SAN PEDRO MANOR

Based on observations, interviews, and record reviews, the facility failed to 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 disease and infection for 1 of 2 residents (Resident #2) reviewed for infection control, in that:<BR/>CNA A did not change her gloves or wash her hands after touching Resident #2's privacy curtain, between change of gloves and, after providing incontinent care for Resident #2.<BR/>These deficient practices could place residents at-risk for infection due to improper care practices. <BR/>The findings included:<BR/>Record review of Resident #2's face sheet, dated 05/16/2024, revealed an admission date of 01/20/2020 and, a readmission date of 09/30/2023, with diagnoses which included: Dislocation of right hip (thighbone separates from the hip bone), Chronic pain, History of urinary tract infection (infection in any part of the urinary system), Cerebellar ataxia (Lack of voluntary coordination of muscles movements originating in the cerebellum part of the brain)and, Hypertension (High blood pressure). <BR/>Record review of Resident #2's Quarterly MDS assessment, dated 02/12/2024, revealed Resident #2 had a BIMS score of 15, which indicated no cognitive impairment. Resident #2 was indicated to always be incontinent of bowel and bladder and, required extensive assistance to total care with her acclivities of daily living. <BR/>Review of Resident #22's care plan, dated 12/27/2021, revealed a problem of has bladder incontinence related to muscle weakness and debility with an intervention of Check as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes <BR/>Observation on 05/16/2024 at 10:52 a.m. revealed, while providing incontinent care for Resident #2, CNA A did not change her gloves or wash her hands after touching the privacy curtain to close it and before providing incontinent care for Resident #2. CNA A changed her gloves after cleaning Resident #2's genitals but did not sanitize her hands before putting clean gloves on. Further observation revealed CNA A changed her gloves after cleaning Resident #2's buttocks but did not sanitize her hands before putting clean gloves on and touching the new brief to fasten them for the resident. <BR/>During an interview on 05/16/2024 at 11:00 a.m. CNA A confirmed she did not change her gloves or wash her hands after touching the privacy curtain and before starting to provide care. CNA A also confirmed she did not sanitized between change of gloves or before touching Resident #2's clean brief. She confirmed receiving infection control training within the year. <BR/>During an interview with the DON on 05/16/2024 at 11:05 a.m., the DON confirmed the staff should have changed her gloves after touching the privacy curtain to prevent contamination and infection to the resident. She confirmed staff should sanitize their hands between change off gloves to prevent infection to the resident. The DON revealed the DON and the ADON provided training on infection control to the staff at least once a year. They checked the staff's skills once a year and did spot check when problems with infection control were noticed. <BR/> Review of facility Nurse aide competency checklist perineal care-female (with or without catheter, undated, revealed wash hands. Wear gloves and follow Standard Precautions if contact with blood or body fluids is likely [ .] wash hands and put on clean gloves for perineal care.<BR/>During an interview on 05/16/2024 at 1:38 p.m. with the DON, she revealed there was no other policy regarding when to change gloves and practice hand hygiene during incontinent care.

Based on observation and interview the facility failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records and failed to safeguard medical record information against loss, destruction, or unauthorized use for 1 of 1 facility.<BR/>Residents' medical records were stored in an unlocked room on the 3rd floor that was being remodeled. Medical record sheets were out of their files and scattered on the floor in multiple places in the room.<BR/>This failure could place resident identifiable information at risk of unauthorized use.<BR/>The findings were:<BR/>Observation on 5/9/23 at 9:20 a.m. revealed surveyors had been placed in a conference room on the 3rd floor. There were no residents on the floor as it was being remodeled and under construction.<BR/>Observation on 5/9/23 at 3:30 p.m. revealed construction workers were working on the 3rd floor and walking in the hallway. An unknown staff member was standing in the hallway waiting on the elevator.<BR/>Observation on 5/10/23 at 4:34 p.m. revealed on the 3rd floor directly across from the conference room hallway a door was open and revealed what appeared to be residents' records on the floor and in file boxes stacked in the room. There were boxes labeled medical records and boxes labeled 2015 and 2020 GA-GR and other boxes labeled with residents' names and dates and others not labeled. Observation further revealed signed Physician's Telephone order forms on the floor and other residents' medical records scattered on the floor. Some boxes were observed to be tilted and stacked up to 6 ft tall in different parts of the room and falling over. There were residents' medical records on the floor and scattered in the corner of the room between boxes. There was a bathroom and the light was on and the new floors in the room had been covered with paper protection and taped together at the seams. Multiple areas of the room had residents' medical records with diagnoses, medications, lab and x-ray results on the floor and footprints on them in one area as if they had been stepped on. Observed several boxes also labeled business office and what looked like thin folders with staff names as well. Many of the boxes were missing lids and had files sticking up out of them as if they had been gone through and not placed back in the box. The door did not have a lock.<BR/>Observation on 5/10/23 at 4:34 p.m. revealed there were several construction workers walking in the hallway on the 3rd floor. <BR/>In an interview on 5/10/23 at 4:45 p.m. the Administrator was notified of the opened and unlocked room with the medical records and stated he would take care of it.<BR/>Observation on 5/11/23 at 8:40 a.m. revealed a worker was changing the doorknob on the room with the medical records and replacing it with a doorknob that had a key lock.<BR/>In an interview on 05/11/23 at 1 p.m. Staff D stated the medical records in the room across from the conference room hallway were her shred records, and then stated the records in the room were from the previous facility owners and Staff D confirmed what the surveyor saw regarding 2015 and 2020 dates on boxes and stated again they were from previous facility owners and not current resident records. Staff D reported current residents' records were locked in her office and she and the Administrator were the only ones with keys to it. Staff D stated the medical records in the room on the 3rd floor should be locked and secured especially with the construction on the 3rd floor. Staff D stated the facility had contacted the previous facility owners to let them know the medical records were at the facility but had not heard anything back from them. Staff D stated the facility would not be shredding anything and would follow the medical records retention policy. <BR/>Observation on 5/11/23 at 3:00 p.m. revealed in the conference room with the surveyors had been a metal shopping cart style cart with accordion files, binders, and boxes. On the top of the cart was a resident's large medical record. Upon examining the accordion folder type file, there was no cover and noted it was a resident's medical record and the resident's name is on the accordion file. There was also a large file box that had a resident's name; handwriting and different forms could be seen sticking out. There were no residents by those names on current resident roster dated 5/9/23 for this survey. <BR/>Interview on 5/11/23 at 3:45 p.m. the DON and Staff D were informed of the cart in the conference room with resident's medical records in it. Staff D stated it might be from the audit and stated she would secure the records immediately.<BR/>Observation on 5/11/23 at 5:30 p.m. revealed the metal cart in the conference room with resident's medical records on it was gone from the conference room. <BR/>In an interview on 5/12/23 at 2:00 p.m. the Administrator stated the medical records that were in the room on the 3rd floor should have been secured. The Administrator further stated the facility's plan was to continue going through the medical records per retention policy and then calling the previous company again to ask them to collect their residents' and staff records. The Administrator stated the facility had a safe storage company they used and the previous company did not but if the records were sent to their safe storage company, they would be kept separate in case the company comes to get them.<BR/>Review of the facility HIPAA compliance policy and procedure dated January 2017 indicated, Policy Statement Protected Health Information (PHI) will be safeguarded against unauthorized use, access, or disclosure in accordance with federal and state laws to prevent access by unauthorized persons.Secure shall be defined as inaccessible to unauthorized individuals, protected shall be defined as safe from environmental damage.2. Store all documents containing PHI in a secure, locked location with limited access to authorized workforce members. 9. Keep records and other documents out of public view and reach. 16. Secure and protect all records and documents from damage, loss, or destruction when an alternative storage space is needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed 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 infections for 1 of 2 (3rd floor)community shower rooms in that:<BR/>The 3rd floor shower room had 2 shower stalls that had drains with gobs of hair. There was brown substance under 1 shower chair, and floors were dirty with darkened areas and brown substance droppings on 1 of the shower stalls. 30 possible residents could use the 3rd floor shower room. <BR/>This could affect all resident that shower in the 3rd floor shared shower and could result in infections. <BR/>The Findings were:<BR/>Observation on 5/6/2025 at 4:21 PM The 3rd floor shower room had 2 shower stalls that had drains with gobs of hair. There was brown substance under 1 shower chair, and floors were dirty with darkened areas and brown substance droppings on 1 of the shower stalls. <BR/>Interview on 5/6/2025 at 4:22 PM with CNA A stated he provided a resident a shower earlier today, he cleaned the shower chair with shampoo and had not disinfectant the shower chair, because the facility did not have anymore products to disinfect the shower chair. CNA A stated the night shifts were to stock the shower rooms. CNA A stated after each resident use, the shower chairs were cleaned between residents. CNA A stated the hsk staff clean the shower stalls and the CNAs clean any feces and shower chairs. <BR/>Interview on 5/6/2025 at 4:31 PM with RN B observed the 3rd floor shower room, floors were dirty, shower grates had lots of hair, and feces on the shower room floor. RN B notified maintenance the shower room on 3rd floor needed a deep cleaning. <BR/>Interview on 5/6/2025 at 4:36 PM, the ADON stated CNAs were supposed wipe the resident shower chairs after each use with disinfectant wipes. The Hsk clean the shower stalls, floors, and drainage. The ADON stated the Hsk staff leaves at 4:00 PM. The ADON stated the DON was in charge of the nursing task and the Maintenance/Hsk supervisor was in charge of the hsk task in the shower rooms. <BR/>Interview on 5/6/2025 at 4:42 PM, the Maintenance Assistant C stated staff were supposed to use disinfected wipes to disinfect the resident shower chairs, between use. Hsk did not clean up feces, the CNAs do. Maintenance Assistant C stated the Hsk staff cleaned the shower rooms and mop the floor. He stated the hsk staff had left for the day. <BR/>Interview on 5/6/2025 at 5:00 PM with the ADM and DON, the ADM and DON stated they would make sure the Maintenance/Hsk supervisor was aware and to educate the staff on cleaning/disinfecting resident shower rooms. <BR/>Interview on 5/8/25 at 12:59 PM a with Maintenance/Hsk Supervisor stated the resident Showers floors had buildup. He cleaned the floors before lunch, and the floor tech does the floors before he leaves between 4:00-5:00 PM. The Hsk sanitizes everything in the shower room, take-out trash, touch up shower chairs, sanitize using 9name of company) chemical. The floor tech checks the floors before-4pm, one last time before he leaves for the day. The Maintenance/Hsk Supervisor stated he was not sure about the buildup on the floors, he cleans the dirt build up and he used a cleaning product that was easy to clean up. The Maintenance/Hsk Supervisor stated the CNAs were responsible for cleaning up the resident feces and urine. The Maintenance/Hsk Supervisor stated the [NAME] staff disinfect and move the cover/grates/drains and clean out the hairs. The Maintenance/Hsk Supervisor stated the female residents had quite a bit of hair that was caked up hair/shampoo on shower drains. The Maintenance/Hsk Supervisor stated the CNAs clean the shower chairs between use with the disinfectant wipes at nurse's station. Policy for CNA responsibilities for cleaning/disinfecting the shower rooms between staff was not provided before exit by the ADM/DON. <BR/>Record review of policy for Housekeeping Services (no date) was documented Policy: It is the policy of this facility to maintain a clean environment for the residents. 7. Floors, are cleaned according to an established schedule. 8. Cleaning agents approved by the Infections Control Committee are in areas known to be contaminated with pathogenic bacteria. <BR/>Record review of policy Cleaning Checklist for Housekeeping, (no date) was documented floor care: sweep the floor, and mop the floor, Shower area task: remove hair form drains, and disinfect shower stalls.

**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 is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 resident (Residents #12 and #92 ) reviewed for incontinent care, in that: 1.While providing incontinent care, CNA G made multiple passes with the same wipe while cleaning Resident #12's buttocks. 2. While providing incontinent care for Resident #92, CNA E did not separate Resident #92's labias to clean the meatus (urinary opening) This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: 1.Record review of Resident #12's face sheet, dated 08/07/2025, revealed an admission date of 04/25/2024, and, a readmission date of 07/29/2025, with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood) , Dysphagia (difficulty swallowing), Hemiplegia (Paralysis of one side of the body), Resistance to multiple antimicrobial drugs, Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Hypertension (high blood pressure), Chronic kidney disease stage 2 (gradual loss of kidney function). Record review of Resident #12's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 00 indicating severe cognitive impairment. Resident #12 required total assistance and was always incontinent of bowel. The resident had an indwelling catheter. Review of Resident #12's care plan, dated 05/09/2025, revealed a problem of has an indwelling urinary catheter due to urinary obstruction and an intervention of Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 08/07/2025 at 10:48 a.m. revealed while providing incontinent care for Resident #12, CNA G wiped Resident #12's buttocks making multiple passes with the same wet wipe. During an interview on 08/07/2025 at 11:07 a.m. CNA G, he said he had wiped Resident #12's buttocks making multiple passes with the same wet wipe. He said he was nervous and he knew to only do one pass per wipe. He stated doing multiple passes could cause a risk for infection for the resident. CNA G confirmed receiving training on incontinent care from the facility. During an interview with the DON on 08/07/2025 at 3:40 p.m., she confirmed a wet wipe should only be used for one pass, during perineal care. She stated doing multiple passes could possibly cause an infection. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were checked yearly. The DON said she spot checked the staff while they provide care for infection control and quality of care. Review of annual skills check revealed CNA G passed competency for Perineal care/incontinent care on 01/20/2025. Review of facility policy, titled Perineal care, undated, revealed wash peri-area using front to back strokes. 2.Record review of Resident #92's face sheet, dated 08/07/2025, revealed an admission date of 01/09/2025, with diagnoses which included: Wernicke's encephalopathy (brain and memory disorder due to a lack of vitamin B1), Dysphagia (difficulty swallowing), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), and Asthma (Long-term inflammatory disease of the airways restricting airflow). Record review of Resident #92's Quarterly MDS assessment, dated 07/08/2025, revealed the resident had a BIMS score of 08, indicating she was moderately cognitively impaired. Resident #92 was always incontinent of bladder and bowel and, required total assistance with her ADLs. Record review of Resident #92's care plan, dated 01/17/2025, revealed a problem of has ADL Self Care Performance Deficit related to Wernicke's encephalopathy, Muscle weakness, with an intervention of Toileting Hygiene: Dependent. Observation on 08/07/2025 at 3:24 p.m., revealed while providing incontinent care for Resident #92, CNA E did not separate Resident #92's labia to clean the meatus (urinary opening). During an interview on 08/07/2025 at 3:37 a.m. CNA E, said she did not separate Resident #92's labia. She said she was nervous but she knew she had to clean between the resident's labia. She stated not cleaning between the labia could cause a risk for infection for the resident. She said she received training on incontinent care from the facility. During an interview with the DON on 08/07/2025 at 3:40 p.m., the DON said the staff had to clean between the resident's labia during female incontinent care. She stated not cleaning between the labia could cause a risk for infection for the resident. The DON revealed the staff received training on infection control and incontinent care at least annually. The DON said the staff skills were checked yearly. The DON said she spot checked the staff while they provided care for infection control and quality of care. Review of annual skills check revealed CNA E passed competency for Perineal care/incontinent care on 02/19/2025. Review of Facility's policy Perineal care - female, undated, revealed First separate inner labia and wash down the center over the urethral area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to prepare and provide food and drink that was palatable, attractive, and at a safe and appetizing temperature, for 3 of 29 residents (Resident #6, #43, and #93) reviewed for palatable and appetizing food, in that: 1. The facility served Resident #6 meals that were cold. 2. The facility served Resident #43 meals that were cold 3. The facility served Resident #93 meals that were cold. These failures could place residents at risk for a diminished quality of life by not receiving food and drink that is palatable, attractive, and at a safe and appetizing temperature. The findings included: 1. A record review of Resident #6's face sheet dated 08/05/25 revealed the latest admission date of 3/26/25 for a 54- year -old male with diagnoses which included type 2 diabetes mellitus( a condition in which the body has trouble controlling blood sugar), depression disorder (a condition in which there is persistent feeling of sadness) and chronic kidney disease( a condition in which the kidney function is impaired). A record review of Resident #6's quarterly MDS assessment dated [DATE] revealed Resident #6 had a BIMS of 15 (a condition in which the cognition is intact). A record review of Resident #6's care plan initiated on 2/28/21 revealed a deficit in activities of daily living. A record review of Resident #43's face sheet dated 8/5/25 revealed an admission date of 5/29/24 for a [AGE] year old male with diagnoses of anemia (a condition in which there is not enough red blood cells), COPD (a condition in which the lung function is diminished) , and muscle weakness ( a condition in which the muscle strength is poor). 2. A record review of Resident #43's annual MDS completed on 5/29/25 revealed a BIMS score of 13 (a condition in which the cognition is intact). A record review of Resident #43's care plan initiated on 7/4/23 revealed a deficit in activities of daily living. A record review of Resident #93's face sheet dated 8/5/25 revealed an admission date of 4/25/24 for a [AGE] year old female resident with diagnoses of blindness in the right eye, ( a loss of vision in one eye), essential hypertension ( a condition in which the blood pressure is high), and syncope ( a condition of temporary loss of consciousness) 3. A record review of Resident #93's quarterly MDS dated [DATE] revealed a BIMS of 13 (a condition in which cognition is intact). A record review of Resident #93's care plan initiated on 4/30/24 revealed a deficit in activities of daily living. During an interview on 8/5/25 at 12:15pm Resident # 6 stated that he eats in his room and his meals are often cold when served. Resident #6 stated that today's lunch was cold and he did not want to eat it. During an interview on 8/5/25 at 1:15pm Resident #93 stated she eats in the room and the breakfast when served is almost always cold. During an interview on 8/6/25 at 7:25am C.N.A.-A stated that the food tray racks have a plastic cover which is removed and when on the resident hallways the food trays are held in an open tray rack cart. During an observation on 8/6/25 at 7:40 am revealed a resident's serving of eggs had a recorded temperature of 94.82F (eggs per CMS should be maintained at 135F) and a resident's serving of sausage had a recorded temperature of 90.32F ( sausage per CMS should be maintained at 140F) During a phone interview on 8/6/25 at 10:15am a family member for Resident #93 stated the meals served are often cold. During a phone interview on 8/6/25 at 11:10am Resident #43 stated he eats in his room and the lunch and supper meals when served are sometimes cold. During an interview on 8/6/25 at 2:45pm the Activity Director stated that resident council meetings were held on 5/5/25 and 8/5/25 in which multiple residents reported that food is often cold when served. Record review of facility dietary policy noted under the Texas Food Establishment Rules dated 10/11/25 pages 68-73 revealed that food served would follow the established guidelines for temperature control.

