PLEASANT MANOR HEALTHCARE REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 of 6 residents (Resident #66) reviewed for dignity. <BR/>The facility failed to promote resident independence and dignity while dining when staff stood over Resident #66 while assisting them to eat on 01/07/25.<BR/>This failure could have compromised residents' independence and dignity for those who require feeding assistance.<BR/>Findings included: <BR/>Record review of Resident #66's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old female with an admission date of 07/05/24. Resident #66 had diagnoses which included Alzheimer's (a type of brain disorder that causes problems with memory, thinking, and behavior), difficulty in walking, muscle weakness, cognitive communication deficit, and osteoporosis (a condition when bone strength weakens and is susceptible to fracture). Resident #66's BIMS score was left blank. The MDS indicated the resident started speech-language and audiology services therapy on 12/09/24 for 4 days a week.<BR/>Record review of Resident #66's care plan dated last revised 11/20/24 reflected she had a nutritional problem or potential nutritional problem related to disease process and ADL self-care performance deficit. <BR/>In an observation on 01/07/25 at 01:05 PM Resident #66 was being assisted with her lunch tray by a SLP who was standing over Resident #66 the entire duration of assistance.<BR/>In an interview on 01/07/25 at 01:20 PM with the SLP she stated she had worked at the facility since September of 2024. She stated that she was conducting an evaluation on Resident #66 due to a recent weight loss. She stated Resident #66 had poor attention span, could feed herself but may require assistance, and she was checking for Dysphasia (a language disorder that affects the ability to produce and understand spoken language). When asked if the SLP had been trained on how to provide feeding assistance she stated Yes, I am sure there was something in the LMS trainings but was unable to recall if she was supposed to sit or stand next to a resident when providing assistance.<BR/>In an interview on 01/07/25 at 2:15 PM with the DOR she stated she had worked at the facility for 3 years. When asked what her expectation was for feeding assistance, she stated that she would need to be notified by nursing that certain signs were occurring so that an SLP could evaluate the residents' cognition and swallowing. She stated that normally CNA's assist residents with feeding, but it would not be out of the ordinary that SLP's would be available and/or assisting. The expectation would be for the SLP to be seated next to the resident while providing assistance, and they were informed that they should be sitting for respect purposes, but this was not necessarily talked about for the evaluations. <BR/>Review of the facility's Feeding checklist for training staff revealed The following table lists the steps that are expected of you in order to feed an individual. The table also provides rationales that explain why you perform some of these steps. The use of this content is for educational purposes only and should only be used as a guide in performing the below skill, subject to the terms and conditions of the Master Services Agreement. no instruction for the employee being trained, to sit next to residents while providing feeding assistance was listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to coordinate assessments with the PASARR program for 1 of 8 Residents (Resident #63) reviewed for PASARR services. <BR/>1. The SW failed to assess Resident #63, based on his behaviors, for a referral for PASARR services.<BR/>2. The MDSC failed to refer Resident #63 for a Level II PASARR Evaluation by the local LIDDA.<BR/>This failure placed residents in the facility at risk for exclusion for PASARR Services.<BR/>Findings Included:<BR/>RR or Resident #63's AR, dated 1/10/2025, reflected an [AGE] year-old male, who admitted to the facility on [DATE]. <BR/>RR of Resident #63's Medical Diagnosis, downloaded from PCC on 1/10/2025, reflected Resident #63 was diagnosed with Depression, Unspecified (which was a mental condition characterized by depressed mood, loss of pleasure, or interest in life) and Schizophrenia, Unspecified (which was a chronic mental illness that affected a person's thoughts, feelings, and behavior.)<BR/>RR of Resident #63's BIMS Score assessment, administered on 1/10/2025, reflected a score of 6, which indicated the resident had severe cognitive impairment.<BR/>RR of Resident #63's CP reflected a Focus area for impaired cognition or impaired thought, initiated on 12/6/2024, R/T disease process. The Goal, revised on 12/29/2024, indicated the resident was supposed to maintain their current level of functioning through 3/5/2025. The Intervention, initiated on 12/6/2024, delegated nursing home to engage in simple structured activities that avoid overly demanding tasks; a Focus area for psychotropic medication, unknown date of initiation, R/T Schizophrenia. The Goal, initiated on 12/13/2024, indicated the resident would not have reactions to antipsychotic drug therapy (Seroquel 25 MG). Antipsychotic was discontinued on 12/19/2024 / Replaced with Anti-Anxiety Drug Therapy (Hydroxyzine 25 MG) The Intervention, initiated on 12/13/2024, delegated nursing home staff to check blood pressure monthly.<BR/>RR of Resident #63's P-1, located in PCC, reflected a document sent from Resident #63's referring entity. The document was dated 12/5/2024. Page 4 of 12 indicated resident did not have evidence of an MI, ID, or DD. <BR/>RR of Resident #63's P-1, located in Simple, reflected a document sent from Resident #63's referring entity. The document was dated 12/5/2024. Page 3 of 8 indicated resident did have evidence of an MI. <BR/>Interview and observation on 1/7/2025 at 12:14 PM with Resident #63 revealed him in bed in his room. He was able to respond to questions, clean, and appropriately dressed. He was new to the facility and stated it was rough getting used to the routine. It was hard remembering who provided which services. <BR/>Interview and RR on 01/10/25 at 10:56 AM with the SW, revealed that she was the facility designee to collaborate with residents and their PASARR eligibility/referrals. Based on Resident #1's P-1, located in PCC, Resident #63 presented to the facility on [DATE] with a negative P-1, meaning he did not have evidence of a MI, ID, or DD. The SW stated she had spent time with Resident #63, who had exhibited changes in his alertness, orientation, mood, and cognition. She was unaware Resident #63 had diagnosis of Depression, Unspecified and Schizophrenia, Unspecified. Had she been aware of his mental health diagnosis, she would have had him re-assessed by a medical provider and then referred him to the LIDDA for the P-2 evaluation as needed. However, she had not discovered the mental health diagnosis; she had not referred the resident for mental health services; she had not referred the resident for a P-2 evaluation. RR of the resident medical records in PCC did not reveal a P-2 or referral to the LIDDA. <BR/>Interview and observation on 1/10/25 at 1:21 PM with the MDSC revealed she was the MDSC at the facility until last week, 1/2/2025. She was responsible, along with the SW, for residents and their PASARR eligibility/referrals. She had been trained as an MDSC at the facility, taken on-line training, and completed the classes for CMAC (Certified MDS Assessment Certification.) The facility followed the guidelines in the RAI for PASSAR processing. Observation of the MDSC revealed her search Simple, a 3rd party data base with HHSC and PASARR, for a P-2 for the LIDDA for Resident #63. Instead of a P-2 for the LIDDA, a P-1 was found. The P-1 found in Simple, was different from the P-1 that was found in PCC. The P-1 found in Simple reflected Resident #63 did have evidence of a MI. Based on the P-1 in simple. The MDSC stated, I just did not see it and there should have been a P-2 submitted for the LIDDA. RR of Simple did not reveal a P-2 for Resident #63. Residents who qualified for PASARR services were available to receive NFSS services, such as PT/OT/ST/DME. Residents who were qualified for, but did not receive NFSS services, were placed at risk for a decrease in options for quality of care. Since she had been removed from her position, CMDSC M and CMDSC N oversaw the MDS/PASARR entries. She was unaware of any support structure in place to catch errors in the PASARR process. <BR/>Interview on 1/10/25 at 2:23 PM with the ADM stated that the SW and the MDSC were responsible for the residents' PASARR eligibility/referrals to the LIDDA. The facility followed the guidelines of the PASARR division. Residents, who benefitted for PASARR services, were eligible for benefit's such, as DME, assistance post DC from the facility with housing, and therapeutic services. Residents who were eligible, but not afforded the opportunity, risked the loss of services provided through the PASRR program. Safeguards in place to ensure residents get linked to PASARR services were team meetings, MDSC checks, morning meetings, and corporate resource personal. In a situation where there were two conflicting P-1s for a resident, the ADM stated the document in Simple would have taken precedence over the one found in PCC. The failure for the SW to assess the resident for MI and make the appropriate referral, along with the MDSC's failure to retrieve the P-1 from Simple, was a process failure. The staff members responsible for the PASARR eligibility/referrals were the SW and the MDSC.<BR/>RR of the CMS RAI Version 3.0 Manual, dated 10/2024, reflected:<BR/>Referral for Level II Resident Review Evaluations is required for individuals previously identified by PASRR to have MI, ID, or a related condition in the following circumstances:<BR/>Referral for Level II Resident Review Evaluations is also required for individuals who may not have previously been identified by PASARR to have MI, ID, or a related condition in the following circumstances:<BR/>1. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a diagnosis of mental illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 Residents (Resident #3) reviewed for respiratory care.<BR/>The facility failed to place Resident #3's oxygen tubing in a bag when not in use. <BR/>This failure could place residents at risk of not receiving appropriate respiratory care.<BR/>The findings were:<BR/>Resident #3<BR/>Record review of Resident #3's undated face sheet reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses of Heart Failure, Acute upper Respiratory Infection, Obstructive Sleep Apnea, and Shortness of Breath. <BR/>Record review of Resident #3s care plan dated 03/31/2022 reflected she had Chronic Obstructive Pulmonary<BR/>Disease (a group of lung diseases that make it difficult to breath) her Goal was to be free of signs and symptoms of respiratory infections through review date. Interventions included to give oxygen therapy as ordered by the physician.<BR/>Record review of Resident #3's quarterly MDS dated [DATE] reflected she had a BIMS score of 15 indicating she was cognitively intact. <BR/>Record review of Resident #3's physicians' orders summary dated 01/08/2025 reflected an order to change oxygen tubing and humidifier bottle, clean filter weekly as needed if equipment is used, every night shift, every Sunday. Keep tubing inside plastic bag when not in use dated 04/22/2021.