BLUEBONNET NURSING AND REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 2 of 3 residents (Residents #1 and #2) reviewed for tube feeding management, in that: 1.The facility failed to follow physician's orders for Resident #1 to cleanse g-tube (gastrostomy tube, a small flexible tube surgically inserted through the abdomen to deliver nutrition, fluids and medication directly to the stomach) site with normal saline and apply split sponge every shift. 2.The facility failed to follow physician's orders for Resident #2 to cleanse g-tube site every day shift. These failures could place resident at risk for not receiving appropriate care and treatment and/or a decline in their health. Findings included: 1.Record review of Resident #1's admission Record dated 8/5/25 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted [DATE]. Diagnoses listing revealed dementia (a group of conditions categorized by impairment of brain function), atherosclerosis (hardening of the arteries), Vitamin B12 Deficiency, anxiety, cerebral infarction (a condition where brain tissues dies due to lac of blood supply) with right sided hemi-paresis, atrial fibrillation (irregular heartbeat), congestive heart failure (chronic condition in which the heart does not pump blood as well as it should), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), osteoarthritis (arthritis that occurs when flexible tissue at the ends of bones wears down), schizoaffective disorder (a mental health condition / mood disorder). Record review of Resident #1's BIMS assessment revealed a score of 9 indicating moderate cognitive impairment. Record review of Resident #1's MDS dated [DATE] revealed Resident #1 presented with functional limitations to upper and lower extremities, was dependent in eating, toileting, bathing, dressing, transfers and mobility. Record review of Resident #1's physicians orders revealed an order dated 5/29/24 to Cleanse g-tube site with NS (normal saline), pat dry and apply split sponge Q (every) shift. Record review of Resident #1's Medication Administration Record dated August 2025 revealed nursing staff were signing off on day shift and night shift from 8/1/25-8/4/25 that they provided stoma site care per physician's order. Observation of Resident #1 on 8/5/25 at 10:05 a.m. revealed multiple (6) brown colored dried substances around stoma (surgically created opening) site. No split drain sponge was observed. 2. Record review of Resident #2's admission record dated 8/5/25 revealed a [AGE] year-old female admitted [DATE]. Diagnoses listing revealed [NAME]-[NAME] syndrome (a disorder of the skin and mucous membranes), hypertension (high blood pressure), diabetes type II, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), hyperlipidemia (high cholesterol), and intracerebral hemorrhage (bleeding in the brain) with left sided hemiplegia (paralysis) and dysphagia (difficulty swallowing). Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Further record review of MDS dated [DATE] revealed Resident #2 had limited range of motion to upper and lower extremity, required set-up assistance with eating; maximum assistance in bathing and upper body dressing; and required total assistance in toileting, bed mobility, lower body dressing, transfers and mobility. Record review of Resident #2's physicians orders revealed an order dated 5/15/25 to cleanse g-tube site very day shift. Record review of Resident #2's care plan revealed intervention for tube feeding included clean insertion site daily as ordered. Observation of Resident #2's stoma site revealed multiple (5) brown colored dried substance around the stoma site. During an interview on 8/5/25 at 10:05 am with LVN A regarding stoma site care for Resident #1, LVN A stated that she would normally utilize a drainage sponge, but up until about a week ago, this resident's tube was sewn in and secured to her skin. LVN A stated that resident's order does indicate to clean stoma site daily and apply drain split sponge. LVN A acknowledged that dried substance surrounding stoma site. During an interview on 8/5/25 at 10:05 am with LVN A regarding stoma site care for Resident #2, LVN A stated that we clean her stoma site every shift. LVN A stated she had not provided stoma care yet for this resident today. LVN A acknowledged dried substance surrounding stoma site. During an interview on 8/5/25 at 1:00 pm with LVN C regarding stoma site care for Resident # 1 and Resident #2, LVN C stated she only works 1 day a week, but when she does work, she clean[s] both sites with normal saline and replaces split drain gauze. During an interview on 8/5/25 with Resident #2, Resident #2 stated, they clean it (stoma site) at night. During an interview on 8/6/25 with the DON, the DON stated that she expects nursing staff to follow physicians' orders for stoma site care and monitor stoma site care each shift. The DON stated that failure to provide proper stoma care could result in infection and complications with the feeding tube. Review of facility policy titled, Nursing Policy & Procedure Manual, Gastrostomy Tube Care (undated), revealed Procedure 9. Perform site or stoma care: b. cleanse the skin area around the catheter or stoma with wound cleanser or normal saline in a circular motion from the center outward and d. If ordered, place gauze dressing on the stoma and tape.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of records. <BR/>The facility failed to ensure Resident #1's bath or shower was documented as given or as refused 9 times in May and June 2025.<BR/>These failures could place residents at risk for improper care due to inaccurate records. <BR/>Findings included: <BR/>Record review of Resident #1's admission Record (face sheet) dated 06/07/2025 revealed she was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder (is a mental health condition that is marked by hallucinations and delusions),anxiety disorder (disorder involving feelings of nervousness, panic and fear) and hypertension (condition in which the force of the blood against the artery walls is too high) . <BR/>Record review of Resident #1's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 15 out of 15, indication her cognitive skills for daily decision making were intact; and the resident was dependent on staff to be showered or bath<BR/>Record review of Resident #1's Care Plan for Self-Care performance deficit, initiated on 01/05/2021 and revised on 03/07/2022, revealed under interventions assist with personal hygiene . <BR/>Record review of Resident #1's undated Kardex revealed the resident preferred to be bathed 2-3 times a week.<BR/>Record review of Resident #1's nurses' notes from 05/01/2025 to 06/01/2025 revealed no notation of Resident #1 had refused to be bathed.<BR/>Record review of the undated Shower Schedule revealed Resident #1 was to be bathed on Monday, Wednesday, and Friday on the 6 am - 2 pm shift. <BR/>Record review of Resident #1's electronic clinical record for the Bathing Task from 05/01/2025 to 06/03/2025 revealed Resident #1 had only been bathed 6 times on: 05/02/2025, 05/05/2025, 05/05/2025, 05/07/2025,05/09/2025, and 05/12/2025; there was no documentation the resident had refused to be bathed; and there was no documentation if Resident #1 was bathed or refused on her scheduled shower days on 05/14/2025, 05/16/2025, 05/19/2025, 05/21/2025, 05/23/2025, 05/26/2025, 05/28/2025, 05/30/2025, and 06/02/2025.<BR/>Observation on 6/7/2025 from 11:00 AM - 11:05 AM revealed the Regional Compliance Nurse completing a shower for Resident #1 and making beds throughout the facility. <BR/>Interview on 6/7/2025 at 11:08 AM, the Regional compliance nurse stated that she had spoken with the CNA's who were responsible for bathing Resident #1 on the following dates: 5/19/2025, 5/21/2025, 5/23/2025, 5/26/2025, 5/28/2025, 5/30/2025, and 6/2/2025.<BR/>Resident #1 was bathed on 5/14/2025 and 5/16/2025 but refused to be bathed on the following dates: 5/19/2025, 5/21/2025, 5/23/2025, 5/26/2025, 5/28/2025, 5/30/2025, and 6/2/2025. The Regional Compliance Nurse indicated that if a resident refused to bathe, the CNA should document this refusal in the Point of Contact Tasks and inform the charge nurse. <BR/>Interview with Resident #1 on 6/7/2025 at 1:30 PM, revealed she had refused some shower days but could not recall which days. <BR/>In a subsequent interview on 6/7/2025 at 1:13 PM, the Regional Compliance Nurse reiterated that nursing staff should also document in the nurses' progress notes if a resident had refused to be bathed. She emphasized that if the resident's bathing status was not recorded in their clinical record-indicating whether the resident had been bathed or had refused to be bathed-it would lead to inaccurate documentation. However, she did not foresee any harm to the resident resulting from this issue.<BR/>Record review of the undated, facility Documentation policy revealed, complete documentation as needed promptly, document or check information on flow sheets each shift or as appropriate for the care or treatment being monitored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment option to choose the alternative option he or she preferred for 1 of 4 residents (Resident #7) reviewed for consent for antipsychotic medications. The facility failed to obtain consent by the responsible party for Resident #7 that her risperidone dosage was being reduced from 0.75 mg to 0.5 mg. This failure could place residents at risk for not being informed about care and treatments that may affect the resident's well-being. Findings included:Record review of Resident #7's admission Record dated 08/22/25, documented an [AGE] year-old female who was initially admitted to the facility 07/16/21 with the last admission date of 03/02/24. Her diagnosis included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified dementia, severe, with other behavioral disturbance (severe dementia of an unknown cause that includes mood disorders, psychotic symptoms and agitation), generalized anxiety disorder (a chronic mental health condition characterized by excessive, persistent, and uncontrollable worry), and psychotic disorder with delusions due to known physiological condition (a condition where delusions, or false beliefs, are caused by the effects of a specific medical or neurological illness, rather than a primary mental health disorder like schizophrenia). Record review of Resident #7's Quarterly MDS dated [DATE] documented a BIMS score of 7, which indicated severe cognitive impairment. Record review of Resident #7's medical chart documented a Form 3713 (Nursing Facility Consent for Antipsychotic or Neuroleptic Medication Treatment) which indicated the physician and responsible party signed the form for 0.75 mg of risperidone to be administered at night on 01/21/25. Record review of Resident #7's current physician's orders as of 08/22/25 indicated she received 0.5 mg of risperidone as of a start date of 07/11/25. Record review of Resident #7's medical chart did not contain a revised Form 3713 to indicate the risperidone dosage had been changed. During an interview with the MDS Coordinator on 08/22/25 at 2:23 pm, the MDS Coordinator stated she was not aware that a new Form 3713 was needed so one had not been completed. Record review of the facility's policy titled Psychotropic Medications dated 02/12/25 documented: Residents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative will be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. The resident's medical record will include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and was able to choose the options he or she preferred. A written consent form may serve as evidence of a resident's consent to psychotropic medication, but other types of documentation are also appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #46) reviewed for incontinent care: The facility failed to ensure CNA E provided incontinent care to Resident #46 in the order of cleanest to dirtiest, and CNA E and Student Aide C performed hand hygiene between glove changes. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings included: Record review of Resident #46's face sheet dated 8/21/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness or reduced strength to one side of the body) affecting the left non-dominant side, and gastrostomy status (a surgically created opening through the abdominal wall into the stomach). Record review of Resident #46's most recent comprehensive MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills and was always incontinent of bowel and bladder. Record review of Resident #46's comprehensive care plan initiated on 7/31/25 revealed the resident had bowel and bladder incontinence with interventions that included to provide incontinent care. Observation on 8/21/25 at 11:15 a.m. during incontinent care, CNA E, after cleaning Resident #46's buttock and anal area, took a clean brief using the same gloves used to clean the resident's buttock and anal area and placed the clean brief on the bed. CNA E and Student Aide C then assisted the resident onto her back and then to her right, removed their gloves, did not wash or sanitize their hands, and put on a new pair of gloves. Student Aide C then applied barrier cream to Resident #46's buttock area, removed her gloves, did not wash or sanitize her hands, and put on a new pair of gloves. During an interview on 8/21/25 at 12:36 p.m., Student Aide C stated she realized she had not washed or sanitized her hands between glove changes and had just forgotten. Student Aide C stated she usually carried a bottle of hand sanitizer with her and should have been used to sanitize her hands otherwise it was considered cross contamination and could results in the resident or the aide getting sick. Student Aide C stated, cross contamination could result in passing on an illness. During an interview on 8/21/25 at 12:48 p.m., CNA E stated she realized she had moved from a dirty area to a clean area and should not have done it and missed that step because she was probably nervous. CNA E stated moving from a dirty area to a clean area with the same gloves could cause an infection and was cross contamination. CNA E stated, taking the clean brief with soiled gloves made the clean brief dirty because it had been touched with dirty gloves. CNA E stated it was the same concept when changing gloves and we need to wash or sanitize our hands between gloves changes to prevent cross contamination. During an interview on 8/21/25 at 7:28 p.m., the DON stated it was her expectation staff were supposed to wash or sanitize their hands between glove changes because it was part of infection control practices and it not done could result in cross contamination and the staff or resident could pass an illness to each other, germs or bug. The DON stated, the aide should have changed her gloves when moving from a dirty area to a clean area because you have now actually done cross contamination. Record review CNA E's C.N.A. Proficiency Audit dated 8/16/25 revealed she had satisfied the requirement for performing hand washing skills and perineal care. Record review of Student Aide C's C.N.A. Proficiency Audit dated 7/5/25 revealed she had satisfied the requirement for performing hand washing skills and perineal care. Record review of the facility document titled, Nursing: Personal Care, Perineal Care dated 4/25/22 revealed in part, .An incontinent resident of urine and/or bowl (sic) should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible.Perform hand hygiene.Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area - CLEAN to DIRTY! .Doff gloves and PPE.Perform hand hygiene.Always perform hand hygiene before and after glove use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 2 of 4 residents (Resident #33 and #35) reviewed for pharmacy services. The facility failed to ensure Medication Aide G documented she dispensed Resident #33's Xanax prescribed for major depressive disorder and Resident #35's Tramadol in the narcotic log for August 2025. This deficient practice could put residents at risk of misappropriation and drug diversion. The findings included: 1. Record review of Resident #33's face sheet dated 8/22/25 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia (general term for a group of symptoms that affect memory, thinking, reasoning, and the ability to perform daily activities), anxiety disorder (mental health condition characterized by excessive fear, worry, or nervousness), and major depressive disorder (mental health condition characterized by persistent and intense feelings of sadness, hopelessness, or a loss of interest or pleasure in most activities). Record review of Resident #33's Order Summary Report dated 8/22/25 revealed the following:- Xanax 5 mg tablet, give 1 tablet by mouth one time a day related to major depressive disorder with order date 5/21/25 and no end date. Record review of Resident #33's Medication Administration Record for August 2025 reflected the resident was administered Xanax 5 mg tablet on 8/22/25 by Medication Aide G. 2. Record review of Resident #35's face sheet dated 8/22/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included pain, fractures of the lower end of right radius (bone in the forearm located on the thumb side), lower end of right ulna (forearm bone located on the side of the little finger), and right femur (thigh bone). Record review of Resident #35's Order Summary Report dated 8/22/25 revealed the following:- Tramadol 50 mg, give 50 mg by mouth every 8 hours as needed for pain with order date 12/6/24 and no end date. Record review of Resident #35's Medication Administration Record for August 2025 reflected the resident was administered Tramadol 50 mg tablet on 8/22/25 by Medication Aide G. During an inspection of Medication Aide G's medication cart on 8/22/25 at 10:09 a.m. revealed the narcotic log for Resident #33's Xanax 5 mg did not reflect the resident's medication was signed out on 8/22/25. During the inspection of the same medication cart, Medication Aide G attempted to document in Resident #35's narcotic log to reflect she had signed out the resident's Tramadol 50 mg on 8/22/25. Medication Aide G stated she had administered Resident #33's Xanax 5 mg at approximately 7:00 a.m. and had administered Resident #35's Tramadol 50 mg at approximately 8:00 a.m. Medication Aide G stated she was supposed to document on Resident #33 and Resident #35's narcotic log immediately after the medication was administered to the resident to avoid a drug diversion. Medication Aide G stated she had forgotten to document in the narcotic logs for Resident #33 and Resident #35 and not doing so could result in an inaccurate narcotic count. During an interview on 8/22/5 at 2:39 p.m., the DON stated it was her expectation, when narcotics were being administered, nursing was supposed to document in the narcotic log immediately after the medication was administered. The DON stated an incident could occur if the staff assigned to the medication cart were called away and did not log out a narcotic, then the narcotic count could be inaccurate and result in a drug diversion. The DON stated, all narcotics should be signed out on the log when they are administered. Record review of the facility document titled Medication Administration and General Guidelines, dated 2025 revealed in part, .Medications are administered at the time they are prepared.In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.Checklist for completing proper steps in the administration of medications.Adheres to the 6 Rights of Medication Administration.Right Medication.Right Documentation.Observed the resident take the medications.Documents the administration of each medication on the MAR & Controlled Medications on the Control Sheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 2 of 4 medication carts (C/D Hall cart and A/C Hall cart) reviewed for labeling and storage of drugs. 1. The facility failed to ensure the C/D Hall medication cart was not left unlocked and unattended.2. The facility failed to provide a change of direction label for Resident #6's Seroquel medication bottle from 50 mg at bedtime to 50 mg two times a day prescribed to treat depression on the A/D medication cart. These deficient practices could place residents at risk of medication misuse and diversion. The finding included: 1. During an observation on 8/21/25 at 9:42 a.m. revealed the C/D Hall medication cart was unlocked and unattended facing the hallway in front of the nurse's station. During an observation and interview on 8/21/25 at 9:47 a.m., the DON walked up to the C/D Hall medication cart and attempted to lock it. The DON stated the C/D Hall medication cart had been assigned to LVN D. The DON saw LVN D walking down the D Hall and summoned LVN D to the nurse's station. During an interview on 8/21/25 at 9:49 a.m., LVN D stated, she had gotten sidetracked and forgot to lock the C/D Hall medication cart. LVN D stated the C/D Hall medication cart should have been locked when not in use because people like you could get into it. LVN D stated, other people could get into the cart and take things they were not supposed to. 2. Record review of Resident #6's face sheet dated 8/21/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia (general term for a group of symptoms that affect memory, thinking, reasoning, and the ability to perform daily activities) with agitation, depression (mental health disorder characterized by a persistent feeling of sadness, emptiness, or loss of interest or pleasure in activities once enjoyed), and anxiety disorder (mental health condition characterized by excessive fear, worry, or nervousness). Record review of Resident #6's Order Summary Report dated 8/21/25 revealed the following:- Seroquel 50 mg tablet, give 50 mg by mouth two times a day related to depression, with order date 8/18/25 and no end date. During observation and interview on 8/21/25 at 8:50 a.m., during the medication pass revealed Resident #6's Seroquel medication indicated 50 mg at bedtime on the pharmacy label. Medication Aide G stated the Seroquel pharmacy label for Resident #6 was incorrect because the physician's orders indicated Seroquel 50 mg was supposed to be given twice a day. Medication Aide G stated the directions on the pharmacy label was incorrect and should have been compared to the physician's orders for accuracy. Medication Aide G stated she was in a hurry and overlooked it. During an interview on 8/21/25 at 7:28 p.m., the DON stated the medication carts were not supposed to be left unlocked when unattended because it was a safety concern. The DON stated residents could get into the medication cart and take something that did not belong to them and could potentially make them sick. The DON stated it was her expectation when administering medications, the orders were supposed to be matched up to the physician's orders and if the pharmacy label did not match the physician's orders, then a change of direction sticker was supposed to be placed on the medication package. The DON stated, the pharmacy label not matching the physician's orders could result in a medication error or the resident missing a medication dose. Record review of the facility document titled Medication Storage in the Facility, dated 2025 revealed in part, .Medication and biologicals are stored safely, securely.The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access. Record review of the facility document titled, Medication Administration and General Guidelines, dated 2025 revealed in part, .Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so.Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, or if there is any reason to question the dosage or directions, they physician's orders are checked for the correct dosage schedule.Checklist for completing proper steps in the administration of medications.Right dose.Right Medication.Right Time.Right Documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 3 of 8 residents (Residents #8, #48 and, #50) reviewed for infection control, in that:<BR/>1. CNA C and NA D failed to wash or sanitize their hands after touching the privacy curtain and before starting incontinent care. CNA C failed to wash her hands after providing care and before leaving the resident's room.<BR/>2. CNA B failed to wash her hands after providing care and before leaving the resident's room. CNA B failed to wash her hands before providing care. <BR/>3. LVN E failed to wear gloves before handling medication. <BR/>These failures could place residents at-risk for infection due to improper care practices. <BR/>The findings included:<BR/>1. Record review of Resident #8's face sheet, dated 06/13/2023, revealed an admission date of 03/24/2020 and, a readmission date of 06/06/2020, with diagnoses which included: Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Lumbar spina bifida (birth disorder that involves the incomplete development of the spine), Hypertension (high blood pressure) and, Type 2 diabetes mellitus (high level of sugar in the blood) <BR/>Record review of Resident #8's Annual MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating no cognitive impairment. The resident received extensive assistance for her activities of daily living, had an indwelling catheter and was always incontinent of bowel. <BR/>Record review of Resident #8's care plan, dated 04/25/2023, revealed a problem of The resident has indwelling Foley catheter in place related to neurogenic dysfunction of bladder, unspecified., with a goal of will remain free from catheter-related trauma and s/sx of infection through the next review date.<BR/>Observation on 06/13/23 at 11:33 a.m. revealed while providing catheter care, after washing their hands, CNA C and NA D both touched the privacy curtain to close it with their bare hands. They did not sanitize or wash their hands prior to donning their gloves and started providing catheter care to Resident #8. Further observation revealed after providing care CNA C removed her gloves, collected the trash bag and closed it. Then, without washing her hands she opened the door of the resident's room, walked to the soiled utility room, opened the door of the soiled utility room and left the bag in the soiled utility room. <BR/>During an interview on 06/13/2023 at 11:33 a.m. with CNA C and NA D, they confirmed the environment around the resident was considered dirty and they should have sanitized their hands prior to providing care. <BR/>Further interview with CNA C, she verbally confirmed not washing her hands prior to leaving the room and touching both the resident's door and the soiled utility room's door. She revealed she was not sure how to proceed about washing her hands and then touching the trash bag. They, both, confirmed they received infection control training within the year. