sheet that she referred to update resident weights in the EHR. She stated she was aware of who was in charge of the weight program but just knew the DON typically addresses weights and the RD reviewed patients' weights. If there was a significant weight loss or change in condition, the DON and RD would be notified immediately, as well as the physician and responsible party. She stated she did not notice any weight loss in Resident #36 because the last weight she entered was 97 lbs. on 12/14/2022, whereas the previous weight entered on 12/06/2022 was 97.8lbs which was not significant weight drop between the two dates. She stated she did look further back at any additional weights prior to 12/06/2022 for resident #36 as to review her weight history. When asked if she notified any parties about the Resident's weight, she stated she talked to the NP and notified her of resident #36's weight being 97lbs as a matter of fact, but not that there was any recent weight loss. She defined a significant weight as 5% or more, the time frame of the weight loss was dependent on the patient and the implications of weight loss that goes unaddressed was dependent on patient and their diagnoses.<BR/>In an interview on 12/15/2022 at 2:52 PM, RD stated she was instructed to come to the facility because the State had questions. She stated she just saw Resident #36's weight loss today, was not notified by nursing staff about her weight loss but picked up on it on her own and spoke with the DON and Administrator. She stated the DON provided information on weight loss on a monthly basis and residents would verbally report weight concerns to her. If there was no significant change, she would at least do a monthly assessment but every now and then she would look at the residents if they appear on the list. With readmissions, she would automatically see the residents for a reassessment. The RD stated that within a week of Resident #36's admission she would have been seen. She would either check the EHR system to see which of her residents were readmitted or she would ask the admissions staff. She stated she did not know how Resident #36 was not reassessed and that she just missed it. She stated no one alerted her after the weight loss indicated on 12/06/22. The RD stated Resident #36 was on Nepro 1.8 at 50m/hour prior to hospitalization. She had expected weight loss because the resident was on Lasix IV while in the hospital and was presently on Lasix 20mg BID. D stated with Lasix the weight would still fluctuate, even if on oral Lasix. RD stated the resident returned on 10/29/2022. Normally the restorative aide would give her a list of residents' weights. If a resident had a Gtube, usually they were weighed weekly. RD stated if weights seemed unusual, she would ask for a reweigh or would go by the most recent recorded weight. RD stated that based on Resident #36's new weight and corrected height, the minimum calories for her would be 1500 for weight gain and BMI of 18 or above would be the goal. When asked about the risks for Resident #36 if changes to her diet were not made, the RD stated the resident would continue to lose weight. RD stated she would have reassessed and increased the enteral feeding. RD stated usually the facility would notify her of any significant weight loss and usually the facility would then do weekly weights. RD stated she was at the facility twice a week and did not recall if she was at the facility between 11/28/2022 and 12/06/2022. RD stated she did not remember if it was the DON or if it was another nurse who made her aware of the weight loss.<BR/>In an interview on 12/15/2022 at 3:08 PM, RD was asked about the Comprehensive Assessment she wrote on 10/20/2022 and where she got the weight of 132.4 lbs., she stated she got the weight from the Restorative Aide. She did not remember which Restorative Aide.<BR/>On 12/16/2022 at 7:30 AM, a request was made to the Administrator for the Restorative Aide Weight Logbook and was requested again from the DON on 12/16/2022 at 12:15 PM. No Restorative Aide Weight Logbook was submitted by the time of exit.<BR/> In an interview on 12/16/2022 at 7:38 AM, RA C stated she was not done with completing training by PT and once done she would be the lead Restorative Aide. RA C started in the Restorative aide role on 12/08/2022, prior to that she was in a CNA role. RA C stated she was trained by the previous Restorative Aide lead who was no longer employed at the facility. RA C stated if weights were off by 3 lbs., she would reweigh and compare to previous weights. RA C stated she had never weighed Resident #36. RA C stated she received training using the Hoyer lift (mechanical lift) when she started as a CNA and that all CNAs should know how to use the Hoyer lift. RA C stated she would give the weight results to the DON and the DON had the Restorative Aide Weight Logbook. RA C stated everyone was weighed on the first of the month including Gtube residents and residents losing weight. RA C stated that her understanding was that residents were to be weighed weekly. RA C stated that Gtube residents should always come up weekly. RA C stated the nurse and RD would review the residents first and then give the Restorative aide a list. RA C stated as soon as a resident was admitted , the resident was weighed even if the admission was late at night. The weighing should be as close to the admission date as possible. <BR/>In an interview on 12/16/22 at 8:25 AM, the Administrator stated the RD was given an admission report from the nursing department for residents on enteral feeds. She was not aware of the weight change not being reported after Resident #36'sweight of 97.8 lbs. was documented on 12/06/22 by the Corporate Nurse. She stated that the weight change should have been reported immediately to the RD and the physician.<BR/>In an interview on 12/16/2022 at 8:35 AM the MDS Nurse stated that she told the RD, face to face last week, that Resident #36 had a significant weight loss. She stated that RD told her ok and that she will see her next week. MDS Nurse stated she did not document the conversation but that she should have. MDS Nurse stated the RD was responsible for notifying the MD and RP of the significant change. MDS Nurse stated it would be Unit Manager A who knew about Resident #36's weight of 97 lbs. was entered on 12/15/2022. MDS Nurse stated she did not know who entered the weight of 97.8 lbs. on 12/06/2022. MDS Nurse stated the facility had a change in Restorative Aides and was unsure if the weights entered were correct because of this change. MDS Nurse stated she was not the MDS nurse when Resident #36 was admitted , it was another MDS nurse who was no longer employed at the facility and that her plan was to review all resident's weights. MDS Nurse stated Resident #36 had the diagnosis of Anasarca and that was found in the hospital records.<BR/>In a telephone interview on 12/16/2022 at 9:08 AM, Corporate Nurse was at the facility for one week during November/December to help out. Corporate Nurse stated she vaguely remembered that Resident #36's weight had decreased but actually looked up her orders and her diagnoses. Corporate Nurse stated Resident #36 had muscle wasting secondary to a stroke, was on Lasix and also had Anasarca (generalized body swelling) which affects the entire body, and it could be dramatic. Corporate Nurse stated on the day she weighed Resident #36, she talked to the aides who said the resident did not look different and asked for a reweigh. Corporate Nurse stated she did not get the reweight as she had to catch a plane and she left the same day she believed. Corporate Nurse stated she spoke to a nurse in the unit but did not remember any names because she had never worked at this facility before. Corporate Nurse stated she did look at Resident #36's records and recalled the diagnosis and this was all that she remembered. Corporate Nurse was asked about Resident #36's weight loss of 20 lbs. Corporate Nurse stated that a reweigh should have been done and that was the biggest issue. Corporate Nurse stated she knew the practitioner was supposed to be coming and she would have been made aware of the resident's weight by the staff. Corporate Nurse stated all the communication was verbal. When asked what the implications were if information was not documented, RN K stated she did not know what Texas rules and requirements were and that she had a Missouri state compact license. RN K stated she realized everything should be documented in order to follow through with the resident's needs and for the NP to be made aware. Corporate Nurse stated she spoke to the staff and assumed they would follow through. Corporate Nurse stated she did not know what the policy and procedure for documentation was for the facility. <BR/>In an interview on 12/16/2022 at 9:59 AM, the DON stated the MDS Nurse would run a report when there was a significant change in weight. The RD would be alerted, the RD would make recommendations and the NP would be notified. The DON stated, she did not know but the MDS nurse would be the one to know if an SBAR would be triggered by a significant weight loss.<BR/> In an interview on 12/16/2022 at 10:50 AM, MDS Nurse stated that yes, a significant weight loss would trigger an SBAR, and that Unit Manager A was responsible for initiating and writing the SBAR. MDS nurse stated that the SBAR should be written now for Resident #36. <BR/>In a telephone interview on 12/16/2022 at 1:48 PM, the NP stated that Resident #36 was one of her residents she saw twice a week. NP stated she was first notified of the significant weight loss yesterday, 12/15/2022. NP stated that she spoke with the consulting dietician (RD) on 12/15/2022 so the dietician could make recommendations. NP stated she would leave the decision making for the RD. NP stated that Resident #36 should be gaining more weight and not losing weight because she is bedbound and that she will be ordering a battery of labs today (12/16/2022). NP stated she was not exactly sure why the resident was losing weight and that the liver failure could be an issue for weight loss. NP stated Resident #36 is her resident and would always need to know what is going on with her. NP stated they may not be weighing the resident the same way all the time and should be weighing with the same clothes and at the same time of day. NP stated she expected that residents get weighed upon admission and then said maybe weekly thereafter. NP stated she did not look at all the data on the resident all the time when visiting but if the facility brought a change to her attention, then she would address it. When asked if she was aware of the 97.8 lb. weight on 12/06/2022, what would she have done for the resident. NP stated she would have ordered the labs and consulted with the RD exactly like she did when she found on 12/15/2022. <BR/>Record review of Resident #36's Dietician Comprehensive assessment dated [DATE] 11:30 AM written by the RD, read in part: .Demographics/Background .4. current diet order: NPO .B. Physical Information 1b. Most Recent Weight 97 lbs., date: 12/15/2022 9:42 AM, .ideal body weight 99 - 121 #, percent of ideal body weight 80% .current height=62 in Medications .Furosemide tablet 20mg, 1 tablet, enterally, two times a day, Pantoprazole Sodium Packet 40 mg, 1 packet, enterally, every 12 hours .Laboratory Data .Pre-Albumin 21.0 . Plan/Recommendations/Additional Comments - Review of weight loss, current wt. 12/11 = 97#, current Ht = 62 in ., BMI = 17.7 underweight .previous weight 11/28 = 119#; 10/21 = 119# there is a weight loss of 18.48%/22# x 30 days. There is an expected weight loss r/t liver disease and stroke. Resident was on Lasix 60 mg. IV with a BUN of 151 high in the hospital, currently the resident is on Lasix PO. There still an expected weight loss, recommend to increase enteral feeding Isosource 1.5 @50ml/hour x 22hours off from 5-7 pm with 30 ml water flush continuous, enteral feeding will provide 1100 ml, 1650 kcal's, 70.18 grams protein, 8386 ml free water/day, continuous 30 ml water flush before and after each medication administration, resident has a unstageable pressure ulcer to sacrum.