<BR/>In an observation and interview on 01/07/25 at 11:49 AM Resident #3s oxygen tubing was laying on top of her concentrator out of the bag and not dated. Resident #3 stated for the most part the nurses changed her oxygen tubing weekly. She stated occasionally she got sick and required her oxygen machine due to her respiratory disease. She stated she liked for it to be clean. <BR/>In an interview on 01/10/25 at 01:25 PM LVN A stated oxygen tubing was supposed to be changed weekly. She stated the tubing should be in a bag when not in use. She stated the nurses had been instructed on changing the tubing and keeping it covered by the DON. She stated there was a physician's order in the computer to change the tubing. Night shift nursing staff were responsible for changing the tubing on Sundays. The risk to residents for having dirty oxygen tubing included respiratory infection. <BR/>In an interview on 01/10/25 at 1:31 PM the DON stated staff were educated by the DON, ADON and LVN resource team. The DON stated if a resident had respiratory equipment tubing it should have been bagged, even if it was used as needed it should be bagged. She stated negative effects for residents having unbagged oxygen tubing could include respiratory infections. She stated staff were instructed to remove oxygen equipment in rooms if not used. The DON stated the department heads do angel room rounds every morning to monitor for things that could negatively affect the resident. <BR/>Record review of facility policy titled Oxygen Equipment dated 05/2017 reflected It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner and to use disposable prefilled humidifiers, tubing, masks, and cannulas for residents receiving oxygen. The equipment is to be discarded after use. The facility will maintain clean tanks, connectors, and concentrators. When oxygen mask or cannula is temporarily not being used it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 1 (Resident #26) of 6 residents reviewed for pharmacy services. <BR/>The facility failed to obtain a stop date for Resident #26's Cipro (an antibiotic used to treat an acute infection) started on 01/01/2025. <BR/>These failures could place residents at risk of side effects (gastrointestinal upset, multiple drug resistant infections) related to long term antibiotic use. <BR/>Findings included: <BR/>Record review of Resident #26's undated face sheet reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses of neuromuscular dysfunction of the bladder (the nerves and muscles that control the bladder aren't working properly), hypertension (elevated blood pressure), legal blindness, and personal history of malignant neoplasm of brain (history of brain cancer).<BR/>Record review of Resident #26's quarterly MDS dated [DATE] reflected he had short term memory problems. His cognitive skills for daily decision making were severely impaired. The MDS reflected Resident #26 required an indwelling catheter. <BR/>Record review of Resident #26's care plan dated 01/01/2025 reflected he had a urinary tract infection. The care plan reflected he had started Cipro 500mg active date 01/01/2025 to 01/06/2025. The goal reflected the urinary tract infection will resolve without complications by the review date. Interventions included to give antibiotic therapy as ordered, monitor/document for side effects and effectiveness.<BR/>Record review of infection surveillance assessment dated [DATE] reflected Resident #26 had a urinary tract infection with an indwelling catheter. He had purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate. The assessment reflected Resident #26 had started Cipro oral tablet 500mg 1 tablet by mouth two times a day for UTI for 5 days. <BR/>Record review of the progress notes for Resident #26 dated 01/01/2025 reflected he had swelling to penis, small amount of pus noted with no noted odor to area, doctor and RP were notified and a new order for Cipro 500mg,<BR/>BID x 7 days for UTI and discharge was obtained. The progress note was signed by the DON. <BR/>Record review of the infection surveillance assessment dated [DATE] reflected Resident #26 had a urinary tract infection with an indwelling catheter. He had other infection of epididymitis (an infection or inflammation of the testis). The assessment reflected Resident #26 had started Levofloxacin Oral (an antibiotic used to treat infection) Tablet 500 MG to start on 01/03/2025, Give 500 mg by mouth one time a day for Bilateral epididymitis (inflammation of the testis) until 01/10/2025. <BR/>Record review of Resident #26's Physicians order summary dated 01/08/2025 reflected an order for Cipro Oral Tablet 500 MG (Ciprofloxacin HCl an antibiotic), Give 1 tablet by mouth two times a day for UTI, monitor swelling to penis, dated 01/01/2025. The order did not contain a stop date /duration for antibiotic therapy. <BR/>Record review of Resident #26's Physicians order summary dated 01/08/2025 reflected an order for Levofloxacin Oral (an antibiotic used to treat infection) Tablet 500 MG to start on 01/03/2025, Give 500 mg by mouth one time a day for Bilateral epididymitis (inflammation of the testis) until 01/10/2025. <BR/>Record review of Resident #26 Medication Administration Record dated 01/08/2025 reflected resident had received 14 doses of Cipro 500mg starting 01/01/2025. <BR/>Record review of Resident #26 Medication Administration Record dated 01/08/2025 reflected resident had received Levofloxacin Oral Tablet 500 MG (Levofloxacin) Give 500 mg by mouth one time a day for 6 doses. <BR/>In an interview on 01/10/2025 at 1:25 PM LVN A stated there should be a stop date on all antibiotic orders used for short term treatment of acute infections. She stated the nurses should have clarified the order with doctor. She stated nurses were instructed to get the stop dates on any short-term medications by in-services monthly given by don. LVN A stated she was unsure why a stop date was not obtained at the time of order for the Cipro order. She stated she was unsure what the negative effects of long-term use of Cipro could be, but she could find out the information. <BR/>In an interview on 01/10/25 at 1:31 PM the DON stated the Cipro for Resident #26 should have been for 5 to 7 days only. She stated the nurses were instructed to obtain a stop date for all antibiotics used for treatment of acute infections at the time of the order being received. She stated the DON and ADON were responsible for the review of orders daily. She stated they review daily for acute changes in residents' condition by looking at daily reports, review electronic medical records dashboard, and clarifying with the doctors for stop dates. The DON stated negative effects for residents that use long term antibiotic could lead to antibiotic resistant infections or intestinal infections. <BR/>In an interview on 01/10/25 at 1:53 PM the PA stated Cipro for Resident should have been for 7 days. She stated the staff should have obtained a stop date at time the order was given. She stated the Levofloxacin Oral Tablet 500 MG (Levofloxacin) 1 po q day ordered on 1/3/24 was ordered by another practitioner. She stated it was not protocol to have two antibiotics at the same time. She stated the facility should have stopped the cipro once the Levofloxacin order was received. She stated the Levofloxacin was ordered when the urine culture came back. <BR/>The PA stated orders were given by encrypted text messages services. The orders were given to the DON or nurses. She stated she did not see any negative effects for Resident #26 being on the cipro for the time he was on it. She stated she would have caught the error at his next visit she sees the resident weekly. <BR/>Record review of facility policy titled Unnecessary Drugs dated 04/2012 and last revised on 11/12/2015 reflected It is the policy of this facility that each resident's drug regimen must be free from unnecessary drugs. <BR/>An unnecessary drug us any drug when used: For excessive duration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 (Resident #75) of 6 residents reviewed for infection control.<BR/>CNA C and NA D failed to wash their hands and change their gloves when removing a soiled brief and placing a clean brief during peri care for Resident #75. <BR/>These failures could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included: <BR/>Record review of Resident #75s undated face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of acute respiratory failure, age-related physical debility, and chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breath).<BR/>Record review of Resident #75's care plan dated 01/02/25 reflected she had bowel and bladder incontinence related to physical dependence with ADL and cognitive deficit related to new surroundings. Her goal was to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included: incontinent checks as required, wash rinse and dry perineum, and change clothing as needed after incontinent episodes. Goals also included to monitor for signs and symptoms of urinary tract infection including pain, burning, blood, cloudiness, no output, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, and changing behavior.<BR/>Record review of Resident #75's MDS dated [DATE], reflected she had a BIMS score of 15 indicating the resident was cognitively intact. The MDS also indicated that Resident #75 was always incontinent of urine and bowel. Resident #75 required substantial/maximal assistance indicating the helper does more than half the effort with toileting hygiene.<BR/>In an observation on 01/07/25 at 3:18 PM of Peri Care on Resident #75<BR/>CNA C and NA D Did not wash hands or use alcohol-based hand sanitizer when changing gloves while removing a soiled brief and application of a clean brief. <BR/>In an interview on 01/07/25 at 3:42 PM NA D stated she was trained on Infection control through Inservice and in meetings by the DON. She stated staff were trained to wash hands or use ABH each time they removed their gloves. She stated risk to residents for not cleansing hands between gloving could spreading of infections.<BR/>In an interview on 01/07/25 at 3:50 PM CNA C stated she would normally use her ABH or wash her hands after removing her gloves. She stated it just slipped her mind. She stated she has been visually checked off on peri care twice in the last 6 by her DON. CNA stated the Risk to residents for not changing her gloves would be urinary tract infections. <BR/>In an interview on 01/10/25 at 1:31 PM the DON stated her expectation was for staff to hand sanitize before and after gloving. She stated staff were educated by the DON, ADON and LVN resource team. The CNAs perform visual check offs on peri care and teaching upon hire and quarterly. She stated the negative effects for staff not washing their hands between glove changes could possibly be the spreading of infection. <BR/>Record review of facility policy titled Hand Hygiene dated 05/2007 and revised 10/2022 reflected to use an alcohol-based hand rub containing at least 62%; or, alternatively, soap and (antimicrobial or non-antimicrobial) and water for the following situations: After removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 of 6 residents (Resident #66) reviewed for dignity. <BR/>The facility failed to promote resident independence and dignity while dining when staff stood over Resident #66 while assisting them to eat on 01/07/25.<BR/>This failure could have compromised residents' independence and dignity for those who require feeding assistance.<BR/>Findings included: <BR/>Record review of Resident #66's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old female with an admission date of 07/05/24. Resident #66 had diagnoses which included Alzheimer's (a type of brain disorder that causes problems with memory, thinking, and behavior), difficulty in walking, muscle weakness, cognitive communication deficit, and osteoporosis (a condition when bone strength weakens and is susceptible to fracture). Resident #66's BIMS score was left blank. The MDS indicated the resident started speech-language and audiology services therapy on 12/09/24 for 4 days a week.<BR/>Record review of Resident #66's care plan dated last revised 11/20/24 reflected she had a nutritional problem or potential nutritional problem related to disease process and ADL self-care performance deficit. <BR/>In an observation on 01/07/25 at 01:05 PM Resident #66 was being assisted with her lunch tray by a SLP who was standing over Resident #66 the entire duration of assistance.<BR/>In an interview on 01/07/25 at 01:20 PM with the SLP she stated she had worked at the facility since September of 2024. She stated that she was conducting an evaluation on Resident #66 due to a recent weight loss. She stated Resident #66 had poor attention span, could feed herself but may require assistance, and she was checking for Dysphasia (a language disorder that affects the ability to produce and understand spoken language). When asked if the SLP had been trained on how to provide feeding assistance she stated Yes, I am sure there was something in the LMS trainings but was unable to recall if she was supposed to sit or stand next to a resident when providing assistance.