Observation, interview and record review revealed the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen.<BR/>1. The floors in the kitchen had food debris on them throughout the kitchen; on the floors in the chemical/storage area and the floors had a greasy appearance to them. The tile was stained underneath the 3 -compartment sink by the stove.<BR/>2. The air vent partitions were a rust color and the vent covers had built up lent on them throughout the kitchen and dishwashing room. Some of the vent covers were modified by using duct tape and zip ties.<BR/>3. There were dirty cooking trays piled up on the 3- compartment sink and inside the sink of the dishwasher. There were black stains on the walls in the dishwashing room.<BR/>4. In the chemical/storage room there were multiple brown (filthy) mop heads inside a food bin; there were empty boxes, empty grease containers, a pot full of used grease on the floor; the 3 metal shelving units had built up lent; the floor mat was overturned onto the bottom shelf of one of the shelving units and looked dirty.<BR/>5. [NAME] A and DA B had hair coming out of the hairnet and baseball cap on the side of their head. DA B was not wearing a beard guard.<BR/>6. The convection oven and the two ovens on the stove had built up burned food debris on the walls.<BR/>These deficient practices could affect resident who ate their meals prepared in the kitchen and could contribute to cross contamination and the spread of foodborne illnesses.<BR/>Review of an audit conducted by the Dietician, dated 12/28/22, revealed there were many areas of the kitchen that points were deducted because the kitchen was not in compliance including; the floors were dirty, there were boxes and items on the floor in the storage areas, air vents had dust, shelving units had dust and staff did not always wear hairnets while in the kitchen. <BR/>Interview on 1/18/23 at 11:13 AM with the Dietician revealed she conducted an audit of the kitchen on 12/28/22 to include the cleanliness of the kitchen. She stated she inquired about the kitchen sanitation including the condition of the floor under the 3- compartment sink. She stated she noted the tile under the sink was stained and there were areas in the kitchen that had not been swept. The Dietician stated there were other areas of concern and stated she provided the DM with a written report. <BR/>Observation on 1/18/23 at 11:30 AM revealed the DM, 1 [NAME] 3 Dietary Aides were on duty. The following was noted during the kitchen observation: the floors throughout the kitchen, the chemical/supply room and in the dishwashing room were full of debris. There was a built- up greasy appearance on the floors and there were stains on the tile in multiple areas including under the 3- compartment sink closest to the stove. There were dirty cooking trays and pots in the 3 compartment sink. There was food debris behind the stove, the convection oven, deep fryer and the prep tables along the far wall and under the prep tables positioned in front of the stove. There were multiple used/brown/filthy mop heads in a food storage bin in the chemical/supply room. There was a rubber floor mat overturned onto the bottom shelf on one of the shelving units. There were 3 shelving units that had built up lent on them. In the dishwashing room, there were black stains along the wall. There were multiple dirty cooking sheets and dishes in the sink for the dishwasher. The air vent metal partitions on the ceiling holding the ceiling panels in place throughout the kitchen were a rust color and the vent covers had built up lent on them,. There were two air vents over the prep table in front of the stove. The vent covers had built up lent on them. Further observation revealed black residue on the walls of the convection oven and on the walls in the two ovens of the stove. It appeared like burnt up burned food residue. <BR/>Observation on 1/18/23 at 11:45 AM revealed the [NAME] and two Dietary Aides wore hairnets. The two Dietary Aides had hair coming out of the hairnet along the sides and the back of their head. <BR/>Interview on 1/18/23 at 11:50 AM with the DM revealed he had worked at the facility for about 60 days. He toured the kitchen with the Surveyor and stated staff was supposed to clean in between breakfast and lunch meals. He stated based on the amount of dirty dishes at the 3-compartment sink and in the sink for the dishwasher, it looked like staff did not clean after the breakfast meal. He stated kitchen staff was also supposed to sweep and spot mop as needed and at the end of the day. The DM further stated one of the DA's and pointed to DA B had swept and mopped the floors this morning. Interview with the DA B at this same time, revealed he had just arrived to the facility and had not done any cleaning. Then the DM stated that it did not look like the floors had been swept or mopped based on the amount of food debris behind the appliances and the greasy appearance on the floor. The DM stated he had a deep cleaning schedule but could not find it at the time. He stated night staff was supposed to deep clean the ovens and ensure the floors were clean but further stated the night cook called in yesterday evening. The DM stated staff was to deep clean all appliances at least once weekly but after looking inside the convection oven and in the two ovens on the stove, he stated the ovens did not look like they had been cleaned in a long while. The DM stated there was black burnt food debris in the all the ovens. The DM pointed out two vent covers that he had to modify by using duct tape and zip ties to hold the covers in place. He stated the MS was responsible for cleaning the vents covers. He stated that he saw maintenance staff clean them maybe 1 month ago. The DM stated the lent on the vent covers that were over the steam table could blow into the food and contaminate the food possibly making residents sick. <BR/>Interview on 1/18/23 at 12:15 PM with the MS revealed he was responsible for replacing the filters inside the vents in the kitchen and repair broken kitchen equipment. He stated he was not responsible for cleaning the vent covers. He stated the kitchen staff was solely responsible for cleaning the kitchen since he had been in his position for 3 years. <BR/>Interview on 1/19/23 at 10:45 AM with DA B revealed he worked from 12 PM to 7:30 or 8 PM. He stated he would sweep and mop the floor in the main kitchen area, wipe down all stations, break down and clean the dishwasher, and would take out the trash before leaving for the day. DA B stated they did not have a morning DA and the DM had been filling this position. He stated he was allowed to use a baseball cap instead of a hairnet. He wore a mask but not a beard guard. DA B stated he understood the purpose of the hairnet and beard guard was to ensure facial hair from falling into the food while prepping the meal trays. DA B stated he had hair that was longer than the bottom of his baseball cap and he confirmed he was not wearing a beard guard. He stated if hair fell into the food it could make residents sick. DA B reviewed the deep cleaning schedule for the week of 1/16/23. He stated the DM had him initial the log yesterday and he mistakenly initialed on Tuesday, 1/17/23, but stated he did not work on 1/17/23. He stated he meant to initial on 1/18/23. <BR/>Interview on 1/19/23 at 10:59 AM with [NAME] A revealed she had worked at the facility for about 1 year. She stated as a [NAME] she was responsible for sweeping, mopping, wiping down the steam table, 3 compartment sink and organizing different areas in the kitchen. [NAME] A stated the DA was supposed to wash dishes between the breakfast and lunch meals but they did not have a morning DA and the DM was filling the position. [NAME] A stated the dishes were not washed after the breakfast meal on 1/18/23. [NAME] A stated not all kitchen staff followed the cleaning schedule and the DM did not enforce it. She stated no one listened and there were no consequences which was why the kitchen was dirty on 1/18/23 [NAME] A stated the vent covers in the kitchen were clean once since she had been working and it was done while the previous DM was working. [NAME] A also stated she understood the hairnet was designed to keep hair from falling in the food. She stated her hair was coming out on the sides of her head and on the back of her head. She stated she would take it on and off when she used the bathroom and sometimes was in a hurry. [NAME] A stated if hair fell in the food it could contaminate the food and make the residents sick. [NAME] A also stated the DM had her initial the cleaning schedule yesterday, 1/18/23, but stated she had not completed tasks per the cleaning schedule. <BR/>Interview on 1/19/23 at 12:15 PM with the ADM revealed he had observed the kitchen on 1/18/23 and believed the debris on the floor was a result of kitchen staff actively working in the kitchen. He state he talked with the DM about the audit completed by the Dietician on 12/28/22 and the DM was supposed to be working on cleaning and making necessary changes to the areas that were marked as not done including cleaning the floors. He stated he provided the DM with guidance according to his job description as part of his training. The ADM stated the DM was fairly new to the facility but had many years of experience as a DM in long term care. <BR/>Review of a facility policy, Cleaning and Disinfection of Kitchen Equipment, undated, read in part: Purpose: To provide information on how to clean and disinfect kitchen equipment. This may include food prep areas, tables, sinks, ovens, floors and other kitchen equipment. Procedure: Equipment used for food preparation must be wiped with a facility-approved cleaning supplies after each use and when visibly soiled.<BR/>Review of the job description for Dietary Supervisor, dated 12/27/21, read in part: Position Summary: To direct the overall operation of the Dietary Department in accordance with current applicable federal, state, and local standards, guidelines and regulations governing the facility and as may be directed by the Administrator and Dietician. To assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner. As the Dietary Supervisor, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. <BR/> <BR/> <BR/> <BR/> <BR/> <BR/>

Based on observations, interviews, and record reviews, the facility failed to 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 disease and infection for 1 of 2 residents (Resident #2) reviewed for infection control, in that:<BR/>CNA A did not change her gloves or wash her hands after touching Resident #2's privacy curtain, between change of gloves and, after providing incontinent care for Resident #2.<BR/>These deficient practices could place residents at-risk for infection due to improper care practices. <BR/>The findings included:<BR/>Record review of Resident #2's face sheet, dated 05/16/2024, revealed an admission date of 01/20/2020 and, a readmission date of 09/30/2023, with diagnoses which included: Dislocation of right hip (thighbone separates from the hip bone), Chronic pain, History of urinary tract infection (infection in any part of the urinary system), Cerebellar ataxia (Lack of voluntary coordination of muscles movements originating in the cerebellum part of the brain)and, Hypertension (High blood pressure). <BR/>Record review of Resident #2's Quarterly MDS assessment, dated 02/12/2024, revealed Resident #2 had a BIMS score of 15, which indicated no cognitive impairment. Resident #2 was indicated to always be incontinent of bowel and bladder and, required extensive assistance to total care with her acclivities of daily living. <BR/>Review of Resident #22's care plan, dated 12/27/2021, revealed a problem of has bladder incontinence related to muscle weakness and debility with an intervention of Check as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes <BR/>Observation on 05/16/2024 at 10:52 a.m. revealed, while providing incontinent care for Resident #2, CNA A did not change her gloves or wash her hands after touching the privacy curtain to close it and before providing incontinent care for Resident #2. CNA A changed her gloves after cleaning Resident #2's genitals but did not sanitize her hands before putting clean gloves on. Further observation revealed CNA A changed her gloves after cleaning Resident #2's buttocks but did not sanitize her hands before putting clean gloves on and touching the new brief to fasten them for the resident. <BR/>During an interview on 05/16/2024 at 11:00 a.m. CNA A confirmed she did not change her gloves or wash her hands after touching the privacy curtain and before starting to provide care. CNA A also confirmed she did not sanitized between change of gloves or before touching Resident #2's clean brief. She confirmed receiving infection control training within the year. <BR/>During an interview with the DON on 05/16/2024 at 11:05 a.m., the DON confirmed the staff should have changed her gloves after touching the privacy curtain to prevent contamination and infection to the resident. She confirmed staff should sanitize their hands between change off gloves to prevent infection to the resident. The DON revealed the DON and the ADON provided training on infection control to the staff at least once a year. They checked the staff's skills once a year and did spot check when problems with infection control were noticed. <BR/> Review of facility Nurse aide competency checklist perineal care-female (with or without catheter, undated, revealed wash hands. Wear gloves and follow Standard Precautions if contact with blood or body fluids is likely [ .] wash hands and put on clean gloves for perineal care.<BR/>During an interview on 05/16/2024 at 1:38 p.m. with the DON, she revealed there was no other policy regarding when to change gloves and practice hand hygiene during incontinent care.

