SWAN HEALTH AT WICHITA FALLS

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 4 (Resident #1, Resident #2, Resident #3, Resident #4) of 4 residents reviewed for infection control, in that:<BR/>The facility failed to implement Enhanced Barrier Precautions for residents requiring ventilation via a tracheostomy tube (a surgically created hole with a tube inserted into the windpipe to provide an alternative airway for breathing) that resided on the vent unit. <BR/>This failure could affect residents and place them at risk for cross contamination and infections.<BR/>The findings included:<BR/>Record review of Resident #1's electronic face sheet dated 12/31/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood). The resident had a Tracheostomy (a surgically created hole with a tube inserted into the windpipe to provide an alternative airway for breathing).<BR/>In an observation and interview on 01/23/2025 at 1:46 pm, Resident #1 was sitting inside his room in a wheelchair. The resident had a Tracheostomy. It was observed there was no indication of implementations of Enhanced Barrier Precautions such as signage or PPE. The resident did not know what Enhanced Barrier Precautions were. He said staff does not wear PPE when providing direct care most of the time. <BR/>Record review of Resident #2's electronic face sheet, dated 12/31/2024 revealed a [AGE] year-old male, with an admission date of 02/07/2024. His diagnosis included: Acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood). The resident had a Tracheostomy (a surgically created hole with a tube inserted into the windpipe to provide an alternative airway for breathing).<BR/>In an observation and interview on 01/23/2025 at 11:58 am, Resident #2 was sitting inside his room in a wheelchair and just had received peri-care. The resident had a Tracheostomy. It was observed there was no indication of implementations of Enhanced Barrier Precautions such as signage or PPE. The resident did not know what Enhanced Barrier Precautions were. He said staff did not wear PPE when providing peri-care. <BR/>Record review of Resident #3's electronic face sheet, dated 12/31/2024 revealed a [AGE] year-old female, with an admission date of 10/12/2018. Her diagnosis included: Chronic respiratory failure with hypoxia (not enough oxygen in the blood). The resident had a Tracheostomy (a surgically created hole with a tube inserted into the windpipe to provide an alternative airway for breathing).<BR/>In an observation and interview on 01/23/2025 at 1:57 pm, Resident #3 was sitting in a chair in their room. The resident had a Tracheostomy. It was observed there was no indication of implementations of Enhanced Barrier Precautions such as signage or PPE. The resident could not speak but could mouth words with her lips. The resident did not know what Enhanced Barrier Precautions were. She said staff does not wear PPE when providing direct care. <BR/>Record review of Resident #4's electronic face sheet, dated 12/31/2024 revealed a [AGE] year-old female, with an admission date of 09/16/2024. Her diagnosis included: Chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood). The resident had a Tracheostomy (a surgically created hole with a tube inserted into the windpipe to provide an alternative airway for breathing).<BR/>In an observation and interview on 01/23/2025 at 1:55 pm, Resident #4 was sitting up in her bed. The resident had a Tracheostomy. It was observed there was no indication of implementations of Enhanced Barrier Precautions such as signage or PPE. The resident could not speak but could mouth her words with her lips. She did not know what Enhanced Barrier Precautions were. She did not know if staff wore PPE while providing direct care. <BR/>In an interview on 01/23/2025 at 10:45 am, LVN A stated this was her 2nd day on the vent unit. When asked if Enhanced Barrier Precautions were implemented on the vent unit, she said she did not know but was wondering about it. She said she thought it should be due to the resident's having an internal device. She said she was going to seek further clarification. <BR/>In an interview and observation on 01/23/2025 at 10:50 am, CNA B was observed completing peri-care on Resident #1. CNA B did not have any PPE on except for gloves. The CNA said the resident was not on any precautions. She said there were no residents on the vent unit that was currently on any type of precautions. She said she only wears gloves when providing direct care to residents that have a Tracheostomy.<BR/>In an interview and observation 1/23/25 at 10:51 am, CNA C was observed completing per-care on Resident #1. CNA C was observed only wearing gloves. CNA C said she did not wear any PPE while providing direct care to Resident #1 because he was not on any type of precautions. She said there were no other residents on the vent unit that were on any type of precautions. She said she only wears gloves while providing care to residents that have a Tracheostomy. <BR/>In an interview on 01/23/25 at 10:55 am, Respiratory Therapist D said residents that have a Tracheostomy should be on Enhanced Barrier Precautions. Respiratory Therapist D said she wears PPE while providing direct care but she did not know if the Nurses or CNAs wore PPE while providing direct patient care . She did not know why there was no signage or PPE readily available to indicate if a resident was on Enhanced Barrier Precautions. <BR/>Record review on 01/23/25 at 2:10 pm, of Resident #1, Resident #2, Resident #3, and Resident #4's care plans revealed no care plan for Enhanced Barrier Precautions. <BR/>In an interview on 01/24/25 at 11:00 am, the DON (who is also the Infection Preventionist) said the facility should have implemented Enhanced Barrier Precautions for the resident that have a Tracheostomy but had not done so yet. She said the facility got the supplies in August 2024 but never got it done. She said a possible negative outcome could be the possible spread of infection. She said the facility did not have a policy for Enhanced Barrier Precautions. <BR/>In an interview on 01/25/25 at 2:30 pm, the Administrator said she purchased the supplies for the facility to implement Enhanced Barrier Precautions last August. Said she was not aware the facility had not implemented Enhanced Barrier Precautions. The Administrator said the facility did not have a policy addressing Enhanced Barrier Precautions. <BR/>Review of website https://www.cdc.gov/preventmdro on 7/20/24, revealed the following: <BR/>Multi drug resistant organism transmission is common in skilled nursing facilities, contributing to substantial resident, morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident activities. EBP may be indicated when contact precautions do not apply for residents with any of the following: wounds or indwelling medical devices regardless of multidrug resistant organism colonization status

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 of 2 residents (Resident #294 and Resident #295) reviewed for advanced directives. <BR/>1. <BR/>The facility failed to complete Resident #294's Out-of-Hospital Do Not Resuscitate (OOH DNR) on admission or in a timely manner.<BR/>2. <BR/>The facility failed to ensure Resident #295's code status was documented on admission or in a timely manner.<BR/>These deficient practices could place residents at risk of not having their wishes known, which could affect whether they receive emergency medical treatment.<BR/>The findings include:<BR/>1. Record review of Resident #294's electronic face sheet, dated 03/20/2025, revealed a [AGE] year old female who was admitted to the facility on [DATE]. Resident #294 had diagnoses which included; critical illness myopathy, respiratory failure, pneumonitis, severe sepsis, bacteremia, malignant neoplasm of brain, acute kidney failure, gastrostomy, heart failure, anemia, urinary tract infection, pleural effusion, pseudomonas, gastro-esophageal reflux disease, anxiety, type 2 diabetes mellitus, malignant neoplasm of thyroid, dysphagia, and atrial fibrillation. <BR/>Record review of Resident #294's computer face sheet, dated 3/19/2025, did not indicate the resident's code status. <BR/>Record review of Resident #294's care plan, dated 3/19/2025, revealed no indication the resident was DNR. <BR/>Record review of Resident #294's Physician Order Report, dated 3/19/2025, revealed no physician's order for DNR status.<BR/>In an interview on 03/19/2025 at approximately 1:50 PM with Resident #294 stated she was unaware if she has signed an advance directive recently but wants to be a DNR (Do Not Resuscitate).<BR/>2. Record review of Resident #295's electronic face sheet, dated 03/20/2025, revealed a [AGE] year old male who was admitted to the facility on [DATE]. Resident #295 had diagnoses which included; acute and chronic respiratory failure (lung failure), chronic obstructive pulmonary disease (lung disease that leads to difficulty breathing), Type 2 diabetes, tracheostomy (surgical airway), depression (a mental health condition including feelings of sadness, loss of interest and low energy levels), anxiety disorder (group of mental health conditions includes excessive and persistent fear or worry impacting daily life and functioning), schizoaffective disorder (combination of schizophrenia and a mood disorder), insomnia (sleep disorder), encephalopathy (brain disfunction or damage), myocardial infarction (heart attack), acute kidney failure, and morbid obesity. <BR/>Record review of Resident #295's computer face sheet, dated 3/19/2025, did not indicate the resident's code status. <BR/>Record review of Resident #295's care plan, dated 3/19/2025, revealed no indication of the resident's code status. <BR/>Record review of Resident #295's Physician Order Report, dated 3/19/2025, revealed no physician's order for Code status.<BR/>In an interview on 03/19/2025 at approximately 2:00 PM with Resident #295 stated he was unaware if he has signed anything like that or not and don't remember anyone asking but I want to be a full code.<BR/>In an interview on 03/19/2025 at 1:25 PM, LVN B stated she was did not know the code status of Resident #294 or Resident #295 and was not sure how to find if Resident #294 or Resident #295 were a full code or DNR but she could find out. <BR/>In an interview on 03/19/2025 at approximately 1:40 pm, the ADON stated all staff should know where to locate a resident's code status. The ADON stated LVN B would have to come out of the resident's room and ask for help to know if Resident #294 was a DNR or full code. She further stated, Resident #294 had been at the facility since 3/13/2025 with no advance directive orders but every new resident who was admitted in was a full code until further orders were obtained. She stated the staff would have performed life saving measures if Resident #294 were to code, since there was not a DNR order. She stated her expectation is for all staff to know their residents and their code status. She also stated, an adverse outcome would be a delay in care or place the resident at risk of having their end of life wishes dishonored.<BR/>Record review of the facility's policy titled Advance Directives, dated September 2022, revealed [in part]:<BR/>Policy Statement:<BR/>The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy .<BR/>Determining Existence of Advance Directive: <BR/>1. <BR/>Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.<BR/>If the Resident Does not have an Advance Directive:<BR/>Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 3 of12 Residents (Resident #8, Resident #5, and Resident #35) reviewed for assessments. <BR/>The facility failed to ensure the MDS reflected the use of bed rails for Resident #8, Resident #5 and Resident #35.<BR/>This deficient practice could place residents at risk of not receiving care for identified care needs.<BR/>Findings include:<BR/>1. Record review of Resident #8's electronic face sheet revealed a [AGE] year-old female who was re-admitted to the facility on [DATE], original admission date 09/16/24. Resident #8 had diagnoses which included respiratory failure, kidney failure and diabetes. <BR/>Record review of Resident #8's Significant Change MDS, dated [DATE], revealed: BIMS of 15, which indicated no impaired cognition. Section P Restraints and Alarms revealed bed rails were not used. <BR/>Record review of Resident #8's electronic Comprehensive Care plan, initiated on 12/26/24, revealed in part: Focus: Resident has an ADL self-care performance deficit. Goal: Resident will be clean, dry, and hygiene and dignity maintained. Interventions: SIDE RAILS: Half rails up as per doctor's order for safety during care provision, to assist with bed mobility and positioning. Observe for injury or entrapment related to side rail use. Reposition every 2 hours and as necessary to avoid injury.<BR/>During an observation on 03/18/25 at 11:00 AM, Resident #8 was resting in bed with half side rails up on both sides of her bed. <BR/>2. Record review of Resident #5's electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included respiratory failure, heart failure and diabetes. <BR/>Record review of Resident #5's Annual MDS, dated [DATE], revealed: BIMS of 12, which indicated no impaired cognition. Section P Restraints and Alarms revealed bed rails were not used. <BR/>Record review of Resident #5's electronic Comprehensive Care plan initiated on 02/21/25, revealed no evidence of the use of side rails. <BR/>During an observation on 03/18/25 at 11:05 AM revealed Resident #5 was resting in bed with half side rails up on both sides of her bed. <BR/>3. Record review of Resident #35's electronic face sheet revealed a [AGE] year-old female who was re-admitted to the facility on [DATE], original admission date 01/28/25. Resident #35 had diagnoses which included fracture of arm, diabetes, anxiety, and muscle weakness. <BR/>Record review of Resident #35's Significant Change MDS, dated [DATE], revealed a BIMS score was not completed. Section P Restraints and Alarms revealed bed rails were not used. <BR/>Record review of Resident #35's electronic Comprehensive Care plan, initiated on 02/14/25, revealed in part: Focus: Resident requires siderails while in bed. Goal: Resident will be safe and free from injury related to use of side rails and will have increased mobility and independence for turning and repositioning. Interventions . Instruct use of side rails & how to use them to promote independent repositioning of self, and Side rails up when in bed at all times for safety and support.<BR/>Record review of Resident #35's Bedrail consent, signed 01/28/25, revealed: 1/2 partial rails to left up and right upper bed. <BR/>During an observation on 03/19/25 at 10:26 AM, revealed Resident #35 was resting in bed with half side rails up on both sides of her bed. <BR/>During an interview on 03/20/25 at 12:09 PM, the DON stated side rails should have been care planned and claimed on the MDS. She stated MDS's were completed by an outside MDS consultant at this time. She stated MDS consultant was responsible for ensuring the MDS was accurate. <BR/>During an interview on 03/20/25 at 12:30 PM, the Administrator stated MDS's were completed by an outside MDS consultant. She stated the consultant worked remotely but attended the facility's daily morning meetings via phone call. The Administrator stated side rails should have been claimed on the MDS assessment. She stated she did not have contact information for the MDS consultant. She stated the facility did not have an MDS policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person -centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 12 residents (Resident #5 and #26) reviewed for care plans.<BR/>1. The facility failed to ensure a care plan was developed to address Resident #5's use of bedrails.<BR/>2. The facility failed to ensure a care plan was developed to address Resident #26's ostomy care.<BR/>These failures could place residents at risk for not receiving necessary care and services or having important care needs identified.<BR/>Findings include:<BR/>Resident #5<BR/>Record review of Resident #5's electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included respiratory failure, heart failure and diabetes. <BR/>Record review of Resident #5's Annual MDS, dated [DATE], revealed a BIMS of 12, which indicated moderate cognitive impairment. Section P Restraints and Alarms revealed bed rails were not used. <BR/>Record review of Resident #5's electronic Comprehensive Care plan, initiated on 02/21/25, revealed no evidence of the use of side rails. <BR/>During an observation on 03/18/25 at 11:05 AM, Resident #5 was resting in bed with half side rails up on both sides of her bed. <BR/>Resident #26<BR/>Record review of Resident #26's electronic face sheet, dated 03/19/2025, revealed a [AGE] year-old female who was admitted initially to the facility on [DATE] with a readmission on [DATE] with the following diagnoses: Chronic Obstructive Pulmonary Disease), congestive heart failure, Respiratory failure, Hight Blood Pressure, Type 2 diabetes.