<BR/>In an interview on 01/07/25 at 2:15 PM with the DOR she stated she had worked at the facility for 3 years. When asked what her expectation was for feeding assistance, she stated that she would need to be notified by nursing that certain signs were occurring so that an SLP could evaluate the residents' cognition and swallowing. She stated that normally CNA's assist residents with feeding, but it would not be out of the ordinary that SLP's would be available and/or assisting. The expectation would be for the SLP to be seated next to the resident while providing assistance, and they were informed that they should be sitting for respect purposes, but this was not necessarily talked about for the evaluations. <BR/>Review of the facility's Feeding checklist for training staff revealed The following table lists the steps that are expected of you in order to feed an individual. The table also provides rationales that explain why you perform some of these steps. The use of this content is for educational purposes only and should only be used as a guide in performing the below skill, subject to the terms and conditions of the Master Services Agreement. no instruction for the employee being trained, to sit next to residents while providing feeding assistance was listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation; the facility failed to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress for 1 (Resident #1) of 5 residents reviewed for neglect.<BR/>The facility failed to:<BR/>1. ensure Resident #1 was evaluated and treated for urinary retention which led to Resident #1 requiring emptying of her bladder in the emergency department on 01/27/24<BR/>2. ensure Resident #1's pain was addressed by providing her prescribed oxycodone for her bilateral (both left and right) ankle fractures and surgery resulting in uncontrolled pain that caused Resident #1 to call 911 for transport to the emergency room on [DATE]<BR/>An Immediate Jeopardy (IJ) situation was identified on 01/31/24. While the IJ was removed on 02/01/24, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures could led to urinary retention and uncontrolled pain, both of which required medical intervention in the emergency room, and place residents at risk of not having their needs met to reach their highest practicable mental, physical and psycho-social wellbeing. <BR/>Findings included:<BR/>Record Review of Resident #1's undated face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of bilateral ankle fracture (post-op), depression, and high blood pressure.<BR/>Record review of Resident #1's EHR Assessments tab revealed an admission assessment on 01/27/24 revealed a BIMS that was 14 (cognitively intact).<BR/>Record review of Resident #1's initial care plan effective 01/27/24 at 12:01 am revealed section V, part a. Pain <BR/>focus: has acute/chronic pain; goal: Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date; <BR/>Intervention: Administer analgesia medication as per orders & <BR/>Intervention: Anticipate need for pain relief and respond immediately to any complaint of pain &<BR/>Intervention: Pain assessment every shift<BR/>Record review of the January 2024 orders for Resident #1 revealed that she had an order for oxycodone (narcotic pain reliever) 10 mg q4 hrs prn, started 01/26/24 at 1:13 pm. In addition, she had an order for methocarbamol 500 mg q8 prn pain (muscle relaxant).<BR/>Record review of the January orders for Resident #1 revealed no order for Tylenol.<BR/>Record review of the January 2024 MAR revealed no administration of methocarbamol nor of oxycodone.<BR/>Record review of the police department call log printed 01/29/24 revealed that Resident #1 called 911 herself on 01/26/24 at 5:46 pm stating that the bed pan was cutting into her skin, she cannot move and she wanted to go to the ER.<BR/>During an interview on 01/30/24 at 1:15 pm with DON she said oxycodone was not part of the emergency kit. DON further stated that Resident #1 was not in pain from her ankles, but the nurse could have called the physician for a different pain medicine that was in the emergency kit.<BR/>During an interview on 01/30/24 at 1:59 pm with LVN A she stated that Resident #1 wanted a foley catheter inserted because she was not able to urinate in the bed pan. LVN A said it was a dignity issue and Resident #1 did not want to urinate in a brief or on the bed pan. LVN A stated that the DON and LVN A and EMS staff spoke to Resident #1 about the dangers of the foley catheter related to infection and after they talked to Resident #1 she declined transport to the emergency department on 01/26/24. LVN A stated Resident #1 was left on the bed pan for 30 minutes on 01/26/24. LVN A said Resident #1 expressed concerns about wearing briefs as a dignity issue and had difficulty using a bed pan. Resident #1 told LVN A that she was uncomfortable using a bed pan due to being continent and requested a foley be placed on 01/27/24. LVN A stated the facility wanted to monitor her due to infection risk of foley. She stated Resident #1 minimally urinated in bed pan on 01/26/24 and aides reported urine in brief on 01/27/24. When asked why the docotr was not asked for a prescription for another pain medicine like hydrocodone to cover until oxycodone arrived LVN could not answer and kept saying the medication was supposed to arrive on the next delivery.<BR/>During an interview on 01/31/24 at 10:45 am (at a different facility) Resident #1 said she was left on the bed pan for an hour with no one checking on her on her first day at the facility (01/26/24). She stated she had ankle pain in both ankles the entire time she was in the facility. She said she tried to urinate in the bed pan but was not able on 01/26/24. She said she kept trying to urinate in the brief over the night of 01/26/24 and into the morning of 01/27/24 and she was able to urinate at one point. Resident #1 stated she was in so much pain she did not eat on either day she was in the facility and that she stopped drinking in the afternoon of 01/27/24 due to not being able to urinate. She said she was in 10 out of 10 pain from her ankles the entire day of 01/27/24 and as the day progressed the pain in her abdomen from her full bladder increased to 10 out of 10 as well. She said she called out in pain and was tearful while yelling for assistance and she was only given Tylenol which did not help. Resident #1 stated that she told at least 5 staff each day that she was in pain and that her needs were ignored. She said she was told her oxycodone was not available in the facility and it was on order. Resident #1 said she called 911 for help with her pain and was taken to the emergency room where she cried to the doctors and begged not to be sent back to that facility.<BR/>Record review of the police department call log printed 01/29/24 revealed that Resident #1 called 911 herself on 01/27/24 at 7:05 pm because she was in pain and the facility was not doing anything for her; operator documented the resident was crying on the phone and stated that broken ankles and bladder was what was causing the pain. <BR/>During an interview with Hospital Nurse 01/30/24 4:00 pm revealed Resident #1 was seen in emergency department 01/27/24 at 7:52 pm for Urinary retention since yesterday (01/26/24) and acute pain after bilateral ORIF of ankles. Resident #1 told Hospital Nurse she had 10 out of 10 pain in bilateral ankles and the facility did not have her pain medicine in stock and gave her Tylenol. In addition, hospital nurse stated that Resident #1 had 593 mls of urine removed and her bladder was distended (over 400 requires emptying per nurse). In addition, the resident tested positive for a UTI which the hospital nurse stated could be caused by or exacerbated by urine retention.<BR/>Multiple attempts to reach the pharmacy over 3 days were not successful.<BR/>Record review of the undated facility policy titled Abuse: Prevention and Prohibition Against revealed each resident has the right to be free from abuse, neglect and misappropriation .<BR/>Record review of the facility policy titled Pain Recognition and Management revealed if pain management is not effective, the MD should be contacted.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 01/31/24 at 2:30 PM. The ADM and DON were notified and provided with the IJ template on 01/31/24 at 2:43 PM.<BR/>The following plan of Removal submitted by the facility was accepted on 02/01/24 at 3:14 pm and included:<BR/>PLAN OF REMOVAL <BR/>F600: Neglect: In the IJ Template given on 1/31/2024, the facility failed to address Resident #1 pain and urinary retention.<BR/>1. <BR/>The Medical Director was notified of the IJ on 01/31/2024 at 4:00 pm.<BR/>2. <BR/>Train the trainer in-servicing was given to the ED, DON, ADON, MDS Nurse and RN/ED Cluster Partners by the Clinical Resource. The training included regarding abuse and neglect including goods and services needed to address a resident's needs in relation to pain. This was completed on 1/31/24.<BR/>3. <BR/>Verbal and written training and knowledge checks were completed with all staff regarding abuse and neglect including goods and services needed to address a resident's needs in relation to pain. This training was given by the ED, DON, ADON, MDS Nurse Clinical Resource and RN/ED Cluster Partners, was initiated on 1/31/24 will be completed on 2/1/24 with all staff prior to the start of their next shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. This training will also be included in the new hire orientation and will be included for agency staff/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. <BR/>4. <BR/> An ad hoc meeting regarding items in the IJ templates will be completed on 1/31/24. Attendees will include the DON, Medical Director, ADON, Clinical Resource, Executive Director and will include the plan of removal items and interventions.<BR/>5. <BR/>The ED or designee will verify staff knowledge on abuse and neglect prevention with 10 staff weekly using the abuse and neglect knowledge checks. This will be completed weekly after the initial training and knowledge checks completed on 2/1/24 and will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance.<BR/>6. <BR/> The DON or designee will monitor q shift pain assessments daily to verify that interventions are in place and pain medications are given appropriately and will monitor new orders and documentation for pain medication availability daily. The DON or designee will monitor MAR and pain medications stored on carts weekly to ensure pain medication availability. These processes were initiated on 1/31/24 will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance.<BR/>7. <BR/>Resident requiring pain management will be reviewed during weekly clinical meeting and the Medical Director and Pain Management Physician will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to DON, ADON, Rehab Director, and Executive Director. The DON and Executive Director will be responsible for ensuring this meeting is held weekly and pain management is reviewed. This meeting will begin on 01/31/2024 will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance.<BR/>8. <BR/>Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 1/31/24 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance.<BR/>MONITORING THE POR:<BR/>Record review on 02/01/24 of the in-service records revealed in-services on 02/01/24 related to abuse, neglect, and change in condition - pain and urinary retention.<BR/>Record review of a sign in sheet for a meeting related to the immediate jeopardy were dated 01/31/24 and showed attendance of DON, Medical Director, ADON, Clinical Resource, and Executive Director.<BR/>Interviews conducted on 02/01/24 between 10:00 am and 12:00 pm with 4 residents revealed no concerns related to neglect, staff assistance, nor with pain.