<BR/>Record review of Resident #36's progress notes from 12/06/2022 to 12/15/2022 revealed that the RD, NP, and RP were not notified of the significant weight loss after 12/06/2022 when the resident's weight was 97.8 lbs. or at any time prior to 12/15/2022 at 1:00 PM. Further review of the progress notes revealed the Dietician Comprehensive Assessments were not completed within 72 hours of admission, readmission or significant change of condition and the SBAR was not completed prior to 12/15/2022.<BR/>Record review of the facility's policy and procedure titled Nutritional Management, dated 2022 read in part: Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Definitions: Acceptable parameters of nutritional status refers to factors that reflect that an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values .Compliance Guidelines: .2. Identification/assessment: a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy .c. A comprehensive nutritional assessment will be completed by a dietician within 72 hours of admission, annually and upon significant change in condition. Follow-up assessments will be completed as needed. Components of the assessment may include, but are not limited to: i. General appearance, ii. Height/weight .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 (CR #1) of 7 residents reviewed for controlled drugs in that:<BR/>-The facility failed to appropriately store CR #1's Norco oral tablet 5-325mg (Hydrocodone -Acetaminophen- medication classified as a schedule II drug (high potential for addiction and abuse) used to treat pain and also used as a cough suppressant) in the DON's office under double lock when CR #1 was discharged to the hospital on [DATE] and returned to the facility 06/21/24. It was discovered on 06/29/24 that the medication was missing after CR #1 requested pain medication.<BR/>-The facility Nursing staff failed to have completed signatures on their Controlled Drugs-Count Record for the month of June 2024 regarding 7am oncoming nurse and 7pm off going nurse for 6/18/24, 6/20/24, 6/24/24, 6/25/24, and 6/28/24. <BR/>This failure could place residents at risk for unwanted discomfort, pain, and further decrease in quality of life.<BR/>Findings include:<BR/>Record review of CR #1's face sheet dated 03/31/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. CR #1's diagnoses included the following: COPD (a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness, lack of coordination, cognitive deficit, spondylosis(age-related wear and tear of the spine) with radiculopathy lumbar region (a condition that affects the nerve roots in the lower back), anxiety, malignant neoplasm of bronchus or lung (a type of cancer that originates in the airways or lung tissue), malignant pleural effusion (cancer causing an abnormal amount of fluid to collect in the thin layers of tissue lining the outside of the lung), and respiratory failure with hypoxia (lack of oxygen in the tissue to sustain bodily functions) . Further review of the face sheet revealed that resident was discharged from the facility on 07/05/24 to the hospital.<BR/>Record review of CR #1's admission MDS dated [DATE] reflected a BIMS score of 15 indicating that resident cognition was intact. Section N (Medication) of CR #1's MDS reflected that CR #1 was receiving and opioid (pain-relieving medicine that work with the brain cells). <BR/>Record review of CR #1's Comprehensive Care Plan dated 06/14/24 reflected CR #1 was being care planned for pain r/t lung cancer with interventions that included to administer analgesics as per ordered. Give &frac12; hour before treatments or care.<BR/>Record review of CR #1's Physician Order Summery Report for the month of June 2024 reflected the following orders:<BR/>-Dated 06/13/24 Norco oral tablet 5-325mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 6 hours as needed for pain.<BR/>-Dated 06/29/24 Tylenol with Codeine #4 tablet 300-60mg (Acetaminophen-Codeine) give 1 tablet by mouth every 6 hours as needed for pain do not give with Norco. <BR/>Record review of CR #1's MAR for the month of June 2024 reflected the medication Norco 5-325mg (Hydrocodone-Acetaminophen) was given twice on the following days: June the 14th and June the 17th by RN B. Further review reflected that Tylenol with Codeine #4 tablet 300-60mg (Acetaminophen-Codeine) was administered to CR #1 on June the 29th. <BR/>Record review of an E-INTERACT (interventions used to improve the identification, evaluation, and management of changes in resident's condition to reduce unnecessary hospital transfer) was done on CR #1 on 06/17/25 for urinary retention with pain (severe pain) uncontrolled with pain medication and CR #1 was sent to the hospital.<BR/>Record review of the facility- self report revealed CR #1's medication Norco oral tablet 5-325mg (Hydrocodone) went missing after resident was discharged to the hospital 06/17/24. CR #1 returned to the facility 06/21/24 and on 06/29/24 CR #1 requested pain medication. The Unit Manager called pharmacy to reorder the medication. The pharmacy informed the facility the medication Norco 5-325mg 120 tablets was delivered to the facility on [DATE] and signed by LVN G. The Police Department was called, and the investigation was ongoing. <BR/>Record review of the facility Pharmacy drug delivery receipt dated 06/16/24 revealed 120 tablets of Norco 5-325mg (Hydrocodone) was delivered to the facility for CR #1 with the Unit Manger signing for the medication. <BR/>Record review of the facility investigation dated 07/01/24 of statement taken from Unit Manger said after he received the medication Norco 5-325mg (Hydrocodone 120 tablets) on 06/16/24 he did not work on the hall after that.<BR/>Record review of the facility's June 2024 Controlled Drugs-Count Record revealed the following: <BR/>-6/18/24 no signature for 7pm off going nurse.<BR/>-6/19/24 no signature for the 7pm off going nurse.<BR/>-6/20/24 no signature for the7am off going nurse.<BR/>-6/24/24 no signature for the 7am oncoming and 7am off going nurses.<BR/>-6/25/24 no signature for the 7am oncoming and 7am off going nurses.<BR/>-6/26/24 7am oncoming and 7am off going was RN B signature.<BR/>-6/26/24 7am oncoming was RN B signature. The off going signature was not legible.<BR/>-6/27/24 7am oncoming nurse was LVN F signature. The off going signature was not legible.<BR/>-6/28/24 7am oncoming nurse had an illegible signature; no signature for the 7am off going nurse.<BR/>-6/29/24 7am oncoming was LVN A signature. <BR/>Record review of statement from LPN D dated 07/01/24 said she was approached by the previous ADON that RN B would be leaving the facility at 2:00PM and that LPN D along with orientee LVN F would be responsible for the floor. LPN D reported that she got report from RN B and while counting the narcotics with RN B she observed there were some medications wrapped on a sheet with a rubber band. LPN D said she enquired about it and RN B told her don't do not worry about those, CR #1 was transferred to the hospital. LPN D said she suggested that the medication should be given to the ADON, but RN B insisted that she should not worry about the wrapped pack of medications and walk away. LPN D said LVN F was given the key to the narcotic cart throughout the shift and handed it to the oncoming nurse. <BR/>Interview on 04/01/25 at 12:08PM via phone with LPN D said she worked at the facility PRN on the morning or evening shift. LPN D said she remembered the incident regarding CR #1 Norco medication missing. LPN D said she did not remember what day it was but that she was orienting a new nurse when around 12PM the previous ADON came to her to tell her another nurse on the hall was going to have to leave at 2pm who name she could not recall. LPN D said she counted the narcotic count with the nurse. LPN D said she remembered counting Norco medication, but did not remember who the medication belonged to. LPN D said when they approached her later about Norco medication missing. She said 120 pills were missing and that was not what she remembered counting. LPN D said when a resident receiving narcotics had to be transferred to the hospital, the narcotic was supposed to be counted and given to the DON. LPN D said she could not remember what medication belonged to who. LPN D said when she finished counting the narcotic with the nurse, she was told by the previous ADON to give the narcotic key to the nurse she was orienting, and she did.<BR/>Record review of statement from RN B dated 07/01/24 indicated on 06/21/24 she was scheduled to work from 7AM-1PM. RN B said CR #1 was scheduled to be re-admitted to the facility on [DATE]. RN B said she counted the narcotic cart with LPN D and gave report. RN B said when she counted the narcotic with LPN D among the narcotics was CR #1 Norco wrapped with 2 count sheets. RN B said she gave the narcotic key to LPN D.<BR/>Interview on 04/01/25 at 9:43AM via phone with RN B said she used to work at the facility full time on the morning shift from 7a-7p. RN B said she stopped working at the facility in August 2024. RN B said she heard there was a problem with the narcotic count on the hall that CR #1 resided on. RN B said she was called to come to the facility to take a drug test which she did. RN B said she tested negative for the drug test. RN B said there was a male nurse that worked on the same hall that refused to take the drug test but did not remember his name. RN B said whenever she counted the narcotic cart, the count was correct.