Fort Bend Healthcare Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one of two residents (Resident #19) reviewed for Quality of Care.<BR/>1. The facility failed to ensure Resident #19's catheter was secured to an anchor to provide slack and to prevent pulling.<BR/>2. The facility failed to ensure Resident #19 did not exhibit skin breakdown at the catheter sight due to the catheter pulling and putting pressure against the tissue.<BR/>These deficient practices could place residents at risk of pain and skin breakdown. <BR/>Findings include:<BR/>Record review of the face sheet for Resident #19, dated 02/17/2022, revealed a [AGE] year old male who was admitted to the facility on [DATE]. Resident #19 had diagnoses which included, but were not limited to, obstructive and reflux uropathy (blockage of urinary tract), muscle weakness, and hydronephrosis (swelling of the kidney due to blockage of the bladder). <BR/>Record review of a Physician's Order, dated 09/15/2021, revealed the resident had a suprapubic catheter, and staff were to check for patency and placement every shift.<BR/>Record review of the, undated, care plan for Resident #19 revealed the resident could wear a leg bag during the day. (A leg bag is a smaller urine collection bag that is secured to the leg with straps, permitting easier mobility). The care plan reflected the bag was to be strapped securely to his leg, to keep from sliding down.<BR/>Interview on 02/15/2022 at 9:34 a.m. with Resident #19 revealed he used a 'big bag' (larger urine collection bag that hooks onto a bed rail) at night, and a leg bag during the day. He said the smaller one fills up, then backs up, causing pain. <BR/>Observation and interview on 02/15/2022 at 2:40 p.m. revealed Resident #19 in his room, sitting on the side of his bed. He said he had a leg bag on. He gave verbal consent for LVN A and the state surveyor to observe the catheter site and the catheter. The resident wore loose-fitting pajama pants. The tubing was on the outside of the disposable brief. There was a catheter anchor (a patch that is secured to the thigh, which has a clamp to secure catheter tubing) on the resident's left thigh. The catheter tubing was not secured to the anchor. The leg bag was strapped to the resident's right calf. There was approximately 150 cc of urine in the leg bag. When the resident stood, the tubing became so taught that it visibly pulled down the skin on the resident's catheter site. The resident complained of pain. The catheter site was in need of cleaning. LVN A said she would gather supplies and clean the catheter site. <BR/>Observation and interview on 02/15/2022 at 2:45 p.m. revealed LVN A cleaned the catheter and the catheter site. There were no concerns with technique. Observation revealed the resident had a small open area on the catheter site, where the tubing was observed to be pulling. The resident said it caused discomfort when the tubing was tight. LVN A acknowledged the skin breakdown and said she would notify the physician. LVN A said the tubing should have been secured to the anchor to provide slack in the tubing. She moved the leg bag to the left calf and secured the tubing with the anchor. She placed a split 4 x 4 inch gauze on the site, and around the catheter.<BR/>Observation and interview on 02/16/2022 at 1:30 p.m. revealed Resident #19 laid in bed, awake. The resident said the leg bag was on his lower left leg. The anchor was still on his left thigh. He said the tubing was clamped to the anchor, allowing slack between the clamp and catheter site. He denied having pain at that time.<BR/>Record review of the facility's policy titled Catheter Care (updated March 2019) revealed the purpose of the policy was to prevent infection and reduce irritation. The policy reflected the staff were to ensure the leg strap was used to secure the catheter tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one of two residents (Resident #19) reviewed for Quality of Care.<BR/>1. The facility failed to ensure Resident #19's catheter was secured to an anchor to provide slack and to prevent pulling.<BR/>2. The facility failed to ensure Resident #19 did not exhibit skin breakdown at the catheter sight due to the catheter pulling and putting pressure against the tissue.<BR/>These deficient practices could place residents at risk of pain and skin breakdown. <BR/>Findings include:<BR/>Record review of the face sheet for Resident #19, dated 02/17/2022, revealed a [AGE] year old male who was admitted to the facility on [DATE]. Resident #19 had diagnoses which included, but were not limited to, obstructive and reflux uropathy (blockage of urinary tract), muscle weakness, and hydronephrosis (swelling of the kidney due to blockage of the bladder). <BR/>Record review of a Physician's Order, dated 09/15/2021, revealed the resident had a suprapubic catheter, and staff were to check for patency and placement every shift.<BR/>Record review of the, undated, care plan for Resident #19 revealed the resident could wear a leg bag during the day. (A leg bag is a smaller urine collection bag that is secured to the leg with straps, permitting easier mobility). The care plan reflected the bag was to be strapped securely to his leg, to keep from sliding down.<BR/>Interview on 02/15/2022 at 9:34 a.m. with Resident #19 revealed he used a 'big bag' (larger urine collection bag that hooks onto a bed rail) at night, and a leg bag during the day. He said the smaller one fills up, then backs up, causing pain. <BR/>Observation and interview on 02/15/2022 at 2:40 p.m. revealed Resident #19 in his room, sitting on the side of his bed. He said he had a leg bag on. He gave verbal consent for LVN A and the state surveyor to observe the catheter site and the catheter. The resident wore loose-fitting pajama pants. The tubing was on the outside of the disposable brief. There was a catheter anchor (a patch that is secured to the thigh, which has a clamp to secure catheter tubing) on the resident's left thigh. The catheter tubing was not secured to the anchor. The leg bag was strapped to the resident's right calf. There was approximately 150 cc of urine in the leg bag. When the resident stood, the tubing became so taught that it visibly pulled down the skin on the resident's catheter site. The resident complained of pain. The catheter site was in need of cleaning. LVN A said she would gather supplies and clean the catheter site. <BR/>Observation and interview on 02/15/2022 at 2:45 p.m. revealed LVN A cleaned the catheter and the catheter site. There were no concerns with technique. Observation revealed the resident had a small open area on the catheter site, where the tubing was observed to be pulling. The resident said it caused discomfort when the tubing was tight. LVN A acknowledged the skin breakdown and said she would notify the physician. LVN A said the tubing should have been secured to the anchor to provide slack in the tubing. She moved the leg bag to the left calf and secured the tubing with the anchor. She placed a split 4 x 4 inch gauze on the site, and around the catheter.<BR/>Observation and interview on 02/16/2022 at 1:30 p.m. revealed Resident #19 laid in bed, awake. The resident said the leg bag was on his lower left leg. The anchor was still on his left thigh. He said the tubing was clamped to the anchor, allowing slack between the clamp and catheter site. He denied having pain at that time.<BR/>Record review of the facility's policy titled Catheter Care (updated March 2019) revealed the purpose of the policy was to prevent infection and reduce irritation. The policy reflected the staff were to ensure the leg strap was used to secure the catheter tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the comprehensive person-centered care plan was reviewed and revised after a change in condition and or falls for 1 (Resident #1) of 4 residents reviewed for care plan revision/timing.<BR/>1. The facility failed to ensure Resident #1's care plan was revised to include interventions and services to decrease the risk of falls in the facility's dining room after suffering a fall on 12/31/24. Resident #1 had similar falls in the facility's dining room on 09/29/23 and 09/21/24 with no injuries.<BR/>2. The facility failed to ensure Resident #1's care plan included interventions and services to appropriately assess and monitor the resident's chronic pain.<BR/>These failures could place residents at risk of not receiving the appropriate care, services, or treatments needed to achieve highest quality of life.<BR/>Findings included: <BR/>Record review of Resident # 1's face sheet, dated, 03/12/25, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included: Unspecified dementia (memory loss, confusion, difficulty thinking or making decisions), unspecified severity, without behavioral disturbance, psychotic disturbance (mental condition where a person has trouble knowing what is real), mood disturbance, anxiety (feeling of worry, fear or nervousness), Alzheimer disease (disease that slowly damage memory and thinking skills), major depressive disorder, cognitive communication deficit (difficulty with thinking and language), unspecified lack of coordination (having trouble controlling movements, making actions unsteady), fracture of unspecified part of neck of right femur (a broken bone in an unknown part of the upper right thigh), subsequent encounter for closed fracture with routine healing (follow-up visit for a broken bone that is healing normally).<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 12/14/24, revealed the resident had a BIMS score of 5, indicating a severe cognitive impairment. Functional abilities substantial/maximal assistance (help does more than half the effort), eating, oral hygiene, toileting hygiene, shower/bath, lower body dressing and personal hygiene. Resident# 1 was not coded for pain or falls.<BR/>Record review of the facility's Incident by Incident Type, dated 12/1/24-3/14/25 revealed Resident #1's fall dated 12/31/24 at 7:00 pm, in the dining room, the resident slid out of the wheelchair while attempting to pick up something on the floor. The nurse observed a skin tear to the right forearm.