Observation, interview and record review revealed the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen.<BR/>1. The floors in the kitchen had food debris on them throughout the kitchen; on the floors in the chemical/storage area and the floors had a greasy appearance to them. The tile was stained underneath the 3 -compartment sink by the stove.<BR/>2. The air vent partitions were a rust color and the vent covers had built up lent on them throughout the kitchen and dishwashing room. Some of the vent covers were modified by using duct tape and zip ties.<BR/>3. There were dirty cooking trays piled up on the 3- compartment sink and inside the sink of the dishwasher. There were black stains on the walls in the dishwashing room.<BR/>4. In the chemical/storage room there were multiple brown (filthy) mop heads inside a food bin; there were empty boxes, empty grease containers, a pot full of used grease on the floor; the 3 metal shelving units had built up lent; the floor mat was overturned onto the bottom shelf of one of the shelving units and looked dirty.<BR/>5. [NAME] A and DA B had hair coming out of the hairnet and baseball cap on the side of their head. DA B was not wearing a beard guard.<BR/>6. The convection oven and the two ovens on the stove had built up burned food debris on the walls.<BR/>These deficient practices could affect resident who ate their meals prepared in the kitchen and could contribute to cross contamination and the spread of foodborne illnesses.<BR/>Review of an audit conducted by the Dietician, dated 12/28/22, revealed there were many areas of the kitchen that points were deducted because the kitchen was not in compliance including; the floors were dirty, there were boxes and items on the floor in the storage areas, air vents had dust, shelving units had dust and staff did not always wear hairnets while in the kitchen. <BR/>Interview on 1/18/23 at 11:13 AM with the Dietician revealed she conducted an audit of the kitchen on 12/28/22 to include the cleanliness of the kitchen. She stated she inquired about the kitchen sanitation including the condition of the floor under the 3- compartment sink. She stated she noted the tile under the sink was stained and there were areas in the kitchen that had not been swept. The Dietician stated there were other areas of concern and stated she provided the DM with a written report. <BR/>Observation on 1/18/23 at 11:30 AM revealed the DM, 1 [NAME] 3 Dietary Aides were on duty. The following was noted during the kitchen observation: the floors throughout the kitchen, the chemical/supply room and in the dishwashing room were full of debris. There was a built- up greasy appearance on the floors and there were stains on the tile in multiple areas including under the 3- compartment sink closest to the stove. There were dirty cooking trays and pots in the 3 compartment sink. There was food debris behind the stove, the convection oven, deep fryer and the prep tables along the far wall and under the prep tables positioned in front of the stove. There were multiple used/brown/filthy mop heads in a food storage bin in the chemical/supply room. There was a rubber floor mat overturned onto the bottom shelf on one of the shelving units. There were 3 shelving units that had built up lent on them. In the dishwashing room, there were black stains along the wall. There were multiple dirty cooking sheets and dishes in the sink for the dishwasher. The air vent metal partitions on the ceiling holding the ceiling panels in place throughout the kitchen were a rust color and the vent covers had built up lent on them,. There were two air vents over the prep table in front of the stove. The vent covers had built up lent on them. Further observation revealed black residue on the walls of the convection oven and on the walls in the two ovens of the stove. It appeared like burnt up burned food residue. <BR/>Observation on 1/18/23 at 11:45 AM revealed the [NAME] and two Dietary Aides wore hairnets. The two Dietary Aides had hair coming out of the hairnet along the sides and the back of their head. <BR/>Interview on 1/18/23 at 11:50 AM with the DM revealed he had worked at the facility for about 60 days. He toured the kitchen with the Surveyor and stated staff was supposed to clean in between breakfast and lunch meals. He stated based on the amount of dirty dishes at the 3-compartment sink and in the sink for the dishwasher, it looked like staff did not clean after the breakfast meal. He stated kitchen staff was also supposed to sweep and spot mop as needed and at the end of the day. The DM further stated one of the DA's and pointed to DA B had swept and mopped the floors this morning. Interview with the DA B at this same time, revealed he had just arrived to the facility and had not done any cleaning. Then the DM stated that it did not look like the floors had been swept or mopped based on the amount of food debris behind the appliances and the greasy appearance on the floor. The DM stated he had a deep cleaning schedule but could not find it at the time. He stated night staff was supposed to deep clean the ovens and ensure the floors were clean but further stated the night cook called in yesterday evening. The DM stated staff was to deep clean all appliances at least once weekly but after looking inside the convection oven and in the two ovens on the stove, he stated the ovens did not look like they had been cleaned in a long while. The DM stated there was black burnt food debris in the all the ovens. The DM pointed out two vent covers that he had to modify by using duct tape and zip ties to hold the covers in place. He stated the MS was responsible for cleaning the vents covers. He stated that he saw maintenance staff clean them maybe 1 month ago. The DM stated the lent on the vent covers that were over the steam table could blow into the food and contaminate the food possibly making residents sick. <BR/>Interview on 1/18/23 at 12:15 PM with the MS revealed he was responsible for replacing the filters inside the vents in the kitchen and repair broken kitchen equipment. He stated he was not responsible for cleaning the vent covers. He stated the kitchen staff was solely responsible for cleaning the kitchen since he had been in his position for 3 years. <BR/>Interview on 1/19/23 at 10:45 AM with DA B revealed he worked from 12 PM to 7:30 or 8 PM. He stated he would sweep and mop the floor in the main kitchen area, wipe down all stations, break down and clean the dishwasher, and would take out the trash before leaving for the day. DA B stated they did not have a morning DA and the DM had been filling this position. He stated he was allowed to use a baseball cap instead of a hairnet. He wore a mask but not a beard guard. DA B stated he understood the purpose of the hairnet and beard guard was to ensure facial hair from falling into the food while prepping the meal trays. DA B stated he had hair that was longer than the bottom of his baseball cap and he confirmed he was not wearing a beard guard. He stated if hair fell into the food it could make residents sick. DA B reviewed the deep cleaning schedule for the week of 1/16/23. He stated the DM had him initial the log yesterday and he mistakenly initialed on Tuesday, 1/17/23, but stated he did not work on 1/17/23. He stated he meant to initial on 1/18/23. <BR/>Interview on 1/19/23 at 10:59 AM with [NAME] A revealed she had worked at the facility for about 1 year. She stated as a [NAME] she was responsible for sweeping, mopping, wiping down the steam table, 3 compartment sink and organizing different areas in the kitchen. [NAME] A stated the DA was supposed to wash dishes between the breakfast and lunch meals but they did not have a morning DA and the DM was filling the position. [NAME] A stated the dishes were not washed after the breakfast meal on 1/18/23. [NAME] A stated not all kitchen staff followed the cleaning schedule and the DM did not enforce it. She stated no one listened and there were no consequences which was why the kitchen was dirty on 1/18/23 [NAME] A stated the vent covers in the kitchen were clean once since she had been working and it was done while the previous DM was working. [NAME] A also stated she understood the hairnet was designed to keep hair from falling in the food. She stated her hair was coming out on the sides of her head and on the back of her head. She stated she would take it on and off when she used the bathroom and sometimes was in a hurry. [NAME] A stated if hair fell in the food it could contaminate the food and make the residents sick. [NAME] A also stated the DM had her initial the cleaning schedule yesterday, 1/18/23, but stated she had not completed tasks per the cleaning schedule. <BR/>Interview on 1/19/23 at 12:15 PM with the ADM revealed he had observed the kitchen on 1/18/23 and believed the debris on the floor was a result of kitchen staff actively working in the kitchen. He state he talked with the DM about the audit completed by the Dietician on 12/28/22 and the DM was supposed to be working on cleaning and making necessary changes to the areas that were marked as not done including cleaning the floors. He stated he provided the DM with guidance according to his job description as part of his training. The ADM stated the DM was fairly new to the facility but had many years of experience as a DM in long term care. <BR/>Review of a facility policy, Cleaning and Disinfection of Kitchen Equipment, undated, read in part: Purpose: To provide information on how to clean and disinfect kitchen equipment. This may include food prep areas, tables, sinks, ovens, floors and other kitchen equipment. Procedure: Equipment used for food preparation must be wiped with a facility-approved cleaning supplies after each use and when visibly soiled.<BR/>Review of the job description for Dietary Supervisor, dated 12/27/21, read in part: Position Summary: To direct the overall operation of the Dietary Department in accordance with current applicable federal, state, and local standards, guidelines and regulations governing the facility and as may be directed by the Administrator and Dietician. To assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner. As the Dietary Supervisor, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. <BR/> <BR/> <BR/> <BR/> <BR/> <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to the ensure the resident received assistance devices to prevent accidents and the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance for 2 of 5 Residents (Resident #1 & Resident #2) whose records were reviewed for falls.<BR/>1. Resident #1 had 4 falls within 24 hours upon admission related to nursing staff not providing Resident #1's fall history through report, lack of staffing and staff not initiating appropriate safety interventions to keep Resident #1 as safe as possible. As a result, he sustained multiple fractures.<BR/>2. Resident #2 had a history of falling out of his wheelchair. Nursing staff failed to ensure his wheelchair was in the locked position and placed away from his bed to prevent further falls.<BR/>These deficient practices could affect any resident and potentially contributed to avoidable falls and injuries.<BR/>The findings were:<BR/>1. Review of Resident #1's face sheet, dated 1/19/23, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified Dementia and Chronic Systolic (congestive) Heart Failure.<BR/>Review of Resident #1's admission assessment, dated 12/30/22 at 3:49 PM, revealed Resident #1 was alert 1-2, understood had memory loss which caused agitation and impulsiveness, complained of dizziness in past 3 days, wore glasses, had moderate hearing impairment, no use of assuasive device noted, history of falls, unable to determine weight bearing limitations and it was noted he had limited range of motion on both legs and feet. Further review revealed LVN F completed the assessment.<BR/>Review of Resident #1's 5-day MDS, dated [DATE], revealed he had vision impairment; his BIMS was 00 (out of 15) indicative of severe cognitive impairment; he exhibited inattention and disorganized thinking; transfers only happened once or twice by 1 person; he was not steady moving from seated to standing position, moving off and on the toilet and surface to surface transfer; he used a wheelchair for mobility; was incontinent of urine; he had a fall in the last month, 2-6 months, fracture related to a fall in the last 6 months prior to admission and he had a fall since admission; he had one fall with no injury and one fall with a major injury.<BR/>Review of Resident #1's 48-hour Care Plan, dated 12/30/22, revealed he was a risk for falls related to history of falls, generalized weakness, poor safety awareness and impulsiveness and the intervention implemented was to keep needed items water, etc., in reach.<BR/>Review of Resident #1's incident log revealed he had a fall on 12/30/22 at 19:51 (7:51 PM), at 12/31/22 at 0:00 (!2 PM) and on 12/31/22 at 10:03 AM. <BR/>Review of incident report for Resident #1, dated 12/30/22 at 7:51 PM revealed, This writer was called due to roommate hollering. Upon entering the room resident was one foot away from mattress, head pointed towards the wall and feet over by the privacy curtain and laying on the floor on stomach but favoring the right side. Right arm was folded under the resident. Resident still has red slip grip socks from hospital and the roommates bedside table was pulled away from the wall and the small refrigerator was knocked over on the floor. This writer and CNA attempted to assist the resident up but stated that he wanted a moment to lay on the floor because he was in a great deal of pain. Does attempt to explain what he was trying to do but gets lost in thought and cannot recall the right words so he stops explaining and sighs heavily. Immediate action taken: Resident stood himself up and walked himself back to bed and laid down, covered himself and keeps saying, there was something I was going to do. Injury Type: Unable to Determine. Injury Location: Right hand palm. Level of pain based on observing the resident was a 5. Mental Status: Oriented to Person. Notes: Resident has history of falls due to impulsivity. Further review revealed LVN F completed this report.<BR/>Review of Resident #1's order summary for December 2022 revealed an order dated 12/30/22 for an x-ray to the right shoulder and right hand due to fall and complaint to pain one time only until 12/31/22.<BR/>Review of an X-ray report for Resident #1, dated 12/30/22, revealed no acute fracture or dislocation of right shoulder and no acute fracture or dislocation of right hand.<BR/>Interview on 1/19/23 at 11:30 AM with Resident #1's RP revealed she was not happy with the fact Resident #1 fell within 2 hours upon admission and then fell again later. She stated Resident #1 had a history of falling at home because he could not walk on his own and he had severe Dementia. She stated she let nursing staff know about his history of falling. The RP stated she did not believe they took care of him the way he needed. Furthermore, she did not believe he would be safe if he returned to the facility so she secured alternative placement.<BR/>Interview on 1/19/23 at 1:15 PM with LVN F revealed she admitted Resident #1 on a Friday and no one was with him upon admission from the hospital. He did not have any visitors. A family member called about a visit and she let him know Resident #1's roommate went to bed early and told the son if he visited it would have to be a quick visit or he could visit early next morning. LVN F stated Resident #1 had a communication deficit (lack of expressive language) and would get agitated. She stated the bed was in the lowest position and the urinal was at bedside within reach. She demonstrated how to use the call light; had it pinned to his gown and provided the bed remote. LVN F stated Resident #1 was a 2 person assist and not able bare weight; he could not stand for long without his knees buckling. She stated Resident #1 was thin but tall. He could follow commands and seemed to understand. LVN F stated Resident #1 fell within 2 hours after admission before dinnertime. She had put him to bed about 2 hours prior to the fall and he was talking on the phone. LVN F stated Assistant MS saw Resident #1 on the floor and told her. LVN F stated she talked with Resident #1's RP about the fall and she stated Resident #1 had fallen at home. LVN F stated Resident #1 was sleeping by the time she left at 10 PM. She stated Resident #1 requested that she leave the overhead light on. LVN F stated she asked the MS about fall mats and he told her she could find them in central supply. She stated she did not implement fall mats.<BR/>Interview on 1/19/23 at 2:13 PM with CNA G revealed she was on duty on 12/30/22 from 2 PM to 10 PM when Resident #1 fell. She stated LVN F told her he was a fall risk. She stated fall protocol usually required the use of a low bed in the lowest position, fall mat, call within reach and more frequent visual checks. She stated she was not sure if the bed was in the lowest position and there was not a fall mat in place. She stated the call light was clipped to Resident #1's gown ad he had 2 urinals by the bedside. CNA B stated Resident #1 got up twice during the shift and did not seem to understand what he was doing. She stated the first time she caught Resident #1 up and she put him back to bed. CNA G stated she thought Resident #1 fell after dinner between 6 PM to 7 PM and had checked on him about an hour before he fell. Resident #1 was found on the floor and he did not say how he fell. He seemed confused. She stated she alerted LVN F who came right away. CNA G stated she thought Resident #1 sustained an injury but could not remember what type of injury.<BR/>Interview on 1/19/23 at 2:35 PM with LVN F revealed she did not get a fall mat from central supply and did not have the CNA get a fall mat because they were the only ones on duty. She stated she did not implement a fall mat. She stated typically there were 2 aides on duty but was not sure if someone called in or what happened. She stated there were three or four other residents who were a fall risk so it made it difficult for her and the 1 aide to complete tasks and do as many visual checks as required on the residents who were a fall risk.<BR/>Interview on 1/19/23 at 6:10 PM with LVN F revealed she did not know Resident #1 was a fall risk until he fell. She stated she knew she would be getting a new admission but nursing staff including the AM nurse did not provide any descriptive information about Resident #1. She stated the hospital nurse also did not tell her in report that Resident #1 was a fall risk. She clarified that she asked the MS about the mats to ensure they were available as needed. She stated she did not know enough about Resident #1 to determine whether the use of a fall mat was beneficial or a safety hazard. LVN F confirmed Resident #1 was not able to bare weight and was unsteady on his feet. However, stated he continued to try and walk on his own and was concerned a mat would be more of a safety hazard. LVN F further stated that she believed Resident #1 was going to fall no matter what because he was so unsteady on his feet and could not bare weight for long.