<BR/>Interviews conducted on 02/01/24 between 1:00 pm and 5:00 pm with 1 housekeeper, 1 LVN, 1 PTA, 1 COTA, 1 ST, and 1 CNA revealed that staff were in-serviced on pain, urinary retention, neglect and abuse. All were able to answer questions appropriately related to notification of and response to resident pain and resident concerns. All were able to answer questions related to reporting neglect and abuse.<BR/>Interviews conducted on 02/14/24 between 11:00 am and 1:30 pm with DON, ADON and MDS nurse revealed they were in-serviced by the corporate RN related to pain, neglect and urinary retention; this was completed 01/31/24.<BR/>Record review of all residents admitted since 01/31/24 revealed no pain related deficient practice. Interviews with all of the residents confirmed no pain related issues nor neglect concerns being voiced.<BR/>Interviews on 02/14/24 between 11:00 am and 1:30 pm with 1 ADON/LVN, 1 LVN, the staffing coordinator, 1 RN and 2 CNAs revealed all have been in-serviced daily since 01/31/24 related to pain (identifying, reporting, following up), neglect (listed all types of neglect and gave examples), and urinary retention (all voiced signs, listening to resident concerns, and reporting to nurse and if no action taken reporting to DON directly). All stated they had been in-serviced on all topics 02/01/24 and now it was being re-iterated.<BR/>In an interview on 02/14/24 at 11:00 am with DON she stated that every resident had been assessed for pain, pain was added to every care plan, and all residents had standing orders for pain medications that could be used by any nurse for immediate pain concerns. DON stated that all physicians engaged to ensure pain would be addressed for all residents, including new admissions. These procedures were in place by 02/01/24.<BR/>The ADM was informed the Immediate Jeopardy was removed on 02/01/2024 at 4:15 p.m. The facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.<BR/>On 02/14/24, two attempts were made to contact the pharmacy without success (in addition to the attempts earlier).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 (Resident #1) of 5 residents reviewed for pain.<BR/>The facility failed to:<BR/>1. ensure Resident #1's prescribed oxycodone was in the facility and provided to Resident #1 for her pain from bilateral broken ankles and surgery<BR/>An Immediate Jeopardy (IJ) situation was identified on 01/31/24. While the IJ was removed on 02/01/24, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures could affect residents by placing them at risk for pain that would prevent residents from achieving their highest practicable physical, mental and psychosocial well-being.<BR/>Findings included:<BR/>Record Review of Resident #1's undated face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of bilateral ankle fracture (post-op), depression, and high blood pressure.<BR/>Record review of Resident #1's EHR Assessments tab revealed an admission assessment of BIMS that was 14 (cognitively intact).<BR/>Record review of Resident #1's initial care plan effective 01/27/24 at 12:01 am revealed section V, part a. Pain <BR/>focus: has acute/chronic pain; goal: Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date; <BR/>Intervention: Administer analgesia medication as per orders & <BR/>Intervention: Anticipate need for pain relief and respond immediately to any complaint of pain &<BR/>Intervention: Pain assessment every shift<BR/>Record review of the January orders for Resident #1 revealed that she had an order for oxycodone (narcotic pain reliever) 10 mg q4 hrs prn, started 01/26/24 at 1:13 pm. In addition, she had an order for methocarbamol 500 mg q8 prn pain (muscle relaxant).<BR/>Record review of the January MAR revealed no administration of methocarbamol nor of oxycodone.<BR/>During an interview on 01/31/24 at 10:45 am (at a different facility) with Resident #1 said she was left on the bed pan for an hour with no one checking on her on her first day at the facility (01/26/24) to the point that the metal felt like it was cutting her skin and she could not move from the bedpan which was extremely uncomfortable. She stated she had ankle pain in both ankles the entire time she was in the facility. She said she tried to urinate in the bed pan but was not able on 01/26/24. She said she kept trying to urinate in the brief over the night of 01/26/24 and into the morning of 01/27/24 and she was able to urinate at one point. Resident #1 stated she was in so much pain she did not eat on either day she was in the facility and that she stopped drinking in the afternoon of 01/27/24 due to not being able to urinate. She said she was in 10 out of 10 pain from her ankles the entire day of 01/27/24 and as the day progressed the pain in her abdomen from her full bladder increased to 10 out of 10 as well. She said she called out in pain and was tearful while yelling for assistance and she was only given Tylenol which did not help. Resident #1 stated that she told at least 5 staff each day that she was in pain and that her needs were ignored. She said she was told her oxycodone was not available in the facility and it was on order. Resident #1 said she called 911 for help with her pain and was taken to the emergency room where she cried to the doctors and begged not to be sent back to that facility.<BR/>Record review of 911 log revealed Resident #1 called 911 herself on 01/26/24 at 5:46 pm stating that the bed pan was cutting into her skin, she cannot move and she wants to go to the ER. <BR/>During an interview on 01/30/24 at 1:15 pm with DON she said oxycodone was not part of the emergency kit. DON further stated that Resident #1 was not in pain from her ankles, but the nurse could have called the physician for a different pain medicine that was in the emergency kit.<BR/>In an interview on 01/30/24 at 1:59 pm with LVN A she stated that the DON and LVN A and EMS staff spoke to Resident #1 about the dangers of the foley catheter related to infection and after they talked to Resident #1 she declined transport to the emergency department on 01/26/24. LVN A further stated that Resident #1's oxycodone did not arrive with her other medications on 01/26/24. She contacted the pharmacy as soon as it opened on 01/27/24 at 8:00 am and was told the oxycodone would arrive on the next shipment, around 4:00 pm. The medication did not arrive with the afternoon delivery around 4:00 pm and LVN A contacted the pharmacy again and placed an order for oxycodone STAT and was told it would be 3-4 hours for delivery. LVN A said the resident wouldn't urinate in the urinal due to dignity. She said she did not recall her complaining of ankle pain, but later stated that Resident #1 mentioned her ankle pain the morning of 01/27/24. When asked why the docotr was not asked for a prescription for another pain medicine like hydrocodone to cover until oxycodone arrived LVN could not answer and kept saying the medication was supposed to arrive on the next delivery.<BR/>Multiple attempts to reach the pharmacy over 3 days were not successful.<BR/>Record review of 911 log revealed Resident #1 called 911 herself on 01/27/24 at 7:05 pm because she was in pain and the facility was not doing anything for her; operator documented the resident was crying on the phone and stated that broken ankles and bladder is what was causing the pain. <BR/>Record review of Resident #1's progress notes revealed notes specific to ankle pain on:<BR/>01/26/24 1:03 pm (first note on admission)<BR/>01/27/24 12:13 pm Pain originates from fracture Located at bilateral ankles Described as ache nonpharmaceutical interventions include elevate and rest<BR/>Further review revealed a progress note 01/27/24 at 6:00 pm revealed pending pharmacy delivery for Oxycodone 10 mg q4hr PRN, this nurse called in STAT order at 1700 after pharmacy delivered facility meds (resident's medication not present in package), was advised it would be sent on next delivery in 3-4 hours<BR/>Record review of pain assessment 01/27/24 at 3:36 pm revealed a score of 7. Further review revealed 01/27/2024 6:36 pm used PAINAD and had a score of 2 (1 for being tensed, and 1 for distracted or reassured by voice/touch).<BR/>Record review of admission assessment titled Pain Management Review revealed resident rated her pain at a 7 and it was in her bilateral ankles. Under staff observation it had checked that Resident #1 Negative verbalizations and vocalizations (e.g., groaning, crying/whimpering, or screaming) This assessment was signed 01/27/24 at 12:11 am.<BR/>During an interview with Hospital Nurse 01/30/24 4:00 pm revealed Resident #1 was seen in emergency department 01/27/24 at 7:52 pm for Urinary retention since yesterday (01/26/24) and acute pain after bilateral ORIF of ankles. Resident #1 told Hospital Nurse she had 10 out of 10 pain in bilateral ankles and the facility did not have her pain medicine in stock and gave her Tylenol (no order in facility orders for Tylenol). In addition, hospital nurse stated that Resident #1 had 593 mls of urine removed and her bladder was distended (over 400 requires emptying per nurse). In addition, the resident tested positive for a UTI which the hospital nurse stated could be caused by or exacerbated by urine retention.<BR/>Record review of the facility policy titled Pain Recognition and Management revealed if pain management is not effective, the MD should be contacted.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 01/31/24 at 2:30 PM. The ADM and DON were notified. The ADM and DON were provided with the IJ template on 01/31/24 at 2:43 PM.<BR/>The following plan of Removal submitted by the facility was accepted on 02/01/24 at 3:14 pm:<BR/>PLAN OF REMOVAL <BR/>F697: Pain Management: In the IJ Template provided on 01/31/2024, the facility failed to administer narcotic medication to Resident #1 as ordered by the Physician.<BR/>1. <BR/>The Medical Director was notified of the IJ on 01/31/2024 at 4:00 pm.<BR/>2. <BR/>Pain assessments were completed for all residents on 1/31/24 and care plans were updated by DON, Cluster RNs and clinical resource RN. Orders for pain assessment for every shift were verified by DON, Cluster RNs and clinical resource RN for all resident on 1/31/24. <BR/>3. <BR/>An ad hoc meeting regarding items in the IJ templates will be completed on 1/31/24. Attendees will include the DON, Medical Director, ADON, Clinical Resource, Executive Director and will include the plan of removal items and interventions.<BR/>4. <BR/>The DON, ADON, MDS Nurse , RN Cluster Partners were in-serviced by the Clinical Resource RN. The DON, ADON, MDS Nurse , RN Cluster Partners and clinical Resource RN will verify Nurse knowledge with 5 Nurses weekly using the pain management knowledge check and all agency nurses prior to working a shift. This will be completed weekly x 4 weeks after the initial training and knowledge checks completed on 2/1/24.<BR/>5. <BR/>The DON or designee will monitor q shift pain assessments daily to verify that interventions are in place and pain medications are given appropriately and will monitor new orders and documentation for pain medication availability daily. The DON or designee will monitor MAR and pain medications stored on carts weekly to ensure pain medication availability. These processes were initiated on 1/31/24 will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance <BR/>6. <BR/>Resident requiring pain management will be reviewed during weekly clinical meeting and the Medical Director and Pain Management Physician will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to DON, ADON, Rehab Director, and Executive Director. The DON and Executive Director will be responsible for ensuring this meeting is held weekly and pain management is reviewed. This meeting will begin on 01/31/2024 will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance <BR/>7. <BR/>Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 1/31/24 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance.<BR/> Monitoring: <BR/>MONITORING THE POR:<BR/>Record review on 02/01/24 of the in-service records revealed in-services on 02/01/24 related to pain.<BR/>Record review of 10 residents revealed pain assessments were completed every shift starting 01/31/24 and care plans were updated related to pain for residents with pain concerns. Further review on 02/14/24 revealed no missed pain assessments for any resident.