<BR/>Record review of Resident#1's Comprehensive Care Plan, updated on 1/25/25, did not reveal goals or interventions related to preventing falls in the dining room. However, the care plan did indicate Resident #1 was at risk for falls. Interventions included staff anticipating and meeting the resident's needs. ensuring Resident #1's call light was within reach and encouraging the resident to call for assistance as needed. Educate the resident/family/ caregivers about safety reminders and what to do if a fall occurs. Ensure Resident #1 wears appropriate footwear when ambulating or mobilizing in wheelchair. Physical therapy to evaluate and treat as ordered or as needed. <BR/>Record review of Resident #1's Care Plan dated 11/25/20 did not reveal the dates the care plan was updated after the resident's falls on 9/29/23 and 9/21/24. Further review of the care plan indicated Resident #1 was at risk for falls r/t history of falls and suffered falls in the facility's dining room on 9/29/23 and 9/21/24. The resident was noted to be found sitting on the dining room floor with no injuries after each fall on 9/29/23 and 9/21/24. Interventions included: place call bell/light within easy reach, respond promptly to calls for assist to toilet, foot ware will fit properly and have non-skid soles, provide reminders to use ambulation and transfer assist devices, keep area free of obstructions to reduce the risk of falls or injury, resident is on the fallen leaf program to indicate she is at high risk for falls. A red band will be placed on her wheelchair and leaf next to her name on the door to indicate to staff that she is a high risk for falls, PT (physical therapy) and OT (occupational therapy) to evaluate and treat as indicated. Assist resident to the dining room and have resident sit at a table, resident has been re-educated on the importance of using the call lights and waiting for help. Call light education done, bed in lowest position and brake extender on wc (wheelchair).<BR/>Record review of a Physical Therapy Evaluation, dated 12/11/24, revealed the reason for the resident's physical therapy referral was due to decline in strength, dynamic balance, functional ambulation, functional mobility .The resident felt unsteady when standing, when walking; had a fear of falling, and worried about falling. The evaluation indicated the resident unable to communicate pain; and lack of pain was determined based upon the resident's behavior. The resident exhibited slow, unsteady gait with forward lean of trunk, inadequate hip extension and inadequate trunk extension which are associated with the underlying causes of muscle weakness, reduced functional activity tolerance and impaired coordination. The resident also exhibited the wide base of support, decreased rotation of hips and shoulders, decreased speed and amplitude of automatic movements, decreased step length (&lt;15), waddling, and pushing her walker far ahead of her. <BR/>Further review of the evaluation revealed weak trunk and lower extremity muscles, reduced reactive balance and reduced recognition of unsafe situations as fall predictors for the resident. The resident's Gross Motor Coordination was also noted as impaired. The resident was referred to physical therapy due to decline in functional mobility and her ability to ambulate due to muscle weakness, decreased balance and coordination and decreased functional endurance. The resident was noted to have cognitive impairment and poor safety awareness. However, she was cooperative. The resident was noted to benefit from physical therapy interventions to improve safety, decrease level of assistance in functional mobility and improve her ability to ambulate. The resident required skilled physical therapy services to increase lower extremity strength, improve dynamic balance, increase coordination, increase functional activity tolerance, minimize falls, facilitate independence with all functional mobility, increase independence with gait in order to enhance patient's quality of life by improving ability to increase performance skills with functional tasks, and perform functional mobility with reduced risk of falls. The recommended level of skilled therapy services also included the need for durable medical equipment for condition and Patient with dementia requiring repetition of structured task to facilitate new learning.<BR/>Further review of the evaluation indicated, due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: falls, decreased participation with functional tasks and further decline in function .<BR/>Record review of Physical Therapy Evaluation & Plan of Treatment, dated 1/8/25, revealed the resident was diagnosed with a fracture of unspecified part of neck of right femur (right hip); generalized muscle weakness; unsteadiness on feet; unspecified abnormalities of gait and mobility; other lack of coordination; and other reduced mobility with an onset date of 1/2/25. The resident's treatment approaches may have included therapeutic exercises; neuromuscular reeducation; gait training therapy; physical therapy evaluation: moderate complexity; therapeutic activities; and wheelchair management training to occur 20 times between 1/8/25 and 3/6/25.<BR/>Further review of the Evaluation & Treatment Plan reflected a goal to safely perform functional transfers with moderate assistance with ability to right self to achieve/maintain balance in order to increase performance skills with functional tasks and decrease level of assistance from caregivers. The plan indicated the resident's transfers level of function prior to 1/2/25 was contact guard assist and her baseline on 1/8/25 was total dependence with attempts to initiate. A goal to complete sit to stand transfers with moderate assistance with ability to right self to achieve/maintain balance in order to increase performance skills with functional tasks, perform mobility with reduced risk of falls and decrease level of assistance from caregivers. The plan indicated the resident's sit to stand level of function prior to 1/2/25 was contact guard assist and her baseline on 1/8/25 was total dependence with attempts to initiate. A goal to increase dynamic standing balance to Poor+ spontaneously righting self when needed in order to decrease loss of balance during functional mobility, improve ability to safely ambulate within environment and reduce the risk for falls. The plan also indicated the resident's sit to stand level of function prior to 1/2/25 was contact guard assist and, her baseline on 1/8/25 was total dependence with attempts to initiate. The plan also indicated the resident's dynamic standing level of function prior to 1/2/25 was fair and her baseline on 1/8/25 was poor.<BR/>Further review of the Evaluation & Treatment Plan indicated the resident was referred to physical therapy due to decline in strength, dynamic balance, functional ambulation, functional mobility .status post hospitalization for an accidental fall and sustaining a right hip femoral neck fracture. The resident was noted to be status post right hip hemiarthroplasty (half of a hip joint replacement). The resident required skilled physical therapy services to increase lower extremity strength, improve dynamic balance, increase coordination, increase functional activity tolerance, minimize falls, facilitate improvement with all functional mobility and increase ability to ambulate in order to enhance patient's quality of life by improving ability to increase performance skills with functional tasks and perform functional mobility with reduced risk of falls. Level of Skilled Services also included need for durable medical equipment for condition and Patient with dementia requiring repetition of structured task to facilitate new learning.<BR/>Record Review of Physical Therapy Discharge Summary revealed dates of service of 1/8/25-1/31/2025. The summary indicated the resident was discharged from physical therapy per physician or case manager. The resident's transfers level of function prior to 1/2/25 was contact guard assist; baseline on 1/8/25 was total dependence with attempts to initiate; on 1/28/25 was maximum assistance; and on discharge 1/31/25 was maximum assistance. The resident's sit to stand level of function prior to 1/2/25 was contact guard assist; baseline on 1/8/25 was total dependence with attempts to initiate; on 1/28/25 was maximum assistance; and on discharge 1/31/25 was maximum assistance. The resident's dynamic standing level of function prior to 1/2/25 was fair; baseline on 1/8/25 was poor; on 1/28/25 was poor; and on discharge 1/31/25 was poor. The discharge summary also indicated the resident had reached maximum potential with skilled services.<BR/>Interview with the MDS coordinator on 3/13/25 at 3:44 pm, she said when she tried different interventions for residents, she referred residents to therapy. She said the Unit Manager was responsible for putting therapy services into a resident's care plan. She said facility management spoke about care plan interventions and updates during the daily morning meeting and scheduled care plan meetings. She said she was not familiar with Resident #1's current care plan. She said the risk of a resident when a care plan does not meet her needs could be another fall or injury.<BR/>Several unsuccessful attempts to interview contracted Physical Therapy Director were made 3/12/25 and 3/13/25.<BR/>Interview with the DON on 3/13/25 at 2:38 pm, she said she had worked at the facility for 4 weeks. She said she was not aware Resident #1 suffered 3 falls in the facility's dining room. She said the facility would consider trying different interventions if the falls indicated a pattern. She said since Resident #1 had 3 similar incidents she considered the resident's falls in the dining room a pattern. She said the risk associated with a care plan not meeting the needs of a resident was the facility not providing the care a resident required.<BR/>Interview with the Administrator on 3/14/25 at 4:16 pm, she said she referred to a care plan as a 'plan of care.' She said she was not aware the resident suffered 3 falls in the facility's dining room. She said she had only been employed with the facility for one month. She said the risk associated with a resident not having an appropriate care plan was the facility not providing adequate, appropriate care and preventative measures.<BR/>In an interview with CNA B on 3/25/25 at 10:50 AM, she said Resident# 1 could stand up and walk on her own. She said the resident rolled herself around in her wheelchair. She said the resident's physical capabilities really depended on her mood. She said the resident slept during the day and was usually awake at night. She said during the day, the resident was sometimes less responsive. She said when the resident was not in the mood during the day, she required 2 persons assist. She said when the resident was in a good mood, she was able to do most things with little to no assistance. She said since the resident came back from the hospital after she broke her hip, the resident seemed fine. She said the resident was able to stand up on her own. She said nothing had changed regarding the care she provided to the resident since she returned to the facility. She said the resident did not have any new assistive devices either.