<BR/>Review of incident report for Resident #1, dated 12/31/22 at 0:00 (12 PM) revealed CNA found resident sitting on floor. Immediate action taken: Assessed had small abrasion to forehead. Cleansed with normal saline and pat dried. Bleeding stopped. Vital signs 103/66, 76, 18, 98.2, 97 RM air, Assisted back to bed. Neuros started again. Mental Status: Oriented to Person. Further review revealed the family representative, the resident physician and DON were notified of the incident. Further review revealed LVN D completed this report.<BR/>Review of Fall Risk Evaluation dated 12/31/22 0:00 (12 PM) revealed Resident #1 was a high risk for falls with a score of 18. He was noted to be disoriented x 2, had poor vision with or without glasses, history of 3 or more falls in the past 3 months and he had balance problems while standing/walking.<BR/>Review of incident reports for Resident #1 did not reveal an incident report dated 12/31/22 at 2:05 AM.<BR/>Review of Fall Risk Evaluation dated 12/31/22 2:05 AM revealed Resident #1 was a high risk for falls with a score of 18. He was noted to be disoriented x 2, had poor vision with or without glasses, history of 3 or more falls in the past 3 months, he had balance problems while standing/walking and requires use of assistive devices (i.e., cane, walker or wheelchair).<BR/>Review of incident report for Resident #1, dated 12/31/22 at 4:30 AM revealed Resident #1's roommate came yelling down hall that resident was on his side and going to fall again. Resident observed holding onto wheelchair very unsteady gait. 'I immediately ran to his side. Resident stated, hurry up get me to bed. Immediate action taken: Resident had to be eased to sitting position too heavy to try continuing to walk to bed as he was not following direction, please slow down and let go of wheelchair. Abrasion to back observed/scratch. Has swelling to head in between eyebrows. Redness to right hip observed. Injury Type: Abrasion. Injury Location: scapula. Mental Status: Oriented to Person. Notes: Abrasion noted to right hip and abrasion to upper back/scratch, swelling now in between eyebrows. NP notified, requested X-RAY to head and Right hip. Further review revealed the family representative, the resident physician and DON were notified of the incident. Further review revealed LVN D completed this report.<BR/>Review of Fall Risk Evaluation dated 12/31/22 4:30 AM revealed Resident #1 was a high risk for falls with a score of 15. He was noted to be disoriented x 3, had adequate vision, history of 3 or more falls in the past 3 months and he had balance problems while standing/walking.<BR/>Review of Resident #1's order summary for December 2022 revealed an order dated 12/31/22 for STAT X-RAY to right hand, digits, wrist and forearm.<BR/>Review of an X-ray report for Resident #1, dated 12/31/22, revealed acute fracture of distal radius of the right forearm; acute fracture of distal radius of the right wrist and of the 5th digit at the PIP joint.<BR/>Review of hospital transfer form dated 12/31/22 revealed Resident #1 was transferred to the hospital at 2:44 PM.<BR/>Interview on 1/20/23 at 8:10 AM with LVN D revealed she worked at the overnight shift and worked on 12/30/22 and 12/31/22. She stated Resident #1 was extremely confused, impulsive and did not retain instruction. She stated Resident #1 was difficult to redirect based on impulsiveness. He also seemed anxious and she suspected it was because he was in a new environment. LVN D stated Resident #1 had his first fall during her shift around midnight. She stated the CNA on duty reported Resident #1 was sitting next to his bed. She assessed Resident #1, started neurochecks and transferred him back into bed. LVN D stated the bed was in the lowest position and she educated Resident #1 about using the call light to ask for assistance. She encouraged Resident #1 to allow them to help him so he would not fall. LVN D stated she changed Resident #1 and continued to encourage him to use the call light before getting up. She stated later on in the shift the roommate came out into the hallway yelling that Resident #1 was up and was going to fall. She ran to the room and saw Resident #1 using the roommate's wheelchair to ambulate. He was walking towards his bed but was extremely wobbly. LVN D stated she walked up beside Resident #1 and held on to his arm. He was clinching on to the wheelchair and she attempted to lock the wheelchair cut could not reach to secure the lock. LVN D stated it was not a good situation and was afraid they were both going to fall. She was able to get Resident #1 to release the wheelchair and she eased him down to the floor. The roommate reported that Resident #1 darted up from the bed and fell trying to get to the restroom and hit his head prior to her entering the room. LVN D stated upon assessment she noted redness to his right hip and ordered x-rays. She passed on the events that took place during her shift, in report, to the morning nurse, LVN E LVN D stated she notified the RP about the falls and she stated he fell at the hospital. The RP said Resident #1 had really bad Dementia. LVN D stated Resident #1 required 1 on 1 supervision and was probably a good candidate for a memory care unit. LVN D stated LVN F told her in report she did not use a fall mat because it would be a tripping hazard. She stated based on her experience with Resident #1 the one night she believed he was going to fall no matter what. She also thought a fall mat would probably have been more of a safety/trip hazard because he was on a mission to get up and go. Although, she stated it might have cushioned his fall. LVN D stated she talked with the ADON and DON both and they did not instruct her to implement any other interventions than were already in place: bed to the lowest position, clipped the call light to his gown, continue to instruct to use it and increase visual checks.<BR/>Interview on 1/20/23 at 9:21 AM with the ADM revealed the Admissions Coordinator would round on the residents in the hospital and get as much information as possible prior to admission. He stated it became obvious very quickly that they were not going to be able to meet his needs in the facility due to Resident #1's impulsivity and not following directives.<BR/>Interview on 1/20/23 at 10:41 AM with the Admissions Coordinator (AC) revealed he started working for the facility during October 2022. He stated he was also an LVN. The AC stated he would get a referral from the hospital, review the clinical documents, visit the patient at the hospital, talk to the aide, nurse and doctor per availability to determine any special needs/equipment the patient might need. He would also talk with family. The AC stated he would present the patient information to the IDT team (department heads) including ADON, DON, ADM, Rehab Director, MDS Coordinator and the SW. The AC stated Resident #1 was referred for skilled nursing for PT/OT with the plan to return home. He had a history of falls at home and had fallen in the hospital 3 times. The hospital had him on 1 on 1 supervision for a period of time but when he visited Resident #1 he was not on 1 to 1 supervision any longer. The AC stated he talked to the nurse who stated Resident #1 was no longer trying to get out of bed. He also spoke with the case manager, with Resident #1 and the RP around 12/22/22 to 12/23/22. He stated he was in contact with the case manager off and on until Resident #1 was ready to be released to determine his discharge plan. The AC stated Resident #1 seemed really nice, able to answer questions, was always in bed, calm and progressing in therapy at the hospital. Resident #1 did not display any agitation or behavior issues and was compliant with treatments per report from nursing. He stated the case manager stated Resident #1 had been on 1 on 1 supervision and it was discontinued on 12/22/23. The AC stated he was not sure if the supervision was continuous but the nurse told him they would be taking him off 1 to 1 supervision. The AC stated per his own experience the Resident would need to be off 1 to 1 supervision 24 hours prior to placement. The AC stated there was not a facility policy that he knew of regarding the supervision and he had not received direction from the nursing facility. The AC stated he presented Resident #1's information to the IDT team on 12/23/22 or 12/24/22. He stated he did not remember everyone who attended the IDT meeting but again stated it was usually the department heads. The IDT reached a consensus that they would accept Resident #1 but stated the admission took place at the end of the month after they secured the contract with Resident #1's insurance provider. <BR/>Interview on 1/20/23 at 1:06 PM with LVN H revealed she worked on 12/30/22 from 6 AM to 2 PM. She stated she knew Resident #1 was admitted on 12/3022 but it was not on her shift. LVN H stated she was not provided any information about Resident #1 including that he had a history of falling. <BR/>Interview on 1/20/23 at 1:43 PM with the Interim DON stated she knew Resident #1 was being admitted but was not sure if she was part of the IDT meeting when staff discussed his appropriateness for placement. She stated the day of admission the floor nurse would receive an admission packet. The first shift nurse would pass on in report that they were expecting a new admission if the resident did not arrive during the first shift and so on. The admitting nurse would document the resident's admission in the 24- hour report and any significant information.<BR/>Interview on 1/20/23 at 2:10 PM with the ADON revealed she was part of the IDT meeting when they discussed Resident #1's placement. She stated she was not sure who all attended but usually it included the DON, SW, therapy, ADM and the BOM. The ADON stated she told LVN H know about Resident #1's admission on [DATE]. LVN H worked the 6 AM to 2 PM shift. The ADON stated she would have provided specifics about Resident #1 including that he was a fall risk. LVN H should have passed the information on in report to LVN F. The ADON stated LVN F asked about implementing a fall mat after Resident #1 fell the first time but she advised her to wait until therapy assessed him. She stated Resident #1 was referred for therapy services with the focused areas being strength and mobility. The ADON stated nursing staff would have to get clearance from management before implementing a floor mat. She stated the interventions in place for Resident #1 included clipping the call light to his gown and increasing rounding on him. She stated they did not put the bed in the lowest position because he was a tall man and would often get up on his own. She stated Resident #1 did not have the strength to get up from the bed in the lowest position and it would be considered a restraint.<BR/>Interview on 1/20/23 at 3:10 PM with the ADM revealed they conducted a fall management in-service on 12/31/22 for the nurses. He stated they had not provided another in-service since to include the CNA's or other staff.<BR/>Interview on 1/20/23 at 3:15 PM with the SC revealed a CNA called in 12/30/22 for the 2 PM to 10 PM shift. He stated they had to make some changes to the assignments and LVN F and CNA G were the only two staff working the hall from 2 PM to 10 PM shift. The SC stated it would have made it difficult to complete normal tasks and to provide the level of supervision Resident #1 required in addition to the 3 or 4 other residents on the hall that were also a fall risk. He stated the census was probably like over 30 residents.<BR/>Interview on 1/20/23 at 4 PM with the Interim DON revealed a fall risk assessment was completed for every resident upon admission and after any fall. She stated nursing staff were to gather information to determine the root cause of the fall. Nursing staff was supposed to ask the who, what, when, where and why and implement interventions according to the root cause analysis.<BR/>Interview on 1/20/23 at 4:09 PM with the Staffing Coordinator (SC) revealed he worked the second floor from 10 PM to 6 AM as a CNA on 12/31/22. He stated upon beginning his shift he would usually make a sweep of all residents, checking on residents to ensure they were in their room, in bed and were ok. He remembered Resident #1 talking to himself and fidgeting with his gown. He asked the Resident if he was ok and the Resident said yes. The SC stated he completed his sweep and then started with incontinent care. He stated Resident #1's roommate came out and asked for help while he was in another resident room by the nurse's station. The SC stated Resident #1 was lying on the floor on his right side by the roommate's bed . Resident #1 said I'm hurting but could not say what happened. The SC stated there was not a fall mat in place. The bed was in the lowest position about 1 foot off the floor. He stated the nurse responded and assessed Resident #1 while on the floor. He and the nurse transferred Resident #1 to bed and the Resident complained of pain to his wrist. The SC stated after the second fall he answered the call light. The roommate was out in the hallway yelling for help. The SC stated when he entered the room he saw Resident #1 crawling on the floor. He stepped out of the room to get the nurse to help and when they returned Resident #1 had put himself back to bed. The SC stated Resident #1 was very confused. The roommate reported he saw Resident #1 crawling on the floor when he woke up. The SC stated he had checked in on Resident #1 about an hour before he was observed crawling on the floor. He stated Resident #1 was wide awake and restless. The SC stated he would round on residents every two hours and in between changing residents. He stated the nurse would also make her own rounds. The SC could not remember if the nurse told him Resident #1 was a fall risk. He stated the fall protocol required they put the resident bed to the lowest position, ensure the environment was clutter free and a fall mat was used if it was not a safety hazard. The SC further stated Resident #1 had the call light clipped to his gown and his overhead light was on. The SC stated Resident #1 was not able to walk and during transfer he was able to bare weight for a short time. He stated the nurse did not implement the use of the fall mat after the additional 2 falls. <BR/>Interview on 1/20/23 at 4:40 PM with the Interim DON revealed she assumed her position on 12/27/22 or 12/28/22. She stated she reviewed Resident #1's hospital documentation after it was faxed to the facility and stated Resident #1 had 3 falls while at the hospital related to impulsivity. She stated Resident #1 had heart failure and his heart was operating at 30 %. The Interim DON stated LVN F called her late in the evening after Resident #1 had his first fall. She understood Resident #1 was using his bedside table to walk and he fell into the roommate's mini refrigerator. The nurse educated Resident #1 on the use of the call light. She stated X-rays were ordered and they were negative for any fractures. The Interim DON stated staff found Resident #1 sitting next to his bed after his 2nd fall and LVN D reported she guided Resident #1 to the floor which was considered to be his 3rd fall. LVN D stated Resident #1 was using his roommate's wheelchair/ to ambulate and was very unsteady. Interim DON stated the last two falls took place during the overnight shift. She stated Resident #1 had 3 falls altogether while at the facility. The Interim DON stated a 2nd set of X-rays were positive for a fracture but was not sure about the exact location. She stated the interventions in place for Resident #1 included: call light was clipped to his gown; he had 2 urinals at bedside and his overnight light was on. She stated nursing staff believed Resident #1 required 1 to 1 supervision because he was determined to get up and walk. He was able to ambulate somewhat; not safely but he could walk. Interim DON stated they obviously could not provide 1 to 1 supervision. Furthermore, nursing staff was not convinced using a fall mat was a safe intervention which she discussed with nursing staff. The Interim DON stated she did not know who received Resident #1's clinical's to determine whether he was appropriate for placement. <BR/>Interview on 1/23/23 at 1:39 PM with the SC revealed he confirmed that on Saturday, 12/31/22, he found Resident #1 on the floor after the first fall during the night shift; later he observed Resident #1 crawling on the floor and then LVN D called him over to Resident #1's room to help transfer Resident #1 to bed after reporting she had lowered him to the floor. The SC stated technically Resident #1 had 3 falls during the night shift.<BR/>Interview on 1/23/23 at 1:42 PM with Resident #4 revealed he remembered Resident #1 after cueing. He stated Resident #1 kept falling. He would get out of bed and would hold on to everything to keep from falling but he fell anyway. Resident #4 stated Resident #1 was not steady and could not walk very good. He stated Resident #1 knocked his mini refrigerator over from on top of his dresser. Resident #4 stated Resident #1 did not want to be in bed. Resident #4 stated he kept calling staff for help because it usually took staff over an hour to respond when he used the call light. He stated the staff responded to his call for help.<BR/>2. Review of Resident #2's face sheet, dated 1/23/23, revealed he was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy and repeated falls. <BR/>Review of Resident #2's admission quarterly MDS, dated [DATE], revealed his BIMS was 8 (out of 15) indicative of severe cognitive impairment; he required extensive assistance by 1 person for bed mobility and transfers; he was unsteady moving from sitting to standing position, on and off the toilet and surface to surface transfer and only able to stabilize with staff assistance.<BR/>Review of Resident #2's Care Plan, revised 11/8/22, revealed he required extensive assistance by 2 persons for bed mobility and transfers. Resident #2 was identified as being a fall risk and interventions included: anticipate and meet needs, avoid rearranging furniture, be sure the call light is within reach and encourage to use it to call for assistance as needed, educate resident and caregivers about safety reminders and what to do if a fall occurs, maintain a clear pathway, free of obstacles. Further review revealed Resident #2 had a fall on 1/13/23 and the interventions included: Call don't fall signs next to bed, check range of motion, monitor/document /report to MD for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, neuro-checks as ordered and vital signs as ordered. <BR/>Review of an incident report, dated 1/13/23, revealed LVN E heard Resident #2 yelling out for nurse at 6:30 AM. She found him on the floor laying on his left side with wheelchair beside him. The wheelchair brakes were not locked. The Resident was wearing non-skid socks. Resident #2 was able to make his needs known and stated he hit his head on the floor. Resident #2's description: I don't know, I just fell. Immediate Action Taken: assessed Resident #2 and observed bump on left side of forehead and purple discoloration to left knee upon sitting Resident #2 up. Resident #2 denied pain. He was assisted to the wheelchair by 2 persons and neurochecks initiated. It was noted he did not have any injuries. Further review revealed LVN E notified Resident #2's physician, family member and the DON about the incident.