<BR/>Record review of Resident #26's significant change MDS Assessment, dated 01/25/2025, revealed Section C - cognitive patterns: Resident #26's had a BIMS of 10 which indicated moderate cognitive impairment Section H-- Bladder and Bowel, revealed she had an ostomy.<BR/>Record review of Resident #26's Care Plan, initiated 02/13/2025, revealed no evidence of ostomy care. <BR/>Record review of Resident #26's Physician orders revealed no order for ostomy care prior to 03/19/2025.<BR/>During an observation and interview on 03/18/2025 at 10:41 AM revealed Resident #6 had an ostomy bag. Resident #26's skin around the ostomy did not appear red and the site was clean. Resident #26 stated that staff assist Resident #26 with her care of her ostomy, she said her only complaint was that staff will not empty it when its only half full. Resident #26 stated she wanted her ostomy bag emptied every night before bedtime no matter how full it was, because she did not want it to bust while she was sleeping. <BR/>During an interview on 03/20/2025 at 12:01 PM, the DON stated her expectation was ostomy care and bed rail use should have been included in the Resident's care plan. The DON stated the MDS nurse was responsible to complete the care plans and she was responsible to monitor. The MDS nurse did not work in the facility, it was an outside contracted source. The DON stated the effect on the resident for their care plans not being accurate could have caused the resident to have care needs not met. The DON stated she was responsible to monitor. The DON stated what led to failure was lack of monitoring by herself and the facility was transitioning from one electronic medical company to another electronic medical company.<BR/>Record review of the facility's policy titled, Colostomy/Ileostomy Care, dated October 2010, revealed, The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. Review the resident's care plan to assess for any special needs of the resident.<BR/>Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, revealed: The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and physical psychosocial well-being.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services.<BR/>The facility failed to ensure DA A performed hand hygiene while preparing resident food trays.<BR/>This failure could place residents at risk for contamination and food borne illnesses.<BR/>Findings include:<BR/>During an observation and interview on 03/18/2025 at 11:50 AM, revealed DA-A opened the refrigerator with her gloves on and took a container of lettuce out. She then used her gloved hands to take the lettuce out of the container and placed it on a resident's plate. DA-A opened the refrigerator door with the same gloved hands and placed the container back in the refrigerator and grabbed another container of chopped tomatoes and opened the container and removed the chopped tomatoes to put on the same resident plate without changing gloves or washing hands. DA-A opened the refrigerator with the same gloves on and removed a bag of lettuce. She then removed the lettuce from the bag with the same gloves and placed it on the same resident's plate. DA-A then got an onion out of the refrigerator and placed it on the resident's plate without changing her gloves. DA-A stated she should have changed gloves and did not have a reason as to why she did not. <BR/>During an interview on 03/20/2025 at 10:37 AM, the DM stated her expectation was for all staff to wash their hands with soap and water as well as change their gloves in between touching surfaces other than food. The DM stated when tasks are changed, you should change gloves. She stated the DA should not have used her glove hands to pick up the lettuce, tomatoes, and onions, and should have used a utensil instead. The DM stated all staff were trained as well as having their food handlers' certificate, so they should know what they were supposed to do. She stated DA-A was hired on 03/31/2023. The DM stated she was responsible for monitoring the staff to ensure staff followed policy regarding hand hygiene. The DM stated the effect on residents could have possibly been the spread of food born illnesses. The DM stated DA-A's laziness led to a failure of not having changed her gloves or using appropriate utensils. <BR/>During an interview on 03/20/2025 at 1:10 PM, the ADMN stated her expectation was to follow the facility policy. She stated the DM was responsible to monitor staff and should have monitored accordingly. The ADMN stated the negative affect for residents could have been the spread of foodborne illnesses. She stated she did not really know what the failure was in why the staff had not washed her hands, but she could have been nervous or just not thinking.<BR/>Record review of the facility's policy titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, dated October 2017, revealed: Employees must wash their hands: .Before coming in contact with any food services .after handling soiled equipment or utensils; During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or After engaging in other activities that contaminate the hands .Gloves are considered single-use items and must be discarded after completing the task for which they are used.<BR/>Record review of the Food and Drug Administration Food Code 2022 Annex 4. Management of Food Safety Practices - Achieving Active Managerial Control of Foodborne Illness Risk Factors Annex 4 - 7: <BR/>Full Document accessed 03/20/2025 revealed: <BR/> .practicing no bare hand contact with ready-to-eat food as well as proper handwashing, and implementing an employee health policy to restrict or exclude ill employees are important control measures for viruses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 4 (Resident #1, Resident #2, Resident #3, Resident #4) of 4 residents reviewed for infection control, in that:<BR/>The facility failed to implement Enhanced Barrier Precautions for residents requiring ventilation via a tracheostomy tube (a surgically created hole with a tube inserted into the windpipe to provide an alternative airway for breathing) that resided on the vent unit. <BR/>This failure could affect residents and place them at risk for cross contamination and infections.<BR/>The findings included:<BR/>Record review of Resident #1's electronic face sheet dated 12/31/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood). The resident had a Tracheostomy (a surgically created hole with a tube inserted into the windpipe to provide an alternative airway for breathing).<BR/>In an observation and interview on 01/23/2025 at 1:46 pm, Resident #1 was sitting inside his room in a wheelchair. The resident had a Tracheostomy. It was observed there was no indication of implementations of Enhanced Barrier Precautions such as signage or PPE. The resident did not know what Enhanced Barrier Precautions were. He said staff does not wear PPE when providing direct care most of the time. <BR/>Record review of Resident #2's electronic face sheet, dated 12/31/2024 revealed a [AGE] year-old male, with an admission date of 02/07/2024. His diagnosis included: Acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood). The resident had a Tracheostomy (a surgically created hole with a tube inserted into the windpipe to provide an alternative airway for breathing).<BR/>In an observation and interview on 01/23/2025 at 11:58 am, Resident #2 was sitting inside his room in a wheelchair and just had received peri-care. The resident had a Tracheostomy. It was observed there was no indication of implementations of Enhanced Barrier Precautions such as signage or PPE. The resident did not know what Enhanced Barrier Precautions were. He said staff did not wear PPE when providing peri-care. <BR/>Record review of Resident #3's electronic face sheet, dated 12/31/2024 revealed a [AGE] year-old female, with an admission date of 10/12/2018. Her diagnosis included: Chronic respiratory failure with hypoxia (not enough oxygen in the blood). The resident had a Tracheostomy (a surgically created hole with a tube inserted into the windpipe to provide an alternative airway for breathing).<BR/>In an observation and interview on 01/23/2025 at 1:57 pm, Resident #3 was sitting in a chair in their room. The resident had a Tracheostomy. It was observed there was no indication of implementations of Enhanced Barrier Precautions such as signage or PPE. The resident could not speak but could mouth words with her lips. The resident did not know what Enhanced Barrier Precautions were. She said staff does not wear PPE when providing direct care. <BR/>Record review of Resident #4's electronic face sheet, dated 12/31/2024 revealed a [AGE] year-old female, with an admission date of 09/16/2024. Her diagnosis included: Chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood). The resident had a Tracheostomy (a surgically created hole with a tube inserted into the windpipe to provide an alternative airway for breathing).<BR/>In an observation and interview on 01/23/2025 at 1:55 pm, Resident #4 was sitting up in her bed. The resident had a Tracheostomy. It was observed there was no indication of implementations of Enhanced Barrier Precautions such as signage or PPE. The resident could not speak but could mouth her words with her lips. She did not know what Enhanced Barrier Precautions were. She did not know if staff wore PPE while providing direct care. <BR/>In an interview on 01/23/2025 at 10:45 am, LVN A stated this was her 2nd day on the vent unit. When asked if Enhanced Barrier Precautions were implemented on the vent unit, she said she did not know but was wondering about it. She said she thought it should be due to the resident's having an internal device. She said she was going to seek further clarification. <BR/>In an interview and observation on 01/23/2025 at 10:50 am, CNA B was observed completing peri-care on Resident #1. CNA B did not have any PPE on except for gloves. The CNA said the resident was not on any precautions. She said there were no residents on the vent unit that was currently on any type of precautions. She said she only wears gloves when providing direct care to residents that have a Tracheostomy.<BR/>In an interview and observation 1/23/25 at 10:51 am, CNA C was observed completing per-care on Resident #1. CNA C was observed only wearing gloves. CNA C said she did not wear any PPE while providing direct care to Resident #1 because he was not on any type of precautions. She said there were no other residents on the vent unit that were on any type of precautions. She said she only wears gloves while providing care to residents that have a Tracheostomy. <BR/>In an interview on 01/23/25 at 10:55 am, Respiratory Therapist D said residents that have a Tracheostomy should be on Enhanced Barrier Precautions. Respiratory Therapist D said she wears PPE while providing direct care but she did not know if the Nurses or CNAs wore PPE while providing direct patient care . She did not know why there was no signage or PPE readily available to indicate if a resident was on Enhanced Barrier Precautions. <BR/>Record review on 01/23/25 at 2:10 pm, of Resident #1, Resident #2, Resident #3, and Resident #4's care plans revealed no care plan for Enhanced Barrier Precautions. <BR/>In an interview on 01/24/25 at 11:00 am, the DON (who is also the Infection Preventionist) said the facility should have implemented Enhanced Barrier Precautions for the resident that have a Tracheostomy but had not done so yet. She said the facility got the supplies in August 2024 but never got it done. She said a possible negative outcome could be the possible spread of infection. She said the facility did not have a policy for Enhanced Barrier Precautions. <BR/>In an interview on 01/25/25 at 2:30 pm, the Administrator said she purchased the supplies for the facility to implement Enhanced Barrier Precautions last August. Said she was not aware the facility had not implemented Enhanced Barrier Precautions. The Administrator said the facility did not have a policy addressing Enhanced Barrier Precautions. <BR/>Review of website https://www.cdc.gov/preventmdro on 7/20/24, revealed the following: <BR/>Multi drug resistant organism transmission is common in skilled nursing facilities, contributing to substantial resident, morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident activities. EBP may be indicated when contact precautions do not apply for residents with any of the following: wounds or indwelling medical devices regardless of multidrug resistant organism colonization status

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the resident's needs safely and in a manner that promotes each resident rights, physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #1) reviewed for nursing practices. <BR/>The facility failed to ensure LVN A had the competency to retrieve a physician order before performing an invasive examination. <BR/>The noncompliance was identified as PNC. The noncompliance began 10/18/23 and ended on 10/27/23. The facility had corrected the noncompliance before the investigation began.<BR/>This failure could place the residents at risk of physical and psychosocial harm. <BR/>Findings included:<BR/>Record review of Resident #1's health record revealed a [AGE] year-old female, admission date 08/09/2022, Diagnoses: other intestinal obstruction unspecified as to partial versus complete obstruction (digested material is prevented from passing normally through the bowel), acute and chronic respiratory failure with hypercapnia (respiratory failure due to mechanical defects, central nervous system depression, imbalance of energy demands of central controllers), pleural effusion (fluid buildup between the lung and the chest), not elsewhere classified, unspecified diastolic heart failure (heart's main pumping chamber becomes stiff and unable to fill properly), hypertension (high blood pressure), fatty liver, unspecified cirrhosis of liver (chronic liver damage), hypokalemia (low potassium), edema (swelling caused by too much fluid trapped in body tissue), portal vein thrombosis (narrowing or blockage of the portal vein by a blood clot), unspecified abdominal pain, abdominal distension (bloating and swelling in belly area), muscular dystrophy (genetic diseases that cause progressive muscle weakness and loss of muscle mass), unspecified, Bells' palsy (muscle weakness on one side of face), dysphagia (difficulty swallowing), oropharyngeal phase (difficulty swallowing in mouth or throat), major depressive disorder (persistently low or depressed mood), recurrent, mild, aphonia, UTI (Urinary Tract Infection), anxiety disorder, GERD (Gastroesophageal reflux disease), pain, unspecified, constipation, other megacolon (abnormal dilation of colon), overactive bladder, difficulty in walking, lack of coordination, abnormal posture, muscle weakness, nausea with vomiting, stiffness to right shoulder, pain in right shoulder, and seasonal allergic rhinitis. <BR/>Record review of Resident #1's health record revealed the most recent Care Plan dated 10/25/2023, page 15 of 35, stated Nutritional Status- [Resident #1] has a history of [NAME] and is at risk for increased abdominal distress, weight loss, and GI Bleed. APPROACH: Give medications per order-monitor for effectiveness report to MD if [Resident #1] c/o increased abdominal distress. Page 30 of 35 stated, Urinary Incontinence - [Resident #1] will remain clean, dry and odor free and on occurrence of skin breakdown will occur over next 90 days. Monitor for S/S of infection and report to MD. Monitor for S/S of skin breakdown -report to MD and family. <BR/>Record review of Resident #1's physician orders, dated 10/18/23, revealed no order for a vaginal exam. <BR/>Interview on 11/04/23 at 10:18 am with Resident #1 and RSD RP revealed, resident was in pain, wanted staff to fix it, and agreed to vaginal exam . No complications from the exam. RSD and RSD RP had no concerns with the exam conducted and did not know if there was an order. <BR/>Interview on 11/04/23 at 12:13 pm with House Supervisor at Hospital, revealed they were informed that a nurse from the facility had done a vaginal exam, but they did not know why she did it. Initial complaint concerned that exam completed with no physician order. <BR/>Interview on 11/04/23 at 3:07 pm with LVN C revealed, she would not do a vaginal exam because we don't do that here. The doctor doesn't order us to do things like that. LVN C stated that the facility would need an order to perform a vaginal exam . <BR/>Interview on 11/04/23 at 4:28 pm with ADON revealed that the facility would need an order before doing an exam like that (vaginal exam) but would usually just send the resident out. ADON revealed it was LVN A that completed the exam. ADON stated, it is nursing 101 that you don't do any treatment or exam or administer medications without an order . <BR/>Interview on 11/04/23 at 5:28 pm with the DON revealed that Resident #1 was having pain and was incontinent. Upon the aide wiping the resident during perineal care, aide noticed what she thought was bowel coming from the resident's vagina and went and got the nurse. LVN A asked the resident if she could do the exam and the resident agreed. LVN A completed the vaginal exam with two aides and two nurses in the room. LVN A notified the NP and he said to send the RSD out to the ER, so they did. The order to send her out to ER was dated 10/18/23 and no order for the exam. DON stated she suspended LVN A on 10/19/23 and LVN A came back on 10/27/23 and was re-educated about expectations of orders on 10/27/23. The DON stated that she reported LVN A to the Board of Nursing. The BON provided an assessment tool (Scope of Practice) for LVN A to use to prevent further incidents. The DON stated that staff knew not to complete an exam like that because we do not do them at this facility. LVN A used to work in an OBGYN clinic and had the knowledge to perform the exam, but the facility staff know not to do an exam without an order. She had been trained on Resident Rights but not specifically physician orders because that is something you learn in school. The DON stated it is common knowledge not to do anything like that (vaginal exam) without a physician's order . <BR/>Record review of the Medication and Treatment Orders, Dental Services Policy dated February 2014 revealed 2. Medication orders and treatment will be administered by nursing service personnel as soon as the order has been received. <BR/>Record review of the Texas Board of Nursing -Nursing Practice, page 6 of 17 revealed, The LVN in Texas provides nursing care to patients with healthcare needs that are predictable in nature, under the direction and supervision of an appropriately licensed supervisor. The term predictable describes health conditions that behave or occur in an expected way.