<BR/>Interview on 04/01/25 at 1:00PM RN B said she was not sure if CR #1's narcotics were on the cart when she counted with LPN D. RN B said it was the facility protocol to count the narcotics and give to the DON when the resident was transferred to the hospital to ensure the medication remained secured. RN B said the narcotics could have been left on the cart because the DON was not at the facility and if not in the facility, the medication must stay on the narcotic cart until the medication can be delivered to the DON.<BR/>Record review of statement from LVN F said on 06/21/24 said she was on orientation with LPN D. LVN F said RN B left the facility at 2:00PM after counting the narcotic cart with LPN D. LVN F said she thought everything was okay.<BR/>Interview on 04/01/25 at 3:33PM via phone with LVN F said on 06/21/24 she was in training with nurse LPN D and did not count the narcotic medication cart. LVN F said she was never given the key to the narcotic cart. LVN F said she was one of the nurses that done a drug test and tested negative for drugs in her system.<BR/>Interview on 03/31/25 at 3:05PM via phone with LPN A said she remembered last year of a resident medication gone missing but did not remember CR #1. LPN A said she worked at the facility on a PRN basis 6a-6p but last year the shift time was from 7a-7p. LPN A said she only worked at the facility on the weekends PRN morning shift. LPN A said when a resident that was receiving narcotics and had to be transferred to the hospital on the weekends, the narcotic had to be counted at the end of each shift with the oncoming nurse following up to that following Monday. After counting the narcotic on that Monday ensuring the count was correct, the narcotic would then be given to the DON to lock the medication away until the resident returned to the facility. <BR/>Interview on 03/31/25 at 5:32PM via phone with the Unit Manager worked at the facility PRN on the weekends as a supervisor. The Unit Manager said it was the morning nurse who name he could not remember brought it to his attention that CR #1's narcotic Norco was missing. The Unit Manger said when CR #1's Norco could not be located, he notified DON A and previous Administrator. The Unit Manager said the protocol was when a resident receiving narcotics was transferred to the hospital, the narcotic must be counted at the end of each shift until it was picked up by the DON. The Unit Manager said LVN G no longer worked at the facility and had not worked at the facility for approximately a year. The Unit Manager said after DON A and the previous Administrator was notified, he did not know what happen regarding the missing narcotic for CR #1. <BR/>Interview on 04/01/25 at 10:45AM with the Human Resource Specialist said all the nurses that had access to the narcotic cart on Hall 200 where CR #1 resided done a drug test except RN E who refused. The Human Resource Specialist said all the nurses that tested for drugs were negative. The Human Resource Specialist said RN E no longer worked at the facility after the incident of CR #1's Norco went missing.<BR/>On 04/01/25 at 11:03AM A call was placed to RN E, no answer. left voicemail with a call back number. RN E did not return the call after making several attempts to contact RN E.<BR/> Interview on 04/01/25 at 1:10PM with the present DON, DON B said if a resident was admitted to the hospital and was receiving narcotics, the narcotics had to be counted by 2 nurses and delivered to the DON for best practices. DON B said if the resident was gone from the facility over 3 days, he believed the narcotic would have to be destroyed. DON B said if the resident returned to the facility and on the same medications, the medications would have to be re-ordered by the physician. DON B said this was how it was done at the previous facility he worked at. The DON B said when the resident was discharged , the narcotic (s) needed to be given to the DON within 24-hour period. DON B said if the resident discharged from the facility on the weekend, the staff would have to continue to count the narcotic at the end of each shift and given to the DON on the following Monday. DON B said when this protocol was not being followed it placed the narcotic at risk of being misplaced. Further interview with DON B said it was the responsibility of the DON to be checking the narcotics on each cart to ensure there were no discrepancies detected with the narcotics and the count sheet and that all signatures were completed on the narcotic sheet. DON B said he had been working at the facility since February 10th, 2025. DON B said he checked the narcotic carts each morning looking for any discrepancies. The DON said the facility had a total of 4 medication carts. <BR/>Record review of DON A work schedule when worked at the facility in June 20204 reflected that DON A was at the facility 06/17/24 (Monday) through 06/21/24 (Friday) as well as 06/24/24 (Monday) through 06/28/24 (Friday).<BR/>Interview on 04/01/25 at 3:18PM via phone with the previous DON, DON A said it was reported that CR #1 Norco was missing when he returned from the hospital. DON A said RN B gave CR #1 his Norco. DON A said it was RN E who refused to be drug tested and resigned. DON A said all the other nurses that had access to the narcotic cart on hall 200 done the drug test and was negative for drugs in their system. DON A said she tried to call RN E later and he never answered. DON A said when a resident on narcotics must be taken to the hospital and gone for more than 24 hours, the narcotics needed to be given to the DON and the drugs are double locked until the resident returned to the facility. DON A said CR #1's narcotic Norco was never located. DON A said whoever counts the narcotic cart was responsible for the narcotic cart. DON A said the facility failed to remove CR #1's medication Norco from the cart and give to the DON so the medication could be double lock for safe keeping. DON A said the staff was in-serviced on the handling of controlled medications. <BR/>Record review of the facility investigation revealed that an in-service was done on 07/01/24 with the staff on controlled substances, storge of medications, abuse, neglect, misappropriation protocols/response. Further review revealed that the facility had conducted a pain questionnaire with the residents with no negative outcome identified. The Regional Nurse had done an audit of the medication room and storage room on 07/01/24 with all medications including narcotics were stored safely. The medication rooms were locked, and medication carts were observed locked when nurse was away from the cart. <BR/>Record review of the facility policy on Controlled Substances revised in April of 2019 reflected in part:<BR/> .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications .At the end of each shift: controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together .Controlled medications will be counted every shift change (scheduled or incidental) by an authorized staff member (RN, LVN, CMA) reporting for duty with an authorized staff member reporting off duty . <BR/>Record review of the facility policy on Identifying Exploitation, Theft and Misappropriation of Resident Property dated April 2021 reflected in part:<BR/> .As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to recognize exploitation of residents and misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without resident's consent .Example of misappropriation of resident property include drug diversion (taking the residents medication) . <BR/>

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 9 percent based on 3 errors out of 31 opportunities, which involved 3 of 5 residents (Resident #1, Resident #2 and Resident #11); and 3 of 5 staff (LVN A, LVN B and LVN D ) reviewed for medication errors.<BR/>- LVN D failed to ensure medication administered to Resident #1 had a Physician's order.<BR/>- LVN A failed to administer the correct eye drop to Resident #2.<BR/>- LVN B failed to administer the correct multivitamin to Resident #11.<BR/>These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.<BR/>Findings included: <BR/>Error #1<BR/>An observation on 12/13/22 at 08:53 AM revealed, LVN D preparing medication for administration to Resident #1 via G-tube, she prepared the solid medications and poured 15 ml of Chlorohexidine 0.12% in individual cops and entered into the resident's room. After administering the medications via G-tube to Resident #1, LVN D dipped 2 sponges into the cup containing Chlorohexidine and used them to wash the inside of the resident's mouth and teeth.<BR/>Record review of Resident #1's Physician's Orders revealed, no active prescription for Chlorhexidine 0.12% (a mouth wash). A prescription for Chlorhexidine- give 15 ml via PEG-Tube in the morning for mouth wash use swab discontinued on 12/07/2022.<BR/>In an interview on 12/13/22 at 11:46 AM, LVN D said that prior to administering medication nursing staff must verify the medication against the resident's orders and medications can only be administered with a Physician's order. She said that Resident #1 used to have an order for Chlorohexidine mouth wash and the medication was in her cart, so she instinctively administered the medication. LVN D said she did not realize Resident #1's mouth wash had been discontinued by the doctor. She said administration of medication without an order could place residents at risk of side effects.<BR/>Error #2<BR/>An observation on 12/13/22 at 09:52 AM revealed, LVN A preparing for administration of medication to Resident #2. She retrieved a box of Artificial Tears Glycerin Solution with 0.2% Glycerin, 0.2% Hypromellose and 1 % Polyethylene Glycol 400 and 8 solid form medications and entered into the resident's room. After administering the 8 oral medications, LVN A placed 1 drop of the Glycerin eye drop in each of Resident #2's eyes.<BR/>Record review of Resident #2's active Physicians Order's for 12/2022 revealed, Artificial Tears Solution 1% (carboxymethyl cellulose sodium) Instill 1 drop in both eyes two times a day for dry eyes.<BR/>An attempt was made to interview LVN A on 12/13/22 at 11:00 AM, the staff member was not available.<BR/>Error #3<BR/>An observation on 12/13/22 at 09:05 AM revealed, LVN B preparing medication for administration to Resident #11. She retrieved 1 tablet of Once Daily Multivitamins with Minerals as well 3 other solid medications, entered into Resident #11's rooms and administered the medications.