<BR/>Observation on 1/18/23 at 2:05 PM revealed Resident #2 sitting in a wheelchair by the nurse's station. Further observation revealed he had bruising over his left eye. Interview with Resident #2's family member revealed Resident #3 had a fall.<BR/>Observation and interview on 1/20/23 at 11:40 AM revealed Resident #2 was lying in bed on his left side with eyes closed and his bed in a low position. The wheelchair was a couple of feet from the bedside. Interview with CNA I revealed she worked Monday through Friday from 8 AM to 5 PM. She stated she noted bruising over Resident #2's left eye on Monday, 1/17/23, and did not know if he had a fall. She stated the nurse did not say anything to her. CNA I stated Resident #2 was able to make his needs known, would use his call light to ask for assistance, was a 1 or 2 person assist with transfers. She stated the following interventions were used when a resident was identified as being a fall risk: call light within reach, low bed to lowest position and talk to nurse about using a fall mat. LVN I stated she would think Resident #2 was a fall risk because she had seen him try to self-transfer without assistance. She stated he was unsteady on his feet. Further observation revealed Resident #2's bed was not in the lowest position. She stated Resident #2 would sit up and the bed was in the position which allowed him to sit up and place his feet on the floor. CNA I stated there was no fall mat and his call light (touch pad) was placed underneath his left hand.<BR/>Observation and interview on 1/20/23 at 1:06 PM revealed Resident #2 was lying in bed on his left side with eyes closed and his bed in a low position. The wheelchair was a couple of feet from the bedside. Interview with LVN H revealed Resident #2 was a fall risk per nursing report. He required assistance with transfers and stated he was able to pivot at one point but not so much anymore. LVN H stated she was aware Resident #2 had bruising over his left eye but did not talk to CNA I about his fall history because it took place earlier in the month. She stated the information would be available in Resident #2's POC. She stated this was the program the aides documented on which provided them with resident ADL information and any special circumstances. LVN H stated the aides should report any change of condition to them when they noted any changes. She stated CNA I should have reported the bruising over Resident #2's left eye if she had not noted the bruising during her previous shift. LVN H stated she understood LVN E found Resident #2 on the floor by the bed but was not sure if he fell out of the bed or the wheelchair. She did not know all of the details and had not looked at his chart. LVN H stated a low bed to the lowest position would be utilized if Resident #2 fell from the bed and if he fell from the wheelchair then it should be positioned out of the reach/sight from Resident #2 and in the locked position. Further observation revealed Resident #2's bed was not in the lowest position, his wheelchair was by his bedside in front of the night stand, his call light was under his left hand and the bed remote was on the floor. LVN H further stated the wheelchair was not in the locked position and a safety hazard if Resident attempted to transfer to the wheelchair. <BR/>Interview on 1/20/23 at 1:20 PM with CNA J revealed she and CNA I were working together on the same hall. She stated she did not know Resident #2 had fallen and had not noted the bruising to his forehead. She stated she would ask the nurse on duty of any new resident changes upon returning from her days off. CNA J review[TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to 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 disease and infection for 1 of 2 residents (Resident #2) reviewed for infection control, in that:<BR/>CNA A did not change her gloves or wash her hands after touching Resident #2's privacy curtain, between change of gloves and, after providing incontinent care for Resident #2.<BR/>These deficient practices could place residents at-risk for infection due to improper care practices. <BR/>The findings included:<BR/>Record review of Resident #2's face sheet, dated 05/16/2024, revealed an admission date of 01/20/2020 and, a readmission date of 09/30/2023, with diagnoses which included: Dislocation of right hip (thighbone separates from the hip bone), Chronic pain, History of urinary tract infection (infection in any part of the urinary system), Cerebellar ataxia (Lack of voluntary coordination of muscles movements originating in the cerebellum part of the brain)and, Hypertension (High blood pressure). <BR/>Record review of Resident #2's Quarterly MDS assessment, dated 02/12/2024, revealed Resident #2 had a BIMS score of 15, which indicated no cognitive impairment. Resident #2 was indicated to always be incontinent of bowel and bladder and, required extensive assistance to total care with her acclivities of daily living. <BR/>Review of Resident #22's care plan, dated 12/27/2021, revealed a problem of has bladder incontinence related to muscle weakness and debility with an intervention of Check as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes <BR/>Observation on 05/16/2024 at 10:52 a.m. revealed, while providing incontinent care for Resident #2, CNA A did not change her gloves or wash her hands after touching the privacy curtain to close it and before providing incontinent care for Resident #2. CNA A changed her gloves after cleaning Resident #2's genitals but did not sanitize her hands before putting clean gloves on. Further observation revealed CNA A changed her gloves after cleaning Resident #2's buttocks but did not sanitize her hands before putting clean gloves on and touching the new brief to fasten them for the resident. <BR/>During an interview on 05/16/2024 at 11:00 a.m. CNA A confirmed she did not change her gloves or wash her hands after touching the privacy curtain and before starting to provide care. CNA A also confirmed she did not sanitized between change of gloves or before touching Resident #2's clean brief. She confirmed receiving infection control training within the year. <BR/>During an interview with the DON on 05/16/2024 at 11:05 a.m., the DON confirmed the staff should have changed her gloves after touching the privacy curtain to prevent contamination and infection to the resident. She confirmed staff should sanitize their hands between change off gloves to prevent infection to the resident. The DON revealed the DON and the ADON provided training on infection control to the staff at least once a year. They checked the staff's skills once a year and did spot check when problems with infection control were noticed. <BR/> Review of facility Nurse aide competency checklist perineal care-female (with or without catheter, undated, revealed wash hands. Wear gloves and follow Standard Precautions if contact with blood or body fluids is likely [ .] wash hands and put on clean gloves for perineal care.<BR/>During an interview on 05/16/2024 at 1:38 p.m. with the DON, she revealed there was no other policy regarding when to change gloves and practice hand hygiene during incontinent care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 1 of 6 residents (Resident #5) reviewed for medication administration in that: <BR/>MA A left Resident #5's medication at the bedside without ensuring the resident consumed the medication. <BR/>This deficient practice could affect residents and place them at risk of not receiving the therapeutic dosage and drug diversion.<BR/>The findings included:<BR/>Record review of Resident #5's face sheet dated 3/23/2023 revealed an admission date of 1/20/2020 with readmission date of 1/07/2022 with diagnoses which included: personal history of urinary tract infections, gastro-esophageal reflux disease without esophagitis, and mechanical loosening of internal right hip prosthetic joint subsequent encounter. <BR/>Record review of Resident #5's quarterly MDS, dated [DATE] revealed a BIMs score of 15 (scale of 0-15) which indicated the resident was cognitively intact. <BR/>Record review of Resident #5's Care Plan dated 12/19/2022 stated: Administer medication as ordered. <BR/>Record review of Resident #5's Order Summary for March 2023 revealed physician orders for the administration of the following medication:<BR/>-simethicone tablet (used to treat gas) with a start date of 9/26/2022. Give 2 tablets by mouth 3 times a day for gas. <BR/>-gabapentin capsule (anticonvulsant medication often used off label to treat nerve pain) 100 mg with a start date of 1/08/2022. Give 1 capsule by mouth 3 times a day related to pain in right hip. <BR/>-macrodantin capsule (nitrofurantoin macrocrystal) (antibiotic used to treat UTI's) 100 mg with a start date of 12/11/2022. Give 1 capsule by mouth one time a day for prophylactic for multiple UTI's. <BR/>-florastor capsule (probiotic used to support digestive health) with a start date of 9/19/2022. Give 1 capsule by mouth two times a day for stomach (sic). <BR/>During an observation/interview on 3/21/2023 at 9:58 a.m. Resident #5 was observed in her bed with the head of the bed elevated, utilizing her personal cell phone. On the bedside table directly beside Resident #5's bed were two medication cups with pills in them. Medication cup #1 had two nickel sized white round pills. Medication cup #2 had one capsule that contained a beige bead like substance, one oblong pill and one round tablet. Resident #5 quickly took the medication cups and consumed the contents of medication cup while this surveyor was observing. Resident #5 stated the two round nickel sized pills in medication cup #1 were gas pills. She stated the pills in medication cup #2 was one pill for her stomach, one antibiotic. She stated she did not know what the 3rd pill was used for right now. Resident #5 stated it was her fault the medication was at the bedside. She stated MA A gave her the medication and she did not take them right away because she was busy playing on her phone. <BR/>During an interview on 3/22/2023 at 11:47 a.m., MA A stated confirmation that she had left Resident #5's medication at the bedside without ensuring the resident consumed the medication on 3/21/2023. MA A stated she does not normally leave medication at the bedside, but Resident #5 was complaining of an upset stomach and waited to eat something before taking her morning medication. MA A stated she normally makes sure the resident swallows the pills but on 3/21/2023 she was called out of the room for something and left the pills with the resident. MA A stated she estimated the time the medication was left on the beside to be approximately 20 minutes. MA A stated Resident #5 was not cleared to self-administer medications. MA A identified the medication as: simethicone gas pills which were nickel size round white tablets, florastor a probiotic which was a capsule with beige colored beads, gabapentin, and nitro mac an antibiotic used to treat a UTI. MA A stated she was trained and knew she was supposed to stay in the room with the resident until she swallowed the pills. <BR/>During an interview on 3/22/2023 at 4:15 p.m., the DON stated her expectations for medication administration was for staff to remain in the resident room until medications were taken (consumed). The DON stated it was important for staff to ensure the medication was consumed to ensure a dosage of medication was not missed and so someone else could not get a hold of the medication. <BR/>Record review of a facility policy, titled Administration of Medications (undated) revealed: 2. Medications must be given in accordance with the resident's service plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit, prevent abuse, neglect and exploitation of residents for three of three incidents (Resident #40, Resident #36, and Resident #9) reviewed for reporting. <BR/>1. The facility failed to follow their policy to report to the State Survey Agency when Resident #40 sprained his ankle when he got his foot caught in the van ramp while being pushed by the transportation driver. <BR/>2. The facility failed to follow their policy to report to the State Survey Agency when Resident #36 was found to have ant bites on her body. <BR/>3. The facility failed to follow their policy to report to the State Survey Agency when Resident #9 was given the wrong medications on 04/22/24. <BR/>These failures could place residents at risk of lacking timely reporting of incidents.<BR/>Findings include:<BR/>1. Record review of the facility's, undated, policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation, or Mistreatment reflected the following:<BR/> Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to:<BR/> .The State Survey Agency <BR/>Record review of Resident #40's MDS, dated [DATE], reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included end stage renal disease (kidney failure), diabetes, osteoporosis, stroke, and seizure disorder. The MDS further reflected Resident #40 had a BIMS of 14, which indicated his cognition was intact. Resident #40 used a manual wheelchair. <BR/>Record review of Resident #40's care plan, dated 08/29/23, reflected he had osteoporosis and interventions included to protect the resident from injury avoiding sudden bumps, jarring with transfers. The care plan further reflected Resident #40 attended dialysis Mondays, Wednesdays, and Fridays. <BR/>Record review of Resident #40's progress note, dated 06/21/24, documented by LVN A, reflected the following:<BR/>Notified by 1st floor nurse that resident had an incident getting onto the transportation bus. This nurse went down to the 1st floor to assess the resident noted resident sitting in wheelchair, leaned over holding onto right foot, when assessed the right foot noted swelling to the right ankle, very sensitive to touch, able to wiggle toes and pedal pulse 3+. Took resident to his room, assisted him to bed, resident cannot bare weight on right foot . Resident stated 'driver of the van was pushing me onto the ramp but had to push me a little fast because there's a little bump to get over on the ramp when my foot got caught in the ramp and pushed my foot all the way back.' MD notified ordered STAT x-ray to right foot Asked resident pain level from 0-10 resident stated a 10, administered Acetaminophen-Codeine Tablet 300-30MG per resident request for pain.<BR/>Record review of radiology results dated 06/21/24, reflected there were no fractures and no new orders given. <BR/>Record Review of the Transportation Company's Accident/Incident Report Form, dated 06/21/24, reflected the following:<BR/> Incident Information<BR/>Incident Description<BR/>[Resident #40] right ankle was injured while being rolled into the rear ramp of the wheelchair van by driver, [Driver]. As [Resident #40] crested the top of the ramp to enter the van, his right foot was not high enough, which caused his foot to roll under the leg. Driver took [Resident #40] back into the facility for examination by a nurse to determine the severity of his injury. <BR/>Observation and interview with Resident #40 on 06/25/24 at 11:23 AM revealed when he was picked up for dialysis last Friday, 06/21/24, the transportation driver pushed him into the transportation van too fast and his foot got caught where the lift and the van connected. The resident said he immediately felt pain because it sprained his ankle. The facility ordered x-rays to ensure it was not broken due to the swelling. Observation of Resident #40's ankle revealed there was some swelling but there was no bruising noted at the time, but there was a pain patch on his ankle. The resident said he got some pain relief with the pain medications and pain patch. Resident #40 said the same transportation driver took him to dialysis on Monday, 06/24/24. <BR/>Interview on 06/26/24 at 4:04 PM with LVN B revealed the transportation van arrived to pick up Resident #40 to take him to dialysis on 06/21/24, and they were loading the resident into the van. Shortly after, the transportation driver brought Resident #40 back into the facility and said as he was pushing the resident into the van, his foot got caught and twisted up on the ramp and Resident #40 immediately expressed pain. LVN B said she looked at the resident's ankle and noticed swelling on the outer side so she called to let his nurse, LVN A, know what had occurred. <BR/>Interview on 06/26/24 at 2:51 PM with LVN A revealed she got a call from LVN B on 06/21/24, and said Resident #40 had hurt his ankle when the transportation driver was pushing him up the ramp into the van. When she was downstairs, she asked the resident what occurred and he said the transportation had pushed him faster to get onto the van, causing his foot to get stuck in the gap where the ramp meets the van and his foot had bent back. LVN A said she assessed the resident's ankle and noted swelling around it. Resident #40 told LVN A he was having pain to his ankle and he was medicated and they ordered x-rays to ensure it was not fractured. <BR/>Interview with the DON on 06/26/24 at 3:20 PM revealed she was told about Resident #40's incident and they called the doctor for x-rays to ensure his ankle was not broken. The DON stated she called the transportation company to find out what happened but said she had not heard back but would be calling them again for a statement.<BR/>2. Record review of Resident #36's, undated, admission Record reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had with diagnoses which included diabetes, stroke, and muscle wasting.<BR/>Record review of Resident #36's quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Her Functional Status reflected she required total assistance with all of her ADLs except eating and oral hygiene. <BR/>Record review of Resident #36's care plan, dated 05/24/24, reflected the resident had behaviors of scratching and picking at her legs, and delusions involving staff and family. <BR/>Record review of Resident #36's nursing notes reflected documentation on 05/12/24 resident with sugar ants all over her bed, moved resident to bed A temporarily, residents left arm with red raised itchy bumps. This Nurse notified MD new T.O.: Benadryl 25 mg PO PRN q8hours. DON was also informed.<BR/>Interview on 06/25/24 at 10:28 AM revealed Resident #36 stated she had ants in her bed a few weeks ago, and she had ant bites all over her legs and arms. The facility treated her room, and she had no problems since then. <BR/>Interview on 06/27//24 at 2:30 PM, the DON stated the incident with Resident #36 and the ants was not reported because the resident was able to tell them what happened. The DON did not feel reporting the injury to the resident was significant enough to rise to the level of reporting.