<BR/>Record review of the Texas Board of Nursing -Nursing Practice, page 28 of 37 revealed, The Board's position, therefore, is that LVNs are educationally prepared to administer medications and treatments as ordered by a physician, podiatrist, dentist, or any other practitioner legally authorized to prescribe the ordered medication. LVNs may also administer medications and treatments ordered by Physician Assistants (PAs) and Advanced Practice Registered Nurses (APRNs) as established under Position Statements 15.1 and 15.18, relating to nurses accepting orders from PAs and APRNs, respectively.<BR/>Record review of Scope of Practice revealed, 2. Is the activity or intervention authorized by a valid order? No -STOP. <BR/>The facility took the following actions to correct the noncompliance:<BR/>Record review of Expectations of Orders dated 10/27/23, revealed LVN A educated on having a physician order before performing any treatment. <BR/>Interview on 11/04/23 at 5:28 pm with DON revealed she suspended LVN A on 10/19/23 and LVN A came back on 10/27/23 and was re-educated about expectations of orders on 10/27/23 and was reported to the Board of Nursing. BON provided an assessment tool (Scope of Practice) for LVN A to use to prevent further incident.<BR/>Interview on 11/4/23 at 2:15pm with LVN B revealed she had the knowledge to not do an exam before contacting the doctor to get an order.<BR/>Interview on 11/4/23 at 3:07pm with LVN C revealed she had the knowledge not to complete an exam without doctor's orders. <BR/>Interview on 11/4/23 at 4:28pm with ADON revealed she knew and felt it was common knowledge for nurse's to know not to do any treatment or exam without an order.<BR/>Interview on 11/4/23at 10:18 am with Family Member #5 (RSD #1 RP) revealed she believed the facility follows orders and whatever the facility staff did helped Resident #1 feel better.<BR/>Interview on 11/4/23 at 12:42 pm with Familiy Member #6 (Resident #4's sister) revealed she felt staff do their job at the facility (follow orders) and make her aware of what is going on with her sister. <BR/>Interview on 11/4/23 at 10:18am with Resident #1 revealed she had no worries about whatever they (facility staff) did and they (facility staff) made her feel better. <BR/>Interveiw on 11/4/23 at 10:55am with Resident #2 revealed staff do what they are supposed to and she had no other concerns. <BR/>Interview on 11/4/23 at 12:42 pm with Resident #4 revealed the facility staff do a thorough job and follow orders. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 3 of 3 residents (Residents #2, #37, and #246) whose care was reviewed in that:<BR/>1. Resident #2 and family member witnessed cursing and fighting over the care for her neighbor (Resident #37) by two staff members. <BR/>2. CNA A and CNA G failed to provide Resident 37 a dignified existence when the staff argued who was going to provide care for the resident and cursed at each other in the presence of the resident.<BR/>3. Resident #246's indwelling urinary catheter bag was not covered.<BR/>These failures could place residents at risk of feeling uncomfortable and disrespected and could decrease residents' self-esteem and/or quality of life.<BR/>The findings include:<BR/>Resident #2<BR/>Review of Resident #2's undated electronic face sheet revealed she was a [AGE] year-old-female admitted on [DATE] with the diagnoses of: hemiplegia and hemiparesis (paralysis of one side of the body), Urinary tract infection (infection of the bladder), pneumonia (infection of the lung) , chronic respiratory failure (chronic failure of the lungs to function), hypoxia (inability to oxygenate the body), tracheostomy (artificial opening in the neck to allow a person to breath), and paralysis of the vocal cords (inability of the vocal cords to function). <BR/>Review of Resident #2's initial MDS dated [DATE] revealed she had a BIMS score of 9 indicating she was moderately impaired and able to make her needs known. <BR/>Review of Resident #2's care plan dated 10/19/2022 revealed the following: Problem, Cognitive Loss/Dementia Resident has impaired cognition in impaired decision making related to diagnosis of dementia Goal: Resident #2 will have a positive experience in daily routine without overly demanding task and without becoming overly stressed. Approach: Resident #2 has the right to make decisions, set expectations and set limits for resident. <BR/>Resident #37<BR/>Review of Resident #37's undated electronic face sheet revealed he was a [AGE] year-old-male admitted on [DATE] with the following diagnoses: Chronic respiratory failure (chronic inability to oxygenate his body), muscle weakness, pressure ulcer of sacral region (pressure wound to his buttock region), urinary tract infection (infection of the bladder), difficulty walking, hypothyroidism (decrease in the hypothyroid hormone production), and depression. <BR/>Review of Resident #37's quarterly MDS dated [DATE] revealed he had a BIMS 15 indicating he was able to make her needs know. Section G (Functional Status) revealed he required extensive assistance from 2-person transfer. <BR/>Review of Resident #37's Care Plan dated 07/16/2022 revealed the following: Problem Resident #37 has Behavior problems, verbal aggression, resist care, repetitive request. Goal: Resident will accept redirection from staff. Approach: Be firm and redirect when approaching resident about behaviors<BR/>In an interview with Resident #37 on 12/07/2022 at 1:30 PM, he said CNA A and CNA G were fighting over who was going to put him to bed (July 15, 2022 during their night shift unsure exact time). He said they were yelling at each other and throwing the F bombs and almost got into a physical fight over him while in the wheelchair. He said a family member in the room next to him had to step in and tell the staff to quiet down that their behavior was unacceptable. He said CNA A behavior made him feel bad and that they do not care about the people who live there. He said the facility is his home and should be treated with some respect. He said CNA A makes his life miserable by making him feel like shit and like they do not care about him because they have to fight about who was going to care for him or give him a bath. <BR/>In an Interview on 12/08/2022 at 10:15 PM (night shift interview) CNA A said she did talk loud and she was a big girl and sometimes she felt like the residents did not like her. When asked if she had any problems with Resident #37, she said yes one time he was outside of his room, and I grabbed his wheelchair and pushed him into his room (forced him). That was why he asked for me not to work with him anymore. She said she could not remember the exact date.<BR/>During a review of facility's Complaint/Grievance Report dated 07/15/2022 revealed Resident #2's family member said on Friday evening 07/15/2022 two black staff members were yelling and cursing at each other over who would put Resident #37 to bed. The grievance report continued to say, Resident #2 became extremely upset at the yelling. The grievance was never resolved. <BR/>During an interview with Resident #2's family member on 12/09/2022 at 3:00 PM, the family member said when the incident occurred on (07/15/2022) she told the staff to quit cursing and yelling. She said she looked down the hall and saw nurses at the nurse's station and no one went to see about what was happening with all the cursing and yelling.<BR/> During an interview on 12/08/2022 at 10:00 PM (night sift interview) Resident #246 said his door was closed during the incident on 07/15/2022) and he thought there was an actual fight going on. Resident #246 said he heard one of the aides say, I'm not going to take this any longer. heard a lot of F bombs. He said he heard Resident #2's family go to Resident #37's room and tell the two aids to quit cursing and yelling. <BR/>Resident #246<BR/>Record review of Resident #246's electronic face sheet revealed she was re-admitted to the facility on [DATE] with a diagnosis that included Pressure ulcer of right buttock- stage 4, Type 2 Diabetes Mellitus, Unspecified injury at level of thoracic spinal cord, Paraplegia, Neuromuscular dysfunction of the bladder and acute prostatitis. <BR/>Review of Resident #246's physician's electronic consolidated orders revealed an order to check foley catheter every shift with soap and water. Ensure catheter drainage bag to gravity, privacy bag in place, and catheter is secure. Every shift; Morning 6:00 AM- 6:00 PM, Night 6:00 PM- 6:00 AM. <BR/>In an interview on 12/08/2022 at 10:00 PM (during night shift interview) Resident #246 said CNA A was heard yelling at a resident across the hall from him. He said this aide always seems to be yelling at residents on his hall. He said she does not yell at him, but he can tell she does not like him. <BR/>After the interview on 12/08/2022 at 10:00 PM Resident #246 asked staff to keep his door open in case the CNA A begin to yell at the resident across the hall again, he could not tell who the resident was but CNA A often yells at them. Resident #246 was unable to tell which resident it was since he is bed ridden and unable to get up. <BR/>Review of a Complaint/Grievance Report resolution dated 07/15/2022 revealed the following and completed by the DON: Multiple staff members and this family member heard the background of the evening of this incident that what happens is not what happened at all CNA (A) was taken off resident care. <BR/>Review of CNA A's Employee Coaching Form dated 05/30/2017 revealed the following: Several Complaints from residents regarding rude behavior two residents expressing that they do not want her to care for them due to her attitude while caring for them. <BR/>Observation on 12/06/22 from 11:36 AM revealed a catheter bag hanging from the resident's bed without a privacy bag. The resident's door was open, and the bag was viewable from the hall. <BR/>Observation on 12/07/22 from 2:00 PM revealed a catheter bag hanging from the resident's bed without a privacy bag. The resident's door was open, and the bag was viewable from the hall . <BR/>Observation on 12/07/22 from 9:36 PM revealed a catheter bag laying on the floor underneath the resident's bed without a privacy bag. The resident's door was open, and the bag was viewable from the hall. <BR/>In an interview on 12/07/22 at 9:40 PM with CNA A revealed that she was not sure why the resident's catheter bag was not covered. She said that she knew it should be covered. <BR/>In an interview on 12/07/22 at 9:45 PM, with the DON said that the catheter bag should always be covered with a privacy bag. She said that she had orders for it and was unsure why it was not covered. She would do additional training to correct the issue. <BR/>In an interview on 12/09/2022 at 1:30 PM, the DON said if resident experiences abuse it should be reported to the Administrator. <BR/>During an interview on 12/09/2022 at 4:30 PM , the Administrator said she was aware of the altercation between the two aides and Resident #37 and the grievance filed by a family member related to the cursing and fighting regarding Resident #37's care. She said she did not consider that any kind of abuse with the two aids fighting in front of Resident #37 even though he was saying it was making him feel uncomfortable the fact they were arguing about putting him to bed. <BR/>Record review of the The facility's Policy and Procedures titled, Quality of Life - Dignity dated October 2009 revealed the following [in part]: <BR/>Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered. <BR/>Review of the facility's policy dated 2001 titled, Quality of Life - Dignity revealed the following [in part]: <BR/>Policy Statement - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.<BR/>Policy and Interpretation and implementation:<BR/>1. Resident will be always treated with dignity and respect.<BR/>2. Treated with dignity means the resident will be assisted in maintain and enhancing his or her self-esteem and self-worth <BR/>7. Staff shall always speak respectfully to residents, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. <BR/>9. Staff shall maintain an environment I which confidential clinical information is protected for example:<BR/>a. Verbal staff-to-staff communication shall be conducted outside the hearing range of residents and the public.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 17 residents (Resident #s 9, 18, and 37) whose rooms were observed in that:<BR/>1. Resident #9's room bathroom had stained floor tiles, dark colored grout in-between the shower stall tiles, and a scraped veneer surface on the bathroom door.<BR/>2. Resident #18's room had pieces of sheet rock and paint missing from the wall with the pieces on the floor. The linoleum floor under the resident's bed appeared discolored and was dirty. His privacy curtain had feces smeared on it.<BR/>3. Resident #37 had feces smeared on his privacy curtain.<BR/>These failures could placed residents at risk for decreased feelings of well-being and quality of life within their immediate physical environment.<BR/>The findings included:<BR/>Review of Resident #9's face sheet, dated 12/08/2022, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE]. Review of the face sheet diagnoses list revealed the resident's diagnoses included: chronic obstructive pulmonary disease (inadequate oxygenation), unspecified (Primary, Admission); morbid (severe) obesity (overweight), uncomplicated; pulmonary hypertension (high blood pressure), unspecified; unspecified diastolic (congestive) heart failure (heart does not pump blood efficiently). <BR/>Observation on 12/06/2022 at 10:22 AM of Resident #9's room bathroom revealed the vinyl floor tiles were stained around the base of the toilet, the tile grout was soiled with a dark colored substance between the tiles, and there was a build-up of a dark colored substance at the bottom of the walls along the baseboards. The bottom half of the bathroom door had a scraped and gouged veneer surface. Resident #9 was not present in her room at the time of the observation.