<BR/>In an interview with the Unit Manager, on 3/25/25 at 11:07 AM, she said the Unit Manager and the MDS nurse was responsible for updating resident care plans. She said every time a resident fell, a new intervention was added to their care plan. She said she was familiar with Resident #1. She said the resident's baseline behavior was pleasantly confused. She said the resident had the ability to speak but did not speak very often. She said sometimes, if you asked the resident a question, she would reply with 'yes' or 'no.' She said she could not recall exactly how many times the resident suffered a fall. She said she thought the resident had suffered a fall in the facility dining room once in the past. She said she did not know how long it had been but there was a long span of time between the fall on 12/31/24 and the previous fall in the dining room. She said the resident had not suffered as many falls as others considered fall risks. She also said she knew residents had the right to fall. She said the resident was still receiving the same care as before she was sent to the hospital. She said one change that occurred since the resident fell on [DATE] was staff always had to monitor the dining room while residents were present. She said when the resident returned from the hospital, she was working with PT and OT. She said she did not know the resident had suffered three falls in the dining room. She said she did not know whether the resident's three falls in the dining room were considered a pattern due to the timeframe between each fall. She said she would have to look at the care plan to determine whether the care plan was appropriate and met the residents' needs. She said she knew the residents' previous care plan was appropriate. She said the resident's current plan did not have interventions that would prevent the resident from falling in the dining room. She said she needed to tweak the resident's care plan. She said she was not sure whether the facility was able to utilize Geri Chairs for residents. She said a Geri Chair with a tabletop was considered a restraint. She said the resident's falls were related to the resident bending down while sitting in her wheelchair and attempting to pick items up off the floor. She said she was considering getting some sort of grabber device for the resident, but the resident had one contracted hand. She said the risk associated with the resident's care plan not meeting the resident's needs was potentially another fall.<BR/>In an interview with Family Member on 03/25/25 at 11:31 AM, she said she was not aware of any changes to the resident's care plan after the resident fell on [DATE]. She said the social worker would call and do a meeting when updates to the care plan were needed.<BR/>In an interview with the Interim Administrator, DON, and Regional Nurse on 3/25/25 at 3:17 PM, the DON said if a resident was nonverbal or unable to regularly make their needs known, she would observe the residents' facial expressions to assess for pain. She said she would consider the resident falling in the dining room three times a pattern. The DON, Interim DON and Regional Nurse all said the resident's current care plan did not meet the resident's needs by appropriately addressing the resident's pattern of falling in the facility's dining room. The DON said the care plan should have been updated on 12/31/24 with interventions to prevent future falls in the dining room. The DON said all facility nurses had been educated on all resident care plans since she began working at the facility a month ago. The Regional Nurse said facility management staff (the DON, Unit Manager, ADON if on staff, MDS Coordinator) were all responsible for reviewing resident care plans. She said if an incident occurred, the nurse responsible for providing care to the resident at the time of the incident would also be responsible for updating the resident's care plan to include the incident. The Regional Nurse said the nurse responsible for providing care at the time of the incident would be responsible for notifying facility management, so they can follow up on updates to the care plan. The Regional Nurse said care plans were also discussed during daily morning meetings, and morning meetings were standard and nothing new to facility staff. The Interim Administrator and DON said the expectation would have been for the Unit Manager and the MDS Coordinator to ensure the resident's care plan had been updated. The Interim Administrator and DON said there were interventions such as, adjusting the resident's wheelchair, the use of non-skid pads, or fall mats that the facility could put in place to appropriately address the resident's needs.<BR/>2. Record review of Resident #1's Care Plan, dated 01/25/25, revealed the resident had chronic pain. The care plan did not reveal methods to be used to assess or screen the resident for pain. However, the care plan did reveal a goal for the resident to actively participate in assessment of the resident's pain, pain management goals, and plan. Interventions included nursing staff assessing for presence of pain at frequent routine intervals; screening the resident for pain daily; assessing to determine if the resident was experiencing pain. If pain was present, conduct and document pain assessment particularly location, nature, intensity, and duration of pain.<BR/>Record review of Resident#1's December 2024 Medication Administration Record (MAR) dated 12/01/2024 - 12/31/2024 revealed Resident#1 was assessed for pain:<BR/>12/31/24: pain level 0<BR/>Record review of Resident#1's January 2025 Medication Administration Record (MAR) dated 01/01/2025 - 01/31/2025 revealed Resident#1 was assessed for pain:<BR/>01/01/25: pain level 3 <BR/>O1/04/25 - 01/06/25 on hold by physician<BR/>12/12/25: pain level 3 <BR/>Record review of Resident #1's Order details dated 11/21/24, revealed Acetaminophen Tablet 325 MG (milligrams). Give 2 tablet by mouth every 6 hours as needed for general discomfort.<BR/>Record review of a Physical Therapy Evaluation, dated 12/11/24, revealed the resident was unable to communicate pain.<BR/>In an interview with CNA B on 3/25/25 at 10:50 AM, She said the resident never verbalized pain, displayed, or indicated when she was in pain based on her behavior. She said laughter was the resident's response to verbal cues, conversation from anyone, and everything was laughter. She said the resident laughed at everything.<BR/>In an interview with RN B on 3/25/25 at 12:02 PM, she said no one would know when the resident was in pain because the resident was nonverbal. She said she was not familiar with the resident's care plan. She said the resident's care plan was on the computer. She said she thought she was notified about the resident's care plan by the DON last week. She said she did not know what goals or interventions the resident was care planned for. She said she knew how to provide care to her assigned residents based on her familiarity of the resident and information she received from other nursing staff during shift report. She said she provided care to the resident as long as she had worked at the facility, so she knew how to meet the resident's needs. She said she was not aware the resident was care planned for chronic pain. She said she did not know nursing staff were responsible for assessing and documenting the residents for pain frequently. RN B was not able to provide an explanation on how she was able to tell when the resident was in pain. She said best practice for assessing pain of nonverbal residents was based on their facial expressions. She said the nursing staff may not have been specifically following the resident's care plan since she returned from the hospital, but nursing staff were closely monitoring the resident, and trying to know how the resident was feeling. She said the purpose of resident care plans was to ensure appropriate management of the resident's needs. She said there might be difficulty with nursing staff appropriately managing resident needs without care plans. She said the risk associated with not following or being familiar with a resident's care plan was a potential decline in health.<BR/>In an interview with CNA A on 3/25/25 at 2:13 PM, she said she was not ever able to tell when the resident was in pain. She said it would be difficult for anyone to tell when the resident was in pain. She said the resident was a happy person and laughed at everything. She said the resident did not seem like she was in pain after she fell but was still lying on the dining room floor on 12/31/24. She said the resident did not appear to be in pain the next day either. She said the day shift CNA told CNA A the resident was not in pain and was lying in bed when CNA A began her shift.<BR/>In an interview with the MD on 3/25/25 at 3:03 PM, he said the resident was prescribed pain medication due to her Arthritis diagnosis. He said the condition could have caused chronic pain for the resident. He said he was not aware of what goals or interventions the facility had care planned for the resident's chronic pain. He said if a resident was not able to verbalize pain, nursing staff should assess for pain based on facial expressions and grimacing. He said the risk associated with a resident not having an appropriate care plan was the resident not having their needs met.<BR/>In an interview with the Interim Administrator, DON, and Regional Nurse on 3/25/25 at 3:17 PM, the DON said the resident's care plan appropriately addressed the resident's chronic pain. She said the resident was being assessed and monitored for pain according to the care plan. She said the resident also had a PRN order for pain medication, and if the medication was not effective, the nursing staff would notify the resident's doctor. The DON said the resident was not completely nonverbal because she randomly spoke. She said she was not aware staff responsible for providing care to the resident were not able to tell when the resident was in pain. She said if the staff were accustomed to working with the resident, they should have been able to at least recognize when something was wrong with the resident. She said nurses should also use their best judgment and use PainAd Scale to assess pain for a nonverbal resident or resident unable to verbalize their pain. She said the PainAd Scale was a pain assessment based on facial expressions. She said the facility recently began using a new electronic health record database management system. She said the new system included a PainAd scale assessment for the nurses to use for documentation purposes. She said the nurses were recently reeducated on risk management, which included training on using the PainAd scale within the electronic health record.