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed the environment around the resident was considered dirty and the staff should change their gloves and wash. Staff should sanitize their hands after touching anything in the environment, before touching the resident and at the start of care. She confirmed the staff was to wash their hands after care prior to leave a room. <BR/>She confirmed the staff were in-serviced, by the ADON, in infection control and incontinent care and skills were checked annually and as needed by managment. <BR/>Record review of the annual skills check for CNA C revealed CNA A passed competency for Infection control on 04/21/2023. <BR/>Record review of the annual skills check for NA D revealed NA D passed competency for Infection control on 03/15/2023. <BR/>Record review of the facility policy, titled perineal care, dated 04/05/2022, revealed 7) provide privacy and modesty by closing the door and/or curtain [ .]10) perform hand hygiene, 11) don gloves and all other PPE per standard precaution [ .] 30 tie off the the disposable plastic bag of trash and/or linen 31) perform hand hygiene<BR/>2. Record review of Resident #48's face sheet, dated 06/13/2023, revealed an admission date of 11/03/2021 and, a readmission date of 07/28/2022, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Hypothyroidism(under active thyroid), Hypercholesterolemia(high level of cholesterol(type of fat) in the blood), Down syndrome (genetic disorder associated with developmental and intellectual disability) .<BR/>Record review of Resident #48's quarterly MDS dated [DATE] revealed the resident did not have a BIMS score and had severe cognitive impairment. The resident was completely dependent of the staff for care and was always incontinent of bowel and bladder. <BR/>Record review of Resident #48's care plan, dated 02/15/2022, revealed a problem of The resident has bladder incontinence related to dementia., with a goal of will remain free from skin breakdown due to<BR/>incontinence and brief use through the next review date.<BR/>Observation on 06/13/23 at 10:39 a.m. revealed after providing incontinent care CNA B removed her gloves, collected the trash bag and closed it. Then, without washing her hands she opened the door of the resident's room, walked to the soiled utility room, opened the door of the soiled utility room and left the bag in the soiled utility room. CNA B came back to Resident #48's room and, without washing her hands, transferred Resident #48 from his bed to his wheelchair with the assistance of CNA A. <BR/>During an interview on 06/13/2023 at 11:10 a.m. with CNA B, she verbally confirmed not washing her hands prior to leaving the room and touching both the resident's door and the soiled utility room's door. She verbally confirmed she did not wash her hands prior to transfer the resident after coming back in the room. She confirmed she received infection control training within the year. She refvealed she did not know she had to wash her hands while entering and before leaving a room. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed staff should wash their hands when entering a room to provide care and before leaving the room. She revealed not washing their hands was increasing the risk for cross contamination and infection, She confirmed the staff were in-serviced in infection control and incontinent care and skills were checked annually and as needed. <BR/>Record review of the annual skills check for CNA C revealed CNA B passed competency for Infection control on 11/09/2022. <BR/>Record review of the facility policy, titled perineal care, dated 04/05/2022, revealed 7) provide privacy and modesty by closing the door and/or curtain [ .]10) perform hand hygiene, 11) don gloves and all other PPE per standard precaution [ .] 30 tie off the the disposable plastic bag of trash and/or linen 31) perform hand hygiene<BR/>3. Record review of Resident #50's face sheet, dated 06/13/2023, revealed an admission date of 03/31/2022 and, a readmission date of 01/15/2023, with diagnoses which included: Dementia(decline in cognitive abilities), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Urinary tract infection(an infection in any part of the urinary system, Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Hypertension(high blood pressure), Hemiplegia(Paralysis of one side of the body).<BR/>Record review of Resident #50's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 6, indicating severe cognitive impairment. The resident needed limited assistance with her activities of daily living.<BR/>Observation on 06/13/23 at 9:00 a.m. revealed while administering medications to Resident #50, LVN E touched a capsule with her bare hands to open it and mix the content with pudding to administer it to the resident. <BR/>During an interview on 06/13/2023 at 09:08 a.m. with LVN E, she verbally confirmed she did not use gloves LVN E asked this surveyor if she should have used gloves before touching a capsule of medication to prevent infection to the residents. She confimed she received infection control training within the year. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed staff should not touch solid medications with their bare hands. She confirmed the staff were in-serviced in infection control and skills were checked annually and as needed. <BR/>Record review of the annual skills check for LVN E revealed LVN E passed competency for Infection control on 02/28/2023. <BR/>Record review of the facility policy, titled Oral solid medication administration, dated 2023, revealed if it is necessary to divide or split the medication prior to administration use an approved device or gloved hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the environment was free of accident hazards and supervision of staff for one resident (#1) of 3 residents who required mechanical lift transfers.<BR/>NA A transferred Resident #1 alone on 01/17/2024 at 08:15 AM with a mechanical lift which required 2 people for safety. One of the straps holding the sling came loose and Resident #1 slipped toward the floor and hit her head on the mechanical lift which caused a head laceration and fractures to C4 (provides sensation for parts of the neck, shoulders and upper arms) and C5 (controls the deltoid muscles of shoulders and biceps, provides sensation to the upper arm down to the elbow).<BR/>The noncompliance was identified as PNC. The IJ began on 01/17/2024 and ended on 01/18/2024. The facility had corrected the noncompliance before the survey began. <BR/>This deficient practice could affect residents who require transfers with the mechanical lift at risk for injury or death.<BR/>The findings included:<BR/>Record review of Resident #1's electronic face sheet dated 04/05/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery (a blood vessel that carries blood from the heart to tissues and organs in the body) and neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function).<BR/>Record review of Resident #1's annual MDS assessment with an ARD of 03/09/2024 reflected she was not a candidate for a BIMS assessment which signified she was severely cognitively impaired. She could rarely understand and rarely be understood. Resident #1 was dependent on staff for her ADL's. She required 2 people for her transfers.<BR/>Record review of Resident #1's comprehensive person-centered care plan revised 01/05/2024 reflected Focus, resident has an ADL self-care performance deficit, Interventions, transfer the resident requires mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual type of transfer) for transfers x 2 staff. Date initiated: 11/05/2021. Further review reflected Focus, alteration in musculoskeletal status r/t fracture of the C2-4, C collar splint (a cervical collar, also known as a neck brace, is a medical device used to support and immobilize a person's neck) as recommended, when out of bed. Date initiated: 01/19/2024.<BR/>Record review of Resident #1's progress note written by LVN B dated 01/17/2024 at 08:41 AM reflected Transfer Notification,] Resident #1] was transferred to a hospital on [DATE] 08:46 AM related to resident fell onto floor, causing a 2 cm laceration to top of head. Hematoma (a pool of mostly clotted blood that forms in tissue) to right forehead, 4x2 with abrasion.<BR/>Record review of Resident #1's hospital CT (computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) dated 01/17/2024 at 09:54 AM reflected Reason for exam, laceration to head, trauma/injury, Findings, nondisplaced transversely oriented fracture ((still broken bones, but the pieces weren't moved far enough to be out of alignment during the break) involving the right C4 inferior articular facet (smooth, anterolaterally(the position of a structure as being away from the middle line, in front of the body) facing articular (referring to the joint or joints) processes of a lumbar vertebra) and right C5 superior articular facet (the superior articular processes project vertically upward from the articular pillars (the columnar arrangement of the articular portions of the cervical vertebrae) between the pedicles (connect the vertebral body to the transverse processes) and the [NAME] (connect the transverse and spinous processes) (a series of levers both muscles of posture and for muscles of active movement).<BR/>Record review of NA A's written statement dated and signed 01/17/24 (untimed) reflected he was looking for someone to help, but no one was around and they were understaffed, so he attempted to place Resident #1 in the bed by himself. During the process, the sling on the mechanical lift on one side came undone and Resident #1 slipped out and he helped to guide her to the floor as safe as possible but she did hit the top of her head, and he immediately called for the nurse.<BR/>Record review of the Administrator's follow-up note (undated) reflected he interviewed NA A on 01/17/2024 and was told NA A did not see anyone in his hall so he did not ask for assistance with the mechanical lift transfer for Resident #1. He stated his investigation of staffing revealed the census at the time was 58 and there were 2 nurses, one medication aide and 4 aides assigned to the units, and administrative staff was available. <BR/>Record review of the Administrator's PIR dated 01/17/2024 at 10:39 AM reflected: Aide was suspended pending investigation. He was subsequently terminated. All staff were given abuse and neglect in-service and were trained on Hoyer policy requiring 2 people. Instructions given for intervening and reporting if witnessing improper Hoyer transfer. 100% of aides were required to perform return demonstration of proper Hoyer lift use. Family, physician, and Medical Director were informed of the incident. All Hoyer lift residents received a heat to toe assessment for any evidence of injury. Monitoring was implemented for incidents involving Hoyer residents. Five return demonstrations to be performed a week for 4 weeks and upon new hire. Training on recognizing sling condition was done with staff. Administrative staff examined all slings to ensure they were in good condition. Hoyer lifts were inspected. They were inspected in November 2023 by an outside company per policy. Aide verbalized to administrator that he knew a Hoyer transfer should be performed by 2 people. He verbalized that he had been trained to use the Hoyer. The NA chose not to wait for assistance as he did not see anyone in his hall. Hoyer was performed properly for getting Resident #1 out of bed. All equipment functioned properly and was in good condition during transfer. Poor decision making on part of the NA led to the incident .QA team had an Ad Hoc meeting to discuss and correct the situation.<BR/>Record review of NA A's CNA Proficiency Audit dated 04/04/2023 reflected he was signed off as an S for Transfers Hoyer lift- 2 person assist.<BR/>Observation on 04/04/2024 at 08:00 AM of Resident #1 revealed she was sitting in the dining room in a Geri-chair and had a C-collar around her neck.<BR/>Interview on 04/05/2024 at 1:00 PM with the Administrator, he stated after Resident #1 was sent out to the hospital for evaluation he reported the incident to HHSC immediately. He stated that later in the day a nurse from the hospital informed a nurse at the facility of Resident #1's fracture. He immediately identified that 100% in-services for the nursing assistants needed to be done and a competency of their performance for mechanical lift transfers. He stated that was completed on 01/18/2024. He stated 100% of the staff, nursing and non-nursing staff were in-serviced on abuse and neglect and on having 2 people for a mechanical lift transfer and to report any variances of that immediately. He stated that was completed on 01/18/2024. He stated he checked the staffing for 1/17/2024 at 08:15 AM when the incident happened, and sufficient staff were available in the building and that NA A chose not to wait.<BR/>Attempted interview on 04/09/2024 with NA A at 10:00 AM revealed the phone number listed for him at the facility was disconnected.<BR/>Observation on 04/05/2024 at 09:10 AM of Resident #1 being transferred from her Geri chair to the bed by CNA D and NA E revealed no concerns.<BR/>Observation on 04/08/2024 at 12:30 PM of Resident #2 being transferred from her Geri chair to the bed by CAN D and CNA F revealed no concerns.<BR/>Interview on 04/09/2024 at 2:50 PM with LVN B revealed she assessed Resident #1 when the incident happened, made notifications to include the Administrator and had Resident #1 transferred to the hospital. <BR/>Interview on 04/09/2024 at 09:00 a.m. with the DON at the time, RN C, she stated Resident #1 was transferred with a mechanical lift by NA A, who did not ask for help. She stated that he was trained on how to use the mechanical lift and everyone was retrained after the incident.<BR/>Record reviews of the other two residents who required Hoyer lift transfers, Resident #2 and Resident #3 reflected both had 2-person transfers care planned and identified in their MDS assessments.<BR/>Record review of the facility policy and procedure titled Hydraulic Lift (undated) reflected The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair It is reserved for those who are paralyzed, obese or too weak to transfer without complete assistance. The number of staff to provide assistance with the transfer should be determined by manufacturer recommendations The resident will receive safe transfer to bed or chair via a mechanical lift device.<BR/>Record review of the owners guide for the MEDLINE Hydraulic lift MODEL: MDS450EL (undated) reflected Transfer From Bed and From Chair To Bed .with the assistance of another caregiver.<BR/>The facility course of action prior to surveyor entrance included:<BR/>Record review of the Administrator's PIR dated 01/17/2024 revealed: All required notifications were made which included the Medical Director, Responsible Party, Physician, Nurse Practitioner, QA Ad Hoc Committee and HHSC.<BR/>Record review of NA A's personnel folder reflected he was immediately suspended pending investigation on 01/17/2024 and subsequently terminated.<BR/>Record review dated 01/17/2024- 54 staff, all staff, were in-serviced on using a staff roster were checked off and signed for in-services titled: Abuse/Neglect, Mechanical Lift.<BR/>Record review of staff competencies dated from 01/17/2024 to 1/18/2024 reflected 100 return demonstrations were completed with the Hoyer transfers and 5 additional observations were done weekly and marked off by nurse managers for an additional 4 weeks. The staff who completed this training for the mechanical lift was all CNA's, MAs, and NAs, 12 CNAs, 6 MAs and 6 Student Nurse Aides to total 24<BR/>Record review of slings examined dated 01/17/2024 to 04/09/2024 reflected the slings were examined weekly for condition and wear.<BR/>STAFF INTERVIEWS ON TRAINING: 04/05/2024 from 2:00 PM to 3:30 PM revealed staff were scheduled for 12-hour shifts, many worked both day, evening, and night shifts.<BR/>On 04/05/2024 at total of 3 LVN's, 5 CNA's and 2 NAs were interviewed on the mechanical lift transfers, 2 people requirement, intervening, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed someone trying to transfer a resident with a mechanical lift with one person, and to let the charge nurse know if they could not find someone to help them with a transfer. They were trained to check the straps for wear and condition and placement on the lift to ensure they were secure. <BR/>On 04/09/2024 between 02:00 PM and 5:00 PM, 2 RN's and 2 CNAs were interviewed on the mechanical lift, 2 people requirement, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed someone trying to transfer a resident with a mechanical lift with one person, and to let the charge nurse know if they could not find someone to help them with a transfer. They were trained to check the straps for wear and condition and placement on the lift to ensure they were secure. <BR/>The noncompliance was identified as past noncompliance IJ. The noncompliance began on 01/17/2024 and ended on 01/18/2024 when all staff had been in-serviced on abuse/neglect, mechanical lift transfers (2 people required) and reporting it immediately if observed with only one person using the lift. The NA was suspended and then terminated before the surveyor entrance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 2 of 3 Residents (Resident #40 and Resident #8) reviewed for respiratory care. The facility failed to ensure Resident #40 and Resident #8's oxygen tubing was not touching the floor. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications and/or infection. The findings included: 1. Record review of Resident# 40's face sheet dated 8/20/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breath), acute upper respiratory infection (short-term infection that affects the upper part of the respiratory system), pneumonia (infection of the lungs), and acute bronchitis (inflammation of the airways that carry air into the lungs). Record review of Resident #40's most recent quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and required oxygen therapy. Record review of Resident #40's Order Summary Report dated 8/20/25 revealed the following orders:- Change nebulizer mask and tubing every week on Sunday and clean filter every night shift every Sunday related to chronic obstructive pulmonary disease with order date 5/5/23 and no end date.- Change oxygen tubing and nasal cannula/mask as needed when visibly soiled with order date 7/21/25 and no end date.- Oxygen 2 to 4 liters per minute via nasal cannula every shift with order date 7/21/25 and no end date. Record review of Resident #40's comprehensive care plan with revision date 4/1/24 revealed the resident required oxygen therapy related to chronic obstructive pulmonary disease and interventions that included to give medications as ordered by the physician, monitor oxygen saturation every shift, and administer oxygen. Observation on 8/20/25 at 8:10 a.m. revealed Resident #40 sitting up in the wheelchair in her room and the oxygen concentrator operating via a nasal cannula and the tubing leading from the nasal cannula to the concentrator was touching the floor. During an observation and interview on 8/20/25 at 9:50 a.m., Resident #40 was observed sitting up in the wheelchair and the oxygen concentrator operating with the nasal cannula attached to the concentrator but not on the resident. Resident #40's nasal cannula was draped over the bedside table with the tubing touching the floor. Resident #40 stated she used the oxygen when she needed it and when she did not need it she would take it off. Resident #40 stated she could only take the nasal cannula off but could not put it back on. During an observation on 8/20/25 at 2:52 p.m., Resident #40 was observed sitting up in the wheelchair sleeping and the oxygen concentrator was operating via the nasal cannula and the tubing touching the floor. During an observation on 8/20/25 at 4:48 p.m., Resident #40 was observed sitting up in the recliner and the oxygen concentrator was operating and the nasal cannula was on the floor. During an observation and interview on 8/20/25 at 4:51 p.m., LVN D stated Resident #40 had a physician's order for continuous oxygen and there was an order to change the oxygen tubing and mask every Sunday because the tubing could get dirty with usage. LVN D stated, Resident #40 often removed her nasal cannula and stated she had been in the resident's room periodically often and was in the resident's room often, at least every 4 hours to administer pain medication. LVN D stated, during those times she would also check to see if the resident was using the oxygen. Observation with LVN D revealed Resident #40 with the nasal cannula on the floor while the oxygen concentrator was operating. LVN D stated, if the oxygen tubing was touching the floor, it's dirty and the tubing could pick up bacteria. LVN D stated, the oxygen concentrator tubing on the floor needed to be changed out. 2. Record review of Resident #8's face sheet dated 8/21/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] and 7/31/25 with diagnoses that included acute and chronic respiratory failure with hypoxia (a sudden onset of when the lungs cannot provide enough oxygen to the blood or cannot remove enough carbon dioxide), acute pulmonary edema (sudden buildup of fluid in the lungs' air sacs which makes it very difficult to breathe), heart failure, and chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breath). Record review of Resident #8's most recent comprehensive MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision- making skills and required oxygen therapy. Record review of Resident #8's Order Summary Report dated 8/21/25 revealed the following orders:- Oxygen 3 liters per minute via nasal cannula every shift with order date 8/1/25 and no end date. Record review of Resident #8's comprehensive care plan with revision date 8/13/25 revealed the resident used oxygen therapy related to heart failure and ineffective gas exchange with interventions that included to give medications as ordered by the physician and provide oxygen therapy per nasal cannula. Observation on 8/21/25 at 10:43 a.m. revealed Resident #8 sitting up in bed and the oxygen concentrator operating via nasal cannula with the oxygen tubing touching the floor. During an observation and interview on 8/21/25 at 10:54 a.m., Resident #8 stated the oxygen tubing was replaced, last evening (8/20/25). LVN F observed Resident #8's oxygen tubing touching the floor and stated the oxygen tubing was not supposed to be touching the floor because it was contaminated because the floor was dirty. During an interview on 8/21/25 at 7:28 p.m., the DON stated, the oxygen tubing on the oxygen concentrator touching the floor meant the tubing was dirty because the floor was dirty. Record review of the facility document titled, Oxygen Administration, undated, revealed in part, .Oxygen therapy includes the administration of oxygen in liters/minute by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases.Goals.The resident will be free from infection.Procedure.Attach the tubing to the regulator and the delivery device to be used.Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes or maintains their quality of life for 3 of 3 residents (Resident #2, Resident #4, and Resident #5) reviewed for dignity. <BR/>1. The facility failed to ensure Resident #2's was provided privacy during incontinent care.<BR/>2. The facility failed to ensure Resident #4's was provided privacy during incontinent care.<BR/>3. The facility failed to ensure Resident #5's was provided privacy during incontinent care.<BR/>These failures could affect residents by contributing to poor self-esteem, and decreased self-worth and quality of life. <BR/>Findings included: <BR/>1. Record review of Resident #2's admission Record, dated 11/26/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Hypertension (high blood pressure), Cognitive Communication Deficit (difficulty with thinking and language), Aphasia (disorder that affects a person's ability to communicate), and UTI. <BR/>Record review of Resident #2's quarterly MDS assessment, dated 9/18/24, revealed the resident's cognitive skills for daily decision making was severely impaired. Further review of the document revealed Resident #2 was always incontinent of bowel and bladder. <BR/>Record review of Resident #2's Care Plan, initiated 1/27/23, revealed: .The resident has bladder incontinence .INCONTINENT care at least q2h .The resident has bowel incontinence .Provide pericare after each incontinent episode .<BR/>Observation of perineal care for Resident #2, on 11/26/24 beginning at 2:18 pm, revealed CNA A and CNA B closed the door but did not draw the privacy curtain completely closed when incontinent care was provided for Resident #2. Resident #2 was in a private room during the observation. <BR/>2. Record review of Resident #4's admission Record, dated 11/27/24, revealed the resident was readmitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning), Cognitive Communication Deficit (difficulty with thinking and language), UTI, and Hemiplegia (paralysis of one side of the body).<BR/>Record review of Resident #4's quarterly MDS assessment, dated 10/12/24, revealed the resident's BIMS score was 1, suggesting severely impaired cognition. Further review of the document revealed Resident #4 was always incontinent of bladder and occasionally incontinent of bowel. <BR/>Record review of Resident #4's Care Plan, initiated 4/1/22, revealed: .The resident has bladder incontinence . INCONTINENT care at least q2h .The resident has bowel incontinence .Provide pericare after each incontinent episode .<BR/>Observation of incontinent care for Resident #4, on 11/26/24 beginning at 1:43 pm, revealed CNA A and CNA B closed the door but did not draw the privacy curtain completely closed when incontinent care was provided for Resident #4. Further observation revealed Resident #4's roommate pulled on the curtain and tried to gain sight of Resident #4 while care was provided. <BR/>3. Record review of Resident #5's admission Record, dated 11/27/24, revealed the resident was readmitted to the facility on [DATE] with diagnoses that included: Cognitive Communication Deficit (difficulty with thinking and language), Dementia (group of thinking and social symptoms that interferes with daily functioning), and Muscle Weakness. <BR/>Record review of Resident #5's quarterly MDS assessment, dated 11/5/24, revealed the resident's BIMS score was 4, suggesting severely impaired cognition. Further review of this document revealed Resident #5 was always incontinent of bladder. <BR/>Record review of Resident #5's Care Plan, initiated 11/19/24, revealed: .The resident has bladder incontinence . INCONTINENT care at least q2h .