<BR/>Review of Resident #18's electronic face sheet dated 12/09/2022 revealed he was admitted to the facility on [DATE] with a diagnoses of Covid (respiratory disease), Congested Heart Failure (Failure of the heart to pump blood as well as it should), Pressure induced deep tissue damage - tip of left great toe, Pressure ulcer on left heel, Pressure induced deep tissue damage on left heel, and Peripheral Vascular Disease (reduction of blood flow to the lower limbs). <BR/>Review of Resident #18's quarterly MDS with an ARD of 10/05/2022 revealed he could usually understand and be understood.<BR/>Observation on 12/06/22 at 11:46 AM revealed Resident #18 was lying in his bed. Visualization of the room revealed brown feces on the privacy curtain of his room, large paint and sheetrock pieces under his bed, and sticky discolored linoleum flooring. <BR/>Observation on 12/07/22 at 1:45 PM revealed Resident #18 was lying in his bed. Visualization of the room revealed brown feces on the privacy curtain of his room, large paint and sheetrock pieces under his bed, and sticky discolored linoleum flooring. <BR/>Observation on 12/08/22 at 9:00 AM revealed Resident #18 was lying in his bed. Visualization of the room revealed brown feces on the privacy curtain of his room, large paint and sheetrock pieces under his bed, and sticky discolored linoleum flooring. <BR/>Review of Resident #37's electronic face sheet dated 12/09/2022 revealed he was admitted to the facility on [DATE] with Acute and Chronic Respiratory Failure (Failure to exchange oxygen and carbon dioxide between the lungs and bloodstream). <BR/>Review of Resident #37's quarterly MDS with an ARD of 11/23/2022 revealed he could usually understand and be understood.<BR/>Observation on 12/06/22 at 2:30 PM revealed Resident #37 was lying in his bed. Visualization of the room revealed brown feces on the privacy curtain of his room. <BR/>In an interview on 12/07/22 at 10:51 AM, the Maintenance Director stated he had not addressed the paint and sheetrock pieces missing from the wall in Resident #18's room due to the resident always being in his bed. He stated that he did not want to paint with a resident being present in the room. He said that he had not received a request to send the privacy curtains to the laundry. <BR/>Review of the facility's policy and procedures for a Homelike Environment, dated February 2014, revealed the following [in part]:<BR/>Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include cleanliness and order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that an assessment was completed for residents within 14 days after a determine a significant change in the physical condition for 2 of 17 residents (Resident #s 9 and #18) whose records were reviewed for assessments in that:.<BR/>1. Resident #9 had multiple incidents of falling within a short time frame, with a fall on 11/12/22 resulting in a head injury and transfer to the emergency room for evaluation. Resident #9 had been independently ambulatory with a rolling walker prior to falling and hitting her head and was confined to a wheelchair for mobility following the fall. A significant change in condition comprehensive MDS assessment was not completed to reflect this fall with injury. <BR/>2. Resident #18 had a decline in ADL's from 04/05/22 to 10/05/22. Resident #18 had limited assistance with ADLs in areas with a decline in ADLs to total dependance in all areas. A significant change in condition comprehensive MDS assessment was not completed.<BR/>This failure could placed residents at risk for not being assessed for decline in condition and the need to revise their care plans to address changes in condition and develop interventions to meet their increased need for care assistance and treatments.<BR/>The findings included:<BR/>Resident #9<BR/>Review of Resident #9's face sheet, dated 12/08/2022, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE]. Review of the face sheet diagnoses list revealed the resident's diagnoses included: chronic obstructive pulmonary disease (inadequate oxygen exchange), unspecified (Primary, Admission); morbid (severe) obesity (overweight) with alveolar hypoventilation; pulmonary hypertension, unspecified (high blood pressure that affects arteries in the heart and lungs) and unspecified diastolic (congestive) heart failure (heart does not pump blood efficiently). <BR/>Review of the facility's incident tracking log, dated October 2022, revealed Resident #9 had six (6) incidents of falling during the month (10/06/22, 10/10/22, 10/11/22, 10/16/22 two times, and 10/25/22) with one fall in the dining room, one fall in the hallway, and four falls in her room. <BR/>Review of Resident #9's Nurse's Notes, dated 11/12/22 at 1:00 AM, revealed [in part] the resident was heard hollering, Help, I'm on the floor. She went to the resident's room and found her laying on her left side on the floor. Resident #9 stated she was trying to go to the restroom. The resident was assessed, and the resident was able to move all extremities without complaint of pain and a knot was noted to the middle of the resident's forehead, with redness in the center of the knot. Neurological checks were completed and were within normal limits. The resident complained of having a headache and was given Tylenol. The resident was assisted off the floor and back into bed by two staff members. The resident stated she had hit her head on the floor. <BR/>Review of Resident #9's Nursing Notes, dated 11/13/22 at 6:00 AM, revealed [in part] the resident was day 2 post fall, unwitnessed. Neurological checks all had been within normal limits. The nurse documented the resident had a knot to her forehead measuring 0.5 inch by 0.5 inch, and throughout the day shift and night shift the size of the knot increased to 3 by 3.5 with increased bruising noted. The physician was notified, and an order was received to send the resident to the local emergency room via ambulance.<BR/>Review of the Nursing Notes, dated 11/13/22 at 10:30 AM revealed Resident #9 returned to the facility with a diagnosis of head injury. The nurse documented follow-up orders were received for a CT (computed tomography) scan with contrast on 12/07/22 at 11:15 AM. The resident's neuro checks, and vital signs were within normal limits. <BR/>Review of the Nursing Notes, dated 11/13/22 at 9:00 PM revealed Resident #9's neuro checks, and vital signs continued to be within normal limits. The nurse documented bruising had set in under the resident's eyes.<BR/>Review of Resident #9's comprehensive care plan, dated 4/14/22, revealed it addressed the resident's risk for falls due to unsteady gait, being unsteady during traditions, decreased strength and endurance. The goal was for the resident to be free of serious falls, with a target date of 7/14/22. There was not documented evidence the care plan had been reviewed and revised.<BR/>Review of Resident #9's MDS assessment history revealed the most recently completed assessment was a quarterly MDS assessment, dated 10/07/22. The resident was assessed as having a BIMS score of 14 out of 15 (cognitively intact), and required supervision with bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, toilet use, and personal hygiene. She required extensive assistance with one person assisting for dressing. The resident's balance was assessed as not steady, but able to stabilize without staff assistance for moving from as seated to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer. She was assessed as using a walker for mobility. The assessment documented the resident had 1 fall without injury and 1 fall with minor injury since the prior assessment (dated 7/07/22). The assessment documented the resident received insulin injections daily and received antipsychotic, antianxiety, antidepressant, and diuretic medication daily. <BR/>During an observation and interview on 12/07/22 at 9:39 AM, Resident #9 was seated in a wheelchair and was wearing non-slip socks on her feet. A rolling walker and bedside commode were observed in the resident's room. Resident #9 had small dark purple bruises beneath both eyes. She stated she had fallen by the bed in her room. Resident #9 stated she needed more help than she used to and was not supposed to use her rolling walker now. She stated she used to walk in her room, but now used the wheelchair since she fell and hit her head.<BR/>In an interview on 12/09/22 at 2:55 PM, the MDS Coordinator stated Resident #9 was ambulatory with a walker prior to falling and hitting her head. She stated the resident had therapy during the past but was too confused and was discharged from services. The MDS Coordinator stated the resident may be able to participate in therapy now. She stated the resident would be discussed during the weekly meeting with therapy staff next week. The MDS Coordinator stated Resident #9 has had a significant decline in ADLs since falling and hitting her head (on 11/12/22). <BR/>Resident #18 <BR/>Record review of Resident #18's admission record revealed he was [AGE] years old. She was admitted to the facility on [DATE] with a diagnosis of Covid (respiratory disease), Congested Heart Failure (Failure of the heart to pump blood as well as it should), Pressure induced deep tissue damage - tip of left great toe, Pressure ulcer on left heel, Pressure induced deep tissue damage on left heel, and Peripheral Vascular Disease (reduction of blood flow to the lower limbs). <BR/>Record review showed Resident # 18 had a decline in ADL's from 04/05/2022 to 10/05/22 on his Quarterly MDS dated [DATE]. Section G revealed the resident had limited assistance in bed mobility, limited assistance in dressing, limited assistance in personal hygiene, physical help in bathing and not steady but was able to stabilize himself with staff assistance moving on and off the toilet and for surface-to surface transfers. <BR/>Record review of Resident#18's On his Quarterly MDS dated [DATE] section G revealed the resident was total dependence in bed mobility, total dependence in dressing, total dependence in personal hygiene, total dependence in bathing and activity did not occur with staff assistance moving on and off the toilet and for surface-to surface transfers.<BR/>Interview with the MDS Coordinator on 12/09/22 at 2:30 PM revealed that she should have completed a Significant Change Assessment on Resident #18. She said that she was new in the position and was just learning it. She said that she would be opening a modification to show the decline in the resident's mobility. She said a Significant Change Assessment should have been completed since the resident had a decline. <BR/>Review of the facility's policy and procedure for Change in a Resident's Condition or Status, dated as revised February 2014, revealed the following [in part]:<BR/>Policy Statement<BR/>Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .<BR/>Policy Interpretation and Implementation<BR/>2. A significant change of condition is a decline or improvement in the resident's status that:<BR/>a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting);<BR/>b. Impacts more than one area of the resident's health status;<BR/>c. Required interdisciplinary review and/or revision to the care plan; and<BR/>d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument .<BR/>6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.<BR/>7. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments as outlined in the MDS RAI Instruction Manual .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 3 of12 Residents (Resident #8, Resident #5, and Resident #35) reviewed for assessments. <BR/>The facility failed to ensure the MDS reflected the use of bed rails for Resident #8, Resident #5 and Resident #35.<BR/>This deficient practice could place residents at risk of not receiving care for identified care needs.<BR/>Findings include:<BR/>1. Record review of Resident #8's electronic face sheet revealed a [AGE] year-old female who was re-admitted to the facility on [DATE], original admission date 09/16/24. Resident #8 had diagnoses which included respiratory failure, kidney failure and diabetes. <BR/>Record review of Resident #8's Significant Change MDS, dated [DATE], revealed: BIMS of 15, which indicated no impaired cognition. Section P Restraints and Alarms revealed bed rails were not used. <BR/>Record review of Resident #8's electronic Comprehensive Care plan, initiated on 12/26/24, revealed in part: Focus: Resident has an ADL self-care performance deficit. Goal: Resident will be clean, dry, and hygiene and dignity maintained. Interventions: SIDE RAILS: Half rails up as per doctor's order for safety during care provision, to assist with bed mobility and positioning. Observe for injury or entrapment related to side rail use. Reposition every 2 hours and as necessary to avoid injury.<BR/>During an observation on 03/18/25 at 11:00 AM, Resident #8 was resting in bed with half side rails up on both sides of her bed. <BR/>2. Record review of Resident #5's electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included respiratory failure, heart failure and diabetes. <BR/>Record review of Resident #5's Annual MDS, dated [DATE], revealed: BIMS of 12, which indicated no impaired cognition. Section P Restraints and Alarms revealed bed rails were not used. <BR/>Record review of Resident #5's electronic Comprehensive Care plan initiated on 02/21/25, revealed no evidence of the use of side rails. <BR/>During an observation on 03/18/25 at 11:05 AM revealed Resident #5 was resting in bed with half side rails up on both sides of her bed. <BR/>3. Record review of Resident #35's electronic face sheet revealed a [AGE] year-old female who was re-admitted to the facility on [DATE], original admission date 01/28/25. Resident #35 had diagnoses which included fracture of arm, diabetes, anxiety, and muscle weakness. <BR/>Record review of Resident #35's Significant Change MDS, dated [DATE], revealed a BIMS score was not completed. Section P Restraints and Alarms revealed bed rails were not used. <BR/>Record review of Resident #35's electronic Comprehensive Care plan, initiated on 02/14/25, revealed in part: Focus: Resident requires siderails while in bed. Goal: Resident will be safe and free from injury related to use of side rails and will have increased mobility and independence for turning and repositioning. Interventions . Instruct use of side rails & how to use them to promote independent repositioning of self, and Side rails up when in bed at all times for safety and support.<BR/>Record review of Resident #35's Bedrail consent, signed 01/28/25, revealed: 1/2 partial rails to left up and right upper bed. <BR/>During an observation on 03/19/25 at 10:26 AM, revealed Resident #35 was resting in bed with half side rails up on both sides of her bed. <BR/>During an interview on 03/20/25 at 12:09 PM, the DON stated side rails should have been care planned and claimed on the MDS. She stated MDS's were completed by an outside MDS consultant at this time. She stated MDS consultant was responsible for ensuring the MDS was accurate. <BR/>During an interview on 03/20/25 at 12:30 PM, the Administrator stated MDS's were completed by an outside MDS consultant. She stated the consultant worked remotely but attended the facility's daily morning meetings via phone call. The Administrator stated side rails should have been claimed on the MDS assessment. She stated she did not have contact information for the MDS consultant. She stated the facility did not have an MDS policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a base line care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of the resident's admission for 8 of 8 residents (Resident #s 1, 10, 25, 28, 37, 38, 96, and 245) whose records were reviewed in that: <BR/>1. Resident #1 did not have a base line care plan developed and implemented following admission to the facility on [DATE] or following readmission on [DATE].<BR/>2. Resident #10 did not have a base line care plan developed and implemented following admission to the facility on [DATE].<BR/>3. Resident #25 did not have a base line care plan developed and implemented following admission to the facility on [DATE] or following readmission on [DATE].<BR/>4. Resident #28 did not have a base line care plan developed and implemented following admission to the facility on [DATE].<BR/>5. Resident #37 did not have a base line care plan developed and implemented following admission to the facility on [DATE].<BR/>6. Resident #38 did not have a base line care plan developed and implemented following admission to the facility on [DATE].<BR/>7. Resident #96 did not have a base line care plan developed and implemented following admission to the facility on [DATE].<BR/>8. Resident #245 did not have a base line care plan developed and implemented following admission to the facility on [DATE].