<BR/>Record review of policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation: 3. The care plan interventions are derived from a thorough analysis of the information person-centered care plan: a. includes measurable objectives and timeframes; .10. When possible, interventions address the underlying source (s) of the problem area(s), not just or triggers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one of two residents (Resident #19) reviewed for Quality of Care.<BR/>1. The facility failed to ensure Resident #19's catheter was secured to an anchor to provide slack and to prevent pulling.<BR/>2. The facility failed to ensure Resident #19 did not exhibit skin breakdown at the catheter sight due to the catheter pulling and putting pressure against the tissue.<BR/>These deficient practices could place residents at risk of pain and skin breakdown. <BR/>Findings include:<BR/>Record review of the face sheet for Resident #19, dated 02/17/2022, revealed a [AGE] year old male who was admitted to the facility on [DATE]. Resident #19 had diagnoses which included, but were not limited to, obstructive and reflux uropathy (blockage of urinary tract), muscle weakness, and hydronephrosis (swelling of the kidney due to blockage of the bladder). <BR/>Record review of a Physician's Order, dated 09/15/2021, revealed the resident had a suprapubic catheter, and staff were to check for patency and placement every shift.<BR/>Record review of the, undated, care plan for Resident #19 revealed the resident could wear a leg bag during the day. (A leg bag is a smaller urine collection bag that is secured to the leg with straps, permitting easier mobility). The care plan reflected the bag was to be strapped securely to his leg, to keep from sliding down.<BR/>Interview on 02/15/2022 at 9:34 a.m. with Resident #19 revealed he used a 'big bag' (larger urine collection bag that hooks onto a bed rail) at night, and a leg bag during the day. He said the smaller one fills up, then backs up, causing pain. <BR/>Observation and interview on 02/15/2022 at 2:40 p.m. revealed Resident #19 in his room, sitting on the side of his bed. He said he had a leg bag on. He gave verbal consent for LVN A and the state surveyor to observe the catheter site and the catheter. The resident wore loose-fitting pajama pants. The tubing was on the outside of the disposable brief. There was a catheter anchor (a patch that is secured to the thigh, which has a clamp to secure catheter tubing) on the resident's left thigh. The catheter tubing was not secured to the anchor. The leg bag was strapped to the resident's right calf. There was approximately 150 cc of urine in the leg bag. When the resident stood, the tubing became so taught that it visibly pulled down the skin on the resident's catheter site. The resident complained of pain. The catheter site was in need of cleaning. LVN A said she would gather supplies and clean the catheter site. <BR/>Observation and interview on 02/15/2022 at 2:45 p.m. revealed LVN A cleaned the catheter and the catheter site. There were no concerns with technique. Observation revealed the resident had a small open area on the catheter site, where the tubing was observed to be pulling. The resident said it caused discomfort when the tubing was tight. LVN A acknowledged the skin breakdown and said she would notify the physician. LVN A said the tubing should have been secured to the anchor to provide slack in the tubing. She moved the leg bag to the left calf and secured the tubing with the anchor. She placed a split 4 x 4 inch gauze on the site, and around the catheter.<BR/>Observation and interview on 02/16/2022 at 1:30 p.m. revealed Resident #19 laid in bed, awake. The resident said the leg bag was on his lower left leg. The anchor was still on his left thigh. He said the tubing was clamped to the anchor, allowing slack between the clamp and catheter site. He denied having pain at that time.<BR/>Record review of the facility's policy titled Catheter Care (updated March 2019) revealed the purpose of the policy was to prevent infection and reduce irritation. The policy reflected the staff were to ensure the leg strap was used to secure the catheter tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 5 Residents reviewed for pharmacy services.<BR/>-Surveyor intervened as LVN A was in the process of administering insulin to Resident #1 that was prescribed for Resident #2. <BR/>This failure could place residents at risk of not receiving medications/procedures as ordered resulting in a decline and medical needs not being met by the facility.<BR/>Findings Included: <BR/>Record review of Resident #1's Face Sheet not dated revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnosis was Type 2 Diabetes (the body either does not produce enough insulin, or it resists insulin).<BR/>Record review of Resident #1's Physician order dated 5/26/2023 read in part . Humalog Kwik Pen (U-100) Insulin 100 unit/mL subcutaneous (13 units) Insulin Pen (ML) Subcutaneous Three times daily starting 5/26/23. Type 2 Diabetes Mellitus without complications .<BR/>Record review of Resident #1's Comprehensive MDS not dated revealed Resident #1's BIMS was 13 out of 15 indicating Resident #1 was cognitively intact. Resident #1 required extensive assistance with 2-person assist for bed mobility, transfers, dressing and toileting. Resident #1 required limited assistance with 1-person assist for personal hygiene. Section N: Medication noted insulin injection.<BR/>Record review of Resident #2's Physician order dated 5/11/2023 read in part . Tresiba FlexTouch U-100 insulin 100 unit/mL (3mL) subcutaneous pen (22 units) Insulin Pen (ML)Subcutaneous Every one day starting 5/11/23. Type 2 Diabetes Mellitus without complications .<BR/>During an interview on 6/20/2023 at 10:10am, Resident #1 said on 6/11/2023 she noticed the insulin pen on her bedside tray had another resident's name on the insulin pen. She said she did not say anything to anyone because she did not want the facility to be upset with her. Resident #1said she was afraid the facility was going to retaliate against her after speaking to this Surveyor.<BR/>Observation on 6/20/2023 at 4:16pm with Resident # 1 revealed LVN A about to administer insulin to Resident #1 in her room. LVN A asked Resident #1 which finger she wanted to use. Resident #1 picked her middle finger and LVN A rubbed the area with an alcohol swab. LVN A checked Resident #1 sugar levels. LVN A said Resident #1's sugar level was 228. LVN A held another alcohol swab in the same area Resident #1's blood sugar was checked and lightly pressed the area to stop the bleeding. LVN A reached to get the insulin to administer it to Resident #1. Surveyor asked LVN A was she sure that was the correct insulin pen and LVN A said yes. Surveyor asked LVN A to see the insulin pen before she administered it to Resident #1. Surveyor asked LVN A to see the insulin cap as well. Observation revealed the insulin cap had Resident #2's name on it. Upon further observation revealed the insulin LVN A was about to administer to Resident #1 was Tresiba FlexTouch U-100 insulin 100 unit/mL (3mL). Surveyor asked LVN A to take a second look at the insulin pen cap label. LVN A went back to retrieve the correct insulin for Resident #1 after Surveyor intervention. <BR/>During an interview on 6/20/2023 at 4:58pm with Director of Nursing, she said she was not aware of a resident receiving another resident's insulin. She said LVN A shared Surveyor's intervention regarding Resident #1's insulin belonging to Resident #2. She said she looked in the med-cart and found two different insulins. She said she had no idea how long this could have been going on. She said the nurses have oversight of their med-carts. She said the med carts should be checked before every med pass. Surveyor asked the DON what the difference between Tresiba FlexTouch U-100 insulin 100 units/ml (3ml)13 units and Humalog Kwik Pen insulin 100 unit/ml. She was said the Tresiba medication was long-acting insulin. She said the Humalog Kwik pen medication was the short acting insulin. She said if the Tresiba was given to Resident #1 it would lower her blood sugar. She said after looking at Resident #1's chart she ran high with her blood sugars. She said if she was aware Resident #1 was given Tresiba the resident would be monitored for any adverse reactions. She said the protocol for medication error was the nurses would inform the DON, the nurses would call the physician to advise the med error of the resident so the physician would give orders and instructions on what to do next for the resident. She said the nurse had to notify the family and during the entire process the resident was being monitored. She said an incident report was documented. She said the last time nursing staff were trained for medication administration was on 6/12/23 and LVN A participated in the training. She said LVN A training consisted of completing her med pass with the Pharmacist. She said the Pharmacist required nursing staff to conduct a return demonstration post training. She said the Pharmacist was responsible for the accuracy of med pass. <BR/>During an interview on 6/20/23 at 6:19pm with LVN A, she said she was familiar with Resident #1 because she conducted med pass in Hallway 100 where Resident #1's room was located. She said she had never had a med error in the 14 years working at the facility. She said the facility's protocol for insulin administrations was to check the computer orders for the resident, gather supplies, wipe down and disinfect her hands, knock on the door, and let the resident know what was about to happen. She said she sanitized her hands and donned (put on) gloves to do blood sugar test, she made sure the resident was no longer bleeding by using the alcohol swab and applying pressure. She said once she receives the number from the blood sugar reader, she notates it in the computer. She said she would remove her gloves and sanitized her hands before going back into the computer and double checking the insulin order to see what was needed for the resident. She said she crossed-checked between the insulin and the computer to ensure accuracy. She said she scrolled to the appropriate amount, crossed-checked the insulin with the resident's name, checked the dosage to ensure she had the right number of units. She said she sanitized her hands and donned gloves, told the resident what she was about to do, and crossed checked a second time to ensure she had the right insulin and the right route (giving insulin from a pen and not a bottle) and disinfected the area with alcohol and administered the insulin. She said she made a mistake with Resident #1's insulin orders because this Surveyor made her nervous. She said she would check the refrigerator if Resident #1's insulin pen was not in the med cart. Secondly, she said would go to the emergency kit in the refrigerator for Resident #1 insulin pen. She