<BR/>Record review of a sign in sheet for a meeting related to the immediate jeopardy were dated 01/31/24 and showed attendance of DON, Medical Director, ADON, Clinical Resource, and Executive Director.<BR/>Interviews conducted on 02/01/24 between 10:00 am and 12:00 pm with 4 residents revealed no concerns related to pain.<BR/>Interviews conducted on 02/01/24 between 1:00 pm and 5:00 pm with 1 housekeeper, 1 LVN (admitting LVN for Resident #1), 1 PTA, 1 COTA, 1 ST, and 1 CNA revealed that staff were in-serviced on pain, urinary retention, neglect and abuse. All were able to answer questions appropriately related to notification of and response to resident pain. <BR/>Interviews conducted on 02/14/24 between 11:00 am and 1:30 pm with DON, ADON and MDS nurse revealed they were in-serviced by the corporate RN related to pain; this was completed 01/31/24.<BR/>Record review of all residents admitted since 01/31/24 revealed no pain related deficient practice. Interviews with all of the residents confirmed no pain related issues.<BR/>In an interview on 02/14/24 at 11:00 am with DON she stated that every resident had been assessed for pain, pain was added to every care plan, and all residents had standing orders for pain medications that could be used by any nurse for immediate pain concerns. DON stated that all physicians engaged to ensure pain would be addressed for all residents, including new admissions. These procedures were in place by 02/01/24.<BR/>Interviews on 02/14/24 between 11:00 am and 1:30 pm with 1 ADON/LVN, 1 LVN, the staffing coordinator, 1 RN and 2 CNAs revealed all have been in-serviced daily since 01/31/24 related to pain (identifying, reporting, following up), neglect (listed all types of neglect and gave examples), and urinary retention (all voiced signs, listening to resident concerns, and reporting to nurse and if no action taken reporting to DON directly). All stated they had been in-serviced on all topics 02/01/24 and now it is being re-iterated.<BR/>The ADM was informed the Immediate Jeopardy was removed on 02/01/2024 at 4:15 p.m. The facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.<BR/>On 02/14/24, two attempts were made to contact the pharmacy without success (in addition to the attempts earlier).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (Resident #32 and Resident #51) of 2 residents reviewed for wound care.<BR/>The facility failed to provide wound care as ordered for Resident #32.<BR/>The facility failed to document wound care for Resident #32 and Resident #51.<BR/>These failures could place residents at risk of worsening pressure injuries.<BR/>Findings included: <BR/>Resident #32:<BR/>A record review of Resident #32's face sheet dated 11/15/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of dysphagia (difficulty swallowing), repeated falls, hypertension (high blood pressure), hyperlipidemia (high cholesterol), and cognitive communication deficit (problems with communication).<BR/>A record review of Resident #32's MDS assessment dated [DATE] reflected a BIMS of 12, which indicated moderately impaired cognition. <BR/>A record review of Resident #32's care plan last revised on 10/02/2023 reflected she had an unstageable DTI on her left heel . Interventions included nursing staff were to follow facility protocol for treatment of injury.<BR/>A record review of Resident #32's physician order dated 10/10/2023 reflected an order to cleanse open area to left buttocks with normal saline, apply calcium alginate, collagen powder and dressing daily until healed. <BR/>A record review of Resident #32's physician order dated 10/24/2023 reflected an order to cleanse with NS, pat dry, apply povidone iodine topical (topical anti-infective) liberally and keep her unstageable DTI to left heel covered with a dry dressing for wound protection three times a day. <BR/>A record review of Resident #32's physician order dated 11/02/2023 reflected an order to cleanse with NS, pat dry, apply calcium alginate, collagenase (topical medication used for removing damaged skin to allow for wound healing and growth of health skin) and cover her unstageable DTI to left heel daily and PRN.<BR/>A record review of Resident #32's physician order dated 11/08/2023 reflected an order to cleans with NS, pat dry, apply povidone-iodine (topical anti-infective), Kerlix wrap (woven gauze) and tape her unstageable DTI to left heel two times a day for wound care.<BR/>A record review of Resident #32's TAR dated November 2023 reflected the following: <BR/>Treatments for daily wound care to her left buttocks were not documented on 11/02/2023, 11/05/2023, and 11/08/2023.<BR/>Treatments for daily wound care three times a day were not documented one of three shifts on 11/01/2023 and on 11/02/2023, respectively.<BR/>Treatments for daily wound care to her left heel were not documented on 11/05/2023 and 11/08/2023.<BR/>Treatments for twice daily wound care to her left heel were not documented on the evening shift on 11/09/2023, nor on the day or evening shifts on 11/13/2023 and 11/14/2023. <BR/>A record review of Resident #32's progress notes dated 10/17/2023-11/14/2023 reflected no documented wound care.<BR/>During an observation and interview on 11/13/2023 at 10:55 a.m., Resident #32 was observed sitting in her wheelchair in her room with her heel bandaged and dated 11/12/2023. Resident #32 stated sometimes it gets changed and sometimes it does not and that the Wound Care Physician wanted wound care to happen more than it had been happening. Resident #32 stated the facility was short-staffed and they tried the best they could. <BR/>During an interview on 11/15/2023 at 3:43 p.m., LVN D stated she did wound care for Resident #32 that day, 11/15/2023, but she did not do it on Tuesday 11/14/2023. LVN D stated no wound care did not get done for Resident #32 on 11/14/2023 either because the Wound Care Physician usually came on Mondays and we were waiting on him to come. LVN D stated LVN E also did treatments on the 600-hall where Resident #32 and Resident #51 resided. LVN D stated possibly wound care was not done if no one signed off on it on the TAR. LVN D stated wound care did not get done Monday because the Wound Care Physician did not come to the facility. LVN D stated yes there was a lot going on and maybe it got missed. LVN D stated there were a lot of falls on Monday 11/13/2023 and Tuesday 11/14/2023, and they were moving a lot of residents to different rooms. LVN D stated the facility did not have a wound care/treatment nurse and I wish we did. LVN D stated we need one because we have a lot of bumps. <BR/>Resident #51:<BR/>A record review of Resident #51's face sheet dated 11/15/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral infarction (stroke), cardiomegaly (enlarged heart), hemiplegia and hemiparesis (paralysis of one side of the body), stage 4 pressure ulcer of sacral region, hyperlipidemia (high cholesterol), major depressive disorder (depression), hypertension (high blood pressure), heart failure, and atrial fibrillation (irregular heartbeat).<BR/>A record review of Resident #51's MDS assessment dated [DATE] reflected a BIMS of 14, which indicated minimally impaired cognition.<BR/>A record review of Resident #51's care plan last revised on 11/08/2023 reflected she had a stage 4 pressure ulcer to her sacrum. Interventions included nursing staff were to administer treatment as ordered and follow facility policies/protocols for the prevention/treatment of skin breakdown. <BR/>A record review of Resident #51's physician order dated 10/24/2023 reflected an order to cleanse her state 4 sacral pressure injury with wound cleanser, pat dry, apply calcium alginate, cover with superabsorbent silicone dressing daily. <BR/>A record review of Resident #51's physician order dated 11/02/2023 reflected an order to cleanse her stage 4 sacral pressure injury with wound cleanser, pat dry, apply calcium alginate, apply collagen powder, and cover with superabsorbent silicone dressing daily and PRN. <BR/>A record review of Resident #51's TAR dated November 2023 reflected treatments for wound care to her stage 4 sacral pressure injury were not documented on 11/01/2023, 11/02/2023, 11/04/2023, 11/05/2023, 11/13/2023 and 11/15/2023. <BR/>A record review of Resident #51's progress notes dated 10/16/2023-11/15/2023 reflected no documented wound care.<BR/>During an observation and interview on 11/14/2023 at 11:07 a.m., Resident #51 stated she got her wounds from the hospital because her doctor told her she had not been repositioned for five weeks. Resident #51 stated the facility did wound care and voiced no concerns.<BR/>During an interview on 11/15/2023 at 3:03 p.m. the DON stated she started working at the facility in mid-October of 2023.<BR/>An interview was attempted with LVN E on 11/15/2023 at 3:53 p.m. but contact with LVN E was unsuccessful. <BR/>During an observation and interview on 11/15/2023 at 4:31 p.m., LVN D was asked where wound care might be documented if not on the TAR, LVN D turned away and did not answer.<BR/>During an interview on 11/15/2023 at 4:32 p.m., the DON stated it was her expectation that nursing staff followed wound care orders. The DON stated staff were supposed to click off and document wound care but if you don't see it clicked off, you can go to the patient and see if the wound care was done. The DON stated, some nurses don't click off on it. The DON said floor nurses were responsible for doing wound care and yes they had enough time. The DON stated there were not that many wounds and there was enough time. The DON stated staff were trained on wound care through in person demonstrations and in-service trainings. The DON stated all nurses were aware they needed to do wound care. The DON stated, if it's a trend, we would pick up on it. When asked how not following orders and documenting wound care could affect wounds, the DON stated, I would have to see the orders and said it depended on the type of wound dressing and the actual wound the DON stated if it were stable or eschar (slough or piece of dead tissue that is cast off from the surface of the skin) only, it can stay on a couple days. <BR/>A record review of the facility's policy titled Wound Care & Treatment Guidelines dated May 2007 reflected the following: <BR/>POLICY: <BR/>It is the policy of this facility to provide excellent wound care to promote healing.<BR/>PROCEDURES:<BR/>13. Documentation of the treatment should be completed.<BR/>A record review of the facility's policy titled Physician Orders dated October 2022 reflected the following: <BR/>POLICY: <BR/>It is the policy of this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately notify her authority, the resident representative when there was a significant change for 1 of 1 residents (Resident #166) reviewed for notification of changes.<BR/>The facility failed to notify Resident #166's responsible party on 08/14/2023, 08/26/2023, 11/04/2023, 11/13/2023, /1/2023, and 02/05/2023, when new adjustments to medication regimen were made. <BR/>This failure could place residents who experience a change in condition at risk of responsible party not being informed in care decisions.<BR/>Findings include:<BR/>Record review of Resident #166's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE], with a principal diagnosis of Cerebral palsy (Neuromuscular deficit), and secondary diagnosis of bipolar disorder. CR#1 was discharged on 07/29/2023.<BR/>Record review of Resident #166's MDS, dated [DATE], revealed the resident had a BIMS score of 10 in Section C. Section I revealed R#1 was triggered for cerebral palsy. Section I revealed that R#1 was triggered for psychotic disorder, bipolar disorder, and depression. Section E triggered R#1 for potential indicators of psychosis which included delusions.