<BR/>This failure could place the residents at risk for not receiving care and services required to meet their individual needs from the date and time they were admitted to the facility.<BR/>The findings included:<BR/>Resident #1<BR/>Record review of Resident #1's Face Sheet, dated 12/08/22, revealed resident was an [AGE] year-old female, who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis included: Metabolic encephalopathy (Primary, Admission); Pneumonia, unspecified organism-admission DX for 8/11/22 admit; Acute pyelonephritis; Acute respiratory failure with hypoxia; Unspecified atrial Fibrillation; Chronic obstructive pulmonary disease, unspecified; Unspecified abdominal pain; Schizoaffective disorder, unspecified; Anxiety disorder, unspecified; Essential (primary) hypertension; her specified arthritis, unspecified site; Edema, unspecified; Unspecified protein-calorie Malnutrition; Difficulty in walking, not elsewhere classified; Abnormal posture; Other lack of Coordination; Muscle weakness (generalized); Pain, unspecified; Unspecified convulsions; Gout, unspecified; Constipation, unspecified; Encounter for examination of eyes and vision without abnormal findings; Enterocolitis due to Clostridium difficile, not specified as recurrent.<BR/>Review of Resident #1's clinical record revealed a baseline care plan had not been completed following the resident's initial admission to the facility on [DATE] or after her readmission on [DATE]. The comprehensive care plan was dated as initiated 10/25/22.<BR/>Resident #10<BR/>Review of Resident #10's face sheet, dated 12/09/22, revealed an [AGE] year-old male, admitted to the facility on [DATE]. Diagnosis included: Acute and chronic respiratory failure with hypercapnia (Primary, Admission); Chronic obstructive pulmonary disease, unspecified; Hypokalemia; Gastro-esophageal reflux disease with esophagitis; Ileus, unspecified; Acute embolism and thrombosis of unspecified deep veins of left lower extremity; Calculus of bile duct with cholecystitis, unspecified, without obstruction; Unspecified severe protein-calorie malnutrition; Difficulty in walking, not elsewhere classified; Muscle weakness (generalized); Abnormal posture; Other lack of coordination; Intestinal malabsorption, unspecified; Constipation, unspecified; Nausea with vomiting, unspecified; Myositis, unspecified; Cellulitis of right upper limb; Vitamin deficiency, unspecified; Vitamin B12 deficiency anemia, unspecified; Diverticulum of bladder; Unspecified mycosis; Pain, unspecified; Fever, unspecified; Critical illness myopathy; and Anemia, unspecified.<BR/>Review of Resident #10's clinical record revealed a base line care plan had not been completed following her initial admission into the facility on [DATE]. The comprehensive care plan was dated as initiated 12/06/22.<BR/>Resident #25<BR/>Review of Resident #25's face sheet, dated 12/08/22, revealed an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. The form documented the resident's most recent qualifying hospital stay was from 10/07/22 to 10/31/22. The face sheet diagnoses list included rhabdomyolysis (Primary, Admission), unspecified atrial fibrillation, essential (primary) hypertension, Alzheimer's disease with late onset, anxiety disorder, anorexia, difficulty in walking, muscle weakness, restless legs syndrome, myopathy, dysphagia, and pain, unspecified.<BR/>Review of Resident #25's clinical record revealed a baseline care plan had not been completed following the resident's initial admission to the facility on [DATE] or after her readmission on [DATE] following hospitalization. The comprehensive care plan was dated as initiated 12/06/22.<BR/>Resident #28<BR/>Review of Resident #28's face sheet, dated 12/09/22, revealed an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. The form documented the resident's most recent qualifying hospital stay was from 5/21/22 to 6/15/22. The face sheet diagnoses list included other myositis, left thigh (Primary, Admission); atherosclerotic heart disease; essential (primary) hypertension; dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; hypokalemia; type 2 diabetes mellitus; gastro-esophageal reflux disease; dysphagia; osteoporosis; constipation; overactive bladder; muscle weakness (generalized); difficulty in walking; vitamin deficiency; allergic rhinitis; pain, unspecified; and repeated falls.<BR/>Review of Resident #28's clinical record revealed a base line care plan had not been completed following her initial admission into the facility on 5/11/22. The comprehensive care plan was dated as initiated 6/24/22.<BR/>Resident #37<BR/>Review of Resident #37's face sheet, dated 12/09/22, revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (Admission); Other lack of coordination; Muscle weakness (generalized); Gastro-esophageal reflux disease without esophagitis; Pressure ulcer of sacral region, stage 2; Shortness of breath; Hypokalemia; Unspecified abdominal pain; Hypothyroidism, unspecified; Constipation, unspecified; Anxiety disorder, unspecified; Depression, unspecified; Nausea with vomiting, unspecified; Pain, unspecified; Iron deficiency anemia, unspecified; Pressure ulcer of sacral region, stage 1; Fever, unspecified; Vitamin deficiency, unspecified; Cough, unspecified; Long term (current) use of antibiotics; Insomnia, unspecified; Other specified disorders of the bladder; Unspecified mood (affective) disorder; Urinary tract infection, site not specified; Polyneuropathy, unspecified; Abdominal posture; Difficulty in walking, not elsewhere classified; Other obstructive and reflux uropathy; and Neuromuscular dysfunction of bladder, unspecified. <BR/>Review of Resident #37's clinical record revealed a baseline care plan had not been completed following the resident's initial admission to the facility on [DATE]. The comprehensive care plan was dated as initiated 06/22/22.<BR/>Resident #38<BR/>Record review of Resident #38's face sheet, dated 12/08/22, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Diagnosis included: Other fracture of fifth lumbar vertebra, Subsequent encounter for fracture with routine healing (Primary, Admission); Encounter for other specified surgical aftercare; Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter; Chronic obstructive pulmonary disease, unspecified; Pressure ulcer of sacral region, stage 2; Pressure ulcer of right heel, unstageable; Pressure ulcer of right heel, stage 3; Pressure ulcer of other site, stage 4; Pressure ulcer of other site, unstageable-Left great toe; Essential (primary) hypertension; Psychotic disorder with delusions due to known physiological condition; Type 2 diabetes mellitus without complications; Other dysphagia; Pruritus, unspecified; Neuralgia and neuritis, unspecified; Dorsalgia, unspecified; Other lack of coordination; Muscle weakness (generalized); Other muscle spasm; Irritant contact dermatitis, unspecified cause; Vitamin deficiency, unspecified; Insomnia, unspecified; Iron deficiency; Disorders of zinc metabolism; Restless legs syndrome; Nicotine dependence, unspecified, uncomplicated; Other specified disorders of the skin and subcutaneous tissue; Pain, unspecified; Other seasonal allergic rhinitis; Constipation, unspecified; Urinary tract infection, site not specified; Hyperlipidemia, unspecified; COVID-19.<BR/>Review of Resident #38's clinical record revealed a baseline care plan had not been completed following the resident's initial admission to the facility on [DATE]. The comprehensive care plan was dated as initiated 08/24/22.<BR/>Resident #96<BR/>Review of Resident #96's face sheet, dated 12/09/22, revealed an [AGE] year-old female who was initially admitted to the facility on [DATE]. The face sheet diagnoses list included unspecified dementia, unspecified severity, with mood disturbance (Primary, Admission); essential (primary) hypertension; chronic kidney disease, unspecified; hyperlipidemia; gastro-esophageal reflux disease; gout; muscle weakness (generalized); other idiopathic peripheral autonomic neuropathy; edema; other symptoms and signs concerning food and fluid intake; and personal history of malignant neoplasm of ovary.<BR/>Review of Resident #96's clinical record revealed a base line care plan had not been completed following her admission into the facility. The comprehensive assessment and comprehensive care plan had not yet been completed.<BR/>In an interview on 12/07/22 at 2:39 PM, Resident #96's family member stated the staff spoke with him and explained what they would do for the resident. He stated he did not receive a copy of resident's initial baseline care plan. He stated he planned for the resident to receive therapy and to return to living at home.<BR/>Resident #245<BR/>Review of Resident #245's face sheet, not dated, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Diagnosis included: Pressure ulcer of sacral regional, stage 4 (Primary, Admission); Pressure ulcer of left lower back, stage 4; Pressure ulcer of right heel, stage 3; Dysphagia, unspecified; Heart failure, unspecified; Acute transverse myelitis in demyelinating disease of central nervous system; Paraplegia, complete; Unspecified convulsions; Type 2 diabetes mellitus with unspecified complications; Insomnia, unspecified; Hypothyroidism, unspecified; Hyperlipidemia, unspecified; Polyneuropathy, unspecified; Hereditary and idiopathic neuropathy, unspecified; Gastro-esophageal reflux disease without esophagitis; Depression, unspecified; Anxiety disorder, unspecified; Abnormal posture; Muscle weakness (generalized); Other lack of coordination; Sequelae of vitamin C deficiency; Edema, unspecified; Unspecified abdominal pain; and Fever, unspecified. <BR/>Review of Resident #245's clinical record revealed a base line care plan had not been completed following her admission into the facility. The comprehensive assessment and comprehensive care plan had not yet been completed.<BR/>In an interview on 12/07/22 at 2:55 PM, the DON stated she was responsible for completing the residents' comprehensive care plans. She stated the initial care plan was discussed with the resident and/or resident's representative. The DON stated the admitting nurse completed the base line care plan that was a paper form that was in the nursing admission packet paperwork. The DON stated the baseline care was placed in the back of the chart or in the physician orders section. The DON stated if the base line care plan was not in the paper chart, then it probably was not done or completed. The DON stated she did not know if the baseline care plan was discussed with the resident and/or resident's representative and if a copy of the baseline care plan was provided to the resident and/or resident's representative.<BR/>In an interview on 12/09/22 at 9:00 AM, the ADON stated if the baseline care plan was not in the resident's chart, then it was not done. The ADON stated the nurses who admitted new residents had not been completing the baseline care plans.<BR/>Review of the facility's policy and procedure for Care Plans - Preliminary, dated as revised August 2006, revealed the following [in part]:<BR/>Policy Statement<BR/>A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 3 of 17 residents (Resident #s 19, 25, and 37) whose records were reviewed for assessments in that: <BR/>1. Resident #19 did not have a comprehensive care plan developed within 7 days following completion of a significant change in condition comprehensive assessment.<BR/>2. Resident #25 did not have a comprehensive care plan developed within 7 days following completion of a significant change in condition comprehensive assessment.<BR/>3. Resident #37 did not have a comprehensive care plan developed within 7 days following completion of a re-admission comprehensive assessment.<BR/>This failure could place the residents at risk for not having individual needs identified and care and services provided to meet their needs and promote quality of care, feelings of well-being and quality of life.<BR/>The findings included:<BR/>Resident #19<BR/>Review of Resident #19's face sheet, dated 12/08/22, revealed a [AGE] year-old female, with a current admission date of 07/21/16 and the latest return date of 08/14/21. Diagnosis included: Hypomagnesemia (Primary), Malignant neoplasm of rectum, Chronic combined systolic (congestive) and diastolic (congestive) heart failure, Chronic obstructive pulmonary disease, Muscle weakness (generalized), Difficulty in walking, Weakness, Other lack of coordination, Abnormal posture, Dependence on supplemental oxygen, Chronic kidney disease, Atherosclerotic heart disease of native coronary artery without angina pectoris, Unspecified protein-calorie malnutrition, Crohn's disease, Unspecified macular degeneration, Anxiety disorder due to known physiological condition, Abnormal weight loss, Diarrhea, Pruritus [NAME], Other specified diseases of anus and rectum, Dementia in other diseases classified elsewhere, Acute and chronic respiratory failure, Elevated white blood cell count, Solitary pulmonary nodule, Chronic respiratory failure with hypercapnia, Pain in right knee, Hypocalcemia, Acidosis, Hypokalemia, Vitamin D deficiency, Deficiency of other vitamins, Vitamin B12 deficiency anemia, Nausea, Dysphagia, oropharyngeal phase, Pain, Other specified noninfective gastroenteritis and colitis, Iron deficiency anemia, Allergic rhinitis due to pollen, and Essential (primary) hypertension.<BR/>Review of Resident #19's MDS assessment history revealed a significant change assessment dated [DATE].<BR/>Review of Resident #19's comprehensive care plan revealed it was last Reviewed/Revised on 06/23/22. There was no documented evidence of a care plan to address the significant change assessment completed on 10/17/22. <BR/>Resident #25<BR/>Review of Resident #25's face sheet, dated 12/08/22, revealed an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. The form documented the resident's most recent qualifying hospital stay was from 10/07/22 to 10/31/22. The face sheet diagnoses list included rhabdomyolysis (Primary, Admission), unspecified atrial fibrillation, essential (primary) hypertension, Alzheimer's disease with late onset, anxiety disorder, anorexia, difficulty in walking, muscle weakness, restless legs syndrome, myopathy, dysphagia, and pain, unspecified.<BR/>Review of Resident #25's MDS assessment history, revealed and entry assessment dated [DATE], an admission assessment combined with discharge date d 10/07/22, an entry assessment dated [DATE], and a significant change assessment dated [DATE].<BR/>Review of Resident #25's comprehensive care plan revealed it was developed 12/06/22, 28 days following completion of the significant change comprehensive assessment dated [DATE]. There was no documented evidence of a care plan prior to 12/06/22. <BR/>Resident #37 <BR/>Review of Resident #37's face sheet dated 12/06/22, revealed a [AGE] year old male who was re-admitted to the facility on [DATE] with relevant diagnoses of; Respiratory Failure (lungs cannot get enough oxygen into the blood), Pressure Ulcer Sacral region; stage 2, Unspecified Abdominal Pain, Neuropathy (numbness and pain in legs), Pain, Muscle weakness, reflux (stomach acid or bile flows into the food pipe and irritates the lining), shortness of breath, hypokalemia (low potassium level), and Difficulty in Walking.<BR/>Review of Resident #37's MDS assessment history revealed, and re-entry assessment dated [DATE].<BR/>Review of Resident #37's comprehensive care plan revealed it was developed on 06/22/22, 29 days following completion of the comprehensive assessment dated [DATE].<BR/>In an interview on 12/07/22 at 2:55 PM, the DON stated she was responsible for completing the residents' comprehensive care plans. She stated the initial care plan was discussed with the resident and/or resident's representative. <BR/>Review of the facility's policy and procedure for Care Plans - Comprehensive, dated as revised October 2010, revealed the following [in part]:<BR/>Policy Statement<BR/>An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident.<BR/>Policy Interpretation and Implementation<BR/>1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.<BR/>2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS.<BR/>4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan.<BR/>7. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS).<BR/>8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.<BR/>9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans:<BR/>a. when there has been a significant change in the resident's condition;<BR/>b. when the desired outcome is not met;<BR/>c. when the resident has been readmitted to the facility from a hospital stay; and <BR/>d. at least quarterly.