<BR/>Record review of Resident #11's Physician's Orders dated 03/01/22 revealed, Multivitamin Tablet- Give 1 tablet by mouth one time a day.<BR/>In an interview on 12/13/22 at 11:32 AM, LVN B said prior to administering medication nursing staff must verify the medication against the MAR. She said the vitamin she administered to Resident #11 was incorrect because multivitamin w/ minerals and multivitamins were not the same and it resulted in Resident #11 receiving more supplementation than ordered. <BR/>In an interview on 12/13/22 at 12:23 PM, the DON said that prior to administering medications to a resident nursing staff are expected to verify the patient information and medication against the MAR. She said medications should be administered as ordered and failure to do so places residents at risk for side effects, decreased therapeutic effect, side effects or allergic reactions.<BR/>Record review of the facility's policy titled Medication Administration without a revision date revealed, 11- compare medication source (bubble pack, vial, etc.) with MAR to verify the resident name, medication name, form, dose, route and time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent decrease in range of motion for 1 of 5 residents (Resident #16) reviewed range of motion.<BR/>-The facility failed to ensure Resident #16, with contractures to both hands, was wearing a hand rolls on both hands and off load bilateral heels. as care planned and ordered by the physician.<BR/>- This failure could place resident at risk for further contractures of the hands and fingers, pain, and a decrease in quality of life.<BR/>Findings included:<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck), tachycardia ( a heart rate over 100 beats a Minute), gastrostomy( a surgical procedure used to insert a tube, often referred to as a G-tube).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) reflected BIMS score marked was 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems, and could not recall the current season, She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/> Record review of physician's order dated 10/03/23 reflected Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. <BR/>Review of Resident #16's care plan review on 10/03/23 revealed a focus of Bilateral Hand Roll and off load Bilateral heels, bilateral hand rolls and off load heel up to 24 hours tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. Goal Resident #16 will have hand rolls and to have Bilateral Heels off loaded daily up to 24 hours as tolerated to assist with preventing contractures and injury to bilateral heels with constant monitoring every 4-6 hours by staff. Care plan update of 02/01/24 had intervention for Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours. With an initiated date of 10/03/23<BR/>Record review of Resident # 16's February 2024 MAR and TAR revealed order to Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. <BR/> With a start date of 10/03/23. Treatment was signed as completed daily for 2/6/24, 2/7/24/ and 2/8/24.<BR/>Observation of Resident #16 on 2/6/24 at 10:00 AM, 12:00 PM, and 2:00 PM, revealed her lying in bed with bilateral hands contracted, with no hand rolls, no heel protectors, and her heels were not off the mattress.<BR/>Observation of Resident #16 lying in bed non-responsive on 2/07/24 at 8:47 AM, 10:30 AM, 12:00 PM, 1:30 PM, and 3:30 PM revealed bilateral hands contracted with no hand rolls, no heel protectors, and her heels were not off the mattress.<BR/>Further observation of Resident #16 lying in bed on 2/8/24 at 11:20 AM with Director Respiratory therapy who was at bed side and helped uncover Resident #16's top linen, revealed resident did not have any hand roll to contracted right hand, and feet were not off loaded off the mattress. She had socks on and heels were not floated.<BR/>During an interview with the C.NA A on 2/7/24 at 4:40 PM C.NA A said the nursing staffs were responsible for placing bilateral hand rolls and floating Resident #16's heels. C.NA A said not floating the heels could result in skin break down, she forget to float the heels ( Float heels means that a Resident's heel should be positioned in such a way as to remove all contact between the heel and the bed) and place the handrolls in Resident #16's hands.<BR/>During an interview with the Treatment Nurse and record review on 02/08/24 at 1:00pm she stated she was responsible for making sure that Resident #16 had bilateral hand rolls and floating heels while providing wound care to the resident.<BR/>During an interview with the DON on 2/8/24 at 4:00 PM, she stated the staffs were to ensure physician orders are implemented as ordered. DON stated the nursing staffs were responsible for ensuring bilateral hand rolls and floating heels. DON stated not implementing physician orders could cause a delay in treatment and there could be a potential for worsening of the condition or delay in progress.<BR/>During an interview with the Administrator on 2/8/24 at 4:30 PM, he stated the staffs were to ensure physician orders are implemented as ordered. If treatment was not implemented as ordered by the physician, it could cause worsening of the condition.<BR/>Record review of the facility's policy titled, Following Physician Orders with an implementation date of 09/28/21 stated, 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Document the order by entering the order and the time, date, and signature on the physician order sheet. B. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 4 medication carts (skilled unit MA cart, 300 hall nurse cart, and 200 hall nurse cart) reviewed for medication storage. <BR/>- The 300-hall nurse's cart contained an opened fluticasone propionate nasal spray with no discard date. Cyclosporine ophthalmic emulsion 0.05% was not in the complete original packet. A box of quality choice original eyelid cleansing wipes did not have a visible expiration date.<BR/>-The 200-hall nurse's cart contained a box of quality choice original eyelid cleansing wipes without a visible expiration date.<BR/>These failures could place residents at risk of adverse medication reactions.<BR/>Findings included:<BR/>During observation and interview on 02/07/24 at 4:40 p.m., the 300-hall nursing cart with RN B revealed a bottle of fluticasone propionate nasal spray with an open date of 9/9/23 and no discard date. Cyclosporine ophthalmic emulsion 0.05% was in a white plastic container with a foil cover but did not have the white plastic cover, which had the resident's name, instructions, and expiration date. The plastic contained 28 ampules. A box of quality choice original eyelid cleansing wipes sensitive mild formula had 20 wipes. The box had pink discoloration, and the expiration date was not visible. RN B said she did not know fluticasone propionate nasal spray had a discard date once it was opened. RN B said the bottle had been open for about six months. RN B said Cyclosporine was covered with the plastic cover, which had all the instructions and the resident's name yesterday when she worked, but she did not see it today. RN B checked the eye wipes box and said he could not find the expiration date, and all medications should have an expiration date. The surveyor asked RN B how she ensured she was not administering expired medications to residents, and RN B did not respond. RN B said she had skills checks on medication administration, and it included medication storage.<BR/>During an observation and interview on 02/07/24 at 4:40 p.m., the 200-hall nursing cart with RN A revealed a box of quality choice original eyelid cleansing wipes sensitive mild formula had five wipes, and the expiration date was not visible. RN A said she could not find any expiration date on the eye cleansing wipes box and that all medications should have an expiration date, but she could not find it on the box or the individual packet. RN B said she had not thought about the wipes expiring. RN B said she had skills check off on medication administration and it included medication storage. RN A said she would call the pharmacy, ask about the expiration date, and get back to the surveyor.<BR/>During an interview on 02/09/24 at 9 30 a.m., the DON said all medication that the pharmacy filled should be stored in the original packet it was delivered to the facility because it has all the instructions on how to administer the medication and expiration date, resident's name and the prescriber. The DON said all medication, even over-the-counter medication, should have a use-by date, and she would further investigate the eyelid cleansing wipes. The DON said she would check and see the expiration date on the opened fluticasone propionate nasal spray and get back with the surveyor. The DON and RN A did not get back to the surveyor with the finding on opened expiration date for the opened fluticasone nasal spray.<BR/>Record review of the facility policy on storage of medication dated 2001 MED - PASS, Inc (Revised November 020) read in part . the facility stores all drugs and biologicals in a safe, secure, and orderly manner . policy interpretation and implementation . #2 drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure a notice of transfer or discharge required under this section was made by the facility at least 30 days before the resident was transferred for one (CR #1) of 3 Residents reviewed for discharge requirement.<BR/>The facility did not give CR #1 and/or the representative a discharge notice when she was transferred to a family home. A copy of a notice of transfer was not provided to the representative of the office of the State Long Term Ombudsman.<BR/>This failure affected one discharged resident and could place the residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options and appeal process.<BR/>Findings Included:<BR/>Record review of the face sheet for CR#1 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction, chronic pain syndrome, anemia in other chronic diseases, Wernicke's encephalopathy, obesity, alcohol use with unspecified alcohol- induced disorder, attention-deficit hyperactivity disorder, metabolic encephalopathy, alcoholic cirrhosis of liver without ascites, fatty liver, muscle weakness, abnormalities of gait and mobility, retention of urine, disorientation, and gastro-esophageal reflux without esophagitis. She was discharged on 05/10/2023. <BR/>Interview with family on 5/25/23 at 9:09 AM she stated that prior to CR #1's discharge resident found letter in a drawer with her belongings. Letter stated facility contacted ombudsman and said resident can file an appeal for her planned discharge. CR #1 claimed that she never received letter by hand nor was she verbally told what the letter was about. The letter had a written date of 4/11/23 and a typed discharged date of 4/26/23. The family stated that CR#1 had private insurance that was coming in to pay for expenses for her care at that time. Facility wanted CR#1 out by 5/11/23and stated that the facility did not send any 30-day discharge notification letter to the family. <BR/>Interview with the Social Worker on 5/25/23 at 11:30 AM she stated that she should have sent a written 30-day discharge notification to CR#1/ or to the family.