<BR/>Observation of incontinent care for Resident #5, on 11/26/24 beginning at 3:21 pm, revealed CNA B closed the door but did not draw the privacy curtain completely closed when incontinent care was provided for Resident #5. Resident #5 did not have a roommate during the observation. <BR/>During an interview on 11/26/24 at 2:45 pm, CNA B said she was expected to always protect the residents' privacy. CNA B further stated she was expected to draw the privacy curtains all the way to protect the residents' privacy during resident care if they had a roommate or if someone walked in, they knew care was being provided and the resident's privacy was not affected. CNA B said residents that were able to walk, and talk could be affected if their privacy was not respected. CNA B further stated Resident #5 allowed anybody in her room and Resident #2 would not know if someone came in or out of her room because she only saw what was in front of her. CNA B said Resident #2 would not know if her privacy was being invaded but she always protected the residents' privacy because that was important. <BR/>During an interview on 11/26/24 at 4:20 pm, CNA A said she was expected to close the privacy curtains all the way when resident care was provided for the residents' privacy. CNA A further stated when the residents' privacy was not respected it might make the residents feel uncomfortable. <BR/>During an interview on 11/27/24 at 12:09 pm, LVN C said her expectation was that privacy was provided to the residents when care was provided. LVN C further stated when care was provided the privacy curtains should be drawn all the way and the door and blinds should be closed so the residents felt comfortable, not embarrassed, and trusted staff even if they were in a private room. <BR/>During an interview on 11/27/24 at 1:19 pm, the DON said her expectation was for the door to be closed and privacy curtains be pulled all the way, even in a private room, when resident care was provided because anyone could walk into the room. The DON further stated when residents' privacy was not respected it could expose the residents to other residents, family members and staff and could affect their dignity. <BR/>During an interview on 11/27/24 at 1:59 pm, the Administrator said residents should be given privacy when care was provided by pulling the privacy curtain all the way around and closing the door and blinds so that they were not exposed and to provide dignity to the residents during care. <BR/>Record review of the facility's policy titled Resident Rights, revised 11/28/16, revealed: .Respect and dignity - The resident has a tight to be treated with respect and dignity .The resident has a right to personal privacy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #46) reviewed for incontinent care: The facility failed to ensure CNA E provided incontinent care to Resident #46 in the order of cleanest to dirtiest, and CNA E and Student Aide C performed hand hygiene between glove changes. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings included: Record review of Resident #46's face sheet dated 8/21/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness or reduced strength to one side of the body) affecting the left non-dominant side, and gastrostomy status (a surgically created opening through the abdominal wall into the stomach). Record review of Resident #46's most recent comprehensive MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills and was always incontinent of bowel and bladder. Record review of Resident #46's comprehensive care plan initiated on 7/31/25 revealed the resident had bowel and bladder incontinence with interventions that included to provide incontinent care. Observation on 8/21/25 at 11:15 a.m. during incontinent care, CNA E, after cleaning Resident #46's buttock and anal area, took a clean brief using the same gloves used to clean the resident's buttock and anal area and placed the clean brief on the bed. CNA E and Student Aide C then assisted the resident onto her back and then to her right, removed their gloves, did not wash or sanitize their hands, and put on a new pair of gloves. Student Aide C then applied barrier cream to Resident #46's buttock area, removed her gloves, did not wash or sanitize her hands, and put on a new pair of gloves. During an interview on 8/21/25 at 12:36 p.m., Student Aide C stated she realized she had not washed or sanitized her hands between glove changes and had just forgotten. Student Aide C stated she usually carried a bottle of hand sanitizer with her and should have been used to sanitize her hands otherwise it was considered cross contamination and could results in the resident or the aide getting sick. Student Aide C stated, cross contamination could result in passing on an illness. During an interview on 8/21/25 at 12:48 p.m., CNA E stated she realized she had moved from a dirty area to a clean area and should not have done it and missed that step because she was probably nervous. CNA E stated moving from a dirty area to a clean area with the same gloves could cause an infection and was cross contamination. CNA E stated, taking the clean brief with soiled gloves made the clean brief dirty because it had been touched with dirty gloves. CNA E stated it was the same concept when changing gloves and we need to wash or sanitize our hands between gloves changes to prevent cross contamination. During an interview on 8/21/25 at 7:28 p.m., the DON stated it was her expectation staff were supposed to wash or sanitize their hands between glove changes because it was part of infection control practices and it not done could result in cross contamination and the staff or resident could pass an illness to each other, germs or bug. The DON stated, the aide should have changed her gloves when moving from a dirty area to a clean area because you have now actually done cross contamination. Record review CNA E's C.N.A. Proficiency Audit dated 8/16/25 revealed she had satisfied the requirement for performing hand washing skills and perineal care. Record review of Student Aide C's C.N.A. Proficiency Audit dated 7/5/25 revealed she had satisfied the requirement for performing hand washing skills and perineal care. Record review of the facility document titled, Nursing: Personal Care, Perineal Care dated 4/25/22 revealed in part, .An incontinent resident of urine and/or bowl (sic) should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible.Perform hand hygiene.Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area - CLEAN to DIRTY! .Doff gloves and PPE.Perform hand hygiene.Always perform hand hygiene before and after glove use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 2 of 4 medication carts (C/D Hall cart and A/C Hall cart) reviewed for labeling and storage of drugs. 1. The facility failed to ensure the C/D Hall medication cart was not left unlocked and unattended.2. The facility failed to provide a change of direction label for Resident #6's Seroquel medication bottle from 50 mg at bedtime to 50 mg two times a day prescribed to treat depression on the A/D medication cart. These deficient practices could place residents at risk of medication misuse and diversion. The finding included: 1. During an observation on 8/21/25 at 9:42 a.m. revealed the C/D Hall medication cart was unlocked and unattended facing the hallway in front of the nurse's station. During an observation and interview on 8/21/25 at 9:47 a.m., the DON walked up to the C/D Hall medication cart and attempted to lock it. The DON stated the C/D Hall medication cart had been assigned to LVN D. The DON saw LVN D walking down the D Hall and summoned LVN D to the nurse's station. During an interview on 8/21/25 at 9:49 a.m., LVN D stated, she had gotten sidetracked and forgot to lock the C/D Hall medication cart. LVN D stated the C/D Hall medication cart should have been locked when not in use because people like you could get into it. LVN D stated, other people could get into the cart and take things they were not supposed to. 2. Record review of Resident #6's face sheet dated 8/21/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia (general term for a group of symptoms that affect memory, thinking, reasoning, and the ability to perform daily activities) with agitation, depression (mental health disorder characterized by a persistent feeling of sadness, emptiness, or loss of interest or pleasure in activities once enjoyed), and anxiety disorder (mental health condition characterized by excessive fear, worry, or nervousness). Record review of Resident #6's Order Summary Report dated 8/21/25 revealed the following:- Seroquel 50 mg tablet, give 50 mg by mouth two times a day related to depression, with order date 8/18/25 and no end date. During observation and interview on 8/21/25 at 8:50 a.m., during the medication pass revealed Resident #6's Seroquel medication indicated 50 mg at bedtime on the pharmacy label. Medication Aide G stated the Seroquel pharmacy label for Resident #6 was incorrect because the physician's orders indicated Seroquel 50 mg was supposed to be given twice a day. Medication Aide G stated the directions on the pharmacy label was incorrect and should have been compared to the physician's orders for accuracy. Medication Aide G stated she was in a hurry and overlooked it. During an interview on 8/21/25 at 7:28 p.m., the DON stated the medication carts were not supposed to be left unlocked when unattended because it was a safety concern. The DON stated residents could get into the medication cart and take something that did not belong to them and could potentially make them sick. The DON stated it was her expectation when administering medications, the orders were supposed to be matched up to the physician's orders and if the pharmacy label did not match the physician's orders, then a change of direction sticker was supposed to be placed on the medication package. The DON stated, the pharmacy label not matching the physician's orders could result in a medication error or the resident missing a medication dose. Record review of the facility document titled Medication Storage in the Facility, dated 2025 revealed in part, .Medication and biologicals are stored safely, securely.The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access. Record review of the facility document titled, Medication Administration and General Guidelines, dated 2025 revealed in part, .Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so.Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, or if there is any reason to question the dosage or directions, they physician's orders are checked for the correct dosage schedule.Checklist for completing proper steps in the administration of medications.Right dose.Right Medication.Right Time.Right Documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 3 of 8 residents (Residents #8, #48 and, #50) reviewed for infection control, in that:<BR/>1. CNA C and NA D failed to wash or sanitize their hands after touching the privacy curtain and before starting incontinent care. CNA C failed to wash her hands after providing care and before leaving the resident's room.<BR/>2. CNA B failed to wash her hands after providing care and before leaving the resident's room. CNA B failed to wash her hands before providing care. <BR/>3. LVN E failed to wear gloves before handling medication. <BR/>These failures could place residents at-risk for infection due to improper care practices. <BR/>The findings included:<BR/>1. Record review of Resident #8's face sheet, dated 06/13/2023, revealed an admission date of 03/24/2020 and, a readmission date of 06/06/2020, with diagnoses which included: Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Lumbar spina bifida (birth disorder that involves the incomplete development of the spine), Hypertension (high blood pressure) and, Type 2 diabetes mellitus (high level of sugar in the blood) <BR/>Record review of Resident #8's Annual MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating no cognitive impairment. The resident received extensive assistance for her activities of daily living, had an indwelling catheter and was always incontinent of bowel. <BR/>Record review of Resident #8's care plan, dated 04/25/2023, revealed a problem of The resident has indwelling Foley catheter in place related to neurogenic dysfunction of bladder, unspecified., with a goal of will remain free from catheter-related trauma and s/sx of infection through the next review date.<BR/>Observation on 06/13/23 at 11:33 a.m. revealed while providing catheter care, after washing their hands, CNA C and NA D both touched the privacy curtain to close it with their bare hands. They did not sanitize or wash their hands prior to donning their gloves and started providing catheter care to Resident #8. Further observation revealed after providing care CNA C removed her gloves, collected the trash bag and closed it. Then, without washing her hands she opened the door of the resident's room, walked to the soiled utility room, opened the door of the soiled utility room and left the bag in the soiled utility room. <BR/>During an interview on 06/13/2023 at 11:33 a.m. with CNA C and NA D, they confirmed the environment around the resident was considered dirty and they should have sanitized their hands prior to providing care. <BR/>Further interview with CNA C, she verbally confirmed not washing her hands prior to leaving the room and touching both the resident's door and the soiled utility room's door. She revealed she was not sure how to proceed about washing her hands and then touching the trash bag. They, both, confirmed they received infection control training within the year. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed the environment around the resident was considered dirty and the staff should change their gloves and wash. Staff should sanitize their hands after touching anything in the environment, before touching the resident and at the start of care. She confirmed the staff was to wash their hands after care prior to leave a room. <BR/>She confirmed the staff were in-serviced, by the ADON, in infection control and incontinent care and skills were checked annually and as needed by managment. <BR/>Record review of the annual skills check for CNA C revealed CNA A passed competency for Infection control on 04/21/2023. <BR/>Record review of the annual skills check for NA D revealed NA D passed competency for Infection control on 03/15/2023. <BR/>Record review of the facility policy, titled perineal care, dated 04/05/2022, revealed 7) provide privacy and modesty by closing the door and/or curtain [ .]10) perform hand hygiene, 11) don gloves and all other PPE per standard precaution [ .] 30 tie off the the disposable plastic bag of trash and/or linen 31) perform hand hygiene<BR/>2. Record review of Resident #48's face sheet, dated 06/13/2023, revealed an admission date of 11/03/2021 and, a readmission date of 07/28/2022, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Hypothyroidism(under active thyroid), Hypercholesterolemia(high level of cholesterol(type of fat) in the blood), Down syndrome (genetic disorder associated with developmental and intellectual disability) .<BR/>Record review of Resident #48's quarterly MDS dated [DATE] revealed the resident did not have a BIMS score and had severe cognitive impairment. The resident was completely dependent of the staff for care and was always incontinent of bowel and bladder. <BR/>Record review of Resident #48's care plan, dated 02/15/2022, revealed a problem of The resident has bladder incontinence related to dementia., with a goal of will remain free from skin breakdown due to<BR/>incontinence and brief use through the next review date.<BR/>Observation on 06/13/23 at 10:39 a.m. revealed after providing incontinent care CNA B removed her gloves, collected the trash bag and closed it. Then, without washing her hands she opened the door of the resident's room, walked to the soiled utility room, opened the door of the soiled utility room and left the bag in the soiled utility room. CNA B came back to Resident #48's room and, without washing her hands, transferred Resident #48 from his bed to his wheelchair with the assistance of CNA A. <BR/>During an interview on 06/13/2023 at 11:10 a.m. with CNA B, she verbally confirmed not washing her hands prior to leaving the room and touching both the resident's door and the soiled utility room's door. She verbally confirmed she did not wash her hands prior to transfer the resident after coming back in the room. She confirmed she received infection control training within the year. She refvealed she did not know she had to wash her hands while entering and before leaving a room. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed staff should wash their hands when entering a room to provide care and before leaving the room. She revealed not washing their hands was increasing the risk for cross contamination and infection, She confirmed the staff were in-serviced in infection control and incontinent care and skills were checked annually and as needed. <BR/>Record review of the annual skills check for CNA C revealed CNA B passed competency for Infection control on 11/09/2022. <BR/>Record review of the facility policy, titled perineal care, dated 04/05/2022, revealed 7) provide privacy and modesty by closing the door and/or curtain [ .]10) perform hand hygiene, 11) don gloves and all other PPE per standard precaution [ .] 30 tie off the the disposable plastic bag of trash and/or linen 31) perform hand hygiene<BR/>3. Record review of Resident #50's face sheet, dated 06/13/2023, revealed an admission date of 03/31/2022 and, a readmission date of 01/15/2023, with diagnoses which included: Dementia(decline in cognitive abilities), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Urinary tract infection(an infection in any part of the urinary system, Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Hypertension(high blood pressure), Hemiplegia(Paralysis of one side of the body).<BR/>Record review of Resident #50's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 6, indicating severe cognitive impairment. The resident needed limited assistance with her activities of daily living.<BR/>Observation on 06/13/23 at 9:00 a.m. revealed while administering medications to Resident #50, LVN E touched a capsule with her bare hands to open it and mix the content with pudding to administer it to the resident. <BR/>During an interview on 06/13/2023 at 09:08 a.m. with LVN E, she verbally confirmed she did not use gloves LVN E asked this surveyor if she should have used gloves before touching a capsule of medication to prevent infection to the residents. She confimed she received infection control training within the year. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed staff should not touch solid medications with their bare hands. She confirmed the staff were in-serviced in infection control and skills were checked annually and as needed. <BR/>Record review of the annual skills check for LVN E revealed LVN E passed competency for Infection control on 02/28/2023. <BR/>Record review of the facility policy, titled Oral solid medication administration, dated 2023, revealed if it is necessary to divide or split the medication prior to administration use an approved device or gloved hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the environment was free of accident hazards and supervision of staff for one resident (#1) of 3 residents who required mechanical lift transfers.<BR/>NA A transferred Resident #1 alone on 01/17/2024 at 08:15 AM with a mechanical lift which required 2 people for safety. One of the straps holding the sling came loose and Resident #1 slipped toward the floor and hit her head on the mechanical lift which caused a head laceration and fractures to C4 (provides sensation for parts of the neck, shoulders and upper arms) and C5 (controls the deltoid muscles of shoulders and biceps, provides sensation to the upper arm down to the elbow).<BR/>The noncompliance was identified as PNC. The IJ began on 01/17/2024 and ended on 01/18/2024. The facility had corrected the noncompliance before the survey began. <BR/>This deficient practice could affect residents who require transfers with the mechanical lift at risk for injury or death.<BR/>The findings included:<BR/>Record review of Resident #1's electronic face sheet dated 04/05/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery (a blood vessel that carries blood from the heart to tissues and organs in the body) and neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function).<BR/>Record review of Resident #1's annual MDS assessment with an ARD of 03/09/2024 reflected she was not a candidate for a BIMS assessment which signified she was severely cognitively impaired. She could rarely understand and rarely be understood. Resident #1 was dependent on staff for her ADL's. She required 2 people for her transfers.<BR/>Record review of Resident #1's comprehensive person-centered care plan revised 01/05/2024 reflected Focus, resident has an ADL self-care performance deficit, Interventions, transfer the resident requires mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual type of transfer) for transfers x 2 staff. Date initiated: 11/05/2021. Further review reflected Focus, alteration in musculoskeletal status r/t fracture of the C2-4, C collar splint (a cervical collar, also known as a neck brace, is a medical device used to support and immobilize a person's neck) as recommended, when out of bed. Date initiated: 01/19/2024.<BR/>Record review of Resident #1's progress note written by LVN B dated 01/17/2024 at 08:41 AM reflected Transfer Notification,] Resident #1] was transferred to a hospital on [DATE] 08:46 AM related to resident fell onto floor, causing a 2 cm laceration to top of head. Hematoma (a pool of mostly clotted blood that forms in tissue) to right forehead, 4x2 with abrasion.<BR/>Record review of Resident #1's hospital CT (computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) dated 01/17/2024 at 09:54 AM reflected Reason for exam, laceration to head, trauma/injury, Findings, nondisplaced transversely oriented fracture ((still broken bones, but the pieces weren't moved far enough to be out of alignment during the break) involving the right C4 inferior articular facet (smooth, anterolaterally(the position of a structure as being away from the middle line, in front of the body) facing articular (referring to the joint or joints) processes of a lumbar vertebra) and right C5 superior articular facet (the superior articular processes project vertically upward from the articular pillars (the columnar arrangement of the articular portions of the cervical vertebrae) between the pedicles (connect the vertebral body to the transverse processes) and the [NAME] (connect the transverse and spinous processes) (a series of levers both muscles of posture and for muscles of active movement).<BR/>Record review of NA A's written statement dated and signed 01/17/24 (untimed) reflected he was looking for someone to help, but no one was around and they were understaffed, so he attempted to place Resident #1 in the bed by himself. During the process, the sling on the mechanical lift on one side came undone and Resident #1 slipped out and he helped to guide her to the floor as safe as possible but she did hit the top of her head, and he immediately called for the nurse.<BR/>Record review of the Administrator's follow-up note (undated) reflected he interviewed NA A on 01/17/2024 and was told NA A did not see anyone in his hall so he did not ask for assistance with the mechanical lift transfer for Resident #1. He stated his investigation of staffing revealed the census at the time was 58 and there were 2 nurses, one medication aide and 4 aides assigned to the units, and administrative staff was available. <BR/>Record review of the Administrator's PIR dated 01/17/2024 at 10:39 AM reflected: Aide was suspended pending investigation. He was subsequently terminated. All staff were given abuse and neglect in-service and were trained on Hoyer policy requiring 2 people. Instructions given for intervening and reporting if witnessing improper Hoyer transfer. 100% of aides were required to perform return demonstration of proper Hoyer lift use. Family, physician, and Medical Director were informed of the incident. All Hoyer lift residents received a heat to toe assessment for any evidence of injury. Monitoring was implemented for incidents involving Hoyer residents. Five return demonstrations to be performed a week for 4 weeks and upon new hire. Training on recognizing sling condition was done with staff. Administrative staff examined all slings to ensure they were in good condition. Hoyer lifts were inspected. They were inspected in November 2023 by an outside company per policy. Aide verbalized to administrator that he knew a Hoyer transfer should be performed by 2 people. He verbalized that he had been trained to use the Hoyer. The NA chose not to wait for assistance as he did not see anyone in his hall. Hoyer was performed properly for getting Resident #1 out of bed. All equipment functioned properly and was in good condition during transfer. Poor decision making on part of the NA led to the incident .QA team had an Ad Hoc meeting to discuss and correct the situation.<BR/>Record review of NA A's CNA Proficiency Audit dated 04/04/2023 reflected he was signed off as an S for Transfers Hoyer lift- 2 person assist.<BR/>Observation on 04/04/2024 at 08:00 AM of Resident #1 revealed she was sitting in the dining room in a Geri-chair and had a C-collar around her neck.<BR/>Interview on 04/05/2024 at 1:00 PM with the Administrator, he stated after Resident #1 was sent out to the hospital for evaluation he reported the incident to HHSC immediately. He stated that later in the day a nurse from the hospital informed a nurse at the facility of Resident #1's fracture. He immediately identified that 100% in-services for the nursing assistants needed to be done and a competency of their performance for mechanical lift transfers. He stated that was completed on 01/18/2024. He stated 100% of the staff, nursing and non-nursing staff were in-serviced on abuse and neglect and on having 2 people for a mechanical lift transfer and to report any variances of that immediately. He stated that was completed on 01/18/2024. He stated he checked the staffing for 1/17/2024 at 08:15 AM when the incident happened, and sufficient staff were available in the building and that NA A chose not to wait.<BR/>Attempted interview on 04/09/2024 with NA A at 10:00 AM revealed the phone number listed for him at the facility was disconnected.<BR/>Observation on 04/05/2024 at 09:10 AM of Resident #1 being transferred from her Geri chair to the bed by CNA D and NA E revealed no concerns.<BR/>Observation on 04/08/2024 at 12:30 PM of Resident #2 being transferred from her Geri chair to the bed by CAN D and CNA F revealed no concerns.<BR/>Interview on 04/09/2024 at 2:50 PM with LVN B revealed she assessed Resident #1 when the incident happened, made notifications to include the Administrator and had Resident #1 transferred to the hospital. <BR/>Interview on 04/09/2024 at 09:00 a.m. with the DON at the time, RN C, she stated Resident #1 was transferred with a mechanical lift by NA A, who did not ask for help. She stated that he was trained on how to use the mechanical lift and everyone was retrained after the incident.