**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 was incontinent of bladder received appropriate treatment and services for 3 of 9 residents (Residents #25, #38, and #246) reviewed for urinary catheters in that:<BR/>1. The facility failed to ensure Resident #25 had an order for a catheter and catheter care.<BR/>2. The facility failed to ensure Resident #38's urinary catheter was flushed 2 times a day and to provide foley catheter care 2 times a day, both as ordered by the physician.<BR/>3. The facility failed to ensure Resident #246's urinary catheter bag was changed when needed and the urinary catheter bag was off the floor.<BR/>This deficient practice could affect residents who had urinary catheters and result in trauma or urinary tract infections.<BR/>Findings include:<BR/>1. <BR/>Review of Resident #25's face sheet, dated 12/08/22, revealed an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. The form documented the resident's most recent qualifying hospital stay was from 10/07/22 to 10/31/22. The face sheet diagnoses list included rhabdomyolysis (skeletal muscle breaks down rapidly) (Primary, Admission), unspecified atrial fibrillation (irregular fast heart rate), essential (primary) hypertension (high blood pressure), Alzheimer's disease with late onset, anxiety disorder, anorexia, difficulty in walking, muscle weakness, restless legs syndrome, dysphagia (difficulty swallowing), and pain, unspecified.<BR/>Review of Resident #25's admission MDS assessment, dated 10/07/22, revealed the resident was assessed as always incontinent of urine and bowels.<BR/>Review of Resident #25's Significant Change in Condition MDS assessment, dated 11/08/22, revealed the resident had an indwelling urinary catheter, was always incontinent of bowels, and was total dependence for toileting and personal hygiene with one person physically assisting her.<BR/>Review of Resident #25's comprehensive care plan, dated 12/06/22, revealed the care plan was created by the DON. The care plan addressed the resident's indwelling urinary catheter and risk for increased incidents of urinary tract infections. The care plan approaches included catheter care per order; change catheter, tubing and [drainage] bag per order; encourage fluid intake; the catheter size to be changed PRN; position the tubing and bag below the level of the bladder and do not kink tubing; and monitor urine for odor, color, sediments, and amount and report abnormalities to the physician.<BR/>Review of Resident #25's physician admission orders, dated 10/06/22, revealed there were no orders for an indwelling urinary catheter or orders related to catheter care. <BR/>Review of Resident #25's Daily Skilled Nurse's Note, dated 10/06/22, revealed documentation the resident was incontinent of bowel and bladder, required extensive assistance with ADLs, and was a fall risk.<BR/>Review of Resident #25's physician admission orders, dated 11/01/22, revealed there were no orders for an indwelling urinary catheter or orders related to catheter care.<BR/>Review of Resident #25's Nursing Admission/readmission Assessment, dated 11/01/22, revealed documentation the resident was always incontinent of bowel and bladder, pads and briefs were used, and the resident had an indwelling urinary catheter.<BR/>Review of Resident #25's current physician orders, dated 12/08/22, revealed there were no orders for an indwelling urinary catheter or orders related to catheter care. There was not a diagnosis for indication of need for an indwelling urinary catheter.<BR/>Review of Resident #25's MAR flowsheets, dated December 2022, revealed there were no orders for an indwelling urinary catheter, catheter change, or catheter care.<BR/>Observation on 12/07/22 at 8:30 AM revealed Resident #25 was lying in bed. A urinary catheter drainage bag was in privacy/dignity bag hanging on the side of the bed frame.<BR/>During an interview and record review on 12/09/22 at 9:15 AM, the ADON stated she entered physician orders into the residents' electronic health records. She stated the physician orders generated the MARs. The ADON reviewed Resident #25's physician orders and no orders were entered for an indwelling urinary catheter, catheter care, or catheter changes . The ADON reviewed the MAR flowsheets and no orders for a catheter were on Resident #25's flowsheets , she acknowledged the error and said it should have been completed. The ADON stated she was not given an order to enter. The ADON reviewed the resident's admission orders, dated 11/01/22, and they did not include the orders for the indwelling urinary catheter, catheter care, or changes . She acknowledged the error and said it should have been completed upon admission. The ADON stated there was no way of knowing if the catheter had been changed or if care was being done. <BR/>During an interview and record review on 12/09/22 at 10:00 AM, Resident #25's chart revealed a physician order request, dated 11/29/22. The request form was addressed to Resident #25's physician, which documented the resident had a Foley Catheter (indwelling urinary catheter) and requested indication for continuation of the Foley Catheter. The physician checked neurogenic bladder and to continue the Foley Catheter for the reason checked above. The physician signed and dated the form 12/01/22. The ADON stated it was a physician's order. The ADON stated the urinary catheter must have been inserted while the resident was at the LTAC hospital 10/07/22 - 11/01/22.<BR/>2. <BR/>Record review of Resident #38's face sheet, dated 12/08/22, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses included fracture to fifth lumbar vertebra (fracture to the back), subsequent encounter for fracture with routine healing (Primary) and encounter for other specified surgical aftercare.<BR/>Record review of Resident #38 Physician's Orders, not dated, revealed orders: A.) flush foley catheter with 30cc sterile water, every shift, Morning 06:00 am-06:00 pm, Night 06:00 am-06:00 am. Start date 08/05/22 with no end date. B.) Foley catheter care every shift with soap and water, every shift, Morning 06:00 am-06:00 pm, Night 06:00 am-06:00 am. Start date 08/22/22 with no end date. <BR/>Record review of Resident #38's Care Plan, last revised 08/23/22, revealed a care plan for Indwelling Catheter with an approach for catheter care per order. <BR/>Record review of the Nurse MAR Flowsheet for November 2022 for the order to flush foley catheter with 30cc sterile water, every shift, revealed Resident #38's foley was not initialed, or blank, meaning it was not completed by the nurse, for a total of 13 times for the month (11/16/22, 11/17/22 X2, 11/21/22, 11/22/22, 11/23/22, 11/24/22, 11/25/22 X2, 11/26/22 X2, and 11/27/22 X2). <BR/>Record review of the Nurse MAR Flowsheet for the November 2022 for the order to perform catheter care, every shift, revealed it was initialed by the nurse; indicating catheter care had been completed. <BR/>Record review of the Nurse MAR Flowsheet for December 2022 for both orders to flush catheter each shift and to perform catheter care each shift was initialed by the nurse as being completed. <BR/>In an interview, during initial rounds, on 12/06/22 at 11:28 a.m., Resident #38 said he must have a catheter as he cannot go on his own since his car accident. He said the only time he had received catheter care is if he has a bowel movement. He said his catheter is only flushed if he asks for it to be done , which is occasionally. He said his catheter had not been flushed since he returned from the hospital on [DATE]. <BR/>In an interview on 12/08/22 5:00 p.m., Resident #38 said his catheter had not been flushed and he had not received catheter care that day. <BR/>A record review of the Nurse MAR Flowsheet for 12/08/22 was initialed by LVN B indicating Resident's #38's catheter had been flushed and catheter care had been completed for the 6 a.m. to 6 p.m. shift. <BR/>In an interview, on 12/08/22 , LVN B stated she had not flushed Resident #38's catheter that day and said she initialed the MAR indicating it had been completed. When asked if catheter care had been completed, she said she did not know as the CNAs did that. When asked why she initialed the MAR, indicating it had been completed, she said I don't know, I'm new, I just initial it as being done . <BR/>In an interview on 12/09/22, Resident #38 said his catheter had not been flushed that day, but he did receive catheter care when he had a bowel movement that morning. <BR/>A record review of the Nurse MAR Flowsheet for 12/09/22 was initialed by LVN C indicating Resident's #38's catheter had been flushed and catheter care had been completed. <BR/>In an interview on 12/09/22 , LVN C stated she had not flushed Resident #38's catheter that day, she was going to do it, but had to clean him up and forgot to flush his catheter. She said she was going to go back after lunch and flush his catheter. When asked why she initialed the MAR, indicating she had flushed his catheter, she said she shouldn't have signed it until she completed the task. She said the risk of initialing the MAR before a task is completed is care might not get done. <BR/>In an interview on 12/09/22 at 1:28 PM, the DON said the MAR should only be signed if a task was completed. If a task was not completed, the nurse should circle the task and chart the reason why it was not preformed. The DON said the potential for harm would be the care would not be provided as ordered and the resident could get a urinary tract infection. <BR/>3. <BR/>Record review of Resident #246's face sheet, dated 12/08/22, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Diagnosis included Stage 4 Pressure Ulcer to the right buttocks, Stage 4 Pressure Ulcer to the sacral region (back), Unspecified injury at unspecified level of thoracic spinal cord (back), paraplegia (paralized), neuromuscular dysfunction of the bladder (dysfunction in urinating). <BR/>Record review of Resident #246's Physician's Orders, not dated, revealed orders: A.) Change foley catheter and drain bag PRN. Start date 12/05/22 with no end date. B.) Foley catheter care every shift with soap and water, every shift, Morning 06:00 am-06:00 pm, Night 06:00 am-06:00 am. Start date 12/05/22 with no end date. <BR/>Record review of Resident #246's Care Plan had not been completed due to recent admission. <BR/>In an interview, during initial rounds, on 12/06/22, Resident #246 said nursing staff did not empty his catheter bag unless it was really full . He said that he cannot remember the last time it was flushed. <BR/>Record review of the Nurse MAR Flowsheet for December 2022 for the order to perform foley catheter care every shift with soap and water. Ensure catheter drainage bag to gravity, privacy bag in place, and catheter was secure. The MAR was initialed by the nurse as being completed each day for the month of December. <BR/>In an interview on 12/07/22 at 9:15 p.m., Resident #246 said his catheter had not been emptied and he had not received catheter care that day. <BR/>A record review of the Nurse MAR Flowsheet for 12/07/22 revealed it was initialed by LVN B indicating Resident's #38's catheter had been flushed and catheter care had been completed. <BR/>Observation on 12/07/22 at 9:30 p.m. revealed the resident's catheter bag on the floor under his bed. The bag and tank were completely full, and the bag was bulging. The clip to hang the bag on the bed, had broken due to the weight of the bag. <BR/>In an interview , on 12/07/22 at 9:40 p.m., CNA A stated that she saw the bag was full, but she had not had a chance to empty it. She started her shift at 6 a.m. <BR/>In an interview on 12/07/22 at 9:50 p.m., the DON stated that Resident #246's bag should have never gotten that full. She said she trained all staff to empty the bags PRN. She said that they were busy on that hall, but that was not an excuse for it. She said that she would do additional in-service in catheter care for all staff. She said the MAR should not be initialed if they had not completed that care area. She said the potential harm could be infection.<BR/>A record review of the facility's policy Catheter Care, Urinary, dated as revised October 2010, revealed the following [in part]:<BR/>Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections.<BR/>Infection Control: 2b. Be sure the catheter tubing and drainage bag are kept off the floor. 2d. Empty the collection bag at least every eight (8) hours.<BR/>Managing Obstruction: 2. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction.<BR/>Documentation: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 9. The signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 2 of 3 residents (Resident #19 and #37) reviewed for oxygen in that:<BR/>The facility failed to ensure Residents #19's and #37's oxygen tubing was dated when changed according to physician orders. <BR/>This deficient practice could affect residents who received oxygen and nebulizer treatments by placing them at risk for respiratory infection.<BR/>The findings include:<BR/>Record review of Resident #19's face sheet, dated 12/08/22, revealed a [AGE] year-old female, last admitted to the facility on [DATE]. Diagnosis included: COVID-19; chronic obstructive pulmonary disease (group of lung diseases that block air flow), unspecified; dependence on supplemental oxygen; Chronic respiratory failure with hypercapnia (excessive carbon dioxide); chronic combined systolic (congestive) and diastolic (congestive) heart failure; chronic kidney disease, unspecified; and malignant neoplasm of rectum (cancer). <BR/>Record review of Resident #19's Quarterly MDS assessment, dated 10/26/22 revealed in Section O, the resident received oxygen therapy. <BR/>Record review of Resident #19's Physician Orders, not dated, revealed orders: A. Oxygen - Continuously - at 3.5/4 lpm via nasal canula continuously. Start date 07/15/22. B. Oxygen - Concentrator - Clean oxygen concentrator and change tubing and change humidifier bottle every week on Sunday on night shift. Date and initial tubing when changed. Start date of 07/15/22. <BR/>Record review of Resident #19's Care Plan, last revised on 06/23/22, revealed the care plan, Resident has episodes of shortness of breath and is at risk for respiratory distress/failure. COPD, CHF, O2 at 3.5-4 lpm.<BR/>In an interview and observation on 12/07/22 at 2:32 PM, Resident #19 said she always required oxygen. Her oxygen tubing was not dated. She did not know when her oxygen tubing was last changed.<BR/>Record review of Resident #37's face sheet, not dated, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Diagnosis included: acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (excessive carbon dioxide in the bloodstream); and shortness of breath. <BR/>Record review of Resident #37's Quarterly MDS assessment, dated 08/23/22 revealed in Section O, the resident received oxygen therapy.<BR/>Record review of Resident #37's Physician Orders, not dated, revealed orders: A. Oxygen - PRN - Oxygen at 2lpm via nasal cannula. PRN. Start date 08/22/22. B. Oxygen - Concentrator - Clean oxygen concentrator and change tubing and change humidifier bottle every week on Sunday on night shift. Date and initial tubing when changed. Start date of 08/22/22. <BR/>Record review of Resident #37's Care Plan, last revised on 06/22/22, revealed the care plan, Resident has episodes of shortness of breath and is at risk for respiratory distress/failure. Respiratory Failure, CHF, sleep apnea, O2 at 2 lpm.<BR/>In an interview and observation on 12/07/22 at 9:51 AM, Resident #37 was lying in bed with oxygen via nasal cannula. His oxygen tubing was dated 10/2022. He said his tubing had not been changed since then. <BR/>In an interview on 12/09/22 at 1:30 PM, the DON said oxygen tubing should be changed and dated each Sunday night. She expected staff to follow physician orders. Failure to do so could potentially cause infection. The DON was responsible for ensuring it was completed. <BR/>Record review of facility's policy Oxygen Therapy, dated as revised 04/05/22, revealed the following [in part]: <BR/>Policy: Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia.<BR/>Indications for Oxygen Therapy: 1. Documented hypoxemia. 3. Acute setting situation which hypoxemia is suspected.<BR/>Oxygen Delivery Forms may include but are not limited to the following: 1. Nasal Cannula.<BR/>Note: Oxygen nasal cannula and other delivery devices will be changed weekly and PRN.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 (resident #37) residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #37's pain was managed at an acceptable level. <BR/>This deficient practice could place residents at risk of pain, discomfort, and a diminished quality of life.<BR/>Findings:<BR/>A review of Resident #37's Electronic Health Record (EHR) indicated the admission date was 05/16/2022 with relevant diagnoses of: Respiratory Failure (lungs cannot get enough oxygen into the blood), Pressure Ulcer Sacral region (base of the spine); stage 2, Unspecified Abdominal Pain, Neuropathy (numbness and pain in legs), Pain and Difficulty in Walking. <BR/>Review of Resident #37's Care Plan Summary dated 06/22/22 documented one of the goals would be the Resident's pain would be minimal signs for symptoms or complaints of pain over the next 90 days <BR/>Review of Resident #37's routine medications indicated the medications for pain control were: <BR/>gabapentin 300mg; 2 capsules three times a day with a start state of 10/12/2022<BR/>Tylenol 325mg; 2 tablets every 6 hours PRN with a start date of 05/16/2022<BR/>Tylenol 4 300-60mg; 1 tablet every 6 hours PRN with a start date of 11/30/2022<BR/>Advil 200mg; 1 tablet every 4 hours PRN with a start date of 12/02/2022<BR/>Review of Resident #37's MDS assessment dated [DATE] revealed Resident #37 experienced pain on a level 10 (the worst pain imaginable), almost constantly during the 5-day lookback period. <BR/>Review of the MDS assessment dated [DATE] showed a Quarterly Assessment which revealed in the pain assessment interview; Section J0300- <BR/>Have you had pain or hurting at any time in the last 5 days? - Yes<BR/>How much of the time have you experienced pain r hurting over the last 5 days? - Almost Constantly<BR/>Please rate your pain over the last 5 days on a zero to ten pain scale, with zero being no pain and ten as the worst pain you can imagine. - 07 <BR/>Review of the MDS dated [DATE] showed a Comprehensive Assessment which revealed in the pain assessment interview; Section J0300- <BR/>Have you had pain or hurting at any time in the last 5 days? - Yes<BR/>How much of the time have you experienced pain r hurting over the last 5 days? - Occasionally<BR/>Please rate your pain over the last 5 days on a zero to ten pain scale, with zero being no pain and ten as the worst pain you can imagine. - 08 <BR/>In an interview with Resident#37 on 12/06/22 at 10:25 AM revealed that he normally, constantly had pain since his admission in May 2022. He said that he told them that the pain medication that had been given does not help. He said that during his interviews with the MDS Coordinator, he has made sure to let her know that the pain limits his day-to-day activity and is constant. <BR/>An interview with the DON (Director of Nursing) on 12/09/22 at 1:28 PM revealed that the Comprehensive Care Plan was initiated a month late. She said that she would have normally of caught that his pain level was not being alleviated, if they had a care plan. She said she was responsible for making sure medication was working and the resident's goals were being met. She said that the MDS Coordinator did the MDS and did not notify her with his pain score. She said that he should have received a routine medication to help him with his chronic pain and that she would be contacting the physician to get a new order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents with PRN orders for psychotropic drugs were limited to 14 days, except if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days for 1 of 4 residents (Resident #37) reviewed for unnecessary medications.