<BR/>Record Review of Resident #166's care plan dated 12/09/2023 reported resident to have a potential for a psychological well-being problem related the anxiety and abuse allegation. Intervention listed for R#1 were to increase communication between family about care including explaining all medications. <BR/>Record Review of Resident #166's medication list per admission record dated 07/22/2022 revealed:<BR/>-Gabapentin 300mg<BR/>-Tizanidine 4mg<BR/>-1 capsule PO TID<BR/>-2 tablets PO TID<BR/>-Nortel 1/35 - 28 day 1 tablet PO QD [active pills only]<BR/>-Atorvastatin 10mg 1 tablet PO Q HS<BR/>-Quetiapine 100mg 1 tablet PO Q HS<BR/>-Midodrine 5mg 1 tablet PO TID<BR/>-Calcium+ D 600/400 1 tablet PO BID<BR/>-Oivalproex 500mg 1 tablet PO BID<BR/>-Pantoprazole 40mg 1 tablet PO BID<BR/>-Spironolactone 25mg 1 tablet PO Q AM<BR/>-Multivitamins 1 tablet PO QAM<BR/>-Escitalopram 10mg + 20mg (total 30mg) 1 tablet each PO Q AM<BR/>-Folic Acid 1mg 1 tablet PO Q AM<BR/>-Furosemide 40mg 1 tablet PO QAM, and<BR/>-Levothyroxine 100mcg 1 tablet PO Q AM before food or other meds.<BR/>Record review of psych service initial assessment note dated 08/26/2022 reported Staff requested visit to assess mental status, mood and to review/manage psych meds. Assessment revealed resident had negative and intrusive thoughts towards herself. The Nurse Practitioner (NP) recommended the following dose adjustment for Resident #166: Prazosin 1 mg Capsule /QHS for night terrors.<BR/>Record review of psych service subsequent assessment note dated 12/31/2022 reported chief complaint of staff requesting visit due to recurring psychosis and aggression Resident #166 displayed to other residents. The Nurse Practitioner (NP) recommended the following dose adjustment for Resident #166: 175 mg PO daily. The reason for dose change was due to ineffective therapy.<BR/>Record Review of medication order for Resident #166 reported: <BR/>-08/14/2023 - Ambien - 5 mg Tablet give 1 tablet at bedtime for insomnia.<BR/>-08/26/23 - Prazosin HCL 1 mg capsule -Give 1 mg at bedtime for night. <BR/>-11/04/2022- Loperamide 2 mg tablet Give 2 tablets PRN for Diarrhea. <BR/>-11/12/2023 - Seroquel 25 mg added per day for psychosis. DC'd 12/31/2023. <BR/>-12/31/2023 - Seroquel 50 mg added per day for psychosis.<BR/>-02/05/2023 - Milk of Magnesia Suspension 400 mg/ 5 ml, give 30 ml per day prn for constipation.<BR/>Interview with FM #1 dated 11/14/2023 at 3:56 PM revealed she had conflicts with the care that was provided toward Resident #166. Resident #166's family member stated that R31 had a mind of a 3-year-old and needed staff to communicate to her any changes in her therapy so she can decide if it is necessary. Resident #166's family member stated that staff including management were not communicating to her the adjustments that were being med to Resident #166 medications. Resident #166's family member stated she was first made aware of the medications Resident #166 was on when Resident #166 discharged from the facility and her medication list was different from when she admitted to the facility. Resident #166's family member stated that she would not have had Resident #166 on the medications regimen she was on had she known about it. <BR/>Interview with Medical Records Supervisor (MRS) dated 11/14/2023 at 12:55 PM revealed the following: upon being asked for medication list of Resident #166 she responded that it was in the EMR. MRS stated that as soon as the records get uploaded the DON is supposed to communicate with physician which meds should be continued or discontinued and/or other adjustments that need to be made. <BR/>Interview with Nurse Practitioner (NP) dated 11/14/2023 at 01:42 PM revealed that Resident #166 was ordered Seroquel for severe paranoia. NP stated Resident #166 would sometimes report signs and symptoms of auditory hallucinations. NP stated that she saw Resident #166 on 11/12/23. NP stated she added 25 mg Seroquel daily because Resident #166 was verbally and physically abusive to other residents.NP stated she witnessed physical assaults and asked about it and it was confirmed with staff. NP stated she increased another dose of Seroquel because staff called in stating resident was continuing with her aggressive behavior. NP stated Resident #166 had night terrors. told me of them. She stated she would have nightmares. I am not the one who gave her Ambien. I believe Ambien is what she came in with. I don't think the medication adjustment had a role in her going to her hospital. She was attention seeking. I felt it was needed for her to be on those medications but if there was no change in her condition, I would have taken the medication off. NP Stated that residents RP was supposed to be communicated by nursing so that they are aware of what medications Resident #166 is on.<BR/>Interview with LVN C and LVN D on 11/20/2023 at 4:30 PM revealed that Nurses are supposed to communicate every new order and dose adjustment to residents and/or responsible parties (RP). LVN D stated that upon reaching out to family members it is the facility job to document in the progress notes that they communicated to RP. When asked why Resident #166's family member was not communicated to LVN C and D stated that this occurred long ago and that the nurses who were working with Resident #166 are no longer here. LVN C and LVN D stated that RP need aware of adjustments of order because that's their right to know what medications they will approve to be ordered by the doctor.<BR/>Interview with LVN C and LVN D on 11/20/2023 at 4:30 PM revealed that Nurses are supposed to communicate every new order and dose adjustment to residents and/or responsible parties (RP). LVN D stated that upon reaching out to family members it is the facility job to document in the progress notes that they communicated to RP. When asked why Resident #166's family member was not communicated to LVN C and D stated that this occurred long ago and that the nurses who were working with Resident #166 are no longer here. LVN C and LVN D stated that RP need aware of adjustments of order because that's their right to know what medications they will approve to be ordered by the doctor.<BR/>Record review of Resident #CR#1's undated care plan, revealed:<BR/>Focus: [CR #1] has left inner ankle wound x2. <BR/>Goal: [CR#1] will maintain or develop clean and intact skin by the review date. <BR/>Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. <BR/>Provide treatment per physician order. <BR/>Specialty mattress to bed. Pressure reduction mattress.<BR/>Turn and reposition per facility protocol and PRN.<BR/>Use a draw sheet or lifting device to move resident.<BR/>In a phone interview with RP for CR#1 on 08/01/2023 at 11am, she said that facility did not notify her that CR#1 had a wound to her foot. She said she observed the wound on 07/29/2023 while visiting.<BR/>In an interview with LVN A on 08/02/2023 at 12:39pm, she said she first saw CR#1 had two wounds to her left ankle on 07/24/2023. She said she worked at the facility for 3 months. She said when a new wound was identified the appearance should be documented. She said the primary doctor, wound care doctor, and family should be notified. She said the Treatment Nurse, ADON, and DON are to be notified. She said she notified Physician C on 07/24/2023. She said she did not notify the family or primary doctor after the wound was identified. She said she did not notify the ADON or DON when the wound was identified. She said she did not document the appearance of the wound observation in a progress note, skin assessment, or SBAR when the wound was assessed on 07/24/2023. She said she did not complete the tasks which caused a delay in CR#1's treatment. <BR/>In an interview with DON on 08/01/2023 at 1:49pm, she said that she started at the facility on 07/26/2023. She said that when a wound is identified the nurse should document the appearance, notified the physician, wound care doctor, family, and DON. She said that if the DON is not available the ADON should be notified. She said that on 07/26/2023 the floor nurse assigned to CR#1 brought to her attention that resident had a wound to left ankle that had not been there when previously worked. She said that she instructed the floor nurse to notified primary doctor, wound care doctor, and family. She said that she reviewed progress notes completed by LVN A who identified the wound initially on 07/24/23. She said that LVN A documented that she notified the wound care doctor but not the family or DON. She said that LVN A did not notify the ADON or DON at the time that CR#1 had a wound identified. She said that LVN A did not follow up on treatment orders after CR#1 was assessed by the wound care doctor on 07/24/2023. She said that because she did not complete the tasks CR#1's treatment was delayed. She said that LVN A did not follow the facilities protocol, and she will receive disciplinary action.<BR/>Record review of facility policy, Change in a Residents Condition or Status dated February 2021 read in part, .4. Unless otherwise instructed by the resident, a nurse will notify the residents representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 (Resident #75) of 6 residents reviewed for infection control.<BR/>CNA C and NA D failed to wash their hands and change their gloves when removing a soiled brief and placing a clean brief during peri care for Resident #75. <BR/>These failures could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included: <BR/>Record review of Resident #75s undated face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of acute respiratory failure, age-related physical debility, and chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breath).<BR/>Record review of Resident #75's care plan dated 01/02/25 reflected she had bowel and bladder incontinence related to physical dependence with ADL and cognitive deficit related to new surroundings. Her goal was to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included: incontinent checks as required, wash rinse and dry perineum, and change clothing as needed after incontinent episodes. Goals also included to monitor for signs and symptoms of urinary tract infection including pain, burning, blood, cloudiness, no output, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, and changing behavior.<BR/>Record review of Resident #75's MDS dated [DATE], reflected she had a BIMS score of 15 indicating the resident was cognitively intact. The MDS also indicated that Resident #75 was always incontinent of urine and bowel. Resident #75 required substantial/maximal assistance indicating the helper does more than half the effort with toileting hygiene.<BR/>In an observation on 01/07/25 at 3:18 PM of Peri Care on Resident #75<BR/>CNA C and NA D Did not wash hands or use alcohol-based hand sanitizer when changing gloves while removing a soiled brief and application of a clean brief. <BR/>In an interview on 01/07/25 at 3:42 PM NA D stated she was trained on Infection control through Inservice and in meetings by the DON. She stated staff were trained to wash hands or use ABH each time they removed their gloves. She stated risk to residents for not cleansing hands between gloving could spreading of infections.<BR/>In an interview on 01/07/25 at 3:50 PM CNA C stated she would normally use her ABH or wash her hands after removing her gloves. She stated it just slipped her mind. She stated she has been visually checked off on peri care twice in the last 6 by her DON. CNA stated the Risk to residents for not changing her gloves would be urinary tract infections. <BR/>In an interview on 01/10/25 at 1:31 PM the DON stated her expectation was for staff to hand sanitize before and after gloving. She stated staff were educated by the DON, ADON and LVN resource team. The CNAs perform visual check offs on peri care and teaching upon hire and quarterly. She stated the negative effects for staff not washing their hands between glove changes could possibly be the spreading of infection. <BR/>Record review of facility policy titled Hand Hygiene dated 05/2007 and revised 10/2022 reflected to use an alcohol-based hand rub containing at least 62%; or, alternatively, soap and (antimicrobial or non-antimicrobial) and water for the following situations: After removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to coordinate assessments with the PASARR program for 1 of 8 Residents (Resident #63) reviewed for PASARR services. <BR/>1. The SW failed to assess Resident #63, based on his behaviors, for a referral for PASARR services.<BR/>2. The MDSC failed to refer Resident #63 for a Level II PASARR Evaluation by the local LIDDA.