<BR/>Record review of the facility's pest control logs for January-June 2024 reflected the facility was treated for ants twice a month.<BR/>3. Record review of Resident #9's face sheet, dated 06/27/24, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE].<BR/>Record review of Resident #9's quarterly MDS, dated [DATE], reflected she had a BIMS score of 03, which indicated cognition was severely impairment. She had active diagnoses which included chronic obstructive pulmonary disease (lung disease), dysphagia (difficulty swallowing), gastro-esophageal reflux disease (acid reflux), type 2 diabetes mellitus (high blood sugar) with diabetic neuropathy (nerve damage) and essential hypertension (high blood pressure). <BR/>Record review of Resident #9's care plan, revised on 05/07/24, reflected:<BR/>Focus: [Resident #9] is taking medication for the management of GERD (Gastroesophageal Reflux Disease). Goal: Will remain free from discomfort, complications or s/sx related to dx of GERD through review date. Interventions: Give medications as ordered. Monitor/document side effects and effectiveness. <BR/>Focus: [Resident #9] is on Pain medication Therapy r/t back, joint and muscle pain secondary to CVA (stroke) and DM (diabetic) Neuropathy. Goal: Will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions: Administer medication as ordered. <BR/>Record review of Resident #9's April 2024 MAR reflected: Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth one time a day for GERD ***DO NOT CRUSH*** and traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours for Pain were held on 04/22/24 and to see nurses' notes.<BR/>Record review of Resident #9's progress notes, dated 04/22/24 at 05:39 AM, by LNV A, reflected: <BR/>Resident was given wrong medications, resident was supposed to be give PANTOPRAZOLE SOD DR 40 MG TAB, and TRAMADOL HCL 50 MG tablet for 6am medication. Instead, was given ALPRAZolam Oral Tablet 0.5 MG, and HYDROCODONE- ACETAMIN 10-325 MG. Resident has no known allergies to the medications. Resident lying in bed, eyes closed, respirations even and unlabored vitals within normal ranges BP 121/52, P 63, O2 97, R 18, T 97.5. Dr. [Name] notified wants patient monitored for any reactions to medications, DON notified as well.<BR/>Interview on 06/25/24 at 2:55 PM with Resident #9 revealed he was doing well. Resident #9 did not appear to recall or know if he was given the wrong medication in April. <BR/>Interview on 06/26/24 at 4:32 PM with LVN A revealed she administered Resident #9 the wrong medications the morning of 04/22/24. She stated she was giving morning medication pass and was prepping another resident medication when a staff went up to her to ask her a question, she got distracted and gave the medications to Resident #9 instead of the other resident. She stated she administered Resident #9 a narcotic pain pill and a Xanax. She stated she made the mistake of not double checking the resident and ended up giving the medication to Resident #9. She stated she realized the mistake and notified the doctor and the DON. She stated Resident #9 was monitored for 72 hours. She stated Resident #9 was not allergic to the medications and there were no side effects to the medications. She stated she was in-serviced the same day (04/22/24) on medication errors. She stated the risk of giving a resident the wrong medication could lead to side effects or resident being allergic to it. <BR/>Interview on 06/27/24 at 2:02 PM with the DON revealed she could not recall all the details; however, LVN A administered Resident #9 the wrong medication back in April 2024. She stated LVN A contacted her right away and informed her she had given the wrong medication to Resident #9. She stated Resident #9 was placed on observation for 72 hours. She stated she in-serviced all the nursing staff on medication administration. The DON stated the risk of giving the wrong medication could lead to unconsciousness or an allergic reaction. The DON stated it was her and the Operational Manager responsibility to report any incidents to the state survey agency. She stated since there was no harm to Resident #9 and resident did not need to be sent to the hospital, they did not feel it needed to be reported to the state. <BR/>Interview on 06/27/24 at 3:49 PM with the Operations Manager revealed she was the abuse coordinator, and it was her and the DON responsibility to report to the state survey agency. She stated she could not recall if she was notified that Resident # 9 was given the wrong medication. She stated she was unsure if it was something that needed to be reported to the state, she stated she would have to look into it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to the ensure the resident received assistance devices to prevent accidents and the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance for 2 of 5 Residents (Resident #1 & Resident #2) whose records were reviewed for falls.<BR/>1. Resident #1 had 4 falls within 24 hours upon admission related to nursing staff not providing Resident #1's fall history through report, lack of staffing and staff not initiating appropriate safety interventions to keep Resident #1 as safe as possible. As a result, he sustained multiple fractures.<BR/>2. Resident #2 had a history of falling out of his wheelchair. Nursing staff failed to ensure his wheelchair was in the locked position and placed away from his bed to prevent further falls.<BR/>These deficient practices could affect any resident and potentially contributed to avoidable falls and injuries.<BR/>The findings were:<BR/>1. Review of Resident #1's face sheet, dated 1/19/23, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified Dementia and Chronic Systolic (congestive) Heart Failure.<BR/>Review of Resident #1's admission assessment, dated 12/30/22 at 3:49 PM, revealed Resident #1 was alert 1-2, understood had memory loss which caused agitation and impulsiveness, complained of dizziness in past 3 days, wore glasses, had moderate hearing impairment, no use of assuasive device noted, history of falls, unable to determine weight bearing limitations and it was noted he had limited range of motion on both legs and feet. Further review revealed LVN F completed the assessment.<BR/>Review of Resident #1's 5-day MDS, dated [DATE], revealed he had vision impairment; his BIMS was 00 (out of 15) indicative of severe cognitive impairment; he exhibited inattention and disorganized thinking; transfers only happened once or twice by 1 person; he was not steady moving from seated to standing position, moving off and on the toilet and surface to surface transfer; he used a wheelchair for mobility; was incontinent of urine; he had a fall in the last month, 2-6 months, fracture related to a fall in the last 6 months prior to admission and he had a fall since admission; he had one fall with no injury and one fall with a major injury.<BR/>Review of Resident #1's 48-hour Care Plan, dated 12/30/22, revealed he was a risk for falls related to history of falls, generalized weakness, poor safety awareness and impulsiveness and the intervention implemented was to keep needed items water, etc., in reach.<BR/>Review of Resident #1's incident log revealed he had a fall on 12/30/22 at 19:51 (7:51 PM), at 12/31/22 at 0:00 (!2 PM) and on 12/31/22 at 10:03 AM. <BR/>Review of incident report for Resident #1, dated 12/30/22 at 7:51 PM revealed, This writer was called due to roommate hollering. Upon entering the room resident was one foot away from mattress, head pointed towards the wall and feet over by the privacy curtain and laying on the floor on stomach but favoring the right side. Right arm was folded under the resident. Resident still has red slip grip socks from hospital and the roommates bedside table was pulled away from the wall and the small refrigerator was knocked over on the floor. This writer and CNA attempted to assist the resident up but stated that he wanted a moment to lay on the floor because he was in a great deal of pain. Does attempt to explain what he was trying to do but gets lost in thought and cannot recall the right words so he stops explaining and sighs heavily. Immediate action taken: Resident stood himself up and walked himself back to bed and laid down, covered himself and keeps saying, there was something I was going to do. Injury Type: Unable to Determine. Injury Location: Right hand palm. Level of pain based on observing the resident was a 5. Mental Status: Oriented to Person. Notes: Resident has history of falls due to impulsivity. Further review revealed LVN F completed this report.<BR/>Review of Resident #1's order summary for December 2022 revealed an order dated 12/30/22 for an x-ray to the right shoulder and right hand due to fall and complaint to pain one time only until 12/31/22.<BR/>Review of an X-ray report for Resident #1, dated 12/30/22, revealed no acute fracture or dislocation of right shoulder and no acute fracture or dislocation of right hand.<BR/>Interview on 1/19/23 at 11:30 AM with Resident #1's RP revealed she was not happy with the fact Resident #1 fell within 2 hours upon admission and then fell again later. She stated Resident #1 had a history of falling at home because he could not walk on his own and he had severe Dementia. She stated she let nursing staff know about his history of falling. The RP stated she did not believe they took care of him the way he needed. Furthermore, she did not believe he would be safe if he returned to the facility so she secured alternative placement.<BR/>Interview on 1/19/23 at 1:15 PM with LVN F revealed she admitted Resident #1 on a Friday and no one was with him upon admission from the hospital. He did not have any visitors. A family member called about a visit and she let him know Resident #1's roommate went to bed early and told the son if he visited it would have to be a quick visit or he could visit early next morning. LVN F stated Resident #1 had a communication deficit (lack of expressive language) and would get agitated. She stated the bed was in the lowest position and the urinal was at bedside within reach. She demonstrated how to use the call light; had it pinned to his gown and provided the bed remote. LVN F stated Resident #1 was a 2 person assist and not able bare weight; he could not stand for long without his knees buckling. She stated Resident #1 was thin but tall. He could follow commands and seemed to understand. LVN F stated Resident #1 fell within 2 hours after admission before dinnertime. She had put him to bed about 2 hours prior to the fall and he was talking on the phone. LVN F stated Assistant MS saw Resident #1 on the floor and told her. LVN F stated she talked with Resident #1's RP about the fall and she stated Resident #1 had fallen at home. LVN F stated Resident #1 was sleeping by the time she left at 10 PM. She stated Resident #1 requested that she leave the overhead light on. LVN F stated she asked the MS about fall mats and he told her she could find them in central supply. She stated she did not implement fall mats.<BR/>Interview on 1/19/23 at 2:13 PM with CNA G revealed she was on duty on 12/30/22 from 2 PM to 10 PM when Resident #1 fell. She stated LVN F told her he was a fall risk. She stated fall protocol usually required the use of a low bed in the lowest position, fall mat, call within reach and more frequent visual checks. She stated she was not sure if the bed was in the lowest position and there was not a fall mat in place. She stated the call light was clipped to Resident #1's gown ad he had 2 urinals by the bedside. CNA B stated Resident #1 got up twice during the shift and did not seem to understand what he was doing. She stated the first time she caught Resident #1 up and she put him back to bed. CNA G stated she thought Resident #1 fell after dinner between 6 PM to 7 PM and had checked on him about an hour before he fell. Resident #1 was found on the floor and he did not say how he fell. He seemed confused. She stated she alerted LVN F who came right away. CNA G stated she thought Resident #1 sustained an injury but could not remember what type of injury.<BR/>Interview on 1/19/23 at 2:35 PM with LVN F revealed she did not get a fall mat from central supply and did not have the CNA get a fall mat because they were the only ones on duty. She stated she did not implement a fall mat. She stated typically there were 2 aides on duty but was not sure if someone called in or what happened. She stated there were three or four other residents who were a fall risk so it made it difficult for her and the 1 aide to complete tasks and do as many visual checks as required on the residents who were a fall risk.<BR/>Interview on 1/19/23 at 6:10 PM with LVN F revealed she did not know Resident #1 was a fall risk until he fell. She stated she knew she would be getting a new admission but nursing staff including the AM nurse did not provide any descriptive information about Resident #1. She stated the hospital nurse also did not tell her in report that Resident #1 was a fall risk. She clarified that she asked the MS about the mats to ensure they were available as needed. She stated she did not know enough about Resident #1 to determine whether the use of a fall mat was beneficial or a safety hazard. LVN F confirmed Resident #1 was not able to bare weight and was unsteady on his feet. However, stated he continued to try and walk on his own and was concerned a mat would be more of a safety hazard. LVN F further stated that she believed Resident #1 was going to fall no matter what because he was so unsteady on his feet and could not bare weight for long.<BR/>Review of incident report for Resident #1, dated 12/31/22 at 0:00 (12 PM) revealed CNA found resident sitting on floor. Immediate action taken: Assessed had small abrasion to forehead. Cleansed with normal saline and pat dried. Bleeding stopped. Vital signs 103/66, 76, 18, 98.2, 97 RM air, Assisted back to bed. Neuros started again. Mental Status: Oriented to Person. Further review revealed the family representative, the resident physician and DON were notified of the incident. Further review revealed LVN D completed this report.<BR/>Review of Fall Risk Evaluation dated 12/31/22 0:00 (12 PM) revealed Resident #1 was a high risk for falls with a score of 18. He was noted to be disoriented x 2, had poor vision with or without glasses, history of 3 or more falls in the past 3 months and he had balance problems while standing/walking.<BR/>Review of incident reports for Resident #1 did not reveal an incident report dated 12/31/22 at 2:05 AM.<BR/>Review of Fall Risk Evaluation dated 12/31/22 2:05 AM revealed Resident #1 was a high risk for falls with a score of 18. He was noted to be disoriented x 2, had poor vision with or without glasses, history of 3 or more falls in the past 3 months, he had balance problems while standing/walking and requires use of assistive devices (i.e., cane, walker or wheelchair).<BR/>Review of incident report for Resident #1, dated 12/31/22 at 4:30 AM revealed Resident #1's roommate came yelling down hall that resident was on his side and going to fall again. Resident observed holding onto wheelchair very unsteady gait. 'I immediately ran to his side. Resident stated, hurry up get me to bed. Immediate action taken: Resident had to be eased to sitting position too heavy to try continuing to walk to bed as he was not following direction, please slow down and let go of wheelchair. Abrasion to back observed/scratch. Has swelling to head in between eyebrows. Redness to right hip observed. Injury Type: Abrasion. Injury Location: scapula. Mental Status: Oriented to Person. Notes: Abrasion noted to right hip and abrasion to upper back/scratch, swelling now in between eyebrows. NP notified, requested X-RAY to head and Right hip. Further review revealed the family representative, the resident physician and DON were notified of the incident. Further review revealed LVN D completed this report.<BR/>Review of Fall Risk Evaluation dated 12/31/22 4:30 AM revealed Resident #1 was a high risk for falls with a score of 15. He was noted to be disoriented x 3, had adequate vision, history of 3 or more falls in the past 3 months and he had balance problems while standing/walking.<BR/>Review of Resident #1's order summary for December 2022 revealed an order dated 12/31/22 for STAT X-RAY to right hand, digits, wrist and forearm.<BR/>Review of an X-ray report for Resident #1, dated 12/31/22, revealed acute fracture of distal radius of the right forearm; acute fracture of distal radius of the right wrist and of the 5th digit at the PIP joint.<BR/>Review of hospital transfer form dated 12/31/22 revealed Resident #1 was transferred to the hospital at 2:44 PM.<BR/>Interview on 1/20/23 at 8:10 AM with LVN D revealed she worked at the overnight shift and worked on 12/30/22 and 12/31/22. She stated Resident #1 was extremely confused, impulsive and did not retain instruction. She stated Resident #1 was difficult to redirect based on impulsiveness. He also seemed anxious and she suspected it was because he was in a new environment. LVN D stated Resident #1 had his first fall during her shift around midnight. She stated the CNA on duty reported Resident #1 was sitting next to his bed. She assessed Resident #1, started neurochecks and transferred him back into bed. LVN D stated the bed was in the lowest position and she educated Resident #1 about using the call light to ask for assistance. She encouraged Resident #1 to allow them to help him so he would not fall. LVN D stated she changed Resident #1 and continued to encourage him to use the call light before getting up. She stated later on in the shift the roommate came out into the hallway yelling that Resident #1 was up and was going to fall. She ran to the room and saw Resident #1 using the roommate's wheelchair to ambulate. He was walking towards his bed but was extremely wobbly. LVN D stated she walked up beside Resident #1 and held on to his arm. He was clinching on to the wheelchair and she attempted to lock the wheelchair cut could not reach to secure the lock. LVN D stated it was not a good situation and was afraid they were both going to fall. She was able to get Resident #1 to release the wheelchair and she eased him down to the floor. The roommate reported that Resident #1 darted up from the bed and fell trying to get to the restroom and hit his head prior to her entering the room. LVN D stated upon assessment she noted redness to his right hip and ordered x-rays. She passed on the events that took place during her shift, in report, to the morning nurse, LVN E LVN D stated she notified the RP about the falls and she stated he fell at the hospital. The RP said Resident #1 had really bad Dementia. LVN D stated Resident #1 required 1 on 1 supervision and was probably a good candidate for a memory care unit. LVN D stated LVN F told her in report she did not use a fall mat because it would be a tripping hazard. She stated based on her experience with Resident #1 the one night she believed he was going to fall no matter what. She also thought a fall mat would probably have been more of a safety/trip hazard because he was on a mission to get up and go. Although, she stated it might have cushioned his fall. LVN D stated she talked with the ADON and DON both and they did not instruct her to implement any other interventions than were already in place: bed to the lowest position, clipped the call light to his gown, continue to instruct to use it and increase visual checks.