<BR/>The facility failed to ensure Resident #37 did not have an order for alprazolam ([Xanax] a benzodiazepine medication) 1 mg by mouth every six hours as needed (PRN) for anxiety disorder beyond 14 days. , <BR/>This failure could place residents at risk of adverse side effects from prolonged use of psychotropic medications.<BR/>The findings include:<BR/>Record review of Resident #37's face sheet, dated 03/20/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included infection of the blood (sepsis), generalized anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), opening in the windpipe to allow breathing (tracheostomy), and loss of movement in all four limbs (quadriplegia).<BR/>Record review of Resident #37's Physician Orders, dated for the month of March 2025, revealed an order for alprazolam (Xanax) 1 mg, every six hours PRN for anxiety disorder. Start date of 02/26/2025. The order did not specify a stop date. The order did not include a rationale to continue the medication beyond 14 days. <BR/>Record review of Resident #37's Medication Administration Records, dated for the month of March 2025, revealed the resident received alprazolam (Xanax) 1 mg, PRN, on 03/06/2025, 03/08/2025, 03/11/2025, 03/12/2025, 03/13/2025, 03/14/2025, 03/16/2025, 03/17/2025 and 03/18/2025. <BR/>Record review of the Pharmacy Recommendations, from 1/01/2025 to 03/04/2025, did not reveal any pharmacy recommendations to stop the alprazolam (Xanax) 1 mg PRN order or a physician provided a rationale to continue at a PRN status.<BR/>In an interview with the DON on 03/20/2025 at 11:26 AM, the DON said she was responsible and was aware of the rule PRN psychotropic medications should have a 14-day stop date, but it was not caught. She said she went through the resident's orders with the pharmacist at the first of the month of March 2024, and the pharmacist failed to give her a recommendation for the order to have a stop date. A potential negative outcome would be the resident would receive unnecessary medication. <BR/>Record review of the facility's policy Antipsychotic Medication Use, dated as revised December 2001, revealed the following [in part]:<BR/>Policy Interpretation and Implementation:<BR/>14. The need to continue PRN doses of psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medications errors for 1 of 3 resident reviewed for IV medications (Resident #245).<BR/>The facility failed to ensure LVN D administered Resident #245's Meropenem (an antibiotic) according to the physician's order. <BR/>This failure placed the residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician, which could cause a serious allergic reaction and side effects. <BR/>Findings include: <BR/>Review of Resident #245's face sheet dated 12/09/22 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Stage 4 pressure ulcer of the sacral region (base of the spine), Stage 4 Pressure ulcer of left lower back, Hypertension (high blood pressure) and Heart failure (heart doesn't pump flood as well as it should)., <BR/>Review of Resident #245's December 2022 Physician Orders revealed Meropenem- 0.9% sodium chloride piggyback; 1 gram/50ML/HR; Amount to administer 25ML/HR; intravenous every 8 hours. Initial start date was 11/26/22; last Dose 12/6/22. And a one-time Dose on 12/07/22 at 11:00 a.m.<BR/>Observation for Resident #245 on 12/07/22 at 1:08 p.m. revealed LVN D administered Meropenem- 0.9% sodium chloride piggyback infusing at 100 ML/HR . LVN D had started and initialed the infusion as 12/07/22 at 12:48 p.m. There was no order to administer at that time or rate. <BR/>Interview and observation with LVN D on 12/07/22 at 1:10 p.m. revealed she did administer the Meropenem incorrectly by setting the pump at 10ML/HR instead of 25ML/HR. She immediately stopped the pump. She said that she did not realize she needed to reset the pump with each use, and she just started it. She said that she knew by infusing it at 4 times the ordered amount could cause side effects. She said that she was a new nurse that had just graduated school. She said that she been trained on Iv administration by the DON. <BR/>Interview with the DON on 12/09/22 at 1:28 p.m. revealed when a nurse administered medications, she needed to compare the Medication Administration Record to the pump to make sure it is correct. She said that LVN D was a new graduate nurse that was just hired, and she did not have any experience. She said that she had trained her, but that she would in-service her again and correct the issue. She said that failure to administer the correct dosage at the correct time and rate could cause the resident serious adverse effects. <BR/>Review of the facility's current Medication Administration policy and procedure, dated December 2012, revealed the following: <BR/>Policy Statement- Medications shall be administered in a safe and timely manner, and as prescribed. <BR/>Policy Interpretation and Implementation- Medications must be administered within 1 hour of their prescribed time, unless otherwise specified. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services.<BR/>The facility failed to ensure DA A performed hand hygiene while preparing resident food trays.<BR/>This failure could place residents at risk for contamination and food borne illnesses.<BR/>Findings include:<BR/>During an observation and interview on 03/18/2025 at 11:50 AM, revealed DA-A opened the refrigerator with her gloves on and took a container of lettuce out. She then used her gloved hands to take the lettuce out of the container and placed it on a resident's plate. DA-A opened the refrigerator door with the same gloved hands and placed the container back in the refrigerator and grabbed another container of chopped tomatoes and opened the container and removed the chopped tomatoes to put on the same resident plate without changing gloves or washing hands. DA-A opened the refrigerator with the same gloves on and removed a bag of lettuce. She then removed the lettuce from the bag with the same gloves and placed it on the same resident's plate. DA-A then got an onion out of the refrigerator and placed it on the resident's plate without changing her gloves. DA-A stated she should have changed gloves and did not have a reason as to why she did not. <BR/>During an interview on 03/20/2025 at 10:37 AM, the DM stated her expectation was for all staff to wash their hands with soap and water as well as change their gloves in between touching surfaces other than food. The DM stated when tasks are changed, you should change gloves. She stated the DA should not have used her glove hands to pick up the lettuce, tomatoes, and onions, and should have used a utensil instead. The DM stated all staff were trained as well as having their food handlers' certificate, so they should know what they were supposed to do. She stated DA-A was hired on 03/31/2023. The DM stated she was responsible for monitoring the staff to ensure staff followed policy regarding hand hygiene. The DM stated the effect on residents could have possibly been the spread of food born illnesses. The DM stated DA-A's laziness led to a failure of not having changed her gloves or using appropriate utensils. <BR/>During an interview on 03/20/2025 at 1:10 PM, the ADMN stated her expectation was to follow the facility policy. She stated the DM was responsible to monitor staff and should have monitored accordingly. The ADMN stated the negative affect for residents could have been the spread of foodborne illnesses. She stated she did not really know what the failure was in why the staff had not washed her hands, but she could have been nervous or just not thinking.<BR/>Record review of the facility's policy titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, dated October 2017, revealed: Employees must wash their hands: .Before coming in contact with any food services .after handling soiled equipment or utensils; During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or After engaging in other activities that contaminate the hands .Gloves are considered single-use items and must be discarded after completing the task for which they are used.<BR/>Record review of the Food and Drug Administration Food Code 2022 Annex 4. Management of Food Safety Practices - Achieving Active Managerial Control of Foodborne Illness Risk Factors Annex 4 - 7: <BR/>Full Document accessed 03/20/2025 revealed: <BR/> .practicing no bare hand contact with ready-to-eat food as well as proper handwashing, and implementing an employee health policy to restrict or exclude ill employees are important control measures for viruses.

Based on interview and record review, the facility failed to evaluate and maintain an effective Quality Assurance and Performance Improvement program that focused on indicators of the outcomes of care and quality of life.<BR/>The facility failed to have documentation and evidence of its QAPI plan being ongoing and comprehensive.<BR/>The facility had not implemented Performance Improvement Projects to address resident quality of care concerns. <BR/>This failure could place the residents at risk for a decreased quality of care and decreased quality of life within their living environment.<BR/>The findings included:<BR/>Review of the facility's 2023 Quality Assurance Performance Improvement Plan revealed it consisted of 2 pages and did not include an effective date for the plan. There was no documented evidence the plan had been reviewed for needed revisions after it was developed. The plan included information regarding the purpose of QAPI, vision and mission statements, guiding principles, the QAPI steering committee, and the scope of the QAPI teams.<BR/>Review of the QAPI Program, revised February 2020, printed from an internet website and provided by the Administrator for review, revealed the program was a generic plan. It had not been modified or revised to be specific to the facility. <BR/>In an interview on 2/09/24 at 3:28 PM, the DON stated she participated in the facility's QAPI committee meetings every month. She stated no PIPs had been developed to address resident quality of care concerns during the past year.<BR/>In an interview on 2/09/24 at 3:32 PM, the Administrator stated she had developed the facility's QAPI program plan in March 2022 when she began employment in the facility. She stated QAPI meetings were held monthly and were attended by the required committee members. The Administrator stated the QAPI committee had not developed any PIPs during the past year as no needs were identified.<BR/>

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in 1 locked compartment and to permit only authorized personnel to have access to controlled medications . <BR/>The facility failed to ensure the controlled medications were secured in the ADON's office. <BR/>This failure could place controlled medications at risk of drug diversion.<BR/>Findings included:<BR/>During an interview and observation on 12/08/22 at 11:12 a.m., the ADON unlocked her office door for us to count the controlled medications. The medications were lying on the desk, not locked up in the locked storage box that was below her desk. When asked, she said that she had left her office after placing them on her desk. When asked who had access to her office, she said her, the Administrator, and the Maintenance Director. She said that she would be putting them in the controlled medication box and would not be leaving them out on her desk again . When asked what the risk could be for leaving the medication on her desk accessible to unauthorized personnel, she stated that it could possibly cause a drug diversion. <BR/>During an interview on 12/08/22 at 1:57 p.m., After the Administrator was advised of the incident, she said that she and the Maintenance Director did have keys to the ADON's office. She said that she would be doing additional in-service to correct the issue. <BR/>During an interview on 12/09/22 at 2:00 p.m., the DON said she was made aware of the controlled medications not being locked behind two locks. She said that this failure could result in a drug diversion and that she would be doing some additional training.<BR/>Review of the policy and procedures on Discarding and Destroying Medications, dated April 2013, stated that All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were that were complete and accurately documented for 1 of 12 (Resident # 6) residents reviewed for resident records.<BR/>The facility failed to ensure Resident #6's physician orders contained orders for the care of Resident # 6's ostomy. <BR/>This failure could place residents at risk of having errors in care and treatment.<BR/>The Findings include:<BR/>Record review of Resident #26's electronic face sheet, dated 03/19/2025, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] with a readmission on [DATE]. Resident #26 had diagnoses which included Chronic Obstructive Pulmonary Disease, congestive heart failure, Respiratory failure, Hight Blood Pressure, Type 2 diabetes.<BR/>Record review of Resident #26's significant change MDS Assessment, dated 01/25/2025, revealed in Section C - cognitive patterns: Resident #26's had a BIMS of 10, which meant moderate cognitive impairment. Section H-- Bladder and Bowel, revealed she had an ostomy.<BR/>Record review of Resident #26's Care Plan, initiated 02/13/2025, revealed no evidence of ostomy care.<BR/>Record review of Resident #26's Physician orders revealed no order for ostomy care, prior to 03/19/2025.<BR/>During an observation and interview on 03/18/2025 at 10:41 AM revealed Resident #26 had an ostomy bag. Resident #26's skin around the ostomy did not appear red and the site clean. Resident #26 stated staff helped her with emptying and changing her ostomy bag. Resident #26 stated her only complaint was that they will not always empty her ostomy bag at bedtime if it is not full, she stated she preferred for her ostomy emptied before bedtime no matter how full the ostomy bag was.<BR/>During an interview on 03/20/2025 at 12:01 PM, the DON stated her expectation was orders for ostomy care should be included in the Resident's active orders. The DON stated the nurse who received the orders for ostomy should have added orders to the resident's record. The DON stated the effect on the resident for their orders not being accurate could have caused the resident to have care needs not met. The DON stated she was responsible to monitor. The DON stated what led to failure was lack of monitoring by herself and the facility was transitioning from one electronic medical company to another electronic medical company.<BR/>Record review of the facility's policy titled, Colostomy/Ileostomy Care dated October 2010 revealed, The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. Review the resident's care plan to assess for any special needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents with PRN orders for psychotropic drugs were limited to 14 days, except if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days for 1 of 4 residents (Resident #37) reviewed for unnecessary medications.<BR/>The facility failed to ensure Resident #37 did not have an order for alprazolam ([Xanax] a benzodiazepine medication) 1 mg by mouth every six hours as needed (PRN) for anxiety disorder beyond 14 days. , <BR/>This failure could place residents at risk of adverse side effects from prolonged use of psychotropic medications.<BR/>The findings include:<BR/>Record review of Resident #37's face sheet, dated 03/20/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included infection of the blood (sepsis), generalized anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), opening in the windpipe to allow breathing (tracheostomy), and loss of movement in all four limbs (quadriplegia).<BR/>Record review of Resident #37's Physician Orders, dated for the month of March 2025, revealed an order for alprazolam (Xanax) 1 mg, every six hours PRN for anxiety disorder. Start date of 02/26/2025. The order did not specify a stop date. The order did not include a rationale to continue the medication beyond 14 days. <BR/>Record review of Resident #37's Medication Administration Records, dated for the month of March 2025, revealed the resident received alprazolam (Xanax) 1 mg, PRN, on 03/06/2025, 03/08/2025, 03/11/2025, 03/12/2025, 03/13/2025, 03/14/2025, 03/16/2025, 03/17/2025 and 03/18/2025. <BR/>Record review of the Pharmacy Recommendations, from 1/01/2025 to 03/04/2025, did not reveal any pharmacy recommendations to stop the alprazolam (Xanax) 1 mg PRN order or a physician provided a rationale to continue at a PRN status.<BR/>In an interview with the DON on 03/20/2025 at 11:26 AM, the DON said she was responsible and was aware of the rule PRN psychotropic medications should have a 14-day stop date, but it was not caught. She said she went through the resident's orders with the pharmacist at the first of the month of March 2024, and the pharmacist failed to give her a recommendation for the order to have a stop date. A potential negative outcome would be the resident would receive unnecessary medication. <BR/>Record review of the facility's policy Antipsychotic Medication Use, dated as revised December 2001, revealed the following [in part]:<BR/>Policy Interpretation and Implementation:<BR/>14. The need to continue PRN doses of psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.