<BR/>Record reviews of the other two residents who required Hoyer lift transfers, Resident #2 and Resident #3 reflected both had 2-person transfers care planned and identified in their MDS assessments.<BR/>Record review of the facility policy and procedure titled Hydraulic Lift (undated) reflected The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair It is reserved for those who are paralyzed, obese or too weak to transfer without complete assistance. The number of staff to provide assistance with the transfer should be determined by manufacturer recommendations The resident will receive safe transfer to bed or chair via a mechanical lift device.<BR/>Record review of the owners guide for the MEDLINE Hydraulic lift MODEL: MDS450EL (undated) reflected Transfer From Bed and From Chair To Bed .with the assistance of another caregiver.<BR/>The facility course of action prior to surveyor entrance included:<BR/>Record review of the Administrator's PIR dated 01/17/2024 revealed: All required notifications were made which included the Medical Director, Responsible Party, Physician, Nurse Practitioner, QA Ad Hoc Committee and HHSC.<BR/>Record review of NA A's personnel folder reflected he was immediately suspended pending investigation on 01/17/2024 and subsequently terminated.<BR/>Record review dated 01/17/2024- 54 staff, all staff, were in-serviced on using a staff roster were checked off and signed for in-services titled: Abuse/Neglect, Mechanical Lift.<BR/>Record review of staff competencies dated from 01/17/2024 to 1/18/2024 reflected 100 return demonstrations were completed with the Hoyer transfers and 5 additional observations were done weekly and marked off by nurse managers for an additional 4 weeks. The staff who completed this training for the mechanical lift was all CNA's, MAs, and NAs, 12 CNAs, 6 MAs and 6 Student Nurse Aides to total 24<BR/>Record review of slings examined dated 01/17/2024 to 04/09/2024 reflected the slings were examined weekly for condition and wear.<BR/>STAFF INTERVIEWS ON TRAINING: 04/05/2024 from 2:00 PM to 3:30 PM revealed staff were scheduled for 12-hour shifts, many worked both day, evening, and night shifts.<BR/>On 04/05/2024 at total of 3 LVN's, 5 CNA's and 2 NAs were interviewed on the mechanical lift transfers, 2 people requirement, intervening, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed someone trying to transfer a resident with a mechanical lift with one person, and to let the charge nurse know if they could not find someone to help them with a transfer. They were trained to check the straps for wear and condition and placement on the lift to ensure they were secure. <BR/>On 04/09/2024 between 02:00 PM and 5:00 PM, 2 RN's and 2 CNAs were interviewed on the mechanical lift, 2 people requirement, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed someone trying to transfer a resident with a mechanical lift with one person, and to let the charge nurse know if they could not find someone to help them with a transfer. They were trained to check the straps for wear and condition and placement on the lift to ensure they were secure. <BR/>The noncompliance was identified as past noncompliance IJ. The noncompliance began on 01/17/2024 and ended on 01/18/2024 when all staff had been in-serviced on abuse/neglect, mechanical lift transfers (2 people required) and reporting it immediately if observed with only one person using the lift. The NA was suspended and then terminated before the surveyor entrance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 13 residents (Resident #1) reviewed for quality of care, in that: <BR/>The facility failed to ensure Resident #1's received timely treatment and care for the resident's Type II Diabetes when the resident went multiple days of blood sugar readings above 400 with no interventions, resulting in the resident being hospitalized on [DATE] and expired on [DATE].<BR/>An immediate jeopardy (IJ) was identified on [DATE] at 01:27 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. <BR/>This deficient practice could place residents at risks for a delay in medical treatment, which could lead to worsening of their condition, hospitalization, or death.<BR/>Findings included: <BR/>Record review of Resident #1's Administration Record, dated [DATE], revealed an [AGE] year-old male who originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident #1 was noted to have discharged [DATE] to an acute care hospital. Resident #1 had diagnoses which included the following: diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes), and heart failure.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 04, which indicated Resident #1's cognition was severely impaired. The MDS revealed Resident #1 was diabetic and received insulin injections. Further review revealed Resident #1 was dependent with mobility in rolling left to right, sit to lying, lying to sitting on side of bed, and sit to stand. Resident #1 required substantial to maximal assistance with chair to bed transfer, toilet transfer, and tub or shower transfer. Resident #1 was noted to have had an indwelling catheter (a tube that drains urine from the bladder into a bag outside the body) and always bowel incontinent. <BR/>Record review of Resident #1's Care Plan, dated as last reviewed [DATE], reflected Resident #1 had diagnosed diabetes mellitus with other neurological complications (date initiated: [DATE] and date revised: [DATE]) and the interventions included: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. and Fasting Serum Blood Sugar as ordered by doctor, report any abnormal levels. The Care Plan reflected Resident #1 had an altered endocrine system (a network of glands and organs in the body that use hormones to control and regulate many of the body's functions) status related to chronic kidney disease (date initiated and revised: [DATE]) and the interventions included: Fasting Blood Glucose as ordered by MD, Monitor/document/report to MD PRN any s/sx (signs and symptoms) of behavioral changes: nervousness, increased irritability, emotional lability (change or inconsistency), insomnia, extreme fatigue, confusion, disorientation, delirium, psychosis, stupor, coma. and Monitor/document/report to MD PRN for s/sx of hyperglycemia (elevated or high blood sugar): increased thirst and appetite, weight loss, fatigue, dry skin, poor healing, muscle cramps, abdominal pain, deep labored breathing (Kussmaul), acetone (fruity) breath, stupor, coma.<BR/>Record review of Resident #1's Order Summary Report, order date range: [DATE] - [DATE], revealed Resident #1 had active blood glucose check orders which included: Glucose Check BID x 7 days then report to PCP on 02/22 two times a day (repeated direction to check blood sugars twice a day) related to type 2 diabetes mellitus with hyperglycemia, ordered and start date: [DATE], Monitor for signs or symptoms of hypoglycemia or hyperglycemia Q shift. Every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy (damage to the nerves that control arm and leg movement), ordered [DATE] and started [DATE], and Monitor resident for confusion, combativeness, and restlessness. If resident is experiencing any of these, check blood sugar, every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy, ordered [DATE] and started [DATE]. Active blood glucose check orders found to not include blood sugar parameters, directing staff when they were to notify the physician of blood sugars below or above the expected range. Resident #1 had active diabetes medication orders which included: Glucagon Emergency Injection Kit 1 MG .Inject 1 mg subcutaneously (between the skin and muscle) as needed for signs or symptoms of hypoglycemia related to type 2 diabetes mellitus with other diabetic neurological complication, ordered and started [DATE] and Trulicity Subcutaneous Solution Pen-injector 0.75 mg/0.5 mL .Inject 0.75 mg subcutaneously one time a day every 7 days(s) related to Type 2 diabetes mellitus with hyperglycemia, ordered [DATE] and started [DATE]. Active diabetes medication orders found to not include an active order for insulin.<BR/>Record review of Resident #1's TAR, dated [DATE] - [DATE], revealed Resident #1's blood sugar checks BID which included: <BR/>- a blood sugar of 577 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, <BR/>- a blood sugar of 432 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, <BR/>- a blood sugar of 550 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, <BR/>- a blood sugar of 487 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, <BR/>- a blood sugar of 498 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, <BR/>- a blood sugar of 502 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, <BR/>- a blood sugar of 486 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P,<BR/>- a blood sugar of 424 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, <BR/>- a blood sugar of 492 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P,<BR/>- a blood sugar of 498 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, and <BR/>- the blood sugar check coded as not taken due to hospitalization by LVN M. <BR/>Record review of Resident #1's progress notes, dated [DATE] at 07:00 p.m., revealed the following note by the ADON, [Resident #1's PCP] notified of resident with blood sugar 577. Asymptomatic (no symptoms). No new orders.<BR/>Record review of Resident #1's progress notes, dated [DATE] at 10:00 a.m., revealed the following note by RN Z, [Resident #1's PCP] is aware of blood sugar this AM (morning) 432; no new orders at this time. <BR/>Record review of Resident #1's progress notes, dated [DATE] at 12:55 p.m., revealed the following note by LVN 1, .[MD X] will no longer be PCP for [Resident #1]. She (Resident #1 RP) stated [MD W] will now be his primary care physician. I informed [MD X], and notified [MD W]'s nurse of change effective today.<BR/>Record review of Resident #1's progress notes, dated from [DATE] at 10:01 a.m. to [DATE] at 03:53 p.m., revealed no progress notes mentioning blood sugar results or notification to physician. <BR/>Record review of Resident #1's progress notes, dated [DATE] at 03:54 p.m., revealed the following note by RN Z, one week of blood sugar results sent to [Resident #1's PCP]. Pending response.<BR/>Record review of Resident #1's progress notes, dated [DATE] at 04:00 p.m., revealed the following note by RN Z, called into room by CNAs. Res (resident) was lying in bed with eyes closed, respirations shallow, difficult to arouse. Unresponsive to tactile stimuli. Upon assessment .blood sugar too high to register on glucometer (machine used to test blood sugar). Immediately contacted [Resident #1's PCP]. New orders received to send to [local hospital] ER (emergency room) for further eval (evaluation) and tx (treatment) . <BR/>Record review of Resident #1's progress notes, dated [DATE] at 04:09 p.m., revealed the following note by LVN N, [Resident #1] was transferred to a hospital on [DATE] 4:05 PM related to High blood sugar, unresponsive.<BR/>Record review of Resident #1's progress notes, dated [DATE] at 11:40 a.m., revealed the following note by RN Z, Res (resident) is admitted to [hospital name and location]; ICU (intensive care unit) DX (diagnoses): Hyperglycemia, Altered Mental Status. <BR/>Record review of Resident #1's hospital records, dated [DATE], reflected Resident #1 was admitted to the ER on [DATE] at 05:44 p.m. The records reflected Resident #1 was discharged from the ER on [DATE] to an alternate hospital. The ER notes dated [DATE] reflected Resident #1's chief complaint was hyperglycemia and an altered mental status. Resident #1 noted to had started seizing when on bed with no prior history of seizures. Resident #1 was intubated and placed on a mechanical ventilator, diagnosed with altered mental status, hyperglycemia (high blood glucose/sugar), hyperosmolar hyperglycemic state (HHS; a life-threatening complication of diabetes when the blood glucose or blood sugar levels are too high for a long period, leading to severe dehydration and confusion), seizure, respiratory failure, GI (gastrointestinal) bleed, sepsis (a condition in which the body's extreme response to an infection become life-threatening), urinary tract infection, and an electrolyte disorder. Glucose level measured at 798 mg/dL on [DATE] at 05:52 p.m. <BR/>Record review of addendum to facility self-report to HHSC Complaint and Incident Intake, dated [DATE] at 03:53 p.m., revealed the following note by the ADMIN, He (Resident #1) passed away on [DATE] at 10:37 p.m. We (the facility) do not have a cause of death at this time.<BR/>Interview with RN Z on [DATE] at 03:01 p.m. revealed she had reviewed Resident #1's weekend blood sugars when she came in to work on Monday, [DATE], seen that they were elevated, and sent the blood sugar results to Resident #1's physician. RN Z stated she had reported his high blood sugar that morning but Resident #1 was awake, alert, and up in the dining room for breakfast and lunch. RN Z stated Resident #1's change in condition started right before she had sent him out, after lunch. RN Z stated she did not hear back from Resident #1's physician when reporting the initial high blood sugar but called the physician again for the change of condition and transfer out to the hospital. RN Z did not state the time for the second call to Resident #1's physician. RN Z described Resident #1's change as condition as being slower to respond, not really answering staff, and just not himself.<BR/>Interview with SNA AC on [DATE] at 03:17 p.m., revealed she had been taking care of Resident# 1 on Sunday, [DATE] and around 05:30 p.m. observed a concern about how Resident #1 was positioned in bed and that Resident #1 was not breathing as good as he normally did. SNA AC stated she had reported her observations to the nurse. SNA AC stated she had worked at the facility for less than a month and had not yet been trained on how to document in the facility's EMR. <BR/>Interview with CNA A on [DATE] at 03:28 p.m., revealed she had been taking care of Resident #1 on Monday, [DATE] during the day. CNA A revealed she had observed Resident #1 to have been behaving normally, chatty and responsive that morning. CNA A stated after lunch, she had reported to Resident #1's nurse (RN Z) that when she and another CNA (CNA B) went into Resident #1's room to get him up from an after-lunch nap, he was not as responsive as normal. CNA A stated she had tried physical stimulus (rubbing Resident #1 wrist), which he did not respond to. CNA A stated she also observed an unknown purple substance around Resident #1's mouth, which she had cleaned off when the nurse came in to check Resident #1's vitals. CNA A did not state she documented her observations in the facility EMR or notify the nurse of the purple substance during the interview as part of her recollection of events. <BR/>Interview with CNA B on [DATE] at 03:37 p.m., revealed she had observed Resident #1 during Monday, [DATE] and had noted that he was his normal responsiveness and able to have a conversation with her that morning. CNA B stated that after lunch Resident #1 started to be different, dazed. CNA B revealed she reported her observations to Resident #1's nurse (RN Z). <BR/>Interview with the ADON on [DATE] at 04:08 p.m., revealed she had worked [DATE] for the 08:00 p.m. blood sugar check shift. The ADON stated that Resident #1 had looked fine, was acting his normal or not any different than he has been since his recent stroke. The ADON stated that for one of her shifts that week Resident #1 had a very high blood sugar and she had called Resident #1's physician who said he did not want to do anything if the resident was asymptomatic (without symptoms). The ADON stated she did not call Resident #1's physician again because when she had called on [DATE], the physician said that if Resident #1 was asymptomatic he was not going to do anything. <BR/>Interview with MD W on [DATE] at 04:37 p.m., revealed he had been notified of changes in Resident #1's blood sugar medications, including the approval of diabetic medication Trulicity by Resident #1's insurance and that Resident #1's prior PCP had wanted to decrease Resident#1's insulin, but had not received any calls regarding Resident #1's high blood sugars until Monday morning, [DATE]. MD W revealed his expectation was for the facility to call him if a resident's blood sugar was below 60, over 400, or symptomatic (having symptoms). MD W stated he believed Resident #1's comorbidities (having more than one medical condition at the same time) were contributing to Resident #1's blood sugar problems. MD W revealed he was not sure that if the facility had contacted him sooner regarding Resident #1's elevated blood sugars, if it would have made a difference but it would have been ideal for the facility to have had contacted him sooner. <BR/>Interview with LVN P on [DATE] at 05:37 p.m., revealed her observations for Resident #1 during her shifts on [DATE]- [DATE] were that he was fine when he had high blood sugars. His behaviors were fine and happy. He was back to his normal self. LVN P stated when Resident #1 had low blood sugars he would become confused and combative. LVN P stated she reported to Resident #1's physician when Resident #1 was experiencing lows but could not remember if she had called the physician for the high blood sugars. LVN P revealed Resident #1 did not have symptoms when his blood sugars were high. LVN P stated Resident #1's respirations were great, he was sleeping well, and he was his normal self. LVN P revealed she felt the physician would have known Resident #1 was having high blood sugars since the physician discontinued Resident #1's insulin. <BR/>Interview with LVN R on [DATE] at 06:11 p.m., revealed her observations for Resident #1 during her shifts on [DATE] - [DATE] were that Resident #1 was good, just tired which was not abnormal for him recently. LVN R stated that she could recall that Resident #1 had an order during that time to monitor Resident #1's blood sugars and then to report it in 7 days, which she believed was either that following Monday ([DATE]) or Tuesday ([DATE]). LVN R stated she did not report Resident #1's high blood sugars during her shifts because of the monitoring order with instruction to report in 7 days and she had reviewed Resident #1's previous blood sugars and found them to be consistent with the blood sugars she had collected. LVN R stated Resident #1's blood sugars were all the same, all in the 400's and not fluctuating, such as from the 100's to the 400's. LVN R also revealed Resident #1 was not showing symptoms, which he did when experiencing a low blood sugar and that she did not have any concerns. <BR/>Interview with MD X on [DATE] at 11:20 a.m., revealed Resident #1's blood sugars had been fluctuating quite a bit due to Resident #1's renal (kidney) failure, which was causing his blood sugars to become difficulty to control. MD X revealed that he did recall the facility's nursing staff contacting him regarding Resident #1's blood sugars but could not recall when without his notes. MD X stated the facility contacted him regarding Resident #1's change in physician on [DATE] and that was the last contact he received from the facility for Resident #1's care. MD X stated prior to the change in physician, he was trying to make chronic (long-term) changes and did not want to make acute (immediate) changes in regulating Resident #1's blood sugar. MD X revealed his expectation for the facility staff to notify him for blood sugars was for them to call if a resident's blood sugar was at 500. MD X revealed that if a resident was at 500 and symptomatic, he would order adjustments and send the resident out to the hospital, but if not symptomatic, he would just make adjustments to the insulin order. MD X revealed Resident #1's insulin orders had been discontinued due to Resident #1 having had bottomed out (experienced a low blood sugar episode) earlier that month (early February), Resident #1 was very brittle, and Resident #1's blood sugars had been going in the wrong direction (blood sugar dropped) with insulin. <BR/>Interview with the RCN on [DATE] at 02:16 p.m., revealed the facility procedure for a blood sugar outside parameters (the expected range) was to follow the order, including to hold the medication, give an additional medication, re-check, and/or immediately contact the physician per the doctor's orders. She stated that staff are expected to contact the physician if there is a pattern in a resident's blood sugars being outside the blood sugar parameters or a pattern of refusals by the resident. She revealed that if a resident was experiencing a high blood sugar, the doctor was to tell them what they are to give to the resident and when to re-check the resident's blood sugar. The RCN stated that the nurse was responsible for entering the physician's order into the facility's EMR, documenting the order and interventions in a progress note, and reporting any changes to the resident's RP. She revealed that reporting high and low blood sugars is important for tracking the resident's blood sugar trends and that if a resident was running a high blood sugar all the time, their medications would need to be adjusted to limit the long-term effects it could have, which may be harmful if not treated. The RCN stated that facility staff should monitor blood sugars as ordered, notify the resident's physician immediately if outside parameters and follow the orders that the physician gives. <BR/>Interview with the ADMIN on [DATE] at 02:34 p.m., revealed reporting any change of condition is important, to let the physician know and be aware of it. The ADMIN revealed his expectation was that staff call the resident's physician, report that they had contacted the physician, make the changes per the physician, and make notifications to the resident's family for any changes of condition. The ADMIN revealed that this was standard nursing practice and an order. <BR/>Record review of facility policy, Notifying the Physician of Change in Status, dated revised [DATE], revealed The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .11. Abnormal lab, x-ray and other diagnostic reports require physician notification.<BR/>Record review of facility policy, Medication Administration Procedures, dated 2003, revealed 13. When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber.<BR/>This failure resulted in an identification of an immediate jeopardy on [DATE] at 01:27 p.m. The administrator was informed and provided the IJ template on [DATE] at 06:00 p.m. and a plan of removal (POR) was requested.<BR/>The plan of removal reflected: <BR/>[DATE]<BR/>Plan of Removal- [Citation Number] Notify of Changes<BR/>Interventions:<BR/> - 100% blood sugar audit completed on [DATE] by Regional Compliance Nurse<BR/> - Blood sugar checks were assessed on [DATE] to ensure that blood sugar parameters were in place, if not, parameters were requested by attending physician and added. <BR/> - 100% of residents with blood sugar checks were audited on [DATE] and Physician(s) were notified of all blood sugars outside of parameters or were excessively high or low. Date completed [DATE].<BR/> - The following in-services were initiated [DATE] by Regional Compliance Nurse. Inservice 100% of staff completion date: [DATE]. Inservice has been added to new-hire packets for all new hires and agency staff to ensure all staff is in-serviced prior to start of their first shift. <BR/> - Perform blood sugar checks as ordered.<BR/> - Ensure any resident who has blood sugar checks has a parameter to the physician or nurse practitioner (NP). This includes when to report new orders for current residents, new admissions, and readmissions.<BR/> - To report to the MD or NP if a blood sugar check is outside the ordered parameters immediately and to initiate any new orders.<BR/> - If resident(s) has an order for glucagon, follow the prescriber's orders.<BR/> - Policy on Notifying the Physician of Change in Status<BR/> - The following in-services were initiated on [DATE] for all NA/CNAs by nursing administration and/or Regional Compliance Nurse. Inservice 100% of NA/CNA completion date [DATE].<BR/> - Hyperglycemia - excessive thirst/dry mouth, excessive urine, increased fatigue/weakness, blurred vision<BR/> - Hypoglycemia-sweating, dizzy, shaking, increased confusion, anxiety, drowsy, change in mental status, slurred speech, nausea, lightheaded, loss of coordination.<BR/> - Notified Medical Director of IJ situation on [DATE] at 6:17 pm. <BR/>Monitoring:<BR/> - At least five (5) times per week, nursing administration will review the previous days orders using the order listing report in [the facility's EMR] to monitor for new orders for blood sugar checks and ensure that parameters are added. This will include new orders for current residents, new admissions, and readmissions. This was initiated on [DATE] continue x 4 weeks. <BR/> - At least 5 times per week nursing administration will review the previous days TARS and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters. This was initiated on [DATE] and will continue x 4 weeks.<BR/> - Nursing Administration will ask at least 10 nursing staff per week a situational question regarding if a resident presented with hyper or hypoglycemia and what they would do. This was initiated on [DATE] and will continue x 4 weeks. <BR/> - DON/Designee will review 5-8 residents slide scale results for proper notification to MD if outside parameters weekly. This will be initiated on [DATE] and continue x 4 weeks.<BR/> - DON/Designee will monitor all blood sugars outside parameters of slide scale for notification to MD weekly x 4 weeks. This was initiated [DATE] and will continue x 4 weeks. <BR/> - Regional Compliance Nurse will monitor for compliance weekly x 4 weeks starting on [DATE]. <BR/> - The QA (Quality Assurance) Committee will review findings and Physician Notification Policy and will make changes as needed monthly. This will occur during the next QAPI (Quality Assurance and Performance Improvement) meeting on [DATE].<BR/>Monitoring of the plan of removal included:<BR/>Interviews were conducted on [DATE] from 02:50 p.m. to 07:47 p.m. with 2 RNs (RN Z and RN AA) of 2 and 9 LVNs (LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, LVN R, and LVN S) of 9, who worked multiple shifts, revealed they had all been trained on the facility policy, Notifying the Physician of Change in Status. The nursing staff were knowledgeable on the requirement that all blood sugar monitoring orders must include blood sugar parameters, and on the protocols to follow including what to document and who to notify if a blood sugar was outside parameters or a resident was showing signs or symptoms of being hypo or hyperglycemic. The staff were able to identify when it would be appropriate to administer glucagon and how to report and document glucagon administration.