said she had always tried to be as careful as possible to prevent harm to the residents. She said if she was to give a resident the wrong insulin, she would immediately inform the doctor, await new orders, while waiting take vitals of the resident, and monitor any changes and conditions, side effects the resident might experience, as well as inform the family and contact the DON. <BR/>During an interview on 6/20/2023 at 7:14pm with the Executive Director, he said he was informed by the nurse (LVN A) that she had a problem with the medication administration. He said she said she was trying to administer the wrong medication to the wrong resident. He said this was a critical factor for any resident. He said he was going to implement a process for nursing staff to have a verification process in place to ensure the correct insulin medication was administered. He said he was going to get the Director of Nursing to train nursing staff and the key to the training was to ensure the nurses were giving the right medication and the correct route to the correct resident. He said he always addressed any issues the family or residents brought to his attention. <BR/>In a follow-up interview on 6/20/2023 at 8:20pm with the Director of Nursing she said all licensed nurses would be trained and monitored on the six rights of medication administration (The basis for medication administration for nurses). She said there would be a second nurse who would go back to check the insulin and dosage before administration as well as nursing staff putting their signatures on an auditing form. <BR/>Record review of the facility's Administering Medication policy titled; Policy Interpretation and Implementation dated April 2019 read in part . (4) Medications are administered in accordance with prescriber orders . (9) The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: (c) if necessary, verifying resident identification with other facility personnel .(10) The individual administering the medication checks 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 right medication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater. The facility had an error rate of 6%, based on 2 errors out of 29 opportunities, which involved two of four residents (Resident #94 and Resident #38) and two of four staff (LVN B and RN A) observed during medication administration reviewed for errors.<BR/>-LVN B failed to administer Thiamine 100 mg tablet to Resident #94 because it was not available.<BR/>-RN A failed to administer Metoprolol 50 mg to Resident #38.<BR/>These failures placed residents in the facility at risk for inadequate therapeutic outcomes and decline in health.<BR/>Findings Include:<BR/>Resident #94<BR/>Record review of the Face Sheet (run time 06/27/24 at 5:12 p.m.) for Resident #94 revealed he was [AGE] years old and was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, chronic kidney disease, congestive heart failure, and hypertension.<BR/>Record review of the Care Plan (undated) for Resident #94 revealed, in part, .give medications per order .<BR/>Observation on 06/26/24 at 08:20 a.m. revealed LVN B at the medication cart in front of Resident #94's room. LVN B was looking at the computer screen for guidance on what medications to dispense. LVN B dispensed the following medications:<BR/>1 Multivitamin tablet<BR/>1 Folic Acid 1 mg tablet<BR/>1 Toprol 25 mg tablet<BR/>1 Pantoprazole 40 mg tablet<BR/>1 Potassium Chloride ER 20 meq tablet<BR/>1 Gabapentin 300 mg<BR/>1 Bumetanide 2 mg tablet<BR/>1 Eliquis 5 mg tablet<BR/>15 cc Lactulose 10mg/15cc<BR/>After LVN B closed the medication cart, the surveyor asked her how many total medications she had. She answered Nine. LVN B entered Resident #94's room and administered the medications.<BR/>Record review of the June 2024 MAR for Resident #94 revealed an order for Thiamine HCl (vitamin B1) 100 mg (1 tablet) to be given daily. The scheduled time was reflected as 07:00 a.m. The medication had not been given during the medication pass observation at 8:20 a.m.<BR/>In an interview on 06/26/24 at 11:10 a.m. LVN B stated she did not administer the Thiamine HCl 100 mg tablet to Resident #94. She said it was not available in the medication cart at the time of the medication administration pass. She said that after she completed her medication pass, she went to the medication room to get the Thiamine 100 mg (over-the-counter medication). She said when she returned to administer the tablet to Resident #94, he had already been sent to the hospital for an increased ammonia level lab result.<BR/>In an interview on 06/26/24 at 3:44 p.m., UM C said Resident #94 had left for the hospital at 10:00 a.m. that day.<BR/>Resident #38<BR/>Record review of the Face Sheet for Resident #38 revealed she was [AGE] years old and was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, pain in right knee, artificial right knee joint, atrial fibrillation (abnormal heart rhythm), and hypertension. <BR/>Record review of the MDS (ARD 05/24/24) assessment for Resident #38 revealed she scored 15 of 15 on the BIMS, indicative of intact cognition.<BR/>Record review of the Care Plan (undated) for Resident #38 revealed, in part, .give medications per order .<BR/>Observation on 06/27/24 at 6:32 a.m. revealed RN A obtained Resident #38's blood pressure (114/80 mmHg ) and heart rate (68 bpm).<BR/>Observation on 06/27/24 at 07:16 a.m. revealed RN A at the medication cart in front of Resident #38's room. RN A was looking at the computer screen for guidance on what medications to dispense. RN A dispensed the following medications:<BR/>1 Tramadol 50 mg tablet<BR/>1 Pregabalin 75 mg tablet<BR/>1 Omeprazole 20 mg tablet<BR/>1 Vitamin D3 25 mg tablet<BR/>1 Multivitamin tablet<BR/>2 Acetaminophen 325 mg tablets<BR/>1 Aspirin 81 mg chewable tablet<BR/>1 Docusate Sodium 100 mg capsule<BR/>After RN A closed the medication cart, the surveyor asked her how many total medications she had. She answered '8' and said she counted both Acetaminophen as one. RN A entered Resident #38's room and administered the medications.<BR/>Record review of Resident #38's Physician Orders for June 2024 revealed an order for Metoprolol Tartrate (Toprol) 50 mg to be administered daily. The scheduled time was reflected as 7:00 a.m. The order reflected the medication was to be held if the systolic blood pressure was below 110 mmHg, if the diastolic blood pressure was below 60 mmHg, or if the heart rate was below 60. The medication had not been given during the medication pass observation.<BR/>Observation and interview on 06/27/24 at 11:50 a.m. revealed RN A was asked to review Resident #38's medications on her computer. RN A looked at the screen and stated she gave the following medications:<BR/>Tylenol (acetaminophen) 325 mg 2<BR/>Omeprazole 20 mg '1'<BR/>Multivitamin '1'<BR/>Toprol 50 mg '1'<BR/>Docusate Sodium 100 mg '1'<BR/>Vitamin D3 '1'<BR/>Pregabalin 75 mg '1'<BR/>Tramadol 50 mg '1'<BR/>Aspirin 81 mg '1'<BR/>RN A said the medications added up to '9,' as she counted the two acetaminophen as one.<BR/>Observation on 06/27/24 at 11:55 a.m. revealed RN A opened the medication cart and showed the surveyor the medication card for Toprol 50 mg for Resident #38. The tablets were bright pink in color. <BR/>Observation and interview on 06/27/24 at 11:58 a.m. revealed RN A exited Resident #38's room. She said Resident #38 just told her she remembered receiving the Toprol.<BR/>In an interview on 06/27/24 at 11:59 a.m. Resident #38 said I don't think it [Toprol] was in there because it is a pink pill and I didn't see it. I usually notice it because of its color. She said she did not take the Toprol for blood pressure, but because she had atrial fibrillation. She said she took it to control her heart rate.<BR/>In an interview on 06/27/24 at 12:00 p.m. RN A said she did not give the Toprol if Resident #38's heart rate was below .(she did not complete the statement). She looked at her paper she had written Resident #38's vital signs on. It reflected '68'. She said the parameter to hold was 'under 60.'

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure an allegation of abuse was reported to State Agency within 24 hours for 1 of 1 resident (Resident #11) reviewed for self-reporting abuse. <BR/>The facility did not report to the State Agency within 24 hours when an outcry of abuse was made by Resident #11 during a group meeting.<BR/>This failure could place residents at risk of harm due to delays in reporting an allegation of abuse. <BR/>Findings included: <BR/>Record review of Resident #11's face sheet not dated revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses were Cerebral Infraction and COPD (airflow blockage). <BR/>Record review of Resident #11's quarterly MDS dated [DATE] revealed Resident #11 had a BIMS Score of 15 out of 15 indicating Resident #11 was cognitively intact. Resident#11 required assistance with bed mobility, transfer, walk in corridor, toileting, dressing and personal hygiene with one person assist. She required set up only for eating. <BR/>Record review of Resident #11's care plan initiated 3/19/2021 read in part . Problem: Resident #11 has hearing deficit on both ears. Goal: dignity will be maintained, and Resident#11 needs will be met. Intervention: Face Resident #11 when speaking .<BR/>During a group meeting on 4/26/23 at 2:30pm, Resident#11 said, I felt something hitting my leg and my heart started pounding until the next day I was so afraid. Resident #11 said it was Med-Aide A who hit her on the leg.