Based on interview and record review, the facility failed to ensure 12 hours of annual in-service training was provided to ensure continuing competency for 2 of 6 CNAs (CNA B and CNA C) whose records were reviewed for completion of in-service training, in that:<BR/>1. CNA B was hired for employment on 1/27/2023. She completed 8.5 hours of annual in-service training.<BR/>2. CNA C was hired for employment on 5/25/2021. She completed 8 hours of annual in-service training.<BR/>These failures could place residents at risk for not receiving quality care and services to meet their physical and psychosocial needs within their living environment.<BR/>The findings included:<BR/>Review of CNA B's personnel file revealed she was hired for employment on 1/27/2023. Review of her in-service training records revealed she had completed 8.5 hours of annual training.<BR/>Review of CNA C's personnel file revealed she was hired for employment on 5/25/2021. Review of her in-service training records revealed she had completed 8 hours of annual training.<BR/>In an interview on 2/09/24 at 8:32 AM, the Staffing Coordinator stated she was also a CNA. She stated the DON did annual NA Proficiency Evaluations and kept them in a binder in her office.<BR/>In an interview on 2/09/24 at 11:39 AM, the DON stated she did NA proficiency evaluations on hire and annually. She stated all of the currently employed CNAs were certified and no nurse aides waiting to test. <BR/>In an interview on 2/09/24 at 4:04 PM, the DON stated she had some printed certificates of completion from computer-based training courses that were 2 hours each, which she kept in staff file folders in her office. She stated the HR Manager maintained records for other computer-based training completed by the staff. The DON stated she did not have a system for documenting individual employee annual in-service training hours to monitor attendance and completion. She stated she did not use a form to record each individual's training hours, the topic, or the date of attendance or completion of the training.<BR/>Review of the facility's policy for In-Service Training Program - Nurse Aide, dated as revised May 2019, revealed the following [in part]:<BR/>Policy Statement<BR/>All nurse aide personnel participate in regularly scheduled in-service training classes.<BR/>Policy Interpretation and Implementation<BR/>1. All personnel are required to attend regularly scheduled in-service training classes.<BR/>2. The facility completes a performance review of nurse aides at least every 12 months. <BR/>3. In-service training is based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews.<BR/>4. Annual in-services:<BR/>a. Ensure the continuing competence of nurse aides;<BR/>b. Are no less than 12 hours per employment year;<BR/>c. Address areas of weakness as determined by nurse aide performance reviews .<BR/>8. All training classes attended by the employee are entered on the respective employee's Record of In-service by the department supervisor or other person(s) as designated by the supervisor.<BR/>9. Records are filed in the employee's personnel file or are maintained by the department supervisor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 1 of 2 residents reviewed for pressure injuries. (Residents #18)<BR/>The facility failed to put physician ordered heel protectors on Resident #18. <BR/>This failure could place residents who had pressure injuries at risk for new development or worsening of existing pressure injuries.<BR/>Findings included : <BR/>Record review of Resident #18's admission record revealed he was [AGE] years old. He was admitted to the facility on [DATE] with a diagnosis of COVID (respiratory disease), Congested Heart Failure (Failure of the heart to pump blood as well as it should), Pressure induced deep tissue damage - tip of left great toe, Pressure ulcer on left heel, Pressure induced deep tissue damage on left heel, and Peripheral Vascular Disease (reduction of blood flow to the lower limbs). <BR/>Record review of the December Physician's Order Report revealed:<BR/>Heel boots on when in bed for offloading pressure (Diagnosis: Pressure ulcer of left heel; stage 1) Every shift- Morning 6:00 AM- 6:00PM, Night 6:00 PM- 6:00 AM. Start date 08/10/22- no end date.<BR/>Record review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #18 was at risk for developing pressure ulcers. <BR/>Record review of December ADL flow sheets documented on Resident #18 revealed that ressure reducing heel boots (boots that reduce pressure on the feet) were worn daily. There were no days documented that the resident declined.<BR/>During an observation and interview on 12/06/22 11:46 AM, Resident #18 was in his room in his bed with the TV on. He appeared slightly confused but was able to communicate. He said that he had issues at times with his legs and pressure ulcers. His legs were under the covers and there was no pressure reducing devices boots used in the bed. There was no pressure ulcers observed on his feet.<BR/>Observation on 12/07/22 at 10:59 AM of Resident #18 revealed resident lying in bed. There were no pressure relieving device on the bed. Noted 2 pressure reducing boots inside of his dresser. <BR/>During an interview on 12/07/22 at 3:45 PM, LVN C revealed that she was just checking off that the pressure reducing boots were on when she was completing the ADL flowsheet. It had already been checked off for the day that the resident was wearing them, but the resident had not had them on. She said that she would start checking to make sure the CNA's put them on or the resident refused to wear them, she would document that. <BR/>During an interview on 12/09/22 1:28 p.m., DON said Resident #18 came to the facility with pressure ulcers. She said that he refused the heel boots at times, but that nursing was not documenting that on the ADL flowsheet. She said that the nursing staff should have followed the physician orders for heel protectors. <BR/>A copy of the facility's policy and procedures on treatments for pressure ulcers was requested by the DON and not provided at the time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were that were complete and accurately documented for 1 of 12 (Resident # 6) residents reviewed for resident records.<BR/>The facility failed to ensure Resident #6's physician orders contained orders for the care of Resident # 6's ostomy. <BR/>This failure could place residents at risk of having errors in care and treatment.<BR/>The Findings include:<BR/>Record review of Resident #26's electronic face sheet, dated 03/19/2025, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] with a readmission on [DATE]. Resident #26 had diagnoses which included Chronic Obstructive Pulmonary Disease, congestive heart failure, Respiratory failure, Hight Blood Pressure, Type 2 diabetes.<BR/>Record review of Resident #26's significant change MDS Assessment, dated 01/25/2025, revealed in Section C - cognitive patterns: Resident #26's had a BIMS of 10, which meant moderate cognitive impairment. Section H-- Bladder and Bowel, revealed she had an ostomy.<BR/>Record review of Resident #26's Care Plan, initiated 02/13/2025, revealed no evidence of ostomy care.<BR/>Record review of Resident #26's Physician orders revealed no order for ostomy care, prior to 03/19/2025.<BR/>During an observation and interview on 03/18/2025 at 10:41 AM revealed Resident #26 had an ostomy bag. Resident #26's skin around the ostomy did not appear red and the site clean. Resident #26 stated staff helped her with emptying and changing her ostomy bag. Resident #26 stated her only complaint was that they will not always empty her ostomy bag at bedtime if it is not full, she stated she preferred for her ostomy emptied before bedtime no matter how full the ostomy bag was.<BR/>During an interview on 03/20/2025 at 12:01 PM, the DON stated her expectation was orders for ostomy care should be included in the Resident's active orders. The DON stated the nurse who received the orders for ostomy should have added orders to the resident's record. The DON stated the effect on the resident for their orders not being accurate could have caused the resident to have care needs not met. The DON stated she was responsible to monitor. The DON stated what led to failure was lack of monitoring by herself and the facility was transitioning from one electronic medical company to another electronic medical company.<BR/>Record review of the facility's policy titled, Colostomy/Ileostomy Care dated October 2010 revealed, The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. Review the resident's care plan to assess for any special needs of the resident.

Based on observation, interview, and record review, the facility failed to post daily nurse staffing information which included the total number and actual hours worked by licensed nurses and certified nurse aides directly responsible for resident care per shift for 1 of 1 day reviewed.<BR/>1. The facility posted a daily nurse staffing form that documented the day of the week, date, resident census, and the first names of the direct care staff licensed nurses and certified nurse aides and their assigned hall location for each of two shifts, 6 AM - 6 PM and 6 PM - 6 AM for 2/09/2024. <BR/>2. The daily nurse staffing form did not include the name of the facility and did not document the number of staff scheduled to work and the actual hours worked by the staff for each shift for 2/09/2024.<BR/>These failures could place the residents and visitors to the facility at risk for not knowing the daily staffing pattern and the number of staff scheduled to provide direct care to the residents to meet their needs.<BR/>The findings included:<BR/>Observation on 2/06/24 at 8:55 AM revealed a daily nurse staffing form was taped to the window of the front office reception area, where the Staffing Coordinator worked at a desk.<BR/>Record review on 2/09/24 at 11:31 AM revealed the daily nurse staffing form revealed it was for Friday, 2/09/2024. It documented the current resident census was 32. The form did not include the name of the facility. The form documented the first names of the licensed nurses and CNAs and their assigned locations for each of two shifts, 6 AM - 6 PM and 6 PM - 6 AM. The form documented the first names of the DON and ADON as being on duty for the 6 AM - 6 PM shift. The names of 2 LVNs charge nurses and 2 CNAs and the CNA Business Office Manager and DON were listed as direct care staff for the 6 AM - 6 PM day shift. The name of the CNA who had left had not been marked off or noted as having left early. The form documented the names of the 2 LVN charge nurses and 2 CNAs scheduled to work on the 6 PM - 6 AM night shift. The form did not include columns to document the number of staff scheduled or actual staff hours worked for each shift. <BR/>In an interview on 2/07/24 at 10:02 AM, the Staffing Coordinator stated the nursing staff worked 12 hour shifts from 6-6. She stated the usual staffing pattern for the Day shift, 6 AM - 6 PM, was 2 charge nurses and 3 CNAs. She stated the usual staffing pattern for the Night shift, 6 PM - 6 AM, was 2 charge nurses and 2 CNAs. She stated sometimes a nurse would work as an aide on the night shift. <BR/>In an interview on 2/09/24 at 8:32 AM, the Staffing Coordinator stated she was also a CNA. She stated she was not scheduled to work the floor as a direct care staff.<BR/>In an interview on 2/09/24 at 9:54 AM, the Business Office Manager stated she was also a CNA and was working the floor today to help out. She stated she came in at 7:00 AM. She stated she was not sure if someone called in or was a no call - no show. She stated she would not be staying to work until 6:00 PM this evening. <BR/>In an interview on 2/09/24 at 11:33 AM, the LVN charge nurse assigned to the North Hall stated there were currently 2 LVN charge nurses on duty and 2 CNAs. She stated the Business Office Manager was a CNA and was working the floor. The LVN stated one of the CNAs who was scheduled to work had just left 30 minutes ago due to having a sick child. The LVN charge nurse stated the DON was working the floor with the CNA Business Office Manager on the North Hall. She stated one CNA was working on the South Hall. The LVN stated no staff numbers or staff hours worked were ever documented on the daily nurse staffing form, just the names of the staff and their assigned location for each shift.<BR/>In an interview on 2/09/24 at 11:39 AM, the DON stated she did not usually work the floor as an aide but had a staff member who had to leave due to a family emergency with a sick child at day care. She stated one CNA had a medical appointment and was not able to work as scheduled. The DON stated the Staffing Coordinator totaled the staff hours worked and wrote them on the staffing sheets. <BR/>In an interview on 2/09/24 at 2:07 PM, the Staffing Coordinator stated she had been using the same daily nurse staffing form for the past 8 years. She stated she took the form the next morning and totaled the hours on the paper and put the hours in the computer. The Staffing Coordinator state she had never listed the staff numbers for scheduled nurses and certified nurse aides and the actual hours worked for each shift on the posted daily nurse staffing form.