<BR/>Interviews were conducted on [DATE] from 03:13 p.m. to 08:37 p.m. with 6 CNAs (CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F) of 9, 3 HAs (HA H, HA I, and HA J) of 3, 2 MAs (MA T and MA U) of 3, and 6 SNAs (SNA AB, SNA AC, SNA AD, SNA AE, SNA AF, and SNA AG) of 8; and on [DATE] at 10:32 a.m. with 1 CNA (CNA G). Interviews revealed they worked multiple shifts, had all been trained and were able to identify signs and symptoms of hypo and hyperglycemia, and were knowledgeable on who they needed to report to. <BR/>In an interview and record review with the RCN on [DATE] at 03:55 p.m., she revealed she had started and was conducting the staff in-services. The RCN confirmed the ADMIN, with her present, had notified the facility's medical director of the Immediate Jeopardy (IJ). The RCN revealed the plan for the facility administration to monitor every new blood sugar order, ensuring that every new order included parameters was to review the previous day's (or days' for new orders over the weekends and holidays) orders by printing out an Order Listing Report from the facility's EMR, which would show all of the previous days' orders. The RCN revealed she had completed the initial blood sugar monitoring audit on [DATE]. She revealed that she had discovered a few residents without parameters on their orders. The RCN revealed she called the residents' physicians to add the parameters, asked the physicians about glucagon orders if not currently included in the residents' active order list, and added the orders with parameters per the physician's order. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days orders using the order listing report in [EMR system name] to monitor for new orders for blood sugar checks and ensure that parameters were added., was the monitoring document the facility would use to track their completion of this monitor. The document revealed this monitor was to be tracked 5 times a week for 4 weeks and that the monitor had been completed on [DATE], [DATE], and [DATE] for week 1. The RCN revealed the plan for facility administration to monitor each resident's blood sugar, that had a blood sugar monitoring order, for being completed per order and to verify the resident's MD or NP was notified if the blood sugar was outside parameters was by printing out the previous day's (or days' if after a weekend and/or holiday) Weights and Vitals Summary report from the facility's EMR, which would show all the previous days' blood sugar results, identify any blood sugars outside parameters, and review the resident's progress notes for a note on notification to the physician and/or nurse practitioner for any blood sugar results outside parameters. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days TARs and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters., was the monitoring document the facility would use to track their completion of this monitoring. The document revealed this monitoring was to be tracked 5 times per week for 4 weeks and that the monitoring had been completed on [DATE], [DATE], and [DATE] for week 1. Weights and Vitals Summary reports for dates [DATE], [DATE], and [DATE] were provided and revealed initials on each page to indicate it had been reviewed and check marks next to each blood sugar out of parameters to indicate a corresponding progress note had been confirmed to indicate the MD or NP had been notified. The RCN revealed the ADON would be responsible for completing the review of the 5-8 residents with sliding scale insulin orders for proper notification of the MD if the blood sugar was outside parameters. The RCN stated that this monitor was the same process or intervention as the intervention for reviewing the TARs for residents with orders for blood sugar monitoring. The RCN revealed the plan for the facility administration to ask at least 10 nursing staff situational questions regarding if a resident had high or low blood sugars and what they would do was to utilize the monitoring document, labeled with Nursing administration will ask at least 10 nursing staff per week a situational question ., mark Yes or No if the staff member answered the question correctly or incorrectly, and if incorrect, document how they answered the question incorrectly and what the nursing administration's plan was for correcting the incorrect answer (ex. in-service training). The document revealed this monitoring was to be completed 10 times per week for 4 weeks, had a spot to put the date, indicate if the answer was correct or incorrect, the staff name of the person questioned, and the name of the interviewer. The document revealed two staff members had been questioned, both on [DATE], and both had answered correctly. The RCN revealed the plan for her to monitor that the facility administration and DON/designee were compliant with the other interventions/monitors for 4 weeks was for her to come to the facility at least one time per week, review the other monitoring forms to ensure they are up to date, review the related Weights and Vitals Summary reports and Order Listing Report that the facility will be maintaining in a specified binder, and to mark Yes or No on the monitoring document, labeled with Regional Compliance Nurse and/or ADO (ADON) compliance monitoring:. The document revealed this monitoring was to be completed for 4 weeks and did not have any weeks marked as completed at the time of the interview. <BR/>In an interview with the ADON on [DATE] at 04:08 p.m., she revealed she had received training on the facility policy, Notifying the Physician of Change in Status, blood sugar checks procedure, administering glucagon per order, reporting blood sugars to the resident's physician or NP immediately if outside parameters or when symptomatic, documenting physician notifications and new orders, and verifying that all new blood sugar monitoring orders included parameters on [DATE]. The ADON revealed she was to print out the Weights and Vitals report and document for new orders daily. The ADON revealed she was to review the reports for new orders and to review the blood sugars to identify if any residents had blood sugars less than 60 or over 400. She revealed that she was to review the progress notes and the 24-hour or 72-hour report to confirm the nurse notified and documented that they notified the physician of a blood sugar outside parameters. The ADON revealed she was to ask CNAs from different shifts to determine if they could recognize signs and symptoms of a hyper or hypoglycem[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 3 of 8 residents (Residents #8, #48 and, #50) reviewed for infection control, in that:<BR/>1. CNA C and NA D failed to wash or sanitize their hands after touching the privacy curtain and before starting incontinent care. CNA C failed to wash her hands after providing care and before leaving the resident's room.<BR/>2. CNA B failed to wash her hands after providing care and before leaving the resident's room. CNA B failed to wash her hands before providing care. <BR/>3. LVN E failed to wear gloves before handling medication. <BR/>These failures could place residents at-risk for infection due to improper care practices. <BR/>The findings included:<BR/>1. Record review of Resident #8's face sheet, dated 06/13/2023, revealed an admission date of 03/24/2020 and, a readmission date of 06/06/2020, with diagnoses which included: Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Lumbar spina bifida (birth disorder that involves the incomplete development of the spine), Hypertension (high blood pressure) and, Type 2 diabetes mellitus (high level of sugar in the blood) <BR/>Record review of Resident #8's Annual MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating no cognitive impairment. The resident received extensive assistance for her activities of daily living, had an indwelling catheter and was always incontinent of bowel. <BR/>Record review of Resident #8's care plan, dated 04/25/2023, revealed a problem of The resident has indwelling Foley catheter in place related to neurogenic dysfunction of bladder, unspecified., with a goal of will remain free from catheter-related trauma and s/sx of infection through the next review date.<BR/>Observation on 06/13/23 at 11:33 a.m. revealed while providing catheter care, after washing their hands, CNA C and NA D both touched the privacy curtain to close it with their bare hands. They did not sanitize or wash their hands prior to donning their gloves and started providing catheter care to Resident #8. Further observation revealed after providing care CNA C removed her gloves, collected the trash bag and closed it. Then, without washing her hands she opened the door of the resident's room, walked to the soiled utility room, opened the door of the soiled utility room and left the bag in the soiled utility room. <BR/>During an interview on 06/13/2023 at 11:33 a.m. with CNA C and NA D, they confirmed the environment around the resident was considered dirty and they should have sanitized their hands prior to providing care. <BR/>Further interview with CNA C, she verbally confirmed not washing her hands prior to leaving the room and touching both the resident's door and the soiled utility room's door. She revealed she was not sure how to proceed about washing her hands and then touching the trash bag. They, both, confirmed they received infection control training within the year. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed the environment around the resident was considered dirty and the staff should change their gloves and wash. Staff should sanitize their hands after touching anything in the environment, before touching the resident and at the start of care. She confirmed the staff was to wash their hands after care prior to leave a room. <BR/>She confirmed the staff were in-serviced, by the ADON, in infection control and incontinent care and skills were checked annually and as needed by managment. <BR/>Record review of the annual skills check for CNA C revealed CNA A passed competency for Infection control on 04/21/2023. <BR/>Record review of the annual skills check for NA D revealed NA D passed competency for Infection control on 03/15/2023. <BR/>Record review of the facility policy, titled perineal care, dated 04/05/2022, revealed 7) provide privacy and modesty by closing the door and/or curtain [ .]10) perform hand hygiene, 11) don gloves and all other PPE per standard precaution [ .] 30 tie off the the disposable plastic bag of trash and/or linen 31) perform hand hygiene<BR/>2. Record review of Resident #48's face sheet, dated 06/13/2023, revealed an admission date of 11/03/2021 and, a readmission date of 07/28/2022, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Hypothyroidism(under active thyroid), Hypercholesterolemia(high level of cholesterol(type of fat) in the blood), Down syndrome (genetic disorder associated with developmental and intellectual disability) .<BR/>Record review of Resident #48's quarterly MDS dated [DATE] revealed the resident did not have a BIMS score and had severe cognitive impairment. The resident was completely dependent of the staff for care and was always incontinent of bowel and bladder. <BR/>Record review of Resident #48's care plan, dated 02/15/2022, revealed a problem of The resident has bladder incontinence related to dementia., with a goal of will remain free from skin breakdown due to<BR/>incontinence and brief use through the next review date.<BR/>Observation on 06/13/23 at 10:39 a.m. revealed after providing incontinent care CNA B removed her gloves, collected the trash bag and closed it. Then, without washing her hands she opened the door of the resident's room, walked to the soiled utility room, opened the door of the soiled utility room and left the bag in the soiled utility room. CNA B came back to Resident #48's room and, without washing her hands, transferred Resident #48 from his bed to his wheelchair with the assistance of CNA A. <BR/>During an interview on 06/13/2023 at 11:10 a.m. with CNA B, she verbally confirmed not washing her hands prior to leaving the room and touching both the resident's door and the soiled utility room's door. She verbally confirmed she did not wash her hands prior to transfer the resident after coming back in the room. She confirmed she received infection control training within the year. She refvealed she did not know she had to wash her hands while entering and before leaving a room. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed staff should wash their hands when entering a room to provide care and before leaving the room. She revealed not washing their hands was increasing the risk for cross contamination and infection, She confirmed the staff were in-serviced in infection control and incontinent care and skills were checked annually and as needed. <BR/>Record review of the annual skills check for CNA C revealed CNA B passed competency for Infection control on 11/09/2022. <BR/>Record review of the facility policy, titled perineal care, dated 04/05/2022, revealed 7) provide privacy and modesty by closing the door and/or curtain [ .]10) perform hand hygiene, 11) don gloves and all other PPE per standard precaution [ .] 30 tie off the the disposable plastic bag of trash and/or linen 31) perform hand hygiene<BR/>3. Record review of Resident #50's face sheet, dated 06/13/2023, revealed an admission date of 03/31/2022 and, a readmission date of 01/15/2023, with diagnoses which included: Dementia(decline in cognitive abilities), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Urinary tract infection(an infection in any part of the urinary system, Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Hypertension(high blood pressure), Hemiplegia(Paralysis of one side of the body).<BR/>Record review of Resident #50's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 6, indicating severe cognitive impairment. The resident needed limited assistance with her activities of daily living.<BR/>Observation on 06/13/23 at 9:00 a.m. revealed while administering medications to Resident #50, LVN E touched a capsule with her bare hands to open it and mix the content with pudding to administer it to the resident. <BR/>During an interview on 06/13/2023 at 09:08 a.m. with LVN E, she verbally confirmed she did not use gloves LVN E asked this surveyor if she should have used gloves before touching a capsule of medication to prevent infection to the residents. She confimed she received infection control training within the year. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed staff should not touch solid medications with their bare hands. She confirmed the staff were in-serviced in infection control and skills were checked annually and as needed. <BR/>Record review of the annual skills check for LVN E revealed LVN E passed competency for Infection control on 02/28/2023. <BR/>Record review of the facility policy, titled Oral solid medication administration, dated 2023, revealed if it is necessary to divide or split the medication prior to administration use an approved device or gloved hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents' right to formulate an advance directive for 1 of 8 residents (Resident #7) reviewed for advanced directives, in that:<BR/>The facility failed to ensure Resident #7's Out-of-Hospital Do Not Resuscitate (OOHDNR) was completed with the correct date. <BR/>This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.<BR/>The findings include:<BR/>Record review of Resident #7's face sheet, dated [DATE], revealed the resident had an admission date of [DATE] with diagnoses that included: unspecified dementia, unspecified severity with agitation, depression, and Parkinson's disease with dyskinesia (movement disorders characterized by involuntary muscle movements). Further review of Resident #7's face sheet, revealed under the section ADVANCE DIRECTIVE: DNR Record review of Resident #7's face sheet further revealed a family member to be identified as Resident #7's MPOA.<BR/>Record review of Resident #7's admission MDS was in progress. The BIMS assessment had not yet been completed.<BR/>Record review of Resident #7's Care Plan, last revised on [DATE], revealed a focus area, Resident has an order for Do Not Resuscitate (DNR) and date initiated [DATE].<BR/>Record review of Resident #7's electronic medical record Order Summary Report, Active Orders as of [DATE], revealed an order dated [DATE] for DNR. <BR/>Record review of Resident #7's electronic clinical record revealed a Request for Do Not Resuscitate (DNR) form, dated [DATE], used to communicate to the resident's physician the resident's/family's request for change to DNR status. Further review revealed A. Request for DNR, 1. How is the request for DNR being made? b. Verbally by a resident who is competent.<BR/>Record review of Resident #7's electronic medical record miscellaneous section revealed clinical records faxed from Resident #7's physician's office when the MD referred Resident #7 for admission. Further review of a History and Physical completed while Resident #7 was in the hospital, dated [DATE], revealed CODE STATUS: Patient is not competent at this time, and does not have a power of attorney set up. At this point, patient will be FULL CODE.<BR/>Record review of Resident #7's electronic clinical record revealed an OOH-DNR for Resident #7, signed by two witnesses and the physician, dated [DATE]. Further review revealed Resident #7 signed the OOH-DNR and dated [DATE].<BR/>During an interview and record review with the SW on [DATE] at 4:38 p.m., the SW confirmed Resident #7's family member was the MPOA however stated the facility did not have a copy of the MPOA. The SW stated, she understood what we were signing when I explained it to her. SW stated she was unsure why the date was inaccurate because the resident had said the date out loud as she filled out the form. The SW further revealed herself to be the one responsible to discuss advance directives with residents and families and ensure correct completion of the documents. SW stated the DNR would be invalid, and resident would be changed to Full Code.<BR/>During an interview and record review with the Administrator on [DATE] at 5:48 p.m., the Administrator confirmed the date on Resident #7's OOH-DNR was incorrect. The Administrator revealed he contacted the MPOA and had obtained a new OOH-DNR for Resident #7. Further review of the OOH-DNR revealed the OOH-DNR did not have a physician's signature. The Administrator was asked if the incomplete DNR was valid, and he state the resident would be considered DNR because of the verbal order from the physician. The Administrator revealed the facility has a form they send to the physician when the resident or family requested to become DNR and once the physician signed the form, the order was written. <BR/>In a follow up interview and record review with the Administrator on [DATE] at 6:35 p.m., the Administrator provided a printout of the Health and Safety Code, Subchapter E. Healthcare Facility Do-Not-Resuscitate Orders, Section 166.202, and stated we follow our policy and were directed to follow the Health and Safety Code.<BR/>Record review of the Health and Safety Code, Subchapter E. Healthcare Facility Do-Not-Resuscitate Orders, Section 166.202 Applicability of Subchapter. (a) This subchapter applies to a DNR order issued in a health care facility or hospital. (b) this subchapter does not apply to an out-of-hospital DNR order as defined by Section 166.081. Review of Section 166.081 in Subchapter C. Out-Of-Hospital Do-Not-Resuscitate Orders revealed (6) Out-of-hospital DNR order: (A) means a legally binding out-of-hospital do-not-resuscitate order, in the form specified by department rule under Section 166.083, prepared and signed by the attending physician of a person, that documents the instructions of a person or the person's legally authorized representative and directs health care professionals acting in an out-of-hospital setting not to initiate or continue the following life -sustaining treatment . (B) (7) Out-of-hospital setting means a location in which health care professionals are called for assistance, including long-term care facilities, in-patient hospice facilities, private homes, hospital out-patient or emergency departments, physician's offices, and vehicles during transport.<BR/>Record review of the facility's policy titled, Do Not Resuscitate Order, revised [DATE], revealed, The facility will honor two types of Do Not Resuscitate orders: a physician's order for Do Not Resuscitate and the Texas Out-of-Hospital DNR Order. Out of Hospital DNR Form, Procedure: Texas Out of Hospital DNR Form, 12. Social services will assist all interested family members and residents will information, education, and execution of the DNR form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of records. <BR/>The facility failed to ensure Resident #1's bath or shower was documented as given or as refused 9 times in May and June 2025.<BR/>These failures could place residents at risk for improper care due to inaccurate records. <BR/>Findings included: <BR/>Record review of Resident #1's admission Record (face sheet) dated 06/07/2025 revealed she was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder (is a mental health condition that is marked by hallucinations and delusions),anxiety disorder (disorder involving feelings of nervousness, panic and fear) and hypertension (condition in which the force of the blood against the artery walls is too high) . <BR/>Record review of Resident #1's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 15 out of 15, indication her cognitive skills for daily decision making were intact; and the resident was dependent on staff to be showered or bath<BR/>Record review of Resident #1's Care Plan for Self-Care performance deficit, initiated on 01/05/2021 and revised on 03/07/2022, revealed under interventions assist with personal hygiene . <BR/>Record review of Resident #1's undated Kardex revealed the resident preferred to be bathed 2-3 times a week.<BR/>Record review of Resident #1's nurses' notes from 05/01/2025 to 06/01/2025 revealed no notation of Resident #1 had refused to be bathed.<BR/>Record review of the undated Shower Schedule revealed Resident #1 was to be bathed on Monday, Wednesday, and Friday on the 6 am - 2 pm shift. <BR/>Record review of Resident #1's electronic clinical record for the Bathing Task from 05/01/2025 to 06/03/2025 revealed Resident #1 had only been bathed 6 times on: 05/02/2025, 05/05/2025, 05/05/2025, 05/07/2025,05/09/2025, and 05/12/2025; there was no documentation the resident had refused to be bathed; and there was no documentation if Resident #1 was bathed or refused on her scheduled shower days on 05/14/2025, 05/16/2025, 05/19/2025, 05/21/2025, 05/23/2025, 05/26/2025, 05/28/2025, 05/30/2025, and 06/02/2025.<BR/>Observation on 6/7/2025 from 11:00 AM - 11:05 AM revealed the Regional Compliance Nurse completing a shower for Resident #1 and making beds throughout the facility. <BR/>Interview on 6/7/2025 at 11:08 AM, the Regional compliance nurse stated that she had spoken with the CNA's who were responsible for bathing Resident #1 on the following dates: 5/19/2025, 5/21/2025, 5/23/2025, 5/26/2025, 5/28/2025, 5/30/2025, and 6/2/2025.<BR/>Resident #1 was bathed on 5/14/2025 and 5/16/2025 but refused to be bathed on the following dates: 5/19/2025, 5/21/2025, 5/23/2025, 5/26/2025, 5/28/2025, 5/30/2025, and 6/2/2025. The Regional Compliance Nurse indicated that if a resident refused to bathe, the CNA should document this refusal in the Point of Contact Tasks and inform the charge nurse. <BR/>Interview with Resident #1 on 6/7/2025 at 1:30 PM, revealed she had refused some shower days but could not recall which days. <BR/>In a subsequent interview on 6/7/2025 at 1:13 PM, the Regional Compliance Nurse reiterated that nursing staff should also document in the nurses' progress notes if a resident had refused to be bathed. She emphasized that if the resident's bathing status was not recorded in their clinical record-indicating whether the resident had been bathed or had refused to be bathed-it would lead to inaccurate documentation. However, she did not foresee any harm to the resident resulting from this issue.<BR/>Record review of the undated, facility Documentation policy revealed, complete documentation as needed promptly, document or check information on flow sheets each shift or as appropriate for the care or treatment being monitored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 3 of 8 residents (Residents #8, #48 and, #50) reviewed for infection control, in that:<BR/>1. CNA C and NA D failed to wash or sanitize their hands after touching the privacy curtain and before starting incontinent care. CNA C failed to wash her hands after providing care and before leaving the resident's room.<BR/>2. CNA B failed to wash her hands after providing care and before leaving the resident's room. CNA B failed to wash her hands before providing care. <BR/>3. LVN E failed to wear gloves before handling medication. <BR/>These failures could place residents at-risk for infection due to improper care practices. <BR/>The findings included:<BR/>1. Record review of Resident #8's face sheet, dated 06/13/2023, revealed an admission date of 03/24/2020 and, a readmission date of 06/06/2020, with diagnoses which included: Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Lumbar spina bifida (birth disorder that involves the incomplete development of the spine), Hypertension (high blood pressure) and, Type 2 diabetes mellitus (high level of sugar in the blood) <BR/>Record review of Resident #8's Annual MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating no cognitive impairment. The resident received extensive assistance for her activities of daily living, had an indwelling catheter and was always incontinent of bowel. <BR/>Record review of Resident #8's care plan, dated 04/25/2023, revealed a problem of The resident has indwelling Foley catheter in place related to neurogenic dysfunction of bladder, unspecified., with a goal of will remain free from catheter-related trauma and s/sx of infection through the next review date.<BR/>Observation on 06/13/23 at 11:33 a.m. revealed while providing catheter care, after washing their hands, CNA C and NA D both touched the privacy curtain to close it with their bare hands. They did not sanitize or wash their hands prior to donning their gloves and started providing catheter care to Resident #8. Further observation revealed after providing care CNA C removed her gloves, collected the trash bag and closed it. Then, without washing her hands she opened the door of the resident's room, walked to the soiled utility room, opened the door of the soiled utility room and left the bag in the soiled utility room. <BR/>During an interview on 06/13/2023 at 11:33 a.m. with CNA C and NA D, they confirmed the environment around the resident was considered dirty and they should have sanitized their hands prior to providing care. <BR/>Further interview with CNA C, she verbally confirmed not washing her hands prior to leaving the room and touching both the resident's door and the soiled utility room's door. She revealed she was not sure how to proceed about washing her hands and then touching the trash bag. They, both, confirmed they received infection control training within the year. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed the environment around the resident was considered dirty and the staff should change their gloves and wash. Staff should sanitize their hands after touching anything in the environment, before touching the resident and at the start of care. She confirmed the staff was to wash their hands after care prior to leave a room. <BR/>She confirmed the staff were in-serviced, by the ADON, in infection control and incontinent care and skills were checked annually and as needed by managment. <BR/>Record review of the annual skills check for CNA C revealed CNA A passed competency for Infection control on 04/21/2023. <BR/>Record review of the annual skills check for NA D revealed NA D passed competency for Infection control on 03/15/2023. <BR/>Record review of the facility policy, titled perineal care, dated 04/05/2022, revealed 7) provide privacy and modesty by closing the door and/or curtain [ .]10) perform hand hygiene, 11) don gloves and all other PPE per standard precaution [ .] 30 tie off the the disposable plastic bag of trash and/or linen 31) perform hand hygiene<BR/>2. Record review of Resident #48's face sheet, dated 06/13/2023, revealed an admission date of 11/03/2021 and, a readmission date of 07/28/2022, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Hypothyroidism(under active thyroid), Hypercholesterolemia(high level of cholesterol(type of fat) in the blood), Down syndrome (genetic disorder associated with developmental and intellectual disability) .<BR/>Record review of Resident #48's quarterly MDS dated [DATE] revealed the resident did not have a BIMS score and had severe cognitive impairment. The resident was completely dependent of the staff for care and was always incontinent of bowel and bladder. <BR/>Record review of Resident #48's care plan, dated 02/15/2022, revealed a problem of The resident has bladder incontinence related to dementia., with a goal of will remain free from skin breakdown due to<BR/>incontinence and brief use through the next review date.<BR/>Observation on 06/13/23 at 10:39 a.m. revealed after providing incontinent care CNA B removed her gloves, collected the trash bag and closed it. Then, without washing her hands she opened the door of the resident's room, walked to the soiled utility room, opened the door of the soiled utility room and left the bag in the soiled utility room. CNA B came back to Resident #48's room and, without washing her hands, transferred Resident #48 from his bed to his wheelchair with the assistance of CNA A. <BR/>During an interview on 06/13/2023 at 11:10 a.m. with CNA B, she verbally confirmed not washing her hands prior to leaving the room and touching both the resident's door and the soiled utility room's door. She verbally confirmed she did not wash her hands prior to transfer the resident after coming back in the room. She confirmed she received infection control training within the year. She refvealed she did not know she had to wash her hands while entering and before leaving a room. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed staff should wash their hands when entering a room to provide care and before leaving the room. She revealed not washing their hands was increasing the risk for cross contamination and infection, She confirmed the staff were in-serviced in infection control and incontinent care and skills were checked annually and as needed. <BR/>Record review of the annual skills check for CNA C revealed CNA B passed competency for Infection control on 11/09/2022. <BR/>Record review of the facility policy, titled perineal care, dated 04/05/2022, revealed 7) provide privacy and modesty by closing the door and/or curtain [ .]10) perform hand hygiene, 11) don gloves and all other PPE per standard precaution [ .] 30 tie off the the disposable plastic bag of trash and/or linen 31) perform hand hygiene<BR/>3. Record review of Resident #50's face sheet, dated 06/13/2023, revealed an admission date of 03/31/2022 and, a readmission date of 01/15/2023, with diagnoses which included: Dementia(decline in cognitive abilities), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Urinary tract infection(an infection in any part of the urinary system, Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Hypertension(high blood pressure), Hemiplegia(Paralysis of one side of the body).<BR/>Record review of Resident #50's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 6, indicating severe cognitive impairment. The resident needed limited assistance with her activities of daily living.<BR/>Observation on 06/13/23 at 9:00 a.m. revealed while administering medications to Resident #50, LVN E touched a capsule with her bare hands to open it and mix the content with pudding to administer it to the resident. <BR/>During an interview on 06/13/2023 at 09:08 a.m. with LVN E, she verbally confirmed she did not use gloves LVN E asked this surveyor if she should have used gloves before touching a capsule of medication to prevent infection to the residents. She confimed she received infection control training within the year. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed staff should not touch solid medications with their bare hands. She confirmed the staff were in-serviced in infection control and skills were checked annually and as needed. <BR/>Record review of the annual skills check for LVN E revealed LVN E passed competency for Infection control on 02/28/2023. <BR/>Record review of the facility policy, titled Oral solid medication administration, dated 2023, revealed if it is necessary to divide or split the medication prior to administration use an approved device or gloved hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of records. <BR/>The facility failed to ensure Resident #1's bath or shower was documented as given or as refused 9 times in May and June 2025.<BR/>These failures could place residents at risk for improper care due to inaccurate records. <BR/>Findings included: <BR/>Record review of Resident #1's admission Record (face sheet) dated 06/07/2025 revealed she was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder (is a mental health condition that is marked by hallucinations and delusions),anxiety disorder (disorder involving feelings of nervousness, panic and fear) and hypertension (condition in which the force of the blood against the artery walls is too high) . <BR/>Record review of Resident #1's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 15 out of 15, indication her cognitive skills for daily decision making were intact; and the resident was dependent on staff to be showered or bath<BR/>Record review of Resident #1's Care Plan for Self-Care performance deficit, initiated on 01/05/2021 and revised on 03/07/2022, revealed under interventions assist with personal hygiene . <BR/>Record review of Resident #1's undated Kardex revealed the resident preferred to be bathed 2-3 times a week.<BR/>Record review of Resident #1's nurses' notes from 05/01/2025 to 06/01/2025 revealed no notation of Resident #1 had refused to be bathed.<BR/>Record review of the undated Shower Schedule revealed Resident #1 was to be bathed on Monday, Wednesday, and Friday on the 6 am - 2 pm shift. <BR/>Record review of Resident #1's electronic clinical record for the Bathing Task from 05/01/2025 to 06/03/2025 revealed Resident #1 had only been bathed 6 times on: 05/02/2025, 05/05/2025, 05/05/2025, 05/07/2025,05/09/2025, and 05/12/2025; there was no documentation the resident had refused to be bathed; and there was no documentation if Resident #1 was bathed or refused on her scheduled shower days on 05/14/2025, 05/16/2025, 05/19/2025, 05/21/2025, 05/23/2025, 05/26/2025, 05/28/2025, 05/30/2025, and 06/02/2025.<BR/>Observation on 6/7/2025 from 11:00 AM - 11:05 AM revealed the Regional Compliance Nurse completing a shower for Resident #1 and making beds throughout the facility. <BR/>Interview on 6/7/2025 at 11:08 AM, the Regional compliance nurse stated that she had spoken with the CNA's who were responsible for bathing Resident #1 on the following dates: 5/19/2025, 5/21/2025, 5/23/2025, 5/26/2025, 5/28/2025, 5/30/2025, and 6/2/2025.<BR/>Resident #1 was bathed on 5/14/2025 and 5/16/2025 but refused to be bathed on the following dates: 5/19/2025, 5/21/2025, 5/23/2025, 5/26/2025, 5/28/2025, 5/30/2025, and 6/2/2025. The Regional Compliance Nurse indicated that if a resident refused to bathe, the CNA should document this refusal in the Point of Contact Tasks and inform the charge nurse. <BR/>Interview with Resident #1 on 6/7/2025 at 1:30 PM, revealed she had refused some shower days but could not recall which days. <BR/>In a subsequent interview on 6/7/2025 at 1:13 PM, the Regional Compliance Nurse reiterated that nursing staff should also document in the nurses' progress notes if a resident had refused to be bathed. She emphasized that if the resident's bathing status was not recorded in their clinical record-indicating whether the resident had been bathed or had refused to be bathed-it would lead to inaccurate documentation. However, she did not foresee any harm to the resident resulting from this issue.<BR/>Record review of the undated, facility Documentation policy revealed, complete documentation as needed promptly, document or check information on flow sheets each shift or as appropriate for the care or treatment being monitored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 3 of 8 residents (Residents #8, #48 and, #50) reviewed for infection control, in that:<BR/>1. CNA C and NA D failed to wash or sanitize their hands after touching the privacy curtain and before starting incontinent care. CNA C failed to wash her hands after providing care and before leaving the resident's room.<BR/>2. CNA B failed to wash her hands after providing care and before leaving the resident's room. CNA B failed to wash her hands before providing care. <BR/>3. LVN E failed to wear gloves before handling medication. <BR/>These failures could place residents at-risk for infection due to improper care practices. <BR/>The findings included:<BR/>1. Record review of Resident #8's face sheet, dated 06/13/2023, revealed an admission date of 03/24/2020 and, a readmission date of 06/06/2020, with diagnoses which included: Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Lumbar spina bifida (birth disorder that involves the incomplete development of the spine), Hypertension (high blood pressure) and, Type 2 diabetes mellitus (high level of sugar in the blood) <BR/>Record review of Resident #8's Annual MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating no cognitive impairment. The resident received extensive assistance for her activities of daily living, had an indwelling catheter and was always incontinent of bowel. <BR/>Record review of Resident #8's care plan, dated 04/25/2023, revealed a problem of The resident has indwelling Foley catheter in place related to neurogenic dysfunction of bladder, unspecified., with a goal of will remain free from catheter-related trauma and s/sx of infection through the next review date.<BR/>Observation on 06/13/23 at 11:33 a.m. revealed while providing catheter care, after washing their hands, CNA C and NA D both touched the privacy curtain to close it with their bare hands. They did not sanitize or wash their hands prior to donning their gloves and started providing catheter care to Resident #8. Further observation revealed after providing care CNA C removed her gloves, collected the trash bag and closed it. Then, without washing her hands she opened the door of the resident's room, walked to the soiled utility room, opened the door of the soiled utility room and left the bag in the soiled utility room. <BR/>During an interview on 06/13/2023 at 11:33 a.m. with CNA C and NA D, they confirmed the environment around the resident was considered dirty and they should have sanitized their hands prior to providing care. <BR/>Further interview with CNA C, she verbally confirmed not washing her hands prior to leaving the room and touching both the resident's door and the soiled utility room's door. She revealed she was not sure how to proceed about washing her hands and then touching the trash bag. They, both, confirmed they received infection control training within the year. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed the environment around the resident was considered dirty and the staff should change their gloves and wash. Staff should sanitize their hands after touching anything in the environment, before touching the resident and at the start of care. She confirmed the staff was to wash their hands after care prior to leave a room. <BR/>She confirmed the staff were in-serviced, by the ADON, in infection control and incontinent care and skills were checked annually and as needed by managment. <BR/>Record review of the annual skills check for CNA C revealed CNA A passed competency for Infection control on 04/21/2023. <BR/>Record review of the annual skills check for NA D revealed NA D passed competency for Infection control on 03/15/2023. <BR/>Record review of the facility policy, titled perineal care, dated 04/05/2022, revealed 7) provide privacy and modesty by closing the door and/or curtain [ .]10) perform hand hygiene, 11) don gloves and all other PPE per standard precaution [ .] 30 tie off the the disposable plastic bag of trash and/or linen 31) perform hand hygiene<BR/>2. Record review of Resident #48's face sheet, dated 06/13/2023, revealed an admission date of 11/03/2021 and, a readmission date of 07/28/2022, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Hypothyroidism(under active thyroid), Hypercholesterolemia(high level of cholesterol(type of fat) in the blood), Down syndrome (genetic disorder associated with developmental and intellectual disability) .<BR/>Record review of Resident #48's quarterly MDS dated [DATE] revealed the resident did not have a BIMS score and had severe cognitive impairment. The resident was completely dependent of the staff for care and was always incontinent of bowel and bladder. <BR/>Record review of Resident #48's care plan, dated 02/15/2022, revealed a problem of The resident has bladder incontinence related to dementia., with a goal of will remain free from skin breakdown due to<BR/>incontinence and brief use through the next review date.<BR/>Observation on 06/13/23 at 10:39 a.m. revealed after providing incontinent care CNA B removed her gloves, collected the trash bag and closed it. Then, without washing her hands she opened the door of the resident's room, walked to the soiled utility room, opened the door of the soiled utility room and left the bag in the soiled utility room. CNA B came back to Resident #48's room and, without washing her hands, transferred Resident #48 from his bed to his wheelchair with the assistance of CNA A. <BR/>During an interview on 06/13/2023 at 11:10 a.m. with CNA B, she verbally confirmed not washing her hands prior to leaving the room and touching both the resident's door and the soiled utility room's door. She verbally confirmed she did not wash her hands prior to transfer the resident after coming back in the room. She confirmed she received infection control training within the year. She refvealed she did not know she had to wash her hands while entering and before leaving a room. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed staff should wash their hands when entering a room to provide care and before leaving the room. She revealed not washing their hands was increasing the risk for cross contamination and infection, She confirmed the staff were in-serviced in infection control and incontinent care and skills were checked annually and as needed. <BR/>Record review of the annual skills check for CNA C revealed CNA B passed competency for Infection control on 11/09/2022. <BR/>Record review of the facility policy, titled perineal care, dated 04/05/2022, revealed 7) provide privacy and modesty by closing the door and/or curtain [ .]10) perform hand hygiene, 11) don gloves and all other PPE per standard precaution [ .] 30 tie off the the disposable plastic bag of trash and/or linen 31) perform hand hygiene<BR/>3. Record review of Resident #50's face sheet, dated 06/13/2023, revealed an admission date of 03/31/2022 and, a readmission date of 01/15/2023, with diagnoses which included: Dementia(decline in cognitive abilities), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Urinary tract infection(an infection in any part of the urinary system, Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Hypertension(high blood pressure), Hemiplegia(Paralysis of one side of the body).<BR/>Record review of Resident #50's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 6, indicating severe cognitive impairment. The resident needed limited assistance with her activities of daily living.<BR/>Observation on 06/13/23 at 9:00 a.m. revealed while administering medications to Resident #50, LVN E touched a capsule with her bare hands to open it and mix the content with pudding to administer it to the resident. <BR/>During an interview on 06/13/2023 at 09:08 a.m. with LVN E, she verbally confirmed she did not use gloves LVN E asked this surveyor if she should have used gloves before touching a capsule of medication to prevent infection to the residents. She confimed she received infection control training within the year. <BR/>During an interview with the DON on 06/14/2023 at 10:25 a.m., she confirmed staff should not touch solid medications with their bare hands. She confirmed the staff were in-serviced in infection control and skills were checked annually and as needed. <BR/>Record review of the annual skills check for LVN E revealed LVN E passed competency for Infection control on 02/28/2023. <BR/>Record review of the facility policy, titled Oral solid medication administration, dated 2023, revealed if it is necessary to divide or split the medication prior to administration use an approved device or gloved hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for 1 of 2 residents (Resident #35) reviewed for care plans. The facility failed to update the comprehensive care plan to reflect Resident #35 was receiving hospice services. This failure could have placed residents at risk of not having their needs identified and met. Findings included: Record review of Resident #35's admission Record documented an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #35 had diagnoses which included dementia in other diseases classified elsewhere, severe, with other behavioral disturbance (a medical diagnosis indicating severe dementia occurring in a patient whose dementia is caused by an underlying physiological condition), Parkinson's Disease with dyskinesia (the loss of dopamine-producing neurons in the brain in which the patient does not experience involuntary, repetitive movements that are often a side effect of Parkinson's medications), and dysphagia, pharyngeal stage (difficulty swallowing). Record review of Resident #35's physician's orders, as of 08/21/25, indicated an order for hospice on 06/26/25.Record review of Resident #35's care plan did not indicate the care plan had been updated to reflect the implementation of hospice.During an interview with the MDS Coordinator on 08/21/25 at 7:17 pm, she stated the initiation of hospice was not in Resident #35's care plan. The MDS Coordinator stated she was the only one to do care plans and it was important for everyone to know that someone was on hospice so there would be coordination of care.Record review of the facility's undated policy titled Comprehensive Care Planning documented the resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete an assessment which accurately reflected the resident's status for 1 of 15 (Resident #1) residents reviewed, in that: <BR/>Resident #1's diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder were not included in the resident's comprehensive and quarterly MDS assessments.<BR/>This failure could result in inadequate care due to an incomplete assessment of her psychological condition. <BR/>The findings were: <BR/>Record review of Resident #1's facesheet, dated 06/12/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia, Unspecified Atrial Fibrillation, and Type 2 Diabetes Mellitus with Diabetic Neuropathy. <BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 6 which indicated severe cognitive impairment. <BR/>Record review of Resident #1's care plan, initiated 11/23/2021, revealed a focus, The resident has impaired cognitive function/dementia or impaired thought processes [sic] Dementia.<BR/>Record review of Resident #1's initial psychological diagnostic assessment, completed by LCSW F, dated, 02/23/2021, revealed diagnoses of Major depressive disorder, recurrent, mild and Generalized anxiety disorder. <BR/>Record review of Resident #1's most recent psychological services progress note, completed by LCSW F, dated 06/05/2023, revealed diagnoses of Major depressive disorder, recurrent, mild and Generalized anxiety disorder. <BR/>Record review of Resident #1's most recent quarterly MDS assessment, dated 03/03/2023, revealed Section I Active Diagnoses, Sub-section Psychiatric/Mood Disorder was left blank. <BR/>Record review of Resident #1's most recent comprehensive MDS assessment, dated 06/01/2022, revealed Section I Active Diagnoses, Sub-section Psychiatric/Mood Disorder was left blank. <BR/>During an interview with the MDS/Care Plan Coordinator on 06/13/2023 at 02:45 p.m., the MDS/Care Plan Coordinator verbally confirmed Resident #1's diagnoses of Major depressive disorder, recurrent, mild and Generalized anxiety disorder were not included on the resident'scomprehensive and quarterly MDS assessments. The MDS/Care Plan Coordinator stated the diagnoses should have been listed on the assessment and that the omission was an oversight. The MDS/Care Plan Coordinator verbally confirmed that Resident #1's medical providers and caregivers may not be aware of the resident's psychological diagnoses if the diagnoses are not included on the resident's comprehensive assessment. <BR/>During an interview with the DON on 06/14/2023 at 5:10 p.m., the DON verbally confirmed that all resident clinical records, including the comprehensive and quarterly MDS assessments, should be complete and accurate.<BR/>Record review of the facility policy, Minimum Data Set (MDS) Policy for MDS Assessment Data Accuracy, dated February 2012, revealed, The purpose of the MDS policy is to ensure each resident receives and accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental and psychological well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 15 (Resident #1) residents reviewed, in that: <BR/>Resident #1's diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder were not included in the resident's care plan. <BR/>This deficient practice could place residents at risk of improper care due to inaccurate care plans.<BR/>The findings were:<BR/>Record review of Resident #1's facesheet, dated 06/12/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia, Unspecified Atrial Fibrillation, and Type 2 Diabetes Mellitus with Diabetic Neuropathy. <BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 6 which indicated severe cognitive impairment. <BR/>Record review of Resident #1's care plan, initiated 11/23/2021, revealed a focus, The resident has impaired cognitive function/dementia or impaired thought processes [sic] Dementia.<BR/>Record review of Resident #1's initial psychological diagnostic assessment, completed by LCSW F, dated, 02/23/2021, revealed diagnoses of Major depressive disorder, recurrent, mild and Generalized anxiety disorder. <BR/>Record review of Resident #1's most recent psychological services progress note, completed by LCSW F, dated 06/05/2023, revealed diagnoses of Major depressive disorder, recurrent, mild and Generalized anxiety disorder. <BR/>Further review of Resident #1's care plan, initiated 05/26/2020, revealed Resident #1's diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder were not addressed by the resident's care plan.<BR/>During an interview with the MDS/Care Plan Coordinator on 06/13/2023 at 02:45 p.m., the MDS/Care Plan Coordinator verbally confirmed Resident #1's diagnoses of Major depressive disorder, recurrent, mild and Generalized anxiety disorder were not addressed by the resident's care plan The MDS/Care Plan Coordinator stated the diagnoses should have been listed on the care plan and that the omission was an oversight. The MDS/Care Plan Coordinator verbally confirmed that Resident #1's medical providers and caregivers may not be aware of the resident's psychological diagnoses if the diagnoses are not included on the resident's care plan. <BR/>During an interview with the DON on 06/14/2023 at 5:10 p.m., the DON verbally confirmed that all resident clinical records, including the residents' care plans, should be complete and accurate.<BR/>Record review of the facility policy, Comprehensive Care Planning, undated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychological needs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of thirteen residents reviewed for notification of changes. <BR/>The facility failed to notify the physician for an acute change in a resident's condition related to type 2 diabetes, resulting in the resident was hospitalized on [DATE] and expired on [DATE].<BR/>An immediate jeopardy (IJ) was identified on [DATE] at 01:27 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. <BR/>This deficient practice could place residents at risks for a delay in medical treatment, which could lead to worsening of their condition, hospitalization, or death.<BR/>Findings included: <BR/>Record review of Resident #1's Administration Record, dated [DATE], revealed an [AGE] year-old male who originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident #1 was noted to have discharged [DATE] to an acute care hospital. Resident #1 had diagnoses which included the following: diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes), and heart failure.