<BR/>During an interview on 4/27/23 at 1:26pm, the ED said he was the Abuse Coordinator. He said he spoke with Med-Aide A on 4/26/23. The ED said Med-Aide A admitted to tapping Resident #11 and Med-Aide A said he may have been rough with Resident #11 when he tapped her leg. The ED said he considered the act of being rough with a resident as abuse. The ED said he would open a grievance on 4/26/23 and open an investigation on 4/27/23. He said his abuse investigation would include talking to other residents and staff members. He said during the investigation he would place Med-Aide A on suspension while the investigation was ongoing. The ED said the allegation of abuse should have been reported because Resident #11 should not have been made to feel uncomfortable and afraid. The ED said abuse should be reported to the State Agency immediately. The ED said the facility staff were in serviced for Abuse on 3/22/23. <BR/>During an interview on 4/27/23 at 1:48pm with RDCL, he said he was aware of the abuse outcry on 4/26/23 involving Resident #11. He said Resident #11 felt the Med-Aide touched her feet and Resident #11 became startled. He said Med-Aide A apologized to Resident #11. The RDCL said a grievance was opened to document the abuse allegation. He said the ED interviewed Med-Aide A and Med-Aide A said Resident #11 voiced concerns that he was rough before med-pass in his attempt to wake her up. He said the plan was to educate, counsel and give Med-Aide A written warning for his actions. He said what he would have done when an outcry of abuse occurred was to ensure residents were safe and protected first. He said he would ensure the perpetrator was immediately removed from Resident #11 and notify the abuse coordinator. He said he would notify ED about the alleged perpetrator and the ED would suspend the employee immediately while the investigation was ongoing. The RDCL said he would generate a report to the State Agency immediately. <BR/>During a telephone interview on 4/27/23 at 3:32pm with Med-Aide A, he said he worked weekends at the facility. He said the ED called him on 4/26/23 regarding the abuse allegation. Med-Aide A could not recall the exact date of the incident. He said Resident #11 got startled when he woke her up by tapping Resident #11's leg. The Med-Aide A said he immediately apologized to Resident #11 and Resident #11 was okay with his apology. The Med-Aide A said he immediately went and told the charge nurse, but he could not recall the name of the charge nurse. He said he was in-serviced on abuse around January 2023 but could not recall the exact date. Med-Aide A said tapping Resident #11 on her leg was a form of physical abuse because Resident#11 got scared. <BR/>Record review of the state on-line self-reporting website on 4/27/23 at 4:28pm revealed no record of facilities self-report regarding outcry of abuse. <BR/>Record review of HHS Long-Term Care Regulatory Provider Letter Date Issued: July 10, 2019, read in part .State and federal law requires an owner or employee of a NF who has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation . NFs must report all suspected or alleged incidents involving abuse immediately, but not later than 24 hours after the incident occurs or is suspected . A NF must report these incidents to the HHSC CII section.<BR/>Record review of the facility's Abuse policy titled; Abuse Protocol dated 11/2016 read in part . The ED will 10. (a) immediately within 24 hours report to The Department of Aging and Disability services and other appropriate authorities' incidents of Patient/Resident Abuse as required under applicable regulations and regulatory guidance. 10. (b) immediately within 24 hours suspend the employee for an abuse allegation until an investigation is completed .<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #195) reviewed for incontinent care. <BR/>The facility failed to ensure CNA A and CNA B properly cleaned Resident #195 during incontinent care. <BR/>This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin breakdown and a decreased quality of life.<BR/>Findings include:<BR/>Record review of Resident #195's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included anemia (a condition in which the body does not have enough healthy red blood cells), type 2 diabetic mellitus (a lifelong (chronic) disease in which there is a high level of sugar (glucose) in the blood) and pneumonia (A severe inflammation of the lungs in which the alveoli (tiny air sacs) are filled with fluid). <BR/>Record review of Resident #195's Comprehensive MDS assessment, dated 04/19/23, revealed a BIMS score of 15 out of 15, which indicated intact cognition. She required extensive assistance from one-person physical assist for dressing, toilet use, and personal hygiene. She was always incontinent of bowel and bladder.<BR/>Record review of Resident #195's care plan, initiated on 04/08/2023 revealed the following: <BR/>Problem: Bowel Continence: Resident is always incontinent of bowel movement (no episodes of continent bowel movements). <BR/>Goals: Incontinence will be managed by staff without evidence of skin break down over the next 90 days. <BR/>Interventions: apply moisture barrier to buttocks. Document when resident is incontinent. Use pads/briefs to manage incontinence. <BR/>Observation on 4/26/23 at 2:20 p.m., revealed CNA A provided incontinent care for Resident #195 and CNA B assisted. CNA A removed Resident #195s brief and tucked it under the resident's buttocks. CNA A did not spread Resident #195's labia to thoroughly clean the area and the resident's urinary meatus. <BR/>In an interview on 4/26/23 at 2:35 p.m. with CNA A and CNA B, CNA A said she received training from other CNAs on the floor upon hire. She said she should have asked Resident #195's to open her legs wider to thoroughly clean before she placed the clean brief on her. She said there was feces on the wipe when the state surveyor asked her to clean the resident again. She said the facility did not have a DON. CNA A said She did not remember when the Unit Manager last spot checked her. CNA A said Resident # 195's skin should had been cleaned and free from feces before the clean brief was applied. She said the failure placed the resident at risk for skin breakdown and infections. CNA A said she recalled doing CNA competency checks for incontinent care at the time of hire. CNA B said she was the shower aide and provided showers to the residents. <BR/>In an interview on 04/26/22 at 2:43 p.m., the DON (from the sister facility), She said the facility hired a DON this week on Monday (4/24/23) who was in training at the corporate office today. She said in the interim she was assisting as an RN at this facility. She said she expected staff to provide prompt and efficient incontinent care to prevent complications of infection and cross contamination. She said CNAs competency check offs/assessments were completed upon hire and every 6 months. She said facility provided weekly hand washing in services to staff. She said she randomly spot check on staff when she came to this facility. She said last time she was in the facility was 2 weeks ago for 2 days, 8 hours each for RN coverage. <BR/>Record review of the facility's Perineal Care Protocol (February 2022) revealed read in part: .Cleansing the perineal area between showers or baths, helps prevent irritation, infection, and skin breakdown as well as keeping the patient comfortable. Separate Labia with hand to expose urethral meatus. Use one stroke method to clean front to back. Wash labia major and skin folds. Use one stroke method to clean front to back .<BR/>Record review of Incontinent Care Skills Checklist for CNA A dated 4/27/23 at 7:15am revealed read in part: .4. Separate Labia with hand to expose urethral meatus. Use one stroke method to clean front to back. 5.Wash labia major and skin folds. Use one stroke method to clean front to back .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 (Resident #34) of 8 residents reviewed for storage of medications.<BR/>The facility failed to ensure Resident #34's medication was kept in a secure location. Resident #34 had medicated ointment at the bedside. <BR/>This deficient practice could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion.<BR/>Findings included:<BR/>Record review of Resident #34's clinical record revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included pressure ulcer, stage 3 (Injury to skin and underlying tissue resulting from prolonged pressure on the skin), pneumonia (is an infection that inflames the air sacs in one or both lungs) and dementia (for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). <BR/>Record review of Resident# 34's Comprehensive MDS assessment, dated [DATE], revealed a BIMS score of 13 out of 15, which indicated intact cognition. She required total dependence with toilet use, transfer and bed mobility from 2 person assist. She required extensive assistance with dressing with one person. She had unhealed pressure ulcers/injuries Stage 3 (wound with full thickness tissue loss). <BR/>Record review of Resident #34 Care plan dated [DATE] revealed:<BR/>Problems: (Resident#34) has an unstageable DTI to left heel [DATE] wound care md here. Area is now stage 3.<BR/>Goals: (Resident#34's) pressure ulcer will improve and have no further skin breakdown.<BR/>Interventions: Treatment to pressure ulcer per physician order. Continued review of the care plan did not reveal Resident #34 could keep the Santyl ointment at the bedside.<BR/>Record review of Resident #34's physician's order dated [DATE] revealed an order to apply Santyl to left heel. Continued review of the physician's orders did not reveal an order to keep at the bedside.<BR/>Observation on [DATE] at 8:57a.m., revealed Resident #34 in bed. A tube of Santyl ointment was sitting on a side table near resident's bed. Resident said, this is for my heel. I have a wound. Nurse might have left it here. <BR/>Observation and interview on [DATE] at 8:59a.m., MA BB stated Resident #34 did not have a physician's order to keep her Santyl at the bedside. She stated the medication was to be kept in the medication room or on the medication cart. She stated Santyl required a physician's order to administer. She stated it was the responsibility of nurses to make sure there were no medications at the bedside. She continued and stated the risk of the medication at the bedside was that a visitor or someone who should not have it could take it.<BR/>In an interview on [DATE] at 1:10 p.m., with the ADON/ Unit Manager, she said the floor nurses performed treatments. She said leaving Med at bedside was safety hazard for the resident. Dementia resident can put it on their mouth. She said it was the responsibility of all staff including the housekeeper when they were cleaning the room to make sure there were no medications at the bedside. <BR/>In an interview on [DATE] at 2:43 p.m., the DON (from the sister facility) said residents were not allowed to have medication in their rooms. She said if a resident was deemed safe to self-administer medication, they would also need a doctor's order. She said she was not aware of Resident #34 having meds at bedside. <BR/>Record review of facility's Medication Storage policy (undated) revealed read in part: .review all OTC Rx meds and remove expired and DC'd meds The policy did not include med at bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 3 of 8 residents (Resident #3, #4 and #17) reviewed for infection control in that:<BR/>-MA BB did not wash or sanitize her hands before entering Resident #3 and #17's room to check their vital signs.<BR/>-MA BB did not disinfect the wrist blood pressure monitor in between Resident #3 and #17 when checking their vital signs.<BR/>- CNA A and CNA B stored dirty linens and soiled brief trash bags on the floor in Resident#195's room. <BR/>- The facility failed to date Resident #4's suprapubic catheter drainage bag according to their policy.<BR/>These failures could affect residents and place them at risk of cross contamination and blocked urinary catheters.