<BR/>Interview with the Business Office Manager on 5/25/23 at 11:45 AM she stated that a copy of the 30-day notification discharge letter was sent to the ombudsman. She showed the surveyor a copy of the letter that was sent to the ombudsman. She apologized for not dating the letter and she stated that she cannot remember the date she gave the 30-day notification letter to CR#1<BR/>Interview with the ombudsman on 2/25/23 at 1:30 PM she stated she did not have a case or record that the facility sent her a 30-day letter of notification for discharge.<BR/>Record review of receipt of grievance/complaint to the facility by CR#1 dated 4/12/23. Administrator went to speak to CR#1about upcoming discharge. Documentation of facility follow up: As per administrator CR#1stated that she is aware about the discharge; but she did not know where she will be going. Result of action taken: Administrator to follow up with family. Resolution of grievance: complaint/grievance was not resolved, and administrator will follow up when closer to discharge date . <BR/>Record review of Social Worker's notes dated 5/04/23 revealed that Social Worker and Business Office Manager met with family to discuss discharge plans. Family informed Social Worker that she will locate a facility in her area and will inform Social Worker of facility's name for referral. Once the facility gets information for a referral facility, the Business Office Manager will inform the family of CR#1's discharge date and discharge alternative. <BR/>Record review of Social Worker's notes dated 5/09/23 revealed that Social Worker spoke to family regarding discharge plans. CR#1was scheduled to discharge home with family. Family will follow up with CR#1's primary care physician with in 7 days of discharged . <BR/>Record review of discharged note dated 5/10/23 - CR#1 was discharged via Dallas transport to family home. The time of pickup was 2:30 PM. The discharged medication and list were given to CR#1. All personnel items were discharged with CR#1. Family was made aware of CR#1's pick up.<BR/>Record review of undated 30 day written discharged notification addressed to CR#1 stated that she will be discharged from [NAME] Care Center effective 30 days from receipt of this letter. The effective date of discharge is 5/11/23. This discharge is based on failure to make payments toward your balance. The facility staff will work with you to prepare the needs to assure a safe and orderly transition. An orientation for discharge planning will be held on April 26, 2023. If there is a conflict with this date, we will be happy to reschedule to a mutually agreeable time prior to the date of discharge. <BR/>Record review of facility's Transfer or Discharge Documentation dated December 2016 read in part. That when a resident is transferred or discharged from the facility, the following information will be documented in the medical record a. The basis for transfer or discharge. b. That an appropriate notice was provided to the resident and/or legal representative. c. The date and time of the transfer or discharge. f. A summary of the resident's overall medical, physical, and mental condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #16<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck), tachycardia ( a heart rate over 100 beats a Minute), gastrostomy( a surgical procedure used to insert a tube, often referred to as a G-tube).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) reflected BIMS score marked was 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems, and could not recall the current season, She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/> Record review of physician's order dated 10/03/23 reflected Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. <BR/>Review of Resident #16's care plan review on 10/03/23 revealed a focus of Bilateral Hand Roll and off load Bilateral heels, bilateral hand rolls and off load heel up to 24 hours tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. Goal Resident #16 will have hand rolls and to have Bilateral Heels off loaded daily up to 24 hours as tolerated to assist with preventing contractures and injury to bilateral heels with constant monitoring every 4-6 hours by staff. Care plan update of 02/01/24 had intervention for Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours. With an initiated date of 10/03/23<BR/>Record review of Resident # 16's February 2024 MAR and TAR revealed order to Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. <BR/> With a start date of 10/03/23. Treatment was signed as completed daily for 2/6/24, 2/7/24/ and 2/8/24.<BR/>Observation of Resident #16 on 2/6/24 at 10:00 AM, 12:00 PM, and 2:00 PM, revealed her lying in bed with bilateral hands contracted, with no hand rolls, no heel protectors, and her heels were not off the mattress.<BR/>Observation of Resident #16 lying in bed non-responsive on 2/07/24 at 8:47 AM, 10:30 AM, 12:00 PM, 1:30 PM, and 3:30 PM revealed bilateral hands contracted with no hand rolls, no heel protectors, and her heels were not off the mattress.<BR/>Further observation of Resident #16 lying in bed on 2/8/24 at 11:20 AM with Director Respiratory therapy who was at bed side and helped uncover Resident #16's top linen, revealed resident did not have any hand roll to contracted right hand, and feet were not off loaded off the mattress. She had socks on and heels were not floated.<BR/>During an interview with the C.NA A on 2/7/24 at 4:40 PM C.NA A said the nursing staffs were responsible for placing bilateral hand rolls and floating Resident #16's heels. C.NA A said not floating the heels could result in skin break down, she forget to float the heels ( Float heels means that a Resident's heel should be positioned in such a way as to remove all contact between the heel and the bed) and place the handrolls in Resident #16's hands.<BR/>During an interview with the Treatment Nurse and record review on 02/08/24 at 1:00pm she stated she was responsible for making sure that Resident #16 had bilateral hand rolls and floating heels while providing wound care to the resident.<BR/>During an interview with the DON on 2/8/24 at 4:00 PM, she stated the staffs were to ensure physician orders are implemented as ordered. DON stated the nursing staffs were responsible for ensuring bilateral hand rolls and floating heels. DON stated not implementing physician orders could cause a delay in treatment and there could be a potential for worsening of the condition or delay in progress.<BR/>During an interview with the Administrator on 2/8/24 at 4:30 PM, he stated the staffs were to ensure physician orders are implemented as ordered. If treatment was not implemented as ordered by the physician, it could cause worsening of the condition.<BR/>Record review of the facility's policy titled, Following Physician Orders with an implementation date of 09/28/21 stated, 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Document the order by entering the order and the time, date, and signature on the physician order sheet. B. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record<BR/>Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment plan of care for 2 of 4 residents (Resident #16, Resident#28) reviewed for comprehensive care plans. <BR/>Resident #28's comprehensive care plan did not have measures to address and provide care for his skin care under the folds and crevices in his perennial (private part) area to include assessing and monitoring these areas daily for skin breakdown and infection.<BR/>The facility failed to implement Resident #16's physician's order for treatment of her bilateral hand roll and off load bilateral heels and as care plan.<BR/>This failure could place residents at the facility at risk of not having their care needs met, which could cause a decline in physical and psychosocial health.<BR/>Findings included:<BR/>Record review of the facility face sheet revealed that Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia) You might also hear people use the term acute hypoxemic respiratory failure (AHRF)), morbid obesity with aveolar hypoventilation (Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness), type 2 diabetes (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and lymphedema (build-up of fluid in soft body tissues when the lymph system is damaged or blocked).<BR/>Record review of Resident #28's care plan dated initiated 10/16/2021 revealed a care plan for ADL's and limited physical mobility r/t weakness, confusion, limited mobility with interventions/task Resident #28 requires total assistance with toilet use and personal hygiene. A care plan for bowel and bladder incontinence dated initiated and revised on 1016/2021 r/t activity intolerance, confusion and impaired mobility with a goal target date of 3/29/2024 to refrain free of skin break down due to incontinence and brief use through the target date, interventions and task included use MD's order for Nystatin powder and to check frequently for incontinence. Wash rinse and dry perineum (cleaning the private areas of a patient), change clothing PRN and after incontinence episodes.<BR/>Record review of Resident #28's quarterly MDS assessment dated [DATE]th, 2024, revealed he had a BIM score of 14, indicating he was cognitively intact. Resident #28 was also coded as being impaired on both sides, upper and lower extremities for functional limitation range in motion dependent on 2 or more helpers (staff) to complete the activities of bathing, showering, toileting hygiene, dressing the upper and lower body, putting on and removing footwear, he also required partial to moderate assistance to roll to the left sides and lye back down on the bed. Resident 3 28 was totally dependent on staff to transfer from bed to chair or wheelchair. Resident #28 was frequently incontinent of bladder and bowel. Resident #28 was coded to be a risk for pressure ulcers.<BR/>Record review of physician orders for February 2024 included orders for Nystatin Powder 100000 UNIT/GM ,Apply to inner thighs, scrotum, abd topically everyday shift for Incontinence; Rash.<BR/>May Apply Zinc skin barrier after each incontinent episode to help reduce skin impairments. <BR/>Prior to wound treatment evaluate resident for Pain: everyday shift for Wound Care<BR/>After wound treatment evaluate resident for pain: everyday shift for Wound treatment.