<BR/>Interview on 1/20/23 at 9:21 AM with the ADM revealed the Admissions Coordinator would round on the residents in the hospital and get as much information as possible prior to admission. He stated it became obvious very quickly that they were not going to be able to meet his needs in the facility due to Resident #1's impulsivity and not following directives.<BR/>Interview on 1/20/23 at 10:41 AM with the Admissions Coordinator (AC) revealed he started working for the facility during October 2022. He stated he was also an LVN. The AC stated he would get a referral from the hospital, review the clinical documents, visit the patient at the hospital, talk to the aide, nurse and doctor per availability to determine any special needs/equipment the patient might need. He would also talk with family. The AC stated he would present the patient information to the IDT team (department heads) including ADON, DON, ADM, Rehab Director, MDS Coordinator and the SW. The AC stated Resident #1 was referred for skilled nursing for PT/OT with the plan to return home. He had a history of falls at home and had fallen in the hospital 3 times. The hospital had him on 1 on 1 supervision for a period of time but when he visited Resident #1 he was not on 1 to 1 supervision any longer. The AC stated he talked to the nurse who stated Resident #1 was no longer trying to get out of bed. He also spoke with the case manager, with Resident #1 and the RP around 12/22/22 to 12/23/22. He stated he was in contact with the case manager off and on until Resident #1 was ready to be released to determine his discharge plan. The AC stated Resident #1 seemed really nice, able to answer questions, was always in bed, calm and progressing in therapy at the hospital. Resident #1 did not display any agitation or behavior issues and was compliant with treatments per report from nursing. He stated the case manager stated Resident #1 had been on 1 on 1 supervision and it was discontinued on 12/22/23. The AC stated he was not sure if the supervision was continuous but the nurse told him they would be taking him off 1 to 1 supervision. The AC stated per his own experience the Resident would need to be off 1 to 1 supervision 24 hours prior to placement. The AC stated there was not a facility policy that he knew of regarding the supervision and he had not received direction from the nursing facility. The AC stated he presented Resident #1's information to the IDT team on 12/23/22 or 12/24/22. He stated he did not remember everyone who attended the IDT meeting but again stated it was usually the department heads. The IDT reached a consensus that they would accept Resident #1 but stated the admission took place at the end of the month after they secured the contract with Resident #1's insurance provider. <BR/>Interview on 1/20/23 at 1:06 PM with LVN H revealed she worked on 12/30/22 from 6 AM to 2 PM. She stated she knew Resident #1 was admitted on 12/3022 but it was not on her shift. LVN H stated she was not provided any information about Resident #1 including that he had a history of falling. <BR/>Interview on 1/20/23 at 1:43 PM with the Interim DON stated she knew Resident #1 was being admitted but was not sure if she was part of the IDT meeting when staff discussed his appropriateness for placement. She stated the day of admission the floor nurse would receive an admission packet. The first shift nurse would pass on in report that they were expecting a new admission if the resident did not arrive during the first shift and so on. The admitting nurse would document the resident's admission in the 24- hour report and any significant information.<BR/>Interview on 1/20/23 at 2:10 PM with the ADON revealed she was part of the IDT meeting when they discussed Resident #1's placement. She stated she was not sure who all attended but usually it included the DON, SW, therapy, ADM and the BOM. The ADON stated she told LVN H know about Resident #1's admission on [DATE]. LVN H worked the 6 AM to 2 PM shift. The ADON stated she would have provided specifics about Resident #1 including that he was a fall risk. LVN H should have passed the information on in report to LVN F. The ADON stated LVN F asked about implementing a fall mat after Resident #1 fell the first time but she advised her to wait until therapy assessed him. She stated Resident #1 was referred for therapy services with the focused areas being strength and mobility. The ADON stated nursing staff would have to get clearance from management before implementing a floor mat. She stated the interventions in place for Resident #1 included clipping the call light to his gown and increasing rounding on him. She stated they did not put the bed in the lowest position because he was a tall man and would often get up on his own. She stated Resident #1 did not have the strength to get up from the bed in the lowest position and it would be considered a restraint.<BR/>Interview on 1/20/23 at 3:10 PM with the ADM revealed they conducted a fall management in-service on 12/31/22 for the nurses. He stated they had not provided another in-service since to include the CNA's or other staff.<BR/>Interview on 1/20/23 at 3:15 PM with the SC revealed a CNA called in 12/30/22 for the 2 PM to 10 PM shift. He stated they had to make some changes to the assignments and LVN F and CNA G were the only two staff working the hall from 2 PM to 10 PM shift. The SC stated it would have made it difficult to complete normal tasks and to provide the level of supervision Resident #1 required in addition to the 3 or 4 other residents on the hall that were also a fall risk. He stated the census was probably like over 30 residents.<BR/>Interview on 1/20/23 at 4 PM with the Interim DON revealed a fall risk assessment was completed for every resident upon admission and after any fall. She stated nursing staff were to gather information to determine the root cause of the fall. Nursing staff was supposed to ask the who, what, when, where and why and implement interventions according to the root cause analysis.<BR/>Interview on 1/20/23 at 4:09 PM with the Staffing Coordinator (SC) revealed he worked the second floor from 10 PM to 6 AM as a CNA on 12/31/22. He stated upon beginning his shift he would usually make a sweep of all residents, checking on residents to ensure they were in their room, in bed and were ok. He remembered Resident #1 talking to himself and fidgeting with his gown. He asked the Resident if he was ok and the Resident said yes. The SC stated he completed his sweep and then started with incontinent care. He stated Resident #1's roommate came out and asked for help while he was in another resident room by the nurse's station. The SC stated Resident #1 was lying on the floor on his right side by the roommate's bed . Resident #1 said I'm hurting but could not say what happened. The SC stated there was not a fall mat in place. The bed was in the lowest position about 1 foot off the floor. He stated the nurse responded and assessed Resident #1 while on the floor. He and the nurse transferred Resident #1 to bed and the Resident complained of pain to his wrist. The SC stated after the second fall he answered the call light. The roommate was out in the hallway yelling for help. The SC stated when he entered the room he saw Resident #1 crawling on the floor. He stepped out of the room to get the nurse to help and when they returned Resident #1 had put himself back to bed. The SC stated Resident #1 was very confused. The roommate reported he saw Resident #1 crawling on the floor when he woke up. The SC stated he had checked in on Resident #1 about an hour before he was observed crawling on the floor. He stated Resident #1 was wide awake and restless. The SC stated he would round on residents every two hours and in between changing residents. He stated the nurse would also make her own rounds. The SC could not remember if the nurse told him Resident #1 was a fall risk. He stated the fall protocol required they put the resident bed to the lowest position, ensure the environment was clutter free and a fall mat was used if it was not a safety hazard. The SC further stated Resident #1 had the call light clipped to his gown and his overhead light was on. The SC stated Resident #1 was not able to walk and during transfer he was able to bare weight for a short time. He stated the nurse did not implement the use of the fall mat after the additional 2 falls. <BR/>Interview on 1/20/23 at 4:40 PM with the Interim DON revealed she assumed her position on 12/27/22 or 12/28/22. She stated she reviewed Resident #1's hospital documentation after it was faxed to the facility and stated Resident #1 had 3 falls while at the hospital related to impulsivity. She stated Resident #1 had heart failure and his heart was operating at 30 %. The Interim DON stated LVN F called her late in the evening after Resident #1 had his first fall. She understood Resident #1 was using his bedside table to walk and he fell into the roommate's mini refrigerator. The nurse educated Resident #1 on the use of the call light. She stated X-rays were ordered and they were negative for any fractures. The Interim DON stated staff found Resident #1 sitting next to his bed after his 2nd fall and LVN D reported she guided Resident #1 to the floor which was considered to be his 3rd fall. LVN D stated Resident #1 was using his roommate's wheelchair/ to ambulate and was very unsteady. Interim DON stated the last two falls took place during the overnight shift. She stated Resident #1 had 3 falls altogether while at the facility. The Interim DON stated a 2nd set of X-rays were positive for a fracture but was not sure about the exact location. She stated the interventions in place for Resident #1 included: call light was clipped to his gown; he had 2 urinals at bedside and his overnight light was on. She stated nursing staff believed Resident #1 required 1 to 1 supervision because he was determined to get up and walk. He was able to ambulate somewhat; not safely but he could walk. Interim DON stated they obviously could not provide 1 to 1 supervision. Furthermore, nursing staff was not convinced using a fall mat was a safe intervention which she discussed with nursing staff. The Interim DON stated she did not know who received Resident #1's clinical's to determine whether he was appropriate for placement. <BR/>Interview on 1/23/23 at 1:39 PM with the SC revealed he confirmed that on Saturday, 12/31/22, he found Resident #1 on the floor after the first fall during the night shift; later he observed Resident #1 crawling on the floor and then LVN D called him over to Resident #1's room to help transfer Resident #1 to bed after reporting she had lowered him to the floor. The SC stated technically Resident #1 had 3 falls during the night shift.<BR/>Interview on 1/23/23 at 1:42 PM with Resident #4 revealed he remembered Resident #1 after cueing. He stated Resident #1 kept falling. He would get out of bed and would hold on to everything to keep from falling but he fell anyway. Resident #4 stated Resident #1 was not steady and could not walk very good. He stated Resident #1 knocked his mini refrigerator over from on top of his dresser. Resident #4 stated Resident #1 did not want to be in bed. Resident #4 stated he kept calling staff for help because it usually took staff over an hour to respond when he used the call light. He stated the staff responded to his call for help.<BR/>2. Review of Resident #2's face sheet, dated 1/23/23, revealed he was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy and repeated falls. <BR/>Review of Resident #2's admission quarterly MDS, dated [DATE], revealed his BIMS was 8 (out of 15) indicative of severe cognitive impairment; he required extensive assistance by 1 person for bed mobility and transfers; he was unsteady moving from sitting to standing position, on and off the toilet and surface to surface transfer and only able to stabilize with staff assistance.<BR/>Review of Resident #2's Care Plan, revised 11/8/22, revealed he required extensive assistance by 2 persons for bed mobility and transfers. Resident #2 was identified as being a fall risk and interventions included: anticipate and meet needs, avoid rearranging furniture, be sure the call light is within reach and encourage to use it to call for assistance as needed, educate resident and caregivers about safety reminders and what to do if a fall occurs, maintain a clear pathway, free of obstacles. Further review revealed Resident #2 had a fall on 1/13/23 and the interventions included: Call don't fall signs next to bed, check range of motion, monitor/document /report to MD for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, neuro-checks as ordered and vital signs as ordered. <BR/>Review of an incident report, dated 1/13/23, revealed LVN E heard Resident #2 yelling out for nurse at 6:30 AM. She found him on the floor laying on his left side with wheelchair beside him. The wheelchair brakes were not locked. The Resident was wearing non-skid socks. Resident #2 was able to make his needs known and stated he hit his head on the floor. Resident #2's description: I don't know, I just fell. Immediate Action Taken: assessed Resident #2 and observed bump on left side of forehead and purple discoloration to left knee upon sitting Resident #2 up. Resident #2 denied pain. He was assisted to the wheelchair by 2 persons and neurochecks initiated. It was noted he did not have any injuries. Further review revealed LVN E notified Resident #2's physician, family member and the DON about the incident.<BR/>Observation on 1/18/23 at 2:05 PM revealed Resident #2 sitting in a wheelchair by the nurse's station. Further observation revealed he had bruising over his left eye. Interview with Resident #2's family member revealed Resident #3 had a fall.<BR/>Observation and interview on 1/20/23 at 11:40 AM revealed Resident #2 was lying in bed on his left side with eyes closed and his bed in a low position. The wheelchair was a couple of feet from the bedside. Interview with CNA I revealed she worked Monday through Friday from 8 AM to 5 PM. She stated she noted bruising over Resident #2's left eye on Monday, 1/17/23, and did not know if he had a fall. She stated the nurse did not say anything to her. CNA I stated Resident #2 was able to make his needs known, would use his call light to ask for assistance, was a 1 or 2 person assist with transfers. She stated the following interventions were used when a resident was identified as being a fall risk: call light within reach, low bed to lowest position and talk to nurse about using a fall mat. LVN I stated she would think Resident #2 was a fall risk because she had seen him try to self-transfer without assistance. She stated he was unsteady on his feet. Further observation revealed Resident #2's bed was not in the lowest position. She stated Resident #2 would sit up and the bed was in the position which allowed him to sit up and place his feet on the floor. CNA I stated there was no fall mat and his call light (touch pad) was placed underneath his left hand.<BR/>Observation and interview on 1/20/23 at 1:06 PM revealed Resident #2 was lying in bed on his left side with eyes closed and his bed in a low position. The wheelchair was a couple of feet from the bedside. Interview with LVN H revealed Resident #2 was a fall risk per nursing report. He required assistance with transfers and stated he was able to pivot at one point but not so much anymore. LVN H stated she was aware Resident #2 had bruising over his left eye but did not talk to CNA I about his fall history because it took place earlier in the month. She stated the information would be available in Resident #2's POC. She stated this was the program the aides documented on which provided them with resident ADL information and any special circumstances. LVN H stated the aides should report any change of condition to them when they noted any changes. She stated CNA I should have reported the bruising over Resident #2's left eye if she had not noted the bruising during her previous shift. LVN H stated she understood LVN E found Resident #2 on the floor by the bed but was not sure if he fell out of the bed or the wheelchair. She did not know all of the details and had not looked at his chart. LVN H stated a low bed to the lowest position would be utilized if Resident #2 fell from the bed and if he fell from the wheelchair then it should be positioned out of the reach/sight from Resident #2 and in the locked position. Further observation revealed Resident #2's bed was not in the lowest position, his wheelchair was by his bedside in front of the night stand, his call light was under his left hand and the bed remote was on the floor. LVN H further stated the wheelchair was not in the locked position and a safety hazard if Resident attempted to transfer to the wheelchair. <BR/>Interview on 1/20/23 at 1:20 PM with CNA J revealed she and CNA I were working together on the same hall. She stated she did not know Resident #2 had fallen and had not noted the bruising to his forehead. She stated she would ask the nurse on duty of any new resident changes upon returning from her days off. CNA J review[TRUNCATED]