<BR/>Findings included:<BR/>Resident#4<BR/>Record review of Resident #4's Face Sheet revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of Urinary Tract Infection (Harmful Bacteria in Urinary Tract), Vascular Dementia (Brain Damage Caused by Multiple Strokes), Obstructive and Reflux Uropathy (Urine Cannot Flow), Hemiplegia Left Side (Paralysis Left Side of Body), and Type 2 Diabetes (Body Does Not Produce Insulin).<BR/>Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS of 6 out of 15 indicating the resident was cognitively severely impaired. Resident #4 required extensive assistance with bed mobility, transfers, locomotion, dressing, and toileting with one person assist. Section H noted, indwelling catheter.<BR/>Record review of Resident #4s Care Plan dated 10/4/2022 to present read in part . Problem: At risk for infection related to indwelling catheter. Has suprapubic catheter placed. Suprapubic catheter change q 2 weeks .Goals: will remain free of urinary tract infection during period of catheterization next 90 days .Intervention: Change drainage bag.<BR/>On 4/25/2023 at 9:40 am Surveyor observed no date on resident #4's suprapubic catheter drainage bag.<BR/>In an interview on 4/25/2023 at 09:41 am with Medication Aide BB, she said they changed the Foley last week because Resident #4's family member always asked for it to be changed so evening nurses changed it. She said residents could get an infection if the Foley catheter was not dated and not changed out when it was supposed to be changed.<BR/>In an interview on 4/25/2023 at 09:45 am with CNA C, she said she thought Resident #4's Catheter was changed last week but she could not recall the date. She said the foley catheter could also get obstructed if not changed out routinely, and the Resident #4 could get an infection.<BR/>In an interview on 4/25/2023 at 09:47 am with the DON, she said not having dates on the Foley catheters could cause infection, especially if they did not know when it was last changed. She said if a catheter was not changed out, there was a high risk for infection. She said the policy was to change the Foley once a month and the bag twice a month. She said the policy said there had to be a date on it. She said nursing staff failed when Resident #4s was not changed out. She said nurses had specific dates to change them, and a date was put on them when admitted , so it got changed on the first and the 20th. She said if the nurses do not read the orders, they are not doing their jobs.<BR/>Resident#17<BR/>Record review of Resident #17's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses type 2 diabetics mellitus, hypertension and cognitive communication deficit. <BR/>Record review of Resident #17's Comprehensive MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. Resident required extensive assistance from one-person physical assist for toilet use, bed mobility and transfer. <BR/>Record review of Resident #17's Care plan dated 2/25/22 revealed the following: <BR/>Problem: Resident has a history of hypertension. Resident currently takes: hypertensive medication.<BR/>Goals: Resident's B/P will stay within their normal limits, will not have s/s of hyper/hypo tension over the next 90 days. <BR/>Interventions: Monitor B/P, increase edema, dizziness, headache, chest pain, etc.-report abn's to MD. <BR/>Resident#3<BR/>Record review of Resident #3's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses chronic kidney disease, dementia and hypertension. <BR/>Record review of Resident #3's Comprehensive MDS dated [DATE] revealed a BIMS score of 06 out of 15 indicating severely impaired cognitively. Resident required total dependence from one-person physical assist for toilet use. Required extensive assistance from one-person physical assist for bed mobility and transfer. <BR/>Record review of Resident #3's Care plan dated 05/11/2021 revealed the following: <BR/>Problem: Resident has a history of hypertension. Resident currently takes: hypertensive medication.<BR/>Goals: Resident's B/P will stay within their normal limits, will not have s/s of hyper/hypo tension over the next 90 days. <BR/>Interventions: Monitor B/P, increase edema, dizziness, headache, chest pain, etc.-report abn's to MD. <BR/>Observation on 04/25/2023 at 9:04a.m., revealed MA BB entering Resident #3's room with blood pressure cuff. MA BB checked Resident #3's vitals without gloves on. MA BB came out of Resident #3's room without washing or sanitizing her hands or the equipment. She then went to see Resident #17.<BR/>Observation on 04/25/2023 at 9:06a.m., revealed MA BB checking Resident #17's vitals with the same equipment used on Resident #3 without washing or sanitizing her hands or the equipment. <BR/>In an interview on 04/25/2023 at 9:08a.m., MA BB said she was going room to room to check resident's vitals so she could administer their morning meds. MA BB confirmed she did not sanitize the blood pressure monitor or use gloves in between residents #3 and #17. She said she was the Activity Director/Medical Records. She said usually there were 2 nurses and a Unit Manager assigned on the floor. She said one nurse called in sick therefore, she was asked to pass the meds to 8 rooms starting from room [ROOM NUMBER] through room [ROOM NUMBER] and room [ROOM NUMBER]. She said she had her medication aide license either year 2008 or 2010. She said she had not done med pass in a long time and was not aware the multiuse equipment had to be sanitized in between residents. MA BB said she received training on infection control sometime last week. She could not recall the exact date.<BR/>Resident#195<BR/>Record review of Resident #195's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included anemia, type 2 diabetic mellitus and pneumonia. <BR/>Record review of Resident #195's Comprehensive MDS assessment, dated 04/19/23, revealed a BIMS score of 15 out of 15, which indicated intact cognition. She required extensive assistance from one-person physical assist for dressing, toilet use, and personal hygiene. She was always incontinent of bowel and bladder.<BR/>Record review of Resident #195's care plan, initiated on 04/08/2023 revealed the following: <BR/>Problem: Bowel Continence: Resident is always incontinent of bowel movement (no episodes of continent bowel movements). <BR/>Goals: Incontinence will be managed by staff without evidence of skin break down over the next 90 days. <BR/>Interventions: apply moisture barrier to buttocks. Document when resident is incontinent. Use pads/briefs to manage incontinence. <BR/>Observation on 4/26/23 at 2:20 p.m., revealed CNA A provided incontinent care for Resident #195 and CNA B assisted. CNA A placed soiled brief in a clear trash and placed the bag on the floor next to resident's foot of the bed. During care CNA B said the resident's sheet were soiled and needed to be changed. CNA B placed soiled linens (fitted sheet, draw sheet and blanket) in a clear trash bag and placed the bag on the floor near the foot resident's bed. <BR/>In an interview on 4/26/23 at 2:37 p.m., with CNA A and CNA B. CNA B said she was a CNA, but she worked as a shower aide and was not assigned to work the floor. She said she did good as far as assisting CNA A. She said she placed the dirty linens on the floor because it was in a plastic bag. She said she was in serviced on infection control a month ago. She could not recall the exact date. CNA A said she placed the soiled brief and trash on the floor because it was close. CNA A said, there was a trash can I should have put the trash in that instead of putting it on the floor. She said this placed risk for cross contamination. She said she was in serviced on infection control a month ago. She could not recall the exact date.<BR/>In an interview on 04/26/22 at 2:43 p.m., with the DON (from the sister facility) Surveyor explained the observation of MA A doing med pass from earlier. MA A without washing/sanitizing her hands was going room to room checking the residents' vitals including blood pressure. MA A said she was not aware that she needed to wipe all multi use equipment between residents. The DON said by not washing hands and sanitizing multi use equipment increases the risk of spreading infections and cross contamination. She said MA A was a medication aide before she was an Activity Director and have worked as medication aide. She said nothing should be left on the floor as it was at risk for cross contamination. She said the facility in-serviced staff on infection control weekly. <BR/>Policy on Linen/trash storage were not provided on exit.<BR/>Record review of facility's Infection control policy (November 2017) revealed read in part: .1. The facility must establish an infection prevention and control program (IPCP) that must include: a. A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all patients, staff, volunteers, visitors, and other individuals providing services under a contractual agreement based upon the facility assessment . <BR/>Record review of facility's in service to all staff on 03/07/23 on Infection Control revealed read in part: .Standard Precautions: standard precautions are based on the principle that all blood, body fluids, non-intact skin, and mucous membranes may contain infectious agents. Standard precautions include: Hand -hygiene.<BR/>The use of personal protective equipment (PPE).<BR/>Appropriate handling of equipment used in the care of patients. Appropriate handling of laundry. Standard precautions apply to everyone, regardless of suspected or confirmed infection status they are called standard because they apply to everyone!<BR/>Record review of facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy (Revised September 2022) revealed read in part: . Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogen standard. Policy Interpretation and Implementation: 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 6. Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufactures' instructions. 7. Only equipment that is designated reusable is used by more than one resident .<BR/>Record review of facilities policy titled, Indwelling Catheter-Male and Female dated 6/14/2006 read in part . Date drainage bag .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 5 Residents reviewed for pharmacy services.<BR/>-Surveyor intervened as LVN A was in the process of administering insulin to Resident #1 that was prescribed for Resident #2. <BR/>This failure could place residents at risk of not receiving medications/procedures as ordered resulting in a decline and medical needs not being met by the facility.<BR/>Findings Included: <BR/>Record review of Resident #1's Face Sheet not dated revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnosis was Type 2 Diabetes (the body either does not produce enough insulin, or it resists insulin).