<BR/>Record review of Resident #28's weekly wound assessments for January 2024 through February 7, 2024 revealed no wound assessment for his perennial, scrotum and folds areas.<BR/>Record review of the facility grievance/complaint form dated 2/7/2024 revealed that Resident #28 filed a grievance that he did not receive care. Resolved by the DON assisting CNA's with providing care and disciplinary action scheduled with CNA assigned Resident #28.<BR/>During an observation and interview on 2/07/2024 at 8:03 am, with Resident #28, laying in his bed, he said that the CNA's do not want to do their job. He said he pushed his call-light at 4:00 pm yesterday and the staff did not come and assist him until 9:00 pm. He said that he has wounds on his bottom and that the staff make him wait and sit in his feces for so long that it dries up on his bottom and they have to scrape the feces off. He said it does not feel good to sit in that at all. He added if he could clean himself, he would but he cannot.<BR/>During an observation on 02/07/24 at 1:30 pm revealed Resident #28's air mattress was wet with urine, and the bed frame towards the foot of the bed was wet and puddles of urine on the floor from the bed to chest by the foot of the bed.<BR/>During an interview on 02/07/24 at 1:20 p.m. CNA N said she had not provided incontinent care for Resident #28 since she came to work today at 6:30 a.m. CNA N said Resident #28 had to call her if he needed to be changed, and she had not gone and checked on Resident #28 for incontinent care. CNA N said she was supposed to make rounds for incontinent care on all residents every two hours. <BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated (to wear off the skin of) with some openings. LVN H said she had worked with Resident #28 last week Friday and Saturday 2/2/24 and 2/3/24, and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 and she assumed the nurses were aware of the skin condition.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she scheduled a disciplinary action for CNA N not providing care for Resident #28, and in-serviced all staff.<BR/>On 2/07/2024 at 8:03 am, an observation and interview with Resident #28, laying in his bed, he said that the CNA's do not want to do their job. He said he pushed his call-light at 4:00 pm yesterday and the staff did not come and assist him until 9:00 pm. He said that he has wounds on his bottom and that the staff make him wait and sit in his feces for so long that it dries up on his bottom and they have to scrape the feces off. He said it does not feel good to sit in that at all. He added if he could clean himself, he would but he cannot.<BR/>During an observation and interview on 02/07/24 at 1:30 pm, it was revealed that Resident #28's under abdominal fold, scrotum, left, and right groin were very red, macerated , and there were tiny openings on all areas. One of the areas on under the abdomen measured about 1.0x1.0 cm. Resident #28 said that it hurts whenever RN A or CNA N cleaned the groin areas, scrotum, and abdominal area. Observation at this time of RN A and CNA N wiping Resident #28 and revealed the wipes had thick white substance and it had a musty odor. <BR/>During an interview on 02/07/24 at 1:20 pm, CNA N said she had not provided incontinent care for Resident #28 since she came to work today at 6:30 a.m. CNA N said Resident #28 had to call her if he needed to be changed, and she had not gone and checked on Resident #28 for incontinent care. CNA N said she was supposed to make rounds for incontinent care on all residents every two hours. <BR/>During an interview on 02/07/24 at 1:24 pm, RN B said she did Resident #28's skin assessment sometimes and the wound care nurse does it at times. RN B said Resident #28 needed two to three staff assistance for incontinent care. RN B said Resident #28 did not have any redness or open area on his buttocks or peri area when she did his skin assessment two weeks ago. RN B said none of the aides had told her that the resident had any open area on his peri area.<BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated with some openings. LVN H said she had worked with Resident #28 last week on Friday and Saturday (2/2/24 and 2/3/24) and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 and she assumed the nurses were aware of the skin condition.<BR/>During an interview on 02/08/24 at 10:42 am, the Wound Care Nurse said she does Resident #28's weekly skin assessment, and she did not see any redness, macerated area, any opening on his groin or abdominal folds. She said she became aware of the area yesterday .<BR/>During an interview on 02/08/24 at 10:54 am, the DON said she became aware of the red macerated area when she came to Resident #28's room. Then DON said she smelled the foul odor and ammonia in the resident room. The DON said the wound care nurse assessments for Resident #28 from January 2024 through February 2024 did not mention Resident #28 had any skin issues on his groin or under his abdomen. The DON said the facility has a new wound care company and the wound care doctor was not notified about the skin condition.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she was already aware of the break in their system with the skin issues and that the team had begun performing skin audits, was training with wound care nurse discussed in QAPI, IDT, physician, PIP, Resident #28, skin assessment was due 2/7/24 and she (the wound care nurse) had not gotten a chance to get to Resident #28, was working the other hall. Resident #28's assessment was due on the 7th of February, If the assessment was due that day and hadn't been conducted that day, she hadn't identified on that day yet because it (the newly identified skin area issue) had not been identified on prior skin assessments it ( the skin issue)was not there in the abdominal fold. They did identify the skin area and put treatment put in place, they are also in process of changing the wound care nurse, they have in-serviced the staff and did a 100 percent skin audit on residents. She said that a care plan was added, and comprehensive care plan should be in place specific for Resident #28's perineal area to include under the folds. She said that any nurse at the facility is responsible for care plans and said a negative outcome could be skin impairment, infection, and delayed treatment. <BR/>Record review of the facility policy and procedure entitled Care Plans, Comprehensive Person-Centered dated revised March 2022 read in part . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . reflects currently recognized standards of practice for problem areas and conditions .assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #16<BR/>Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck), tachycardia ( a heart rate over 100 beats a Minute), gastrostomy( a surgical procedure used to insert a tube, often referred to as a G-tube).<BR/>Record review of Resident #16's MDS assessment dated [DATE] (annual ) reflected BIMS score marked was 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems, and could not recall the current season, She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and bladder.<BR/> Record review of physician's order dated 10/03/23 reflected Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. <BR/>Review of Resident #16's care plan review on 10/03/23 revealed a focus of Bilateral Hand Roll and off load Bilateral heels, bilateral hand rolls and off load heel up to 24 hours tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. Goal Resident #16 will have hand rolls and to have Bilateral Heels off loaded daily up to 24 hours as tolerated to assist with preventing contractures and injury to bilateral heels with constant monitoring every 4-6 hours by staff. Care plan update of 02/01/24 had intervention for Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours. With an initiated date of 10/03/23<BR/>Record review of Resident # 16's February 2024 MAR and TAR revealed order to Bilateral Hand Rolls and Off Load Heels up to 24 hour as tolerated with skin checks every 4-6 hours to prevent possible injury to the skin. <BR/> With a start date of 10/03/23. Treatment was signed as completed daily for 2/6/24, 2/7/24/ and 2/8/24.<BR/>Observation of Resident #16 on 2/6/24 at 10:00 AM, 12:00 PM, and 2:00 PM, revealed her lying in bed with bilateral hands contracted, with no hand rolls, no heel protectors, and her heels were not off the mattress.<BR/>Observation of Resident #16 lying in bed non-responsive on 2/07/24 at 8:47 AM, 10:30 AM, 12:00 PM, 1:30 PM, and 3:30 PM revealed bilateral hands contracted with no hand rolls, no heel protectors, and her heels were not off the mattress.<BR/>Further observation of Resident #16 lying in bed on 2/8/24 at 11:20 AM with Director Respiratory therapy who was at bed side and helped uncover Resident #16's top linen, revealed resident did not have any hand roll to contracted right hand, and feet were not off loaded off the mattress. She had socks on and heels were not floated.<BR/>During an interview with the C.NA A on 2/7/24 at 4:40 PM C.NA A said the nursing staffs were responsible for placing bilateral hand rolls and floating Resident #16's heels. C.NA A said not floating the heels could result in skin break down, she forget to float the heels ( Float heels means that a Resident's heel should be positioned in such a way as to remove all contact between the heel and the bed) and place the handrolls in Resident #16's hands.<BR/>During an interview with the Treatment Nurse and record review on 02/08/24 at 1:00pm she stated she was responsible for making sure that Resident #16 had bilateral hand rolls and floating heels while providing wound care to the resident.<BR/>During an interview with the DON on 2/8/24 at 4:00 PM, she stated the staffs were to ensure physician orders are implemented as ordered. DON stated the nursing staffs were responsible for ensuring bilateral hand rolls and floating heels. DON stated not implementing physician orders could cause a delay in treatment and there could be a potential for worsening of the condition or delay in progress.<BR/>During an interview with the Administrator on 2/8/24 at 4:30 PM, he stated the staffs were to ensure physician orders are implemented as ordered. If treatment was not implemented as ordered by the physician, it could cause worsening of the condition.<BR/>Record review of the facility's policy titled, Following Physician Orders with an implementation date of 09/28/21 stated, 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Document the order by entering the order and the time, date, and signature on the physician order sheet. B. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record<BR/>Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment plan of care for 2 of 4 residents (Resident #16, Resident#28) reviewed for comprehensive care plans. <BR/>Resident #28's comprehensive care plan did not have measures to address and provide care for his skin care under the folds and crevices in his perennial (private part) area to include assessing and monitoring these areas daily for skin breakdown and infection.<BR/>The facility failed to implement Resident #16's physician's order for treatment of her bilateral hand roll and off load bilateral heels and as care plan.<BR/>This failure could place residents at the facility at risk of not having their care needs met, which could cause a decline in physical and psychosocial health.<BR/>Findings included:<BR/>Record review of the facility face sheet revealed that Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia) You might also hear people use the term acute hypoxemic respiratory failure (AHRF)), morbid obesity with aveolar hypoventilation (Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness), type 2 diabetes (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and lymphedema (build-up of fluid in soft body tissues when the lymph system is damaged or blocked).<BR/>Record review of Resident #28's care plan dated initiated 10/16/2021 revealed a care plan for ADL's and limited physical mobility r/t weakness, confusion, limited mobility with interventions/task Resident #28 requires total assistance with toilet use and personal hygiene. A care plan for bowel and bladder incontinence dated initiated and revised on 1016/2021 r/t activity intolerance, confusion and impaired mobility with a goal target date of 3/29/2024 to refrain free of skin break down due to incontinence and brief use through the target date, interventions and task included use MD's order for Nystatin powder and to check frequently for incontinence. Wash rinse and dry perineum (cleaning the private areas of a patient), change clothing PRN and after incontinence episodes.<BR/>Record review of Resident #28's quarterly MDS assessment dated [DATE]th, 2024, revealed he had a BIM score of 14, indicating he was cognitively intact. Resident #28 was also coded as being impaired on both sides, upper and lower extremities for functional limitation range in motion dependent on 2 or more helpers (staff) to complete the activities of bathing, showering, toileting hygiene, dressing the upper and lower body, putting on and removing footwear, he also required partial to moderate assistance to roll to the left sides and lye back down on the bed. Resident 3 28 was totally dependent on staff to transfer from bed to chair or wheelchair. Resident #28 was frequently incontinent of bladder and bowel. Resident #28 was coded to be a risk for pressure ulcers.<BR/>Record review of physician orders for February 2024 included orders for Nystatin Powder 100000 UNIT/GM ,Apply to inner thighs, scrotum, abd topically everyday shift for Incontinence; Rash.<BR/>May Apply Zinc skin barrier after each incontinent episode to help reduce skin impairments. <BR/>Prior to wound treatment evaluate resident for Pain: everyday shift for Wound Care<BR/>After wound treatment evaluate resident for pain: everyday shift for Wound treatment.<BR/>Record review of Resident #28's weekly wound assessments for January 2024 through February 7, 2024 revealed no wound assessment for his perennial, scrotum and folds areas.<BR/>Record review of the facility grievance/complaint form dated 2/7/2024 revealed that Resident #28 filed a grievance that he did not receive care. Resolved by the DON assisting CNA's with providing care and disciplinary action scheduled with CNA assigned Resident #28.<BR/>During an observation and interview on 2/07/2024 at 8:03 am, with Resident #28, laying in his bed, he said that the CNA's do not want to do their job. He said he pushed his call-light at 4:00 pm yesterday and the staff did not come and assist him until 9:00 pm. He said that he has wounds on his bottom and that the staff make him wait and sit in his feces for so long that it dries up on his bottom and they have to scrape the feces off. He said it does not feel good to sit in that at all. He added if he could clean himself, he would but he cannot.<BR/>During an observation on 02/07/24 at 1:30 pm revealed Resident #28's air mattress was wet with urine, and the bed frame towards the foot of the bed was wet and puddles of urine on the floor from the bed to chest by the foot of the bed.<BR/>During an interview on 02/07/24 at 1:20 p.m. CNA N said she had not provided incontinent care for Resident #28 since she came to work today at 6:30 a.m. CNA N said Resident #28 had to call her if he needed to be changed, and she had not gone and checked on Resident #28 for incontinent care. CNA N said she was supposed to make rounds for incontinent care on all residents every two hours. <BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated (to wear off the skin of) with some openings. LVN H said she had worked with Resident #28 last week Friday and Saturday 2/2/24 and 2/3/24, and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 and she assumed the nurses were aware of the skin condition.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she scheduled a disciplinary action for CNA N not providing care for Resident #28, and in-serviced all staff.<BR/>On 2/07/2024 at 8:03 am, an observation and interview with Resident #28, laying in his bed, he said that the CNA's do not want to do their job. He said he pushed his call-light at 4:00 pm yesterday and the staff did not come and assist him until 9:00 pm. He said that he has wounds on his bottom and that the staff make him wait and sit in his feces for so long that it dries up on his bottom and they have to scrape the feces off. He said it does not feel good to sit in that at all. He added if he could clean himself, he would but he cannot.<BR/>During an observation and interview on 02/07/24 at 1:30 pm, it was revealed that Resident #28's under abdominal fold, scrotum, left, and right groin were very red, macerated , and there were tiny openings on all areas. One of the areas on under the abdomen measured about 1.0x1.0 cm. Resident #28 said that it hurts whenever RN A or CNA N cleaned the groin areas, scrotum, and abdominal area. Observation at this time of RN A and CNA N wiping Resident #28 and revealed the wipes had thick white substance and it had a musty odor. <BR/>During an interview on 02/07/24 at 1:20 pm, CNA N said she had not provided incontinent care for Resident #28 since she came to work today at 6:30 a.m. CNA N said Resident #28 had to call her if he needed to be changed, and she had not gone and checked on Resident #28 for incontinent care. CNA N said she was supposed to make rounds for incontinent care on all residents every two hours. <BR/>During an interview on 02/07/24 at 1:24 pm, RN B said she did Resident #28's skin assessment sometimes and the wound care nurse does it at times. RN B said Resident #28 needed two to three staff assistance for incontinent care. RN B said Resident #28 did not have any redness or open area on his buttocks or peri area when she did his skin assessment two weeks ago. RN B said none of the aides had told her that the resident had any open area on his peri area.<BR/>During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated with some openings. LVN H said she had worked with Resident #28 last week on Friday and Saturday (2/2/24 and 2/3/24) and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds.<BR/>During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 and she assumed the nurses were aware of the skin condition.<BR/>During an interview on 02/08/24 at 10:42 am, the Wound Care Nurse said she does Resident #28's weekly skin assessment, and she did not see any redness, macerated area, any opening on his groin or abdominal folds. She said she became aware of the area yesterday .<BR/>During an interview on 02/08/24 at 10:54 am, the DON said she became aware of the red macerated area when she came to Resident #28's room. Then DON said she smelled the foul odor and ammonia in the resident room. The DON said the wound care nurse assessments for Resident #28 from January 2024 through February 2024 did not mention Resident #28 had any skin issues on his groin or under his abdomen. The DON said the facility has a new wound care company and the wound care doctor was not notified about the skin condition.<BR/>During an interview on 2/10/2024 at 1:49 pm with the DON, she said she was already aware of the break in their system with the skin issues and that the team had begun performing skin audits, was training with wound care nurse discussed in QAPI, IDT, physician, PIP, Resident #28, skin assessment was due 2/7/24 and she (the wound care nurse) had not gotten a chance to get to Resident #28, was working the other hall. Resident #28's assessment was due on the 7th of February, If the assessment was due that day and hadn't been conducted that day, she hadn't identified on that day yet because it (the newly identified skin area issue) had not been identified on prior skin assessments it ( the skin issue)was not there in the abdominal fold. They did identify the skin area and put treatment put in place, they are also in process of changing the wound care nurse, they have in-serviced the staff and did a 100 percent skin audit on residents. She said that a care plan was added, and comprehensive care plan should be in place specific for Resident #28's perineal area to include under the folds. She said that any nurse at the facility is responsible for care plans and said a negative outcome could be skin impairment, infection, and delayed treatment. <BR/>Record review of the facility policy and procedure entitled Care Plans, Comprehensive Person-Centered dated revised March 2022 read in part . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . reflects currently recognized standards of practice for problem areas and conditions .assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services was provided such care, consistent with professional standards of practice for 1 of 4 residents (Resident #6) reviewed for respiratory therapy in that:<BR/>The facility failed to ensure Resident # 6's concentrator filter was not covered with a substantial amount of dust.<BR/>This failure placed residents who received oxygen therapy at risk of respiratory complications.