<BR/>This failure placed residents in the facility at risk for exclusion for PASARR Services.<BR/>Findings Included:<BR/>RR or Resident #63's AR, dated 1/10/2025, reflected an [AGE] year-old male, who admitted to the facility on [DATE]. <BR/>RR of Resident #63's Medical Diagnosis, downloaded from PCC on 1/10/2025, reflected Resident #63 was diagnosed with Depression, Unspecified (which was a mental condition characterized by depressed mood, loss of pleasure, or interest in life) and Schizophrenia, Unspecified (which was a chronic mental illness that affected a person's thoughts, feelings, and behavior.)<BR/>RR of Resident #63's BIMS Score assessment, administered on 1/10/2025, reflected a score of 6, which indicated the resident had severe cognitive impairment.<BR/>RR of Resident #63's CP reflected a Focus area for impaired cognition or impaired thought, initiated on 12/6/2024, R/T disease process. The Goal, revised on 12/29/2024, indicated the resident was supposed to maintain their current level of functioning through 3/5/2025. The Intervention, initiated on 12/6/2024, delegated nursing home to engage in simple structured activities that avoid overly demanding tasks; a Focus area for psychotropic medication, unknown date of initiation, R/T Schizophrenia. The Goal, initiated on 12/13/2024, indicated the resident would not have reactions to antipsychotic drug therapy (Seroquel 25 MG). Antipsychotic was discontinued on 12/19/2024 / Replaced with Anti-Anxiety Drug Therapy (Hydroxyzine 25 MG) The Intervention, initiated on 12/13/2024, delegated nursing home staff to check blood pressure monthly.<BR/>RR of Resident #63's P-1, located in PCC, reflected a document sent from Resident #63's referring entity. The document was dated 12/5/2024. Page 4 of 12 indicated resident did not have evidence of an MI, ID, or DD. <BR/>RR of Resident #63's P-1, located in Simple, reflected a document sent from Resident #63's referring entity. The document was dated 12/5/2024. Page 3 of 8 indicated resident did have evidence of an MI. <BR/>Interview and observation on 1/7/2025 at 12:14 PM with Resident #63 revealed him in bed in his room. He was able to respond to questions, clean, and appropriately dressed. He was new to the facility and stated it was rough getting used to the routine. It was hard remembering who provided which services. <BR/>Interview and RR on 01/10/25 at 10:56 AM with the SW, revealed that she was the facility designee to collaborate with residents and their PASARR eligibility/referrals. Based on Resident #1's P-1, located in PCC, Resident #63 presented to the facility on [DATE] with a negative P-1, meaning he did not have evidence of a MI, ID, or DD. The SW stated she had spent time with Resident #63, who had exhibited changes in his alertness, orientation, mood, and cognition. She was unaware Resident #63 had diagnosis of Depression, Unspecified and Schizophrenia, Unspecified. Had she been aware of his mental health diagnosis, she would have had him re-assessed by a medical provider and then referred him to the LIDDA for the P-2 evaluation as needed. However, she had not discovered the mental health diagnosis; she had not referred the resident for mental health services; she had not referred the resident for a P-2 evaluation. RR of the resident medical records in PCC did not reveal a P-2 or referral to the LIDDA. <BR/>Interview and observation on 1/10/25 at 1:21 PM with the MDSC revealed she was the MDSC at the facility until last week, 1/2/2025. She was responsible, along with the SW, for residents and their PASARR eligibility/referrals. She had been trained as an MDSC at the facility, taken on-line training, and completed the classes for CMAC (Certified MDS Assessment Certification.) The facility followed the guidelines in the RAI for PASSAR processing. Observation of the MDSC revealed her search Simple, a 3rd party data base with HHSC and PASARR, for a P-2 for the LIDDA for Resident #63. Instead of a P-2 for the LIDDA, a P-1 was found. The P-1 found in Simple, was different from the P-1 that was found in PCC. The P-1 found in Simple reflected Resident #63 did have evidence of a MI. Based on the P-1 in simple. The MDSC stated, I just did not see it and there should have been a P-2 submitted for the LIDDA. RR of Simple did not reveal a P-2 for Resident #63. Residents who qualified for PASARR services were available to receive NFSS services, such as PT/OT/ST/DME. Residents who were qualified for, but did not receive NFSS services, were placed at risk for a decrease in options for quality of care. Since she had been removed from her position, CMDSC M and CMDSC N oversaw the MDS/PASARR entries. She was unaware of any support structure in place to catch errors in the PASARR process. <BR/>Interview on 1/10/25 at 2:23 PM with the ADM stated that the SW and the MDSC were responsible for the residents' PASARR eligibility/referrals to the LIDDA. The facility followed the guidelines of the PASARR division. Residents, who benefitted for PASARR services, were eligible for benefit's such, as DME, assistance post DC from the facility with housing, and therapeutic services. Residents who were eligible, but not afforded the opportunity, risked the loss of services provided through the PASRR program. Safeguards in place to ensure residents get linked to PASARR services were team meetings, MDSC checks, morning meetings, and corporate resource personal. In a situation where there were two conflicting P-1s for a resident, the ADM stated the document in Simple would have taken precedence over the one found in PCC. The failure for the SW to assess the resident for MI and make the appropriate referral, along with the MDSC's failure to retrieve the P-1 from Simple, was a process failure. The staff members responsible for the PASARR eligibility/referrals were the SW and the MDSC.<BR/>RR of the CMS RAI Version 3.0 Manual, dated 10/2024, reflected:<BR/>Referral for Level II Resident Review Evaluations is required for individuals previously identified by PASRR to have MI, ID, or a related condition in the following circumstances:<BR/>Referral for Level II Resident Review Evaluations is also required for individuals who may not have previously been identified by PASARR to have MI, ID, or a related condition in the following circumstances:<BR/>1. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a diagnosis of mental illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 Residents (Resident #3) reviewed for respiratory care.<BR/>The facility failed to place Resident #3's oxygen tubing in a bag when not in use. <BR/>This failure could place residents at risk of not receiving appropriate respiratory care.<BR/>The findings were:<BR/>Resident #3<BR/>Record review of Resident #3's undated face sheet reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses of Heart Failure, Acute upper Respiratory Infection, Obstructive Sleep Apnea, and Shortness of Breath. <BR/>Record review of Resident #3s care plan dated 03/31/2022 reflected she had Chronic Obstructive Pulmonary<BR/>Disease (a group of lung diseases that make it difficult to breath) her Goal was to be free of signs and symptoms of respiratory infections through review date. Interventions included to give oxygen therapy as ordered by the physician.<BR/>Record review of Resident #3's quarterly MDS dated [DATE] reflected she had a BIMS score of 15 indicating she was cognitively intact. <BR/>Record review of Resident #3's physicians' orders summary dated 01/08/2025 reflected an order to change oxygen tubing and humidifier bottle, clean filter weekly as needed if equipment is used, every night shift, every Sunday. Keep tubing inside plastic bag when not in use dated 04/22/2021.<BR/>In an observation and interview on 01/07/25 at 11:49 AM Resident #3s oxygen tubing was laying on top of her concentrator out of the bag and not dated. Resident #3 stated for the most part the nurses changed her oxygen tubing weekly. She stated occasionally she got sick and required her oxygen machine due to her respiratory disease. She stated she liked for it to be clean. <BR/>In an interview on 01/10/25 at 01:25 PM LVN A stated oxygen tubing was supposed to be changed weekly. She stated the tubing should be in a bag when not in use. She stated the nurses had been instructed on changing the tubing and keeping it covered by the DON. She stated there was a physician's order in the computer to change the tubing. Night shift nursing staff were responsible for changing the tubing on Sundays. The risk to residents for having dirty oxygen tubing included respiratory infection. <BR/>In an interview on 01/10/25 at 1:31 PM the DON stated staff were educated by the DON, ADON and LVN resource team. The DON stated if a resident had respiratory equipment tubing it should have been bagged, even if it was used as needed it should be bagged. She stated negative effects for residents having unbagged oxygen tubing could include respiratory infections. She stated staff were instructed to remove oxygen equipment in rooms if not used. The DON stated the department heads do angel room rounds every morning to monitor for things that could negatively affect the resident. <BR/>Record review of facility policy titled Oxygen Equipment dated 05/2017 reflected It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner and to use disposable prefilled humidifiers, tubing, masks, and cannulas for residents receiving oxygen. The equipment is to be discarded after use. The facility will maintain clean tanks, connectors, and concentrators. When oxygen mask or cannula is temporarily not being used it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 (Resident #75) of 6 residents reviewed for infection control.<BR/>CNA C and NA D failed to wash their hands and change their gloves when removing a soiled brief and placing a clean brief during peri care for Resident #75. <BR/>These failures could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included: <BR/>Record review of Resident #75s undated face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of acute respiratory failure, age-related physical debility, and chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breath).<BR/>Record review of Resident #75's care plan dated 01/02/25 reflected she had bowel and bladder incontinence related to physical dependence with ADL and cognitive deficit related to new surroundings. Her goal was to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included: incontinent checks as required, wash rinse and dry perineum, and change clothing as needed after incontinent episodes. Goals also included to monitor for signs and symptoms of urinary tract infection including pain, burning, blood, cloudiness, no output, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, and changing behavior.<BR/>Record review of Resident #75's MDS dated [DATE], reflected she had a BIMS score of 15 indicating the resident was cognitively intact. The MDS also indicated that Resident #75 was always incontinent of urine and bowel. Resident #75 required substantial/maximal assistance indicating the helper does more than half the effort with toileting hygiene.<BR/>In an observation on 01/07/25 at 3:18 PM of Peri Care on Resident #75<BR/>CNA C and NA D Did not wash hands or use alcohol-based hand sanitizer when changing gloves while removing a soiled brief and application of a clean brief. <BR/>In an interview on 01/07/25 at 3:42 PM NA D stated she was trained on Infection control through Inservice and in meetings by the DON. She stated staff were trained to wash hands or use ABH each time they removed their gloves. She stated risk to residents for not cleansing hands between gloving could spreading of infections.