<BR/>Record review of Resident #1's Physician order dated 5/26/2023 read in part . Humalog Kwik Pen (U-100) Insulin 100 unit/mL subcutaneous (13 units) Insulin Pen (ML) Subcutaneous Three times daily starting 5/26/23. Type 2 Diabetes Mellitus without complications .<BR/>Record review of Resident #1's Comprehensive MDS not dated revealed Resident #1's BIMS was 13 out of 15 indicating Resident #1 was cognitively intact. Resident #1 required extensive assistance with 2-person assist for bed mobility, transfers, dressing and toileting. Resident #1 required limited assistance with 1-person assist for personal hygiene. Section N: Medication noted insulin injection.<BR/>Record review of Resident #2's Physician order dated 5/11/2023 read in part . Tresiba FlexTouch U-100 insulin 100 unit/mL (3mL) subcutaneous pen (22 units) Insulin Pen (ML)Subcutaneous Every one day starting 5/11/23. Type 2 Diabetes Mellitus without complications .<BR/>During an interview on 6/20/2023 at 10:10am, Resident #1 said on 6/11/2023 she noticed the insulin pen on her bedside tray had another resident's name on the insulin pen. She said she did not say anything to anyone because she did not want the facility to be upset with her. Resident #1said she was afraid the facility was going to retaliate against her after speaking to this Surveyor.<BR/>Observation on 6/20/2023 at 4:16pm with Resident # 1 revealed LVN A about to administer insulin to Resident #1 in her room. LVN A asked Resident #1 which finger she wanted to use. Resident #1 picked her middle finger and LVN A rubbed the area with an alcohol swab. LVN A checked Resident #1 sugar levels. LVN A said Resident #1's sugar level was 228. LVN A held another alcohol swab in the same area Resident #1's blood sugar was checked and lightly pressed the area to stop the bleeding. LVN A reached to get the insulin to administer it to Resident #1. Surveyor asked LVN A was she sure that was the correct insulin pen and LVN A said yes. Surveyor asked LVN A to see the insulin pen before she administered it to Resident #1. Surveyor asked LVN A to see the insulin cap as well. Observation revealed the insulin cap had Resident #2's name on it. Upon further observation revealed the insulin LVN A was about to administer to Resident #1 was Tresiba FlexTouch U-100 insulin 100 unit/mL (3mL). Surveyor asked LVN A to take a second look at the insulin pen cap label. LVN A went back to retrieve the correct insulin for Resident #1 after Surveyor intervention. <BR/>During an interview on 6/20/2023 at 4:58pm with Director of Nursing, she said she was not aware of a resident receiving another resident's insulin. She said LVN A shared Surveyor's intervention regarding Resident #1's insulin belonging to Resident #2. She said she looked in the med-cart and found two different insulins. She said she had no idea how long this could have been going on. She said the nurses have oversight of their med-carts. She said the med carts should be checked before every med pass. Surveyor asked the DON what the difference between Tresiba FlexTouch U-100 insulin 100 units/ml (3ml)13 units and Humalog Kwik Pen insulin 100 unit/ml. She was said the Tresiba medication was long-acting insulin. She said the Humalog Kwik pen medication was the short acting insulin. She said if the Tresiba was given to Resident #1 it would lower her blood sugar. She said after looking at Resident #1's chart she ran high with her blood sugars. She said if she was aware Resident #1 was given Tresiba the resident would be monitored for any adverse reactions. She said the protocol for medication error was the nurses would inform the DON, the nurses would call the physician to advise the med error of the resident so the physician would give orders and instructions on what to do next for the resident. She said the nurse had to notify the family and during the entire process the resident was being monitored. She said an incident report was documented. She said the last time nursing staff were trained for medication administration was on 6/12/23 and LVN A participated in the training. She said LVN A training consisted of completing her med pass with the Pharmacist. She said the Pharmacist required nursing staff to conduct a return demonstration post training. She said the Pharmacist was responsible for the accuracy of med pass. <BR/>During an interview on 6/20/23 at 6:19pm with LVN A, she said she was familiar with Resident #1 because she conducted med pass in Hallway 100 where Resident #1's room was located. She said she had never had a med error in the 14 years working at the facility. She said the facility's protocol for insulin administrations was to check the computer orders for the resident, gather supplies, wipe down and disinfect her hands, knock on the door, and let the resident know what was about to happen. She said she sanitized her hands and donned (put on) gloves to do blood sugar test, she made sure the resident was no longer bleeding by using the alcohol swab and applying pressure. She said once she receives the number from the blood sugar reader, she notates it in the computer. She said she would remove her gloves and sanitized her hands before going back into the computer and double checking the insulin order to see what was needed for the resident. She said she crossed-checked between the insulin and the computer to ensure accuracy. She said she scrolled to the appropriate amount, crossed-checked the insulin with the resident's name, checked the dosage to ensure she had the right number of units. She said she sanitized her hands and donned gloves, told the resident what she was about to do, and crossed checked a second time to ensure she had the right insulin and the right route (giving insulin from a pen and not a bottle) and disinfected the area with alcohol and administered the insulin. She said she made a mistake with Resident #1's insulin orders because this Surveyor made her nervous. She said she would check the refrigerator if Resident #1's insulin pen was not in the med cart. Secondly, she said would go to the emergency kit in the refrigerator for Resident #1 insulin pen. She said she had always tried to be as careful as possible to prevent harm to the residents. She said if she was to give a resident the wrong insulin, she would immediately inform the doctor, await new orders, while waiting take vitals of the resident, and monitor any changes and conditions, side effects the resident might experience, as well as inform the family and contact the DON. <BR/>During an interview on 6/20/2023 at 7:14pm with the Executive Director, he said he was informed by the nurse (LVN A) that she had a problem with the medication administration. He said she said she was trying to administer the wrong medication to the wrong resident. He said this was a critical factor for any resident. He said he was going to implement a process for nursing staff to have a verification process in place to ensure the correct insulin medication was administered. He said he was going to get the Director of Nursing to train nursing staff and the key to the training was to ensure the nurses were giving the right medication and the correct route to the correct resident. He said he always addressed any issues the family or residents brought to his attention. <BR/>In a follow-up interview on 6/20/2023 at 8:20pm with the Director of Nursing she said all licensed nurses would be trained and monitored on the six rights of medication administration (The basis for medication administration for nurses). She said there would be a second nurse who would go back to check the insulin and dosage before administration as well as nursing staff putting their signatures on an auditing form. <BR/>Record review of the facility's Administering Medication policy titled; Policy Interpretation and Implementation dated April 2019 read in part . (4) Medications are administered in accordance with prescriber orders . (9) The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: (c) if necessary, verifying resident identification with other facility personnel .(10) The individual administering the medication checks 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 right medication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a hospice election form, hospice plan of care, the physician certification and recertification specific to the terminal illness, and hospice medication information form for 1 (Resident #38) of 1 resident reviewed for hospice care.<BR/>This deficient practice could place residents who receive hospice services at risk for receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs.<BR/>Findings:<BR/>Record review of Resident #38's face sheet dated 4/27/2023 revealed an [AGE] year-old male admitted on [DATE] with diagnoses of Senile Degeneration of the Brain (Mental Decline), Indwelling Urethral Catheter (Urinary Catheter), Multiple Fractures of Ribs, Left Side (Broken Ribs). <BR/>Record review of Resident #38's April 2023 orders revealed he was admitted to hospice services on 9/15/2022 with a diagnosis of Senile Degeneration of the Brain.<BR/>Record review of Resident #38's clinical record dates 9/15/2022 to 4/25/2023 reflected no hospice election form, hospice plan of care, physician certification and recertification specific to the terminal illness, or hospice medication information form from Hospice A.<BR/>Record review of Resident #38's medical file dated 3/27/2023 to 4/24/2023 revealed no documentation of any communication or coordination of care with the hospice company.<BR/>Record review of Resident #38's Hospice Sign In Sheet with dates 3/32/2023 to 4/24/2023 revealed no hospice staff sign-ins since 3/27/2023. <BR/>In an interview on 04/26/23 at 9:51 am with Unit Manager, she said there was no paperwork from hospice on Resident#38. She said she was responsible for requesting paperwork from the hospice company. She said it was important to have the paperwork because it was a record of the resident's plan of care and led to the continuity of care.<BR/>In an interview on 04/26/23 9:57 am with the DON, she said she could not explain why there was no hospice documentation for Resident #38 on file. She said it was important for the follow-up of care so facility staff understand what hospice was doing, for family involvement and coordination of care so everyone could work together to meet resident needs.<BR/>Record review of facility's policy titled, Hospice Program dated 2017 read in part . Obtaining the following information from the hospice .The most recent hospice plan of care specific to each resident .Hospice election form .Physician certification and recertification of the terminal illness specific to each resident .Hospice medication information specific to each resident .