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 04, which indicated Resident #1's cognition was severely impaired. The MDS revealed Resident #1 was diabetic and received insulin injections. Further review revealed Resident #1 was dependent with mobility in rolling left to right, sit to lying, lying to sitting on side of bed, and sit to stand. Resident #1 required substantial to maximal assistance with chair to bed transfer, toilet transfer, and tub or shower transfer. Resident #1 was noted to have had an indwelling catheter (a tube that drains urine from the bladder into a bag outside the body) and always bowel incontinent. <BR/>Record review of Resident #1's Care Plan, dated as last reviewed [DATE], reflected Resident #1 had diagnosed diabetes mellitus with other neurological complications (date initiated: [DATE] and date revised: [DATE]) and the interventions included: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. and Fasting Serum Blood Sugar as ordered by doctor, report any abnormal levels. The Care Plan reflected Resident #1 had an altered endocrine system (a network of glands and organs in the body that use hormones to control and regulate many of the body's functions) status related to chronic kidney disease (date initiated and revised: [DATE]) and the interventions included: Fasting Blood Glucose as ordered by MD, Monitor/document/report to MD PRN any s/sx (signs and symptoms) of behavioral changes: nervousness, increased irritability, emotional lability (change or inconsistency), insomnia, extreme fatigue, confusion, disorientation, delirium, psychosis, stupor, coma. and Monitor/document/report to MD PRN for s/sx of hyperglycemia (elevated or high blood sugar): increased thirst and appetite, weight loss, fatigue, dry skin, poor healing, muscle cramps, abdominal pain, deep labored breathing (Kussmaul), acetone (fruity) breath, stupor, coma.<BR/>Record review of Resident #1's Order Summary Report, order date range: [DATE] - [DATE], revealed Resident #1 had active blood glucose check orders which included: Glucose Check BID x 7 days then report to PCP on 02/22 two times a day (repeated direction to check blood sugars twice a day) related to type 2 diabetes mellitus with hyperglycemia, ordered and start date: [DATE], Monitor for signs or symptoms of hypoglycemia or hyperglycemia Q shift. Every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy (damage to the nerves that control arm and leg movement), ordered [DATE] and started [DATE], and Monitor resident for confusion, combativeness, and restlessness. If resident is experiencing any of these, check blood sugar, every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy, ordered [DATE] and started [DATE]. Active blood glucose check orders found to not include blood sugar parameters, directing staff when they were to notify the physician of blood sugars below or above the expected range. Resident #1 had active diabetes medication orders which included: Glucagon Emergency Injection Kit 1 MG .Inject 1 mg subcutaneously (between the skin and muscle) as needed for signs or symptoms of hypoglycemia related to type 2 diabetes mellitus with other diabetic neurological complication, ordered and started [DATE] and Trulicity Subcutaneous Solution Pen-injector 0.75 mg/0.5 mL .Inject 0.75 mg subcutaneously one time a day every 7 days(s) related to Type 2 diabetes mellitus with hyperglycemia, ordered [DATE] and started [DATE]. Active diabetes medication orders found to not include an active order for insulin.<BR/>Record review of Resident #1's TAR, dated [DATE] - [DATE], revealed Resident #1's blood sugar checks BID which included: <BR/>- a blood sugar of 577 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, <BR/>- a blood sugar of 432 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, <BR/>- a blood sugar of 550 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, <BR/>- a blood sugar of 487 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, <BR/>- a blood sugar of 498 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, <BR/>- a blood sugar of 502 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, <BR/>- a blood sugar of 486 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P,<BR/>- a blood sugar of 424 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, <BR/>- a blood sugar of 492 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P,<BR/>- a blood sugar of 498 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, and <BR/>- the blood sugar check coded as not taken due to hospitalization by LVN M. <BR/>Record review of Resident #1's progress notes, dated [DATE] at 07:00 p.m., revealed the following note by the ADON, [Resident #1's PCP] notified of resident with blood sugar 577. Asymptomatic (no symptoms). No new orders.<BR/>Record review of Resident #1's progress notes, dated [DATE] at 10:00 a.m., revealed the following note by RN Z, [Resident #1's PCP] is aware of blood sugar this AM (morning) 432; no new orders at this time. <BR/>Record review of Resident #1's progress notes, dated [DATE] at 12:55 p.m., revealed the following note by LVN 1, .[MD X] will no longer be PCP for [Resident #1]. She (Resident #1 RP) stated [MD W] will now be his primary care physician. I informed [MD X], and notified [MD W]'s nurse of change effective today.<BR/>Record review of Resident #1's progress notes, dated from [DATE] at 10:01 a.m. to [DATE] at 03:53 p.m., revealed no progress notes mentioning blood sugar results or notification to physician. <BR/>Record review of Resident #1's progress notes, dated [DATE] at 03:54 p.m., revealed the following note by RN Z, one week of blood sugar results sent to [Resident #1's PCP]. Pending response.<BR/>Record review of Resident #1's progress notes, dated [DATE] at 04:00 p.m., revealed the following note by RN Z, called into room by CNAs. Res (resident) was lying in bed with eyes closed, respirations shallow, difficult to arouse. Unresponsive to tactile stimuli. Upon assessment .blood sugar too high to register on glucometer (machine used to test blood sugar). Immediately contacted [Resident #1's PCP]. New orders received to send to [local hospital] ER (emergency room) for further eval (evaluation) and tx (treatment) . <BR/>Record review of Resident #1's progress notes, dated [DATE] at 04:09 p.m., revealed the following note by LVN N, [Resident #1] was transferred to a hospital on [DATE] 4:05 PM related to High blood sugar, unresponsive.<BR/>Record review of Resident #1's progress notes, dated [DATE] at 11:40 a.m., revealed the following note by RN Z, Res (resident) is admitted to [hospital name and location]; ICU (intensive care unit) DX (diagnoses): Hyperglycemia, Altered Mental Status. <BR/>Record review of Resident #1's hospital records, dated [DATE], reflected Resident #1 was admitted to the ER on [DATE] at 05:44 p.m. The records reflected Resident #1 was discharged from the ER on [DATE] to an alternate hospital. The ER notes dated [DATE] reflected Resident #1's chief complaint was hyperglycemia and an altered mental status. Resident #1 noted to had started seizing when on bed with no prior history of seizures. Resident #1 was intubated and placed on a mechanical ventilator, diagnosed with altered mental status, hyperglycemia (high blood glucose/sugar), hyperosmolar hyperglycemic state (HHS; a life-threatening complication of diabetes when the blood glucose or blood sugar levels are too high for a long period, leading to severe dehydration and confusion), seizure, respiratory failure, GI (gastrointestinal) bleed, sepsis (a condition in which the body's extreme response to an infection become life-threatening), urinary tract infection, and an electrolyte disorder. Glucose level measured at 798 mg/dL on [DATE] at 05:52 p.m. <BR/>Record review of addendum to facility self-report to HHSC Complaint and Incident Intake, dated [DATE] at 03:53 p.m., revealed the following note by the ADMIN, He (Resident #1) passed away on [DATE] at 10:37 p.m. We (the facility) do not have a cause of death at this time.<BR/>Interview with RN Z on [DATE] at 03:01 p.m. revealed she had reviewed Resident #1's weekend blood sugars when she came in to work on Monday, [DATE], seen that they were elevated, and sent the blood sugar results to Resident #1's physician. RN Z stated she had reported his high blood sugar that morning but Resident #1 was awake, alert, and up in the dining room for breakfast and lunch. RN Z stated Resident #1's change in condition started right before she had sent him out, after lunch. RN Z stated she did not hear back from Resident #1's physician when reporting the initial high blood sugar but called the physician again for the change of condition and transfer out to the hospital. RN Z did not state the time for the second call to Resident #1's physician. RN Z described Resident #1's change as condition as being slower to respond, not really answering staff, and just not himself.<BR/>Interview with SNA AC on [DATE] at 03:17 p.m., revealed she had been taking care of Resident# 1 on Sunday, [DATE] and around 05:30 p.m. observed a concern about how Resident #1 was positioned in bed and that Resident #1 was not breathing as good as he normally did. SNA AC stated she had reported her observations to the nurse. SNA AC stated she had worked at the facility for less than a month and had not yet been trained on how to document in the facility's EMR. <BR/>Interview with CNA A on [DATE] at 03:28 p.m., revealed she had been taking care of Resident #1 on Monday, [DATE] during the day. CNA A revealed she had observed Resident #1 to have been behaving normally, chatty and responsive that morning. CNA A stated after lunch, she had reported to Resident #1's nurse (RN Z) that when she and another CNA (CNA B) went into Resident #1's room to get him up from an after-lunch nap, he was not as responsive as normal. CNA A stated she had tried physical stimulus (rubbing Resident #1 wrist), which he did not respond to. CNA A stated she also observed an unknown purple substance around Resident #1's mouth, which she had cleaned off when the nurse came in to check Resident #1's vitals. CNA A did not state she documented her observations in the facility EMR or notify the nurse of the purple substance during the interview as part of her recollection of events. <BR/>Interview with CNA B on [DATE] at 03:37 p.m., revealed she had observed Resident #1 during Monday, [DATE] and had noted that he was his normal responsiveness and able to have a conversation with her that morning. CNA B stated that after lunch Resident #1 started to be different, dazed. CNA B revealed she reported her observations to Resident #1's nurse (RN Z). <BR/>Interview with the ADON on [DATE] at 04:08 p.m., revealed she had worked [DATE] for the 08:00 p.m. blood sugar check shift. The ADON stated that Resident #1 had looked fine, was acting his normal or not any different than he has been since his recent stroke. The ADON stated that for one of her shifts that week Resident #1 had a very high blood sugar and she had called Resident #1's physician who said he did not want to do anything if the resident was asymptomatic (without symptoms). The ADON stated she did not call Resident #1's physician again because when she had called on [DATE], the physician said that if Resident #1 was asymptomatic he was not going to do anything. <BR/>Interview with MD W on [DATE] at 04:37 p.m., revealed he had been notified of changes in Resident #1's blood sugar medications, including the approval of diabetic medication Trulicity by Resident #1's insurance and that Resident #1's prior PCP had wanted to decrease Resident#1's insulin, but had not received any calls regarding Resident #1's high blood sugars until Monday morning, [DATE]. MD W revealed his expectation was for the facility to call him if a resident's blood sugar was below 60, over 400, or symptomatic (having symptoms). MD W stated he believed Resident #1's comorbidities (having more than one medical condition at the same time) were contributing to Resident #1's blood sugar problems. MD W revealed he was not sure that if the facility had contacted him sooner regarding Resident #1's elevated blood sugars, if it would have made a difference but it would have been ideal for the facility to have had contacted him sooner. <BR/>Interview with LVN P on [DATE] at 05:37 p.m., revealed her observations for Resident #1 during her shifts on [DATE]- [DATE] were that he was fine when he had high blood sugars. His behaviors were fine and happy. He was back to his normal self. LVN P stated when Resident #1 had low blood sugars he would become confused and combative. LVN P stated she reported to Resident #1's physician when Resident #1 was experiencing lows but could not remember if she had called the physician for the high blood sugars. LVN P revealed Resident #1 did not have symptoms when his blood sugars were high. LVN P stated Resident #1's respirations were great, he was sleeping well, and he was his normal self. LVN P revealed she felt the physician would have known Resident #1 was having high blood sugars since the physician discontinued Resident #1's insulin. <BR/>Interview with LVN R on [DATE] at 06:11 p.m., revealed her observations for Resident #1 during her shifts on [DATE] - [DATE] were that Resident #1 was good, just tired which was not abnormal for him recently. LVN R stated that she could recall that Resident #1 had an order during that time to monitor Resident #1's blood sugars and then to report it in 7 days, which she believed was either that following Monday ([DATE]) or Tuesday ([DATE]). LVN R stated she did not report Resident #1's high blood sugars during her shifts because of the monitoring order with instruction to report in 7 days and she had reviewed Resident #1's previous blood sugars and found them to be consistent with the blood sugars she had collected. LVN R stated Resident #1's blood sugars were all the same, all in the 400's and not fluctuating, such as from the 100's to the 400's. LVN R also revealed Resident #1 was not showing symptoms, which he did when experiencing a low blood sugar and that she did not have any concerns. <BR/>Interview with MD X on [DATE] at 11:20 a.m., revealed Resident #1's blood sugars had been fluctuating quite a bit due to Resident #1's renal (kidney) failure, which was causing his blood sugars to become difficulty to control. MD X revealed that he did recall the facility's nursing staff contacting him regarding Resident #1's blood sugars but could not recall when without his notes. MD X stated the facility contacted him regarding Resident #1's change in physician on [DATE] and that was the last contact he received from the facility for Resident #1's care. MD X stated prior to the change in physician, he was trying to make chronic (long-term) changes and did not want to make acute (immediate) changes in regulating Resident #1's blood sugar. MD X revealed his expectation for the facility staff to notify him for blood sugars was for them to call if a resident's blood sugar was at 500. MD X revealed that if a resident was at 500 and symptomatic, he would order adjustments and send the resident out to the hospital, but if not symptomatic, he would just make adjustments to the insulin order. MD X revealed Resident #1's insulin orders had been discontinued due to Resident #1 having had bottomed out (experienced a low blood sugar episode) earlier that month (early February), Resident #1 was very brittle, and Resident #1's blood sugars had been going in the wrong direction (blood sugar dropped) with insulin. <BR/>Interview with the RCN on [DATE] at 02:16 p.m., revealed the facility procedure for a blood sugar outside parameters (the expected range) was to follow the order, including to hold the medication, give an additional medication, re-check, and/or immediately contact the physician per the doctor's orders. She stated that staff are expected to contact the physician if there is a pattern in a resident's blood sugars being outside the blood sugar parameters or a pattern of refusals by the resident. She revealed that if a resident was experiencing a high blood sugar, the doctor was to tell them what they are to give to the resident and when to re-check the resident's blood sugar. The RCN stated that the nurse was responsible for entering the physician's order into the facility's EMR, documenting the order and interventions in a progress note, and reporting any changes to the resident's RP. She revealed that reporting high and low blood sugars is important for tracking the resident's blood sugar trends and that if a resident was running a high blood sugar all the time, their medications would need to be adjusted to limit the long-term effects it could have, which may be harmful if not treated. The RCN stated that facility staff should monitor blood sugars as ordered, notify the resident's physician immediately if outside parameters and follow the orders that the physician gives. <BR/>Interview with the ADMIN on [DATE] at 02:34 p.m., revealed reporting any change of condition is important, to let the physician know and be aware of it. The ADMIN revealed his expectation was that staff call the resident's physician, report that they had contacted the physician, make the changes per the physician, and make notifications to the resident's family for any changes of condition. The ADMIN revealed that this was standard nursing practice and an order. <BR/>Record review of facility policy, Notifying the Physician of Change in Status, dated revised [DATE], revealed The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .11. Abnormal lab, x-ray and other diagnostic reports require physician notification.<BR/>Record review of facility policy, Medication Administration Procedures, dated 2003, revealed 13. When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber.<BR/>This failure resulted in an identification of an immediate jeopardy on [DATE] at 01:27 p.m. The Administrator was informed and provided the IJ template on [DATE] at 06:00 p.m. and a plan of removal (POR) was requested.<BR/>The plan of removal reflected: <BR/>[DATE]<BR/>Plan of Removal- F580 Notify of Changes<BR/>Interventions:<BR/> - 100% blood sugar audit completed on [DATE] by Regional Compliance Nurse<BR/> - Blood sugar checks were assessed on [DATE] to ensure that blood sugar parameters were in place, if not, parameters were requested by attending physician and added. <BR/> - 100% of residents with blood sugar checks were audited on [DATE] and Physician(s) were notified of all blood sugars outside of parameters or were excessively high or low. Date completed [DATE].<BR/> - The following in-services were initiated [DATE] by Regional Compliance Nurse. Inservice 100% of staff completion date: [DATE]. Inservice has been added to new-hire packets for all new hires and agency staff to ensure all staff is in-serviced prior to start of their first shift. <BR/> - Perform blood sugar checks as ordered.<BR/> - Ensure any resident who has blood sugar checks has a parameter to the physician or nurse practitioner (NP). This includes when to report new orders for current residents, new admissions, and readmissions.<BR/> - To report to the MD or NP if a blood sugar check is outside the ordered parameters immediately and to initiate any new orders.<BR/> - If resident(s) has an order for glucagon, follow the prescriber's orders.<BR/> - Policy on Notifying the Physician of Change in Status<BR/> - The following in-services were initiated on [DATE] for all NA/CNAs by nursing administration and/or Regional Compliance Nurse. Inservice 100% of NA/CNA completion date [DATE].<BR/> - Hyperglycemia - excessive thirst/dry mouth, excessive urine, increased fatigue/weakness, blurred vision<BR/> - Hypoglycemia-sweating, dizzy, shaking, increased confusion, anxiety, drowsy, change in mental status, slurred speech, nausea, lightheaded, loss of coordination.<BR/> - Notified Medical Director of IJ situation on [DATE] at 6:17 pm. <BR/>Monitoring:<BR/> - At least five (5) times per week, nursing administration will review the previous days orders using the order listing report in [the facility's EMR] to monitor for new orders for blood sugar checks and ensure that parameters are added. This will include new orders for current residents, new admissions, and readmissions. This was initiated on [DATE] continue x 4 weeks. <BR/> - At least 5 times per week nursing administration will review the previous days TARS and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters. This was initiated on [DATE] and will continue x 4 weeks.<BR/> - Nursing Administration will ask at least 10 nursing staff per week a situational question regarding if a resident presented with hyper or hypoglycemia and what they would do. This was initiated on [DATE] and will continue x 4 weeks. <BR/> - DON/Designee will review 5-8 residents slide scale results for proper notification to MD if outside parameters weekly. This will be initiated on [DATE] and continue x 4 weeks.<BR/> - DON/Designee will monitor all blood sugars outside parameters of slide scale for notification to MD weekly x 4 weeks. This was initiated [DATE] and will continue x 4 weeks. <BR/> - Regional Compliance Nurse will monitor for compliance weekly x 4 weeks starting on [DATE]. <BR/> - The QA (Quality Assurance) Committee will review findings and Physician Notification Policy and will make changes as needed monthly. This will occur during the next QAPI (Quality Assurance and Performance Improvement) meeting on [DATE].<BR/>Monitoring of the plan of removal included:<BR/>Interviews were conducted on [DATE] from 02:50 p.m. to 07:47 p.m. with 2 RNs (RN Z and RN AA) of 2 and 9 LVNs (LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, LVN R, and LVN S) of 9, who worked multiple shifts, revealed they had all been trained on the facility policy, Notifying the Physician of Change in Status. The nursing staff were knowledgeable on the requirement that all blood sugar monitoring orders must include blood sugar parameters, and on the protocols to follow including what to document and who to notify if a blood sugar was outside parameters or a resident was showing signs or symptoms of being hypo or hyperglycemic. The staff were able to identify when it would be appropriate to administer glucagon and how to report and document glucagon administration.<BR/>Interviews were conducted on [DATE] from 03:13 p.m. to 08:37 p.m. with 6 CNAs (CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F) of 9, 3 HAs (HA H, HA I, and HA J) of 3, 2 MAs (MA T and MA U) of 3, and 6 SNAs (SNA AB, SNA AC, SNA AD, SNA AE, SNA AF, and SNA AG) of 8; and on [DATE] at 10:32 a.m. with 1 CNA (CNA G). Interviews revealed they worked multiple shifts, had all been trained and were able to identify signs and symptoms of hypo and hyperglycemia, and were knowledgeable on who they needed to report to. <BR/>In an interview and record review with the RCN on [DATE] at 03:55 p.m., she revealed she had started and was conducting the staff in-services. The RCN confirmed the ADMIN, with her present, had notified the facility's medical director of the Immediate Jeopardy (IJ). The RCN revealed the plan for the facility administration to monitor every new blood sugar order, ensuring that every new order included parameters was to review the previous day's (or days' for new orders over the weekends and holidays) orders by printing out an Order Listing Report from the facility's EMR, which would show all of the previous days' orders. The RCN revealed she had completed the initial blood sugar monitoring audit on [DATE]. She revealed that she had discovered a few residents without parameters on their orders. The RCN revealed she called the residents' physicians to add the parameters, asked the physicians about glucagon orders if not currently included in the residents' active order list, and added the orders with parameters per the physician's order. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days orders using the order listing report in [EMR system name] to monitor for new orders for blood sugar checks and ensure that parameters were added., was the monitoring document the facility would use to track their completion of this monitor. The document revealed this monitor was to be tracked 5 times a week for 4 weeks and that the monitor had been completed on [DATE], [DATE], and [DATE] for week 1. The RCN revealed the plan for facility administration to monitor each resident's blood sugar, that had a blood sugar monitoring order, for being completed per order and to verify the resident's MD or NP was notified if the blood sugar was outside parameters was by printing out the previous day's (or days' if after a weekend and/or holiday) Weights and Vitals Summary report from the facility's EMR, which would show all the previous days' blood sugar results, identify any blood sugars outside parameters, and review the resident's progress notes for a note on notification to the physician and/or nurse practitioner for any blood sugar results outside parameters. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days TARs and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters., was the monitoring document the facility would use to track their completion of this monitoring. The document revealed this monitoring was to be tracked 5 times per week for 4 weeks and that the monitoring had been completed on [DATE], [DATE], and [DATE] for week 1. Weights and Vitals Summary reports for dates [DATE], [DATE], and [DATE] were provided and revealed initials on each page to indicate it had been reviewed and check marks next to each blood sugar out of parameters to indicate a corresponding progress note had been confirmed to indicate the MD or NP had been notified. The RCN revealed the ADON would be responsible for completing the review of the 5-8 residents with sliding scale insulin orders for proper notification of the MD if the blood sugar was outside parameters. The RCN stated that this monitor was the same process or intervention as the intervention for reviewing the TARs for residents with orders for blood sugar monitoring. The RCN revealed the plan for the facility administration to ask at least 10 nursing staff situational questions regarding if a resident had high or low blood sugars and what they would do was to utilize the monitoring document, labeled with Nursing administration will ask at least 10 nursing staff per week a situational question ., mark Yes or No if the staff member answered the question correctly or incorrectly, and if incorrect, document how they answered the question incorrectly and what the nursing administration's plan was for correcting the incorrect answer (ex. in-service training). The document revealed this monitoring was to be completed 10 times per week for 4 weeks, had a spot to put the date, indicate if the answer was correct or incorrect, the staff name of the person questioned, and the name of the interviewer. The document revealed two staff members had been questioned, both on [DATE], and both had answered correctly. The RCN revealed the plan for her to monitor that the facility administration and DON/designee were compliant with the other interventions/monitors for 4 weeks was for her to come to the facility at least one time per week, review the other monitoring forms to ensure they are up to date, review the related Weights and Vitals Summary reports and Order Listing Report that the facility will be maintaining in a specified binder, and to mark Yes or No on the monitoring document, labeled with Regional Compliance Nurse and/or ADO (ADON) compliance monitoring:. The document revealed this monitoring was to be completed for 4 weeks and did not have any weeks marked as completed at the time of the interview. <BR/>In an interview with the ADON on [DATE] at 04:08 p.m., she revealed she had received training on the facility policy, Notifying the Physician of Change in Status, blood sugar checks procedure, administering glucagon per order, reporting blood sugars to the resident's physician or NP immediately if outside parameters or when symptomatic, documenting physician notifications and new orders, and verifying that all new blood sugar monitoring orders included parameters on [DATE]. The ADON revealed she was to print out the Weights and Vitals report and document for new orders daily. The ADON revealed she was to review the reports for new orders and to review the blood sugars to identify if any residents had blood sugars less than 60 or over 400. She revealed that she was to review the progress notes and the 24-hour or 72-hour report to confirm the nurse notified and documented that they notified the physician of a blood sugar outside parameters. The ADON revealed she was to ask CNAs from different shifts to determine if they could recognize signs and symptoms of a hyper or hypoglycemia and what they were supposed to do if they observed those signs or symptoms. The ADON revealed she planned to in-service the staff member if they answered incorrectly and document on the monitoring form