<BR/>In an interview on 01/07/25 at 3:50 PM CNA C stated she would normally use her ABH or wash her hands after removing her gloves. She stated it just slipped her mind. She stated she has been visually checked off on peri care twice in the last 6 by her DON. CNA stated the Risk to residents for not changing her gloves would be urinary tract infections. <BR/>In an interview on 01/10/25 at 1:31 PM the DON stated her expectation was for staff to hand sanitize before and after gloving. She stated staff were educated by the DON, ADON and LVN resource team. The CNAs perform visual check offs on peri care and teaching upon hire and quarterly. She stated the negative effects for staff not washing their hands between glove changes could possibly be the spreading of infection. <BR/>Record review of facility policy titled Hand Hygiene dated 05/2007 and revised 10/2022 reflected to use an alcohol-based hand rub containing at least 62%; or, alternatively, soap and (antimicrobial or non-antimicrobial) and water for the following situations: After removing gloves.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety and sanitation in the facility's only kitchen.<BR/>The facility failed to ensure all expired pantry items were discarded.<BR/>This failure could place residents at risk for health complications, foodborne illnesses and decreased a quality of life. <BR/>Findings include: <BR/>Observation of the kitchen pantry on 01/07/2025 at 10:28 AM revealed:<BR/>1 large container of Italian Seasoning with Rec 12/11/23, open 12/11/23 Ex 12/2024 written in black permanent marker on the side. <BR/>1 large container of Parsley Flakes with R 12/11/23 Ex 6/11/24 written in black permanent marker on the side. <BR/>1 container of Ground Cumin Seeds with Rec 10-30-23 Ex 10-30-2024 written in black permanent marker on the side. <BR/>1 container of Ground Turmeric with R 11/27/23 Ex 11/27/24 written in black permanent marker on the side. <BR/>1 container of Curry Powder with R 11/27/23 E 5/27/24 written in black permanent marker on the side. <BR/>Interview with the DM on 01/07/25 at 10:34 AM revealed that employees who received the food delivery would label the items received with the received date, date of opening, and expiration date based off the open date if a use by date was not printed on the product. <BR/>Interview with the ADM on 01/10/25 at 11:00 AM revealed the facility kitchen follows guidance from the TFER.<BR/>Review of the FDA 2022 Food Code revealed, <BR/>3-501.18 Disposition of Ready-to-Eat, Time/Temperature Control for Safety Food<BR/>o Food held beyond its labeled use-by or expiration date, or past the allowed storage time for safety reasons, must be discarded.<BR/>3-302.12 Food Storage Containers Identified with Common Name of Food<BR/>o This section indirectly reinforces the importance of proper labeling and identifying food to avoid usage of expired or unsafe items.<BR/>3-701.11 Discarding or Reconditioning Unsafe, Adulterated, or Contaminated Food<BR/>o This section states that food that is unsafe, adulterated, or not honestly presented must be discarded. Expired food often falls into this category if it is deemed unsafe.<BR/>3-306.14 Return of Food to Prevent Contamination<BR/>o This section implies that food returned or deemed unfit for service should be discarded to avoid risks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan furnishing services to attain, or maintain, the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #30) reviewed for comprehensive care plans.<BR/>The facility failed to care plan Resident #30's high risk of elopement.<BR/>This failure placed resident at risk of their needs having gone unmet. <BR/>Findings included:<BR/>Record review of Resident #30's quarterly MDS assessment dated [DATE], reflected the resident was a [AGE] year-old male with an admission date of 09/24/23. Resident #30 had diagnoses which included Parkinson's Disease (a neurodegenerative disease primarily of the central nervous system, affecting both motor and non-motor systems), cognitive communication deficit (impairment in thought organization, attention, memory, and safety awareness), hallucinations, and anxiety. The MDS reflected the resident had a BIMS score of 07, which indicated the resident had severe cognitive impairment. <BR/>Record review of Resident #30's elopement/wandering evaluation dated 10/23/2024 reflected a score of 14, indicating the resident was a high risk of elopement.<BR/>Record review of Resident #30's care plan dated last revised on 10/13/24 reflected no interventions for elopement or wandering. <BR/>In an observation on 01/07/25 at 10:53 AM resident #30 was standing in his room watching television.<BR/>In an interview on 01/08/25 at 01:58 PM with the DON she stated the MDS Coordinator was responsible for creating the care plan. She stated there had recently been a change in the MDS Coordinator because the previous MDS person at the facility did not work out for them, and the DON did not see where Resident 30 had been care planned for elopement. <BR/>In an interview on 01/10/25 at 10:04 AM with the MDSR she stated that she had held that position since about 2019. She stated she worked as an MDS resource for multiple facilities. She stated that if a resident had any risk of elopement, the resident should be care planned for elopement interventions. <BR/>Record review of facility policy titled Care and Treatment, Care Planning dated reviewed on 08/2015 reflected, It is the policy of this facility that the interdisciplinary team shall develop a comprehensive care plan for each resident. A comprehensive care plan is developed within seven days of completion of the resident minimum data set.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications and biologicals were stored in locked compartments for 1 of 1 medication carts and 1 of 1 medication rooms reviewed for medication storage. <BR/>The facility failed to ensure the medication cart and medication room was locked and medications were secure and not accessible to other staff, resident, or visitors while unattended by MA on 01/08/2025.<BR/>This failure could have resulted in harm due to unauthorized access to medications, biologicals, and needles.<BR/>Findings included:<BR/>Observation on 01/08/2025 at 9:02 MA B left the medication cart unlocked outside of room [ROOM NUMBER] in the hallway with the keys on top of the cart while she washed hands inside of the restroom and obtained gloves to administer eye drops. <BR/>Observation on 01/08/25 at 9:05 AM the facility's only medication storage room was unlocked, and no facility staff were present.<BR/>In an interview on 01/08/2025 at 9:30AM MA B stated she should never walk away from the cart leaving it open with keys on top. She stated she had been trained to never walk away from an unlocked medication cart. She stated she was sidetracked looking for large gloves. MA B stated the negative effects for leaving the cart unlocked could be a resident may take the keys, other could have access to the medications in the cart. MA B stated she had been visually checked off on med pass monthly with the Pharmacist and DON. <BR/>In an interview on 01/08/25 at 9:17 AM with the DON she stated the medication storage room was supposed to be locked and that another staff member thought the door locked automatically as the doorknob was recently replaced.<BR/>In an interview on 01/10/25 at 1:31 PM the DON stated it was her expectation for the medication assistants and Nurses to lock the medication cart when unattended. She stated the staff had been instructed to never leave the keys on top of the cart, always keep the keys on their person, and keep the cart locked. She stated the DON and ADON make rounds frequently and monitor staff as well as instruct them through in-services and when they are checked off visually on medication pass. She stated potential negative effects for the leaving the medication cart open could be missing medications, possible drug diversion.<BR/>Review of the facility's Medication Access and Storage/Drug Destruction Policy revealed: It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications: Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety and sanitation in the facility's only kitchen.<BR/>The facility failed to ensure all expired pantry items were discarded.<BR/>This failure could place residents at risk for health complications, foodborne illnesses and decreased a quality of life. <BR/>Findings include: <BR/>Observation of the kitchen pantry on 01/07/2025 at 10:28 AM revealed:<BR/>1 large container of Italian Seasoning with Rec 12/11/23, open 12/11/23 Ex 12/2024 written in black permanent marker on the side. <BR/>1 large container of Parsley Flakes with R 12/11/23 Ex 6/11/24 written in black permanent marker on the side. <BR/>1 container of Ground Cumin Seeds with Rec 10-30-23 Ex 10-30-2024 written in black permanent marker on the side. <BR/>1 container of Ground Turmeric with R 11/27/23 Ex 11/27/24 written in black permanent marker on the side. <BR/>1 container of Curry Powder with R 11/27/23 E 5/27/24 written in black permanent marker on the side. <BR/>Interview with the DM on 01/07/25 at 10:34 AM revealed that employees who received the food delivery would label the items received with the received date, date of opening, and expiration date based off the open date if a use by date was not printed on the product. <BR/>Interview with the ADM on 01/10/25 at 11:00 AM revealed the facility kitchen follows guidance from the TFER.<BR/>Review of the FDA 2022 Food Code revealed, <BR/>3-501.18 Disposition of Ready-to-Eat, Time/Temperature Control for Safety Food<BR/>o Food held beyond its labeled use-by or expiration date, or past the allowed storage time for safety reasons, must be discarded.<BR/>3-302.12 Food Storage Containers Identified with Common Name of Food<BR/>o This section indirectly reinforces the importance of proper labeling and identifying food to avoid usage of expired or unsafe items.<BR/>3-701.11 Discarding or Reconditioning Unsafe, Adulterated, or Contaminated Food<BR/>o This section states that food that is unsafe, adulterated, or not honestly presented must be discarded. Expired food often falls into this category if it is deemed unsafe.<BR/>3-306.14 Return of Food to Prevent Contamination<BR/>o This section implies that food returned or deemed unfit for service should be discarded to avoid risks.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety and sanitation in the facility's only kitchen.<BR/>The facility failed to ensure all expired pantry items were discarded.<BR/>This failure could place residents at risk for health complications, foodborne illnesses and decreased a quality of life. <BR/>Findings include: <BR/>Observation of the kitchen pantry on 01/07/2025 at 10:28 AM revealed:<BR/>1 large container of Italian Seasoning with Rec 12/11/23, open 12/11/23 Ex 12/2024 written in black permanent marker on the side. <BR/>1 large container of Parsley Flakes with R 12/11/23 Ex 6/11/24 written in black permanent marker on the side. <BR/>1 container of Ground Cumin Seeds with Rec 10-30-23 Ex 10-30-2024 written in black permanent marker on the side. <BR/>1 container of Ground Turmeric with R 11/27/23 Ex 11/27/24 written in black permanent marker on the side. <BR/>1 container of Curry Powder with R 11/27/23 E 5/27/24 written in black permanent marker on the side. <BR/>Interview with the DM on 01/07/25 at 10:34 AM revealed that employees who received the food delivery would label the items received with the received date, date of opening, and expiration date based off the open date if a use by date was not printed on the product. <BR/>Interview with the ADM on 01/10/25 at 11:00 AM revealed the facility kitchen follows guidance from the TFER.<BR/>Review of the FDA 2022 Food Code revealed, <BR/>3-501.18 Disposition of Ready-to-Eat, Time/Temperature Control for Safety Food<BR/>o Food held beyond its labeled use-by or expiration date, or past the allowed storage time for safety reasons, must be discarded.<BR/>3-302.12 Food Storage Containers Identified with Common Name of Food<BR/>o This section indirectly reinforces the importance of proper labeling and identifying food to avoid usage of expired or unsafe items.<BR/>3-701.11 Discarding or Reconditioning Unsafe, Adulterated, or Contaminated Food<BR/>o This section states that food that is unsafe, adulterated, or not honestly presented must be discarded. Expired food often falls into this category if it is deemed unsafe.<BR/>3-306.14 Return of Food to Prevent Contamination<BR/>o This section implies that food returned or deemed unfit for service should be discarded to avoid risks.