<BR/>Findings include:<BR/>Record review Resident #6's face sheet dated 01/03/24 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses which included cerebral infarction (disrupted blood flow to the brain), aphasia(a language disorder caused by damage in a specific area of the brain that controls language expression), hypertension (blood vessels have persistently raised pressure) and chronic obstructive pulmonary disease(group of diseases that cause airflow blockage and breathing related problems).<BR/>Record review of Resident #6's quarterly MDS assessment, dated 12/06/2023, revealed 99 for a BIMS score because Resident #6 was not able to complete the assessment. Further review revealed Resident #6 did indicate he was on oxygen. <BR/>Record review of Resident #6's care plan dated 10/16/21 revealed: Resident #6 required oxygen therapy related to COPD(lung disease causing restricted airflow and breathing problems). Interventions: monitor for S/S of respiratory distress and report to MD.<BR/>During an observation on 02/06/24 at 10:07 a.m., revealed Resident #6's oxygen concentrator was covered with a substantial amount of dust. <BR/>During an observation and interview on 02/06/24 at 10:11 a.m., RT M said the filter on Resident #6's concentrator was covered with dust. RT M said if the filter was not clean, it could stop the oxygen flow, which could cause respiratory distress for Resident #6. RT M said Resident #6 could inhale some of the allergens that should have been filtered out, which could cause an allergic reaction for the resident. RT M said the nursing staff cleaned the oxygen concentrator filters.<BR/>During an interview on 02/06/24 at 11:12 a.m., LVN P said the nursing staff was responsible for cleaning Resident #6's concentrator filter, and the night nurse should clean it. LVN P said if the filter was covered with dust, Resident #6 may not get adequate filtered air, and she was unsure if Resident #6 could inhale some of the particles that were supposed to be filtered. LVN P said if Resident # 6 did not get enough oxygen, Resident #6 could have respiratory distress.<BR/>During an interview on 02/09/24 at 10:13 a.m., the DON said respiratory was supposed to clean the filters on the concentrator every week. The DON said if the filter on Resident #6's concentrator was covered with dust, the concentrator would not deliver sufficient air quality to Resident #6. The DON said Resident #6 could go into respiratory distress.<BR/>Record review of the facility policy on oxygen administration dated 2001 MED - PASS, Inc. (Revised October 200) read in part . the purpose of this procedure is to provide guidelines for safe oxygen administration .

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 out of 3 dumpsters, dumpster A.<BR/>-On 4/8/2024 at 8:08am, one of the facility's dumpster was observed with no lid attached or on it and was a quarter full.<BR/>This failure has the potential to affect 54 residents in the facility, staff, and visitors by placing them at risk for infection and a decreased quality of life due to having an exterior environment which could attract pests, rodents and other animals.<BR/>Findings included:<BR/>Observation on 4/8/25 at 8:08am, Surveyor A and [NAME] A observed the facility dumpster area, which was in the lot behind the dietary department. The facility stand-alone dumpster was not covered. The lid was detached and placed on the side next to the dumpster. <BR/>Observation on 4/9/25 at 8:47am, the right lid to the same dumpster was open. It was marked in white chalk 4/09.<BR/>Interview with [NAME] A on 4/8/25 at 8:08am, she said she did not know why the dumpster was open. [NAME] A said that not closing the lids could attract rodents because of the dumpster being located near a sewage line at the facility. She said she would go to her supervisor about this issue. <BR/>Interview with the Dietary Manager on 4/8/25 at 8:20am, she said that the trash company said they would deliver a new dumpster on 4/9/25 because the metal rod that connects the lids to the dumpster was broken. She was going to call again to get an update on the time of arrival. <BR/>Interview on 4/9/25 at 8:47am, the Dietary Manager said she did not know about the white chalk labelled 4/09. She said that if the dumpster was broken it should not be in use. She said the facility had two other dumpsters across from this one that could be used, and she used a mop to close the right lid. <BR/>Interview with the Administrator on 4/8/25 at 8:24am, he said the trash company called him and said they were going to deliver it that day. In a later interview on 4/10/25 at 5:47pm, the Administrator said the dumpster with the broken lid didn't need to be used as the facility had two other working dumpsters with lids. <BR/>Record review of facility's policy and procedure of Food-Related Garbage and Refuse last revised October 2017 read in part, Food-related garbage and refuse are disposed of in accordance with current state laws .7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 4 medication carts (skilled unit MA cart, 300 hall nurse cart, and 200 hall nurse cart) reviewed for medication storage. <BR/>- The 300-hall nurse's cart contained an opened fluticasone propionate nasal spray with no discard date. Cyclosporine ophthalmic emulsion 0.05% was not in the complete original packet. A box of quality choice original eyelid cleansing wipes did not have a visible expiration date.<BR/>-The 200-hall nurse's cart contained a box of quality choice original eyelid cleansing wipes without a visible expiration date.<BR/>These failures could place residents at risk of adverse medication reactions.<BR/>Findings included:<BR/>During observation and interview on 02/07/24 at 4:40 p.m., the 300-hall nursing cart with RN B revealed a bottle of fluticasone propionate nasal spray with an open date of 9/9/23 and no discard date. Cyclosporine ophthalmic emulsion 0.05% was in a white plastic container with a foil cover but did not have the white plastic cover, which had the resident's name, instructions, and expiration date. The plastic contained 28 ampules. A box of quality choice original eyelid cleansing wipes sensitive mild formula had 20 wipes. The box had pink discoloration, and the expiration date was not visible. RN B said she did not know fluticasone propionate nasal spray had a discard date once it was opened. RN B said the bottle had been open for about six months. RN B said Cyclosporine was covered with the plastic cover, which had all the instructions and the resident's name yesterday when she worked, but she did not see it today. RN B checked the eye wipes box and said he could not find the expiration date, and all medications should have an expiration date. The surveyor asked RN B how she ensured she was not administering expired medications to residents, and RN B did not respond. RN B said she had skills checks on medication administration, and it included medication storage.<BR/>During an observation and interview on 02/07/24 at 4:40 p.m., the 200-hall nursing cart with RN A revealed a box of quality choice original eyelid cleansing wipes sensitive mild formula had five wipes, and the expiration date was not visible. RN A said she could not find any expiration date on the eye cleansing wipes box and that all medications should have an expiration date, but she could not find it on the box or the individual packet. RN B said she had not thought about the wipes expiring. RN B said she had skills check off on medication administration and it included medication storage. RN A said she would call the pharmacy, ask about the expiration date, and get back to the surveyor.<BR/>During an interview on 02/09/24 at 9 30 a.m., the DON said all medication that the pharmacy filled should be stored in the original packet it was delivered to the facility because it has all the instructions on how to administer the medication and expiration date, resident's name and the prescriber. The DON said all medication, even over-the-counter medication, should have a use-by date, and she would further investigate the eyelid cleansing wipes. The DON said she would check and see the expiration date on the opened fluticasone propionate nasal spray and get back with the surveyor. The DON and RN A did not get back to the surveyor with the finding on opened expiration date for the opened fluticasone nasal spray.<BR/>Record review of the facility policy on storage of medication dated 2001 MED - PASS, Inc (Revised November 020) read in part . the facility stores all drugs and biologicals in a safe, secure, and orderly manner . policy interpretation and implementation . #2 drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 1 of 2 quarters reviewed for committee attendance, in that:<BR/>The infection preventionist was not present for QAPI meetings from May 2022 to August 2022.<BR/>This failure could place residents at risk of infections.<BR/>Findings included:<BR/>Record review of the QAPI Committee sign-in sheets revealed the IP never signed in for their meetings from May 2022 - August 2022.<BR/>In an interview on 12/16/22 at 3:29PM, the Administrator stated the IP was hired as an IP staff in the month of February 2022. When asked if she was required to be present for the meetings, she said she would need to check the policy to see what it said. <BR/>In an interview on 12/16/22 at 3:35PM the HR staff stated the IP was their only staff with an IP certification and she was hired this year. <BR/>Record review of the QAPI meeting notes from May, June, July, August of 2022 revealed during those months there was no discussion on tracking and trending of infections or infection control data. [DATE] was the first month in which infection control tacking and trending was discussed due to slight increase of respiratory infections with 12 residents acquiring pneumonia.<BR/>In an interview on 12/16/22 at 03:49PM, the IP stated whenever she attended the meeting, she signed in for attendance. She refused to answer whether she attended every QAPI meeting she had since being hired in March 2022. She said if she did not sign in for the meeting it must mean that she was not at the QAPI meeting on a that particular day. She stated without her present, the management would not be able to discuss reported numbers of infection rates in the facility.<BR/>In an interview on 12/16/22 at 3:51PM, the Administrator stated she was hired on in the past month and she did not know the implications of not having an IP staff as part of the QAPI meeting because she had never had a meeting without one since she was hired.<BR/>Record review of the IP's personnel file revealed the IP was hired on 3/07/2022 and was certified as an Infection Preventionist since 2/14/2021. <BR/>Record review of the facility's QAPI program and plan, dated 2017, stated, . The QAPI committee at the minimum consists of . 4) The infection Preventionist .