Based on observation, interview, and record review, the facility failed to ensure the resident environment was safe, clean, comfortable, and homelike for 2 of 3 shower rooms reviewed for environment, in that: <BR/>The A and D hall shower rooms contained barrels with soiled linen and trash including soiled briefs. <BR/>This deficient practice could place residents at risk of living in an unsanitary environment, and psychosocial harm due to diminished quality of life. <BR/>The findings were: <BR/>Observation on 07/19/2024 at 9:32 a.m. revealed a barrel with soiled linen and a barrel with trash (including soiled briefs) were located in the A hall shower room. <BR/>Observation on 07/19/2024 at 9:36 a.m. revealed a barrel with soiled linen and a barrel with trash (including soiled briefs) were located in the D hall shower room. <BR/>During an interview with CNA D on 07/19/2024 at 9:52 a.m., CNA D stated that the normal facility procedure was to keep a barrel with soiled linen and a barrel with trash (including soiled briefs) in the shower room, including while residents were receiving showers. <BR/>During an interview with Resident #4 on 07/19/2024 at 9:45 a.m., Resident #4 stated that she dislikes having a shower in a space that contains other residents' soiled clothing and soiled briefs. <BR/>Record review of the facility policy, Resident Rights, undated, revealed, The resident has a right to a dignified existence .a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the environment was free of accident hazards and supervision of staff for one resident (#1) of 3 residents who required mechanical lift transfers.<BR/>NA A transferred Resident #1 alone on 01/17/2024 at 08:15 AM with a mechanical lift which required 2 people for safety. One of the straps holding the sling came loose and Resident #1 slipped toward the floor and hit her head on the mechanical lift which caused a head laceration and fractures to C4 (provides sensation for parts of the neck, shoulders and upper arms) and C5 (controls the deltoid muscles of shoulders and biceps, provides sensation to the upper arm down to the elbow).<BR/>The noncompliance was identified as PNC. The IJ began on 01/17/2024 and ended on 01/18/2024. The facility had corrected the noncompliance before the survey began. <BR/>This deficient practice could affect residents who require transfers with the mechanical lift at risk for injury or death.<BR/>The findings included:<BR/>Record review of Resident #1's electronic face sheet dated 04/05/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery (a blood vessel that carries blood from the heart to tissues and organs in the body) and neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function).<BR/>Record review of Resident #1's annual MDS assessment with an ARD of 03/09/2024 reflected she was not a candidate for a BIMS assessment which signified she was severely cognitively impaired. She could rarely understand and rarely be understood. Resident #1 was dependent on staff for her ADL's. She required 2 people for her transfers.<BR/>Record review of Resident #1's comprehensive person-centered care plan revised 01/05/2024 reflected Focus, resident has an ADL self-care performance deficit, Interventions, transfer the resident requires mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual type of transfer) for transfers x 2 staff. Date initiated: 11/05/2021. Further review reflected Focus, alteration in musculoskeletal status r/t fracture of the C2-4, C collar splint (a cervical collar, also known as a neck brace, is a medical device used to support and immobilize a person's neck) as recommended, when out of bed. Date initiated: 01/19/2024.<BR/>Record review of Resident #1's progress note written by LVN B dated 01/17/2024 at 08:41 AM reflected Transfer Notification,] Resident #1] was transferred to a hospital on [DATE] 08:46 AM related to resident fell onto floor, causing a 2 cm laceration to top of head. Hematoma (a pool of mostly clotted blood that forms in tissue) to right forehead, 4x2 with abrasion.<BR/>Record review of Resident #1's hospital CT (computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) dated 01/17/2024 at 09:54 AM reflected Reason for exam, laceration to head, trauma/injury, Findings, nondisplaced transversely oriented fracture ((still broken bones, but the pieces weren't moved far enough to be out of alignment during the break) involving the right C4 inferior articular facet (smooth, anterolaterally(the position of a structure as being away from the middle line, in front of the body) facing articular (referring to the joint or joints) processes of a lumbar vertebra) and right C5 superior articular facet (the superior articular processes project vertically upward from the articular pillars (the columnar arrangement of the articular portions of the cervical vertebrae) between the pedicles (connect the vertebral body to the transverse processes) and the [NAME] (connect the transverse and spinous processes) (a series of levers both muscles of posture and for muscles of active movement).<BR/>Record review of NA A's written statement dated and signed 01/17/24 (untimed) reflected he was looking for someone to help, but no one was around and they were understaffed, so he attempted to place Resident #1 in the bed by himself. During the process, the sling on the mechanical lift on one side came undone and Resident #1 slipped out and he helped to guide her to the floor as safe as possible but she did hit the top of her head, and he immediately called for the nurse.<BR/>Record review of the Administrator's follow-up note (undated) reflected he interviewed NA A on 01/17/2024 and was told NA A did not see anyone in his hall so he did not ask for assistance with the mechanical lift transfer for Resident #1. He stated his investigation of staffing revealed the census at the time was 58 and there were 2 nurses, one medication aide and 4 aides assigned to the units, and administrative staff was available. <BR/>Record review of the Administrator's PIR dated 01/17/2024 at 10:39 AM reflected: Aide was suspended pending investigation. He was subsequently terminated. All staff were given abuse and neglect in-service and were trained on Hoyer policy requiring 2 people. Instructions given for intervening and reporting if witnessing improper Hoyer transfer. 100% of aides were required to perform return demonstration of proper Hoyer lift use. Family, physician, and Medical Director were informed of the incident. All Hoyer lift residents received a heat to toe assessment for any evidence of injury. Monitoring was implemented for incidents involving Hoyer residents. Five return demonstrations to be performed a week for 4 weeks and upon new hire. Training on recognizing sling condition was done with staff. Administrative staff examined all slings to ensure they were in good condition. Hoyer lifts were inspected. They were inspected in November 2023 by an outside company per policy. Aide verbalized to administrator that he knew a Hoyer transfer should be performed by 2 people. He verbalized that he had been trained to use the Hoyer. The NA chose not to wait for assistance as he did not see anyone in his hall. Hoyer was performed properly for getting Resident #1 out of bed. All equipment functioned properly and was in good condition during transfer. Poor decision making on part of the NA led to the incident .QA team had an Ad Hoc meeting to discuss and correct the situation.<BR/>Record review of NA A's CNA Proficiency Audit dated 04/04/2023 reflected he was signed off as an S for Transfers Hoyer lift- 2 person assist.<BR/>Observation on 04/04/2024 at 08:00 AM of Resident #1 revealed she was sitting in the dining room in a Geri-chair and had a C-collar around her neck.<BR/>Interview on 04/05/2024 at 1:00 PM with the Administrator, he stated after Resident #1 was sent out to the hospital for evaluation he reported the incident to HHSC immediately. He stated that later in the day a nurse from the hospital informed a nurse at the facility of Resident #1's fracture. He immediately identified that 100% in-services for the nursing assistants needed to be done and a competency of their performance for mechanical lift transfers. He stated that was completed on 01/18/2024. He stated 100% of the staff, nursing and non-nursing staff were in-serviced on abuse and neglect and on having 2 people for a mechanical lift transfer and to report any variances of that immediately. He stated that was completed on 01/18/2024. He stated he checked the staffing for 1/17/2024 at 08:15 AM when the incident happened, and sufficient staff were available in the building and that NA A chose not to wait.<BR/>Attempted interview on 04/09/2024 with NA A at 10:00 AM revealed the phone number listed for him at the facility was disconnected.<BR/>Observation on 04/05/2024 at 09:10 AM of Resident #1 being transferred from her Geri chair to the bed by CNA D and NA E revealed no concerns.<BR/>Observation on 04/08/2024 at 12:30 PM of Resident #2 being transferred from her Geri chair to the bed by CAN D and CNA F revealed no concerns.<BR/>Interview on 04/09/2024 at 2:50 PM with LVN B revealed she assessed Resident #1 when the incident happened, made notifications to include the Administrator and had Resident #1 transferred to the hospital. <BR/>Interview on 04/09/2024 at 09:00 a.m. with the DON at the time, RN C, she stated Resident #1 was transferred with a mechanical lift by NA A, who did not ask for help. She stated that he was trained on how to use the mechanical lift and everyone was retrained after the incident.<BR/>Record reviews of the other two residents who required Hoyer lift transfers, Resident #2 and Resident #3 reflected both had 2-person transfers care planned and identified in their MDS assessments.<BR/>Record review of the facility policy and procedure titled Hydraulic Lift (undated) reflected The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair It is reserved for those who are paralyzed, obese or too weak to transfer without complete assistance. The number of staff to provide assistance with the transfer should be determined by manufacturer recommendations The resident will receive safe transfer to bed or chair via a mechanical lift device.<BR/>Record review of the owners guide for the MEDLINE Hydraulic lift MODEL: MDS450EL (undated) reflected Transfer From Bed and From Chair To Bed .with the assistance of another caregiver.<BR/>The facility course of action prior to surveyor entrance included:<BR/>Record review of the Administrator's PIR dated 01/17/2024 revealed: All required notifications were made which included the Medical Director, Responsible Party, Physician, Nurse Practitioner, QA Ad Hoc Committee and HHSC.<BR/>Record review of NA A's personnel folder reflected he was immediately suspended pending investigation on 01/17/2024 and subsequently terminated.<BR/>Record review dated 01/17/2024- 54 staff, all staff, were in-serviced on using a staff roster were checked off and signed for in-services titled: Abuse/Neglect, Mechanical Lift.<BR/>Record review of staff competencies dated from 01/17/2024 to 1/18/2024 reflected 100 return demonstrations were completed with the Hoyer transfers and 5 additional observations were done weekly and marked off by nurse managers for an additional 4 weeks. The staff who completed this training for the mechanical lift was all CNA's, MAs, and NAs, 12 CNAs, 6 MAs and 6 Student Nurse Aides to total 24<BR/>Record review of slings examined dated 01/17/2024 to 04/09/2024 reflected the slings were examined weekly for condition and wear.<BR/>STAFF INTERVIEWS ON TRAINING: 04/05/2024 from 2:00 PM to 3:30 PM revealed staff were scheduled for 12-hour shifts, many worked both day, evening, and night shifts.<BR/>On 04/05/2024 at total of 3 LVN's, 5 CNA's and 2 NAs were interviewed on the mechanical lift transfers, 2 people requirement, intervening, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed someone trying to transfer a resident with a mechanical lift with one person, and to let the charge nurse know if they could not find someone to help them with a transfer. They were trained to check the straps for wear and condition and placement on the lift to ensure they were secure. <BR/>On 04/09/2024 between 02:00 PM and 5:00 PM, 2 RN's and 2 CNAs were interviewed on the mechanical lift, 2 people requirement, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed someone trying to transfer a resident with a mechanical lift with one person, and to let the charge nurse know if they could not find someone to help them with a transfer. They were trained to check the straps for wear and condition and placement on the lift to ensure they were secure. <BR/>The noncompliance was identified as past noncompliance IJ. The noncompliance began on 01/17/2024 and ended on 01/18/2024 when all staff had been in-serviced on abuse/neglect, mechanical lift transfers (2 people required) and reporting it immediately if observed with only one person using the lift. The NA was suspended and then terminated before the surveyor entrance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote and protect the resident's right to a dignified existence for 1 (Resident #13) of 40 residents reviewed for dignity, in that: <BR/>Resident #13 was dependent upon staff to perform all activities of daily living and was observed with hair on her chin. <BR/>This deficient practice could lead to diminished quality of life and psychosocial harm due to feelings of shame or embarrassment. <BR/>The findings were: <BR/>Record review of Resident #13's face sheet, dated 07/18/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Vascular Dementia, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, and Muscle Weakness. <BR/>Record review of Resident #13's Quarterly MDS assessment, dated 06/12/2024, revealed a BIMS score of 9 which indicated moderate cognitive impairment. Further review revealed Resident #13 had limited range of motion with impairment on both sides of her upper extremities (shoulder, elbow, wrist, and hand). Further review revealed Resident #13 was wholly dependent upon staff to perform all activities of daily living, including maintaining personal hygiene. <BR/>Record review of Resident #13's Visual/Bedside [NAME] Report, as of 07/19/2024, revealed, Personal Hygiene/Oral Care. Personal Hygiene/Oral Care: the resident requires x 1 staff participation with personal hygiene and oral care. Personal Hygiene/Oral Care: the resident requires total assistance with personal hygiene care. <BR/>Record review of Resident #13's care plan, revised 03/01/2022, revealed a focus: [Resident #13] has Hemiplegia/Hemiparesis [related to] affects from cerebral infarction and interventions, Assist with ADLs [activities of daily living] /Mobility as needed. Further review revealed an additional focus, [Resident #13] has an ADL [activities of daily living] Self Care Performance Deficit related to dementia, hemiplegia, limited mobility, and stroke and Personal Hygiene: the resident requires total assistance with personal hygiene care.<BR/>Observation on 07/18/2024 at 2:09 p.m. revealed Resident #13 had chin hair approximately two inches in length. <BR/>During an interview with Resident #13 on 07/18/2024 at 2:09 p.m., Resident #13 stated that she dislikes having chin hair and feels embarrassed by it. <BR/>During an interview with CNA C on 07/18/2024 at 2:14 p.m., CNA C confirmed she cared for Resident #13, stated she had not noticed the resident's chin hair, and stated she had been directed to shave both male and female residents. <BR/>During an interview with CNA D on 07/19/2024 at 9:38 a.m., CNA D stated Resident #13 will allow CNAs to shave her chin hair and sometimes asks that her hair be tweezed. <BR/>During an interview with the DON on 07/19/2024 at 10:30 a.m., the DON confirmed that ADL care included shaving residents who wished to be clean-shaven. <BR/>Record review of the facility policy, Resident Rights, undated, revealed, The resident has a right to a dignified existence .

Based on observation, interview, and record review, the facility failed to ensure the resident environment was safe, functional, sanitary, and comfortable for residents, staff, and visitors for 1 of 3 halls reviewed for environment, in that: <BR/>The facility beauty shop on D Hall was unlocked and contained potentially dangerous materials. <BR/>This deficient practice could result in accidents and/or injury. <BR/>The findings were: <BR/>Observation on 07/16/2024 at 12:55 p.m. revealed the facility beauty shop was unlocked. Further observation revealed an unlocked cabinet containing hairspray, hair mousse, and hair dye - on which all were printed warning, danger, flammable, keep out of reach of children and harmful if swallowed. <BR/>During an interview with CNA F on 07/16/2024 at 12:55 p.m., CNA F confirmed the facility beauty shop was unlocked and contained hairspray, hair mousse, and hair dye - on which all were printed warning, danger, flammable, keep out of reach of children and harmful if swallowed. <BR/>During an interview with the DON on 07/19/2024 at 10:30 a.m., the DON stated that a lock had been installed on the beauty shop and staff had been trained to ensure that the beauty shop was secured when not in use. <BR/>Record review of the facility policy, Resident Rights, undated, revealed, .a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 15 (Resident #1) residents reviewed, in that: <BR/>Resident #1's diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder were not included in the resident's care plan. <BR/>This deficient practice could place residents at risk of improper care due to inaccurate care plans.<BR/>The findings were:<BR/>Record review of Resident #1's facesheet, dated 06/12/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia, Unspecified Atrial Fibrillation, and Type 2 Diabetes Mellitus with Diabetic Neuropathy. <BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 6 which indicated severe cognitive impairment. <BR/>Record review of Resident #1's care plan, initiated 11/23/2021, revealed a focus, The resident has impaired cognitive function/dementia or impaired thought processes [sic] Dementia.<BR/>Record review of Resident #1's initial psychological diagnostic assessment, completed by LCSW F, dated, 02/23/2021, revealed diagnoses of Major depressive disorder, recurrent, mild and Generalized anxiety disorder. <BR/>Record review of Resident #1's most recent psychological services progress note, completed by LCSW F, dated 06/05/2023, revealed diagnoses of Major depressive disorder, recurrent, mild and Generalized anxiety disorder. <BR/>Further review of Resident #1's care plan, initiated 05/26/2020, revealed Resident #1's diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder were not addressed by the resident's care plan.<BR/>During an interview with the MDS/Care Plan Coordinator on 06/13/2023 at 02:45 p.m., the MDS/Care Plan Coordinator verbally confirmed Resident #1's diagnoses of Major depressive disorder, recurrent, mild and Generalized anxiety disorder were not addressed by the resident's care plan The MDS/Care Plan Coordinator stated the diagnoses should have been listed on the care plan and that the omission was an oversight. The MDS/Care Plan Coordinator verbally confirmed that Resident #1's medical providers and caregivers may not be aware of the resident's psychological diagnoses if the diagnoses are not included on the resident's care plan. <BR/>During an interview with the DON on 06/14/2023 at 5:10 p.m., the DON verbally confirmed that all resident clinical records, including the residents' care plans, should be complete and accurate.<BR/>Record review of the facility policy, Comprehensive Care Planning, undated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychological needs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote and protect the resident's right to a dignified existence for 1 (Resident #13) of 40 residents reviewed for dignity, in that: <BR/>Resident #13 was dependent upon staff to perform all activities of daily living and was observed with hair on her chin. <BR/>This deficient practice could lead to diminished quality of life and psychosocial harm due to feelings of shame or embarrassment. <BR/>The findings were: <BR/>Record review of Resident #13's face sheet, dated 07/18/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Vascular Dementia, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, and Muscle Weakness. <BR/>Record review of Resident #13's Quarterly MDS assessment, dated 06/12/2024, revealed a BIMS score of 9 which indicated moderate cognitive impairment. Further review revealed Resident #13 had limited range of motion with impairment on both sides of her upper extremities (shoulder, elbow, wrist, and hand). Further review revealed Resident #13 was wholly dependent upon staff to perform all activities of daily living, including maintaining personal hygiene. <BR/>Record review of Resident #13's Visual/Bedside [NAME] Report, as of 07/19/2024, revealed, Personal Hygiene/Oral Care. Personal Hygiene/Oral Care: the resident requires x 1 staff participation with personal hygiene and oral care. Personal Hygiene/Oral Care: the resident requires total assistance with personal hygiene care. <BR/>Record review of Resident #13's care plan, revised 03/01/2022, revealed a focus: [Resident #13] has Hemiplegia/Hemiparesis [related to] affects from cerebral infarction and interventions, Assist with ADLs [activities of daily living] /Mobility as needed. Further review revealed an additional focus, [Resident #13] has an ADL [activities of daily living] Self Care Performance Deficit related to dementia, hemiplegia, limited mobility, and stroke and Personal Hygiene: the resident requires total assistance with personal hygiene care.<BR/>Observation on 07/18/2024 at 2:09 p.m. revealed Resident #13 had chin hair approximately two inches in length. <BR/>During an interview with Resident #13 on 07/18/2024 at 2:09 p.m., Resident #13 stated that she dislikes having chin hair and feels embarrassed by it. <BR/>During an interview with CNA C on 07/18/2024 at 2:14 p.m., CNA C confirmed she cared for Resident #13, stated she had not noticed the resident's chin hair, and stated she had been directed to shave both male and female residents. <BR/>During an interview with CNA D on 07/19/2024 at 9:38 a.m., CNA D stated Resident #13 will allow CNAs to shave her chin hair and sometimes asks that her hair be tweezed. <BR/>During an interview with the DON on 07/19/2024 at 10:30 a.m., the DON confirmed that ADL care included shaving residents who wished to be clean-shaven. <BR/>Record review of the facility policy, Resident Rights, undated, revealed, The resident has a right to a dignified existence .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 15 (Resident #1) residents reviewed, in that: <BR/>Resident #1's diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder were not included in the resident's care plan. <BR/>This deficient practice could place residents at risk of improper care due to inaccurate care plans.<BR/>The findings were:<BR/>Record review of Resident #1's facesheet, dated 06/12/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia, Unspecified Atrial Fibrillation, and Type 2 Diabetes Mellitus with Diabetic Neuropathy. <BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 6 which indicated severe cognitive impairment. <BR/>Record review of Resident #1's care plan, initiated 11/23/2021, revealed a focus, The resident has impaired cognitive function/dementia or impaired thought processes [sic] Dementia.<BR/>Record review of Resident #1's initial psychological diagnostic assessment, completed by LCSW F, dated, 02/23/2021, revealed diagnoses of Major depressive disorder, recurrent, mild and Generalized anxiety disorder. <BR/>Record review of Resident #1's most recent psychological services progress note, completed by LCSW F, dated 06/05/2023, revealed diagnoses of Major depressive disorder, recurrent, mild and Generalized anxiety disorder. <BR/>Further review of Resident #1's care plan, initiated 05/26/2020, revealed Resident #1's diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder were not addressed by the resident's care plan.<BR/>During an interview with the MDS/Care Plan Coordinator on 06/13/2023 at 02:45 p.m., the MDS/Care Plan Coordinator verbally confirmed Resident #1's diagnoses of Major depressive disorder, recurrent, mild and Generalized anxiety disorder were not addressed by the resident's care plan The MDS/Care Plan Coordinator stated the diagnoses should have been listed on the care plan and that the omission was an oversight. The MDS/Care Plan Coordinator verbally confirmed that Resident #1's medical providers and caregivers may not be aware of the resident's psychological diagnoses if the diagnoses are not included on the resident's care plan. <BR/>During an interview with the DON on 06/14/2023 at 5:10 p.m., the DON verbally confirmed that all resident clinical records, including the residents' care plans, should be complete and accurate.<BR/>Record review of the facility policy, Comprehensive Care Planning, undated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychological needs .