**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 fed by enteral means, received 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 one of four residents (Resident #19) reviewed for enteral feeding.<BR/>The facility failed to ensure nursing staff provided g-tube (a tube into the stomach that delivers formula for nutrition) care for Resident #19 per physician orders. <BR/>This failure could result in the spread of resident infections. <BR/>Findings included:<BR/>Record review of Resident #19's face sheet, dated 06/27/24, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE].<BR/>Record review of Resident #19's quarterly MDS, dated [DATE], reflected she had a BIMS score of 03, which indicated her cognition was severely impaired. She had active diagnoses which included dysphagia (difficulty swallowing) following nontraumatic intracerebral hemorrhage (stroke), cognitive communication deficit, and hydrocephalus (fluid in the brain). The MDS assessment Section K - Nutritional approaches reflected Resident #19 had a feeding tube and was also on a mechanically altered diet. <BR/>Record review of Resident #19's care plan, revised on 05/07/24, reflected Focus: [Resident #19] requires tube feeding PRN r/t poor PO intake secondary to intracranial hemorrhage. Goal: Feeding Tube insertion site will be free of s/sx of infection through the review date. Interventions: Bolus Feeding Of: Glucerna 1.5 at 237 cc if patient does not consume 50% of meal. Flush with 120mL of H20 with each bolus feeding in pt . eats less than 50%. Provide local care to Feeding Tube site as ordered and monitor for s/sx of infection.<BR/>Record review of Resident #19's physician order, dated 09/15/23, reflected: Cleanse G-tube stoma with NSS, Pat dry and apply dry dressing every day shift. <BR/>Record review of Resident #19's physician order, dated 09/15/23, reflected: Enteral Feed Order every shift Inspect and monitor gastrostomy stoma for signs and symptoms of local infection [NAME] as: redness; pain; tenderness; unusual odor, drainage; or discharge; hypergranulation of tissue surrounding stoma. Notify MD if S/S noted. <BR/>Record review of Resident #19's June 2024 MAR/TAR reflected Resident #19 was provided with her g-tube care/treatment on 06/26/24 and 06/27/24. <BR/>Observation and interview on 06/25/24 at 3:29 PM revealed Resident #19 sitting in the dining area. Resident #19 stated she was doing well. Resident #19 stated she had a g-tube; however, Resident #19 was unable to respond to further questions. Resident #19 was not a good historian. <BR/>Observation on 06/27/24 at 11:53 AM of Resident #19's g-tube stoma with LVN revealed gastric tube insertion site revealed no dressing was in place, yellow exudate noted to site. No redness noted and Resident #19 denied any pain or discomfort. <BR/>Interview on 06/27/24 at 11:47 AM with LVN F stated she was the nurse assigned to Resident #19. LVN F stated Resident #19 had a g-tube; however, the resident did not utilize her g-tube since the resident was able to eat and took medications by mouth. LVN F stated she was unsure if Resident #19 had orders for g-tube care. LVN F reviewed Resident #19 orders and stated Resident #19 had orders to clean g-tube stoma; however, she had not done it since being employed. LVN F stated she had been employed for 4 weeks and today (06/27/24) was her second day working by herself. <BR/>Follow-up interview on 06/27/24 at 12:22 PM, LVN F stated she was the nurse assigned to Resident #19 yesterday (06/26/24) and did not provide g-tube care. LVN F stated she was aware Resident #19 had a g-tube but since Resident #19 ate by mouth the g-tube was not prioritized. She stated she documented on the resident MAR/TAR that she completed the treatment even though she did not. LVN F stated she overlooked the order and clicked that she completed the treatment. LVN F stated the risk of not providing g-tube care could lead to an infection. <BR/>Interview on 06/27/24 at 1:44 PM with the ADON revealed she was the ADON assigned for the third floor. She stated she was not aware Resident #19's g-tube stoma had not been cared for until today (06/27/24). The ADON stated Resident #19's g-tube was not being utilized unless the resident ate less than 50% of a meal then the resident required a bolus feeding. She stated it was the nurse's responsibility to follow physician orders. The ADON stated if the residents g-tubes were not being cared for it could lead to an infection. <BR/>Interview on 06/27/24 at 2:02 PM with the DON revealed her expectations were for her nurses to follow physician orders. She stated they had a system in place were once a week every Tuesday the ADONs were responsible to check residents g-tubes. She stated she was unaware Resident #19's g-tube had not been cared for. She stated the risk of not providing g-tube care could lead to infection. <BR/>Follow-up interview on 06/27/24 at 2:22 PM with the ADON revealed once a week on every Tuesday she was responsible to complete rounds and check residents g-tubes were being cared for. She stated she could not recall if she observed Resident #19's g-tube on Tuesday (06/25/24). The ADON stated it was her responsibility to follow-up and ensure g-tube care were being provided to residents. <BR/>Record review of LVN F's Licensed Nurse Comprehensive Clinical Competency Review -Skills Checklist reflected LVN F completed Confirm placement of feeding tubes, Enteral Feedings-Safety Precautions on 06/15/24. <BR/>Record review of the facility's Gastrostomy Tube policy, revised May 2007, reflected the following:<BR/> It is the policy of this facility to provide proper care and maintenance of a gastrostomy tube. <BR/>Daily checklist for gastrostomy tubes: Check the following each day. This information covers: PEG , Surgical, Balloon, and Low-profile gastrostomy tubes. <BR/>-Daily, all stoma sites will be cleaned with NS , pat dry with dry clean 4 x 4, apply protective ointment If indicated (some resident will require Anti-fungal Protective Ointment). Apply sterile dressing. Flextrak (optional) anchoring device may to be used to anchor G-tube to prevent tugging effect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #9) reviewed for pharmacy services.<BR/>LVN A failed to administer the correct physician ordered medication (Pantoprazole Sodium Delayed Release 40 mg tablet and Tramadol HcL 50 mg tablet), and she instead administered Alprazolam Oral Tablet 0.5 mg (anti-anxiety medication), and Hydrocodone-Acetaminophen 10-325 mg (narcotic pain medication), which was another resident's medication on 04/22/24. <BR/>This failure could place residents at risk for significant medication errors and jeopardize the resident health and safety. <BR/>Finding included:<BR/>Record review of Resident #9's face sheet, dated 06/27/24, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE].<BR/>Record review of Resident #9's quarterly MDS, dated [DATE], reflected she had a BIMS score of 03, which indicated his cognition was severely impaired. Resident #9 had active diagnoses which included chronic obstructive pulmonary disease (lung disease), dysphagia (difficulty swallowing), gastro-esophageal reflux disease (acid reflux), type 2 diabetes mellitus with diabetic neuropathy (nerve damage) and essential hypertension (high blood pressure). <BR/>Record review of Resident #9's care plan, revised on 05/07/24, reflected:<BR/>Focus: [Resident #9] is taking medication for the management of GERD (Gastroesophageal Reflux Disease). Goal: Will remain free from discomfort, complications or s/sx related to dx of GERD through review date. Interventions: Give medications as ordered. Monitor/document side effects and effectiveness. <BR/>Focus: [Resident #9] is on Pain medication Therapy r/t back, joint and muscle pain secondary to CVA (stoke) and DM (diabetic) Neuropathy. Goal: Will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions: Administer medication as ordered. <BR/>Record review of Resident #9's April 2024 MAR reflected: Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth one time a day for GERD ***DO NOT CRUSH*** and traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours for Pain were held on 04/22/24 and to see nurses' notes.<BR/>Record review of Resident #9's progress notes, dated 04/22/24 at 5:39 AM, by LVN A, reflected: <BR/>Resident was given wrong medications, resident was supposed to be give PANTOPRAZOLE SOD DR 40 MG TAB , and TRAMADOL HCL 50 MG TABLET for 6am medication. Instead, was given ALPRAZolam Oral Tablet 0.5 MG, and HYDROCODONE- ACETAMIN 10-325 MG. Resident has no known allergies to the medications. Resident lying in bed, eyes closed, respirations even and unlabored vitals within normal ranges BP 121/52, P 63, O2 97, R 18, T 97.5. Dr. [Name] notified wants patient monitored for any reactions to medications, DON notified as well.<BR/>Interview on 06/25/24 at 2:55 PM of Resident #9 revealed he was doing well. Resident #9 did not appear to recall or know if he had been given the wrong medication in April. Resident #9 stated he had no concerns regarding his medications. <BR/>Interview on 06/26/24 at 4:32 PM with LVN A revealed she administered Resident #9 the wrong medications the morning of 04/22/24. She stated she was giving morning medication pass and was prepping another resident's medication when a staff came up to her to ask her a question, she got distracted and gave the medications to Resident #9 instead of the other resident. She stated she administered Resident #9 a narcotic pain pill and a Xanax. She stated she made the mistake of not double checking the resident and ended up giving the medication to Resident #9. She stated she realized the mistake and notified the doctor and the DON. She stated Resident #9 was monitored for 72 hours, she stated resident slept throughout the day. She stated Resident #9 was not allergic to the medications and there were no side effects to the medications. She stated she was in-serviced the same day (04/22/24) on medication error. She stated the risk of giving a resident the wrong medication could lead to side effects or the resident being allergic to it. <BR/>Interview on 06/27/24 at 1:44 PM with the ADON revealed she was made aware of Resident #9's medication error. She stated LVN A realized right away she had given Resident #9 the wrong medications. She stated LVN A notified the doctor and the DON immediately. She stated all nurses were in-serviced on medication administration. She stated the risk of giving the wrong medication could be an allergic reaction. <BR/>Interview on 06/27/24 at 2:02 PM with the DON revealed she could not recall all the details; however, LVN A administered Resident #9 the wrong medication back in April 2024. She stated the LVN A contacted her right away and informed her she had given the wrong medication to Resident #9. She stated Resident #9 was placed on observation for 72 hours. She stated she in-serviced all the nursing staff on medication administration. The DON stated the risk of giving the wrong medication could lead to unconsciousness or an allergic reaction. <BR/>Record review of In-service Education Record Medication Errors, dated 04/22/24, reflected LVN A and 21 other nursing staff were in-serviced on 04/22/24. <BR/>Record review of the facility's policy titled Care and Treatment, Medication & Treatment Orders, revised on May 2007, reflected the following:<BR/>It is the policy of this facility that medications and treatments are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe .<BR/> .6. Residents shall be identified prior to administration of a medication or treatment . <BR/> .8. Documentation of the Medication Order. <BR/>- Each medication order is documented in the resident's medical order with the date, time, and signature of the person receiving the order. The order is recorded on the physician order sheet, or the telephone order sheet if it is a verbal order and the medications Administration Record (MAR).

Based on observations, interviews, and record reviews, the facility failed to 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 disease and infection for 1 of 2 residents (Resident #2) reviewed for infection control, in that:<BR/>CNA A did not change her gloves or wash her hands after touching Resident #2's privacy curtain, between change of gloves and, after providing incontinent care for Resident #2.<BR/>These deficient practices could place residents at-risk for infection due to improper care practices. <BR/>The findings included:<BR/>Record review of Resident #2's face sheet, dated 05/16/2024, revealed an admission date of 01/20/2020 and, a readmission date of 09/30/2023, with diagnoses which included: Dislocation of right hip (thighbone separates from the hip bone), Chronic pain, History of urinary tract infection (infection in any part of the urinary system), Cerebellar ataxia (Lack of voluntary coordination of muscles movements originating in the cerebellum part of the brain)and, Hypertension (High blood pressure). <BR/>Record review of Resident #2's Quarterly MDS assessment, dated 02/12/2024, revealed Resident #2 had a BIMS score of 15, which indicated no cognitive impairment. Resident #2 was indicated to always be incontinent of bowel and bladder and, required extensive assistance to total care with her acclivities of daily living. <BR/>Review of Resident #22's care plan, dated 12/27/2021, revealed a problem of has bladder incontinence related to muscle weakness and debility with an intervention of Check as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes <BR/>Observation on 05/16/2024 at 10:52 a.m. revealed, while providing incontinent care for Resident #2, CNA A did not change her gloves or wash her hands after touching the privacy curtain to close it and before providing incontinent care for Resident #2. CNA A changed her gloves after cleaning Resident #2's genitals but did not sanitize her hands before putting clean gloves on. Further observation revealed CNA A changed her gloves after cleaning Resident #2's buttocks but did not sanitize her hands before putting clean gloves on and touching the new brief to fasten them for the resident. <BR/>During an interview on 05/16/2024 at 11:00 a.m. CNA A confirmed she did not change her gloves or wash her hands after touching the privacy curtain and before starting to provide care. CNA A also confirmed she did not sanitized between change of gloves or before touching Resident #2's clean brief. She confirmed receiving infection control training within the year. <BR/>During an interview with the DON on 05/16/2024 at 11:05 a.m., the DON confirmed the staff should have changed her gloves after touching the privacy curtain to prevent contamination and infection to the resident. She confirmed staff should sanitize their hands between change off gloves to prevent infection to the resident. The DON revealed the DON and the ADON provided training on infection control to the staff at least once a year. They checked the staff's skills once a year and did spot check when problems with infection control were noticed. <BR/> Review of facility Nurse aide competency checklist perineal care-female (with or without catheter, undated, revealed wash hands. Wear gloves and follow Standard Precautions if contact with blood or body fluids is likely [ .] wash hands and put on clean gloves for perineal care.<BR/>During an interview on 05/16/2024 at 1:38 p.m. with the DON, she revealed there was no other policy regarding when to change gloves and practice hand hygiene during incontinent care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse, and neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency in accordance with State law through established procedures for three (Resident #40, Resident #36, and Resident #9) of three incidents (Resident #40, Resident #36, and Resident #9) reviewed for reporting.<BR/>1. The facility failed to report to the State Survey Agency when Resident #40 sprained his ankle when he got his foot caught in the van ramp while being pushed by the transportation driver. <BR/>2. The facility failed to report to the State Survey Agency when Resident #36 was found to have ant bites on her body. <BR/>3. The facility failed to report to the State Survey Agency when Resident #9 was given the wrong medications on 04/22/24.<BR/>These failures could affect place residents by resulting inat risk of a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment.<BR/>Findings included:<BR/>1. Record review of Resident #40's MDS dated [DATE] reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included end stage renal disease, diabetes, osteoporosis, stroke, and seizure disorder. The MDS further reflected Resident #40 had a BIMS of 14, whick indicated his cognition was intact, and used a manual wheelchair. <BR/>Record review of Resident #40's care plan dated 08/29/23 reflected he had osteoporosis and interventions included to protect the resident from injury avoiding sudden bumps, jarring with transfers. The care plan further reflected Resident #40 attended dialysis Mondays, Wednesdays, and Fridays. <BR/>Record review of Resident #40's progress note dated 06/21/24 documented by LVN A revealed the following:<BR/>Notified by 1st floor nurse that resident had an incident getting onto the transportation bus. This nurse went down to the 1st floor to assess the resident noted resident sitting in wheelchair, leaned over holding onto right foot, when assessed the right foot noted swelling to the right ankle, very sensitive to touch, able to wiggle toes and pedal pulse 3+. Took resident to his room, assisted him to bed, resident can not bare [sic] weight on right foot Resident stated 'driver of the van was pushing me onto the ramp but had to push me a little fast because there's a little bump to get over on the ramp when my foot got caught in the ramp and pushed my foot all the way back.' MD notified ordered STAT x-ray to right foot Asked resident pain level from 0-10 resident stated a 10, administered Acetaminophen-Codeine Tablet 300-30MG per resident request for pain.<BR/>Record review of radiology results dated 06/21/24 revealed there were no fractures and no new orders given. <BR/>Record review of the Transportation Company's Accident/Incident Report Form dated 06/21/24 reflected the following:<BR/> .Incident Information<BR/>Incident Description<BR/>[Resident #40] right ankle was injured while being rolled into the rear ramp of the wheelchair van by driver, [Driver]. As [Resident #40] crested the top of the ramp to enter the van, his right foot was not high enough, which caused his foot to roll under the leg. Driver took [Resident #40] back into the facility for examination by a nurse to determine the severity of his injury. <BR/>Observation and interview with Resident #40 on 06/25/24 at 11:23 AM revealed when he was picked up for dialysis last Friday, 06/21/24, the transportation driver pushed him into the transportation van too fast and his foot got caught where the lift and the van connected. The resident said he immediately felt pain because it sprained his ankle. The facility ordered x-rays to ensure it was not broken due to the swelling. Observation of Resident #40's ankle revealed there was some swelling but there was no bruising noted at the time, but there was a pain patch on his ankle. The resident said he got some pain relief with the pain medications and pain patch. Resident #40 said the same transportation driver took him to dialysis on Monday, 06/24/24. <BR/>Interview on 06/26/24 at 4:04 PM with LVN B revealed the transportation van had arrived to pick up Resident #40 to take him to dialysis on, 06/21/24, and they were loading the resident into the van. Shortly after, the transportation driver brought Resident #40 back into the facility and said as he was pushing the resident into the van, his foot had got caught and twisted up on the ramp and Resident #40 immediately expressed pain. LVN B said she looked at the resident's ankle and noticed swelling on the outer side so she called to let his nurse, LVN A, know what had occurred. <BR/>Interview on 06/26/24 at 2:51 PM with LVN A revealed she got a call from LVN B, 06/21/24, and said Resident #40 had hurt his ankle when the transportation driver was pushing him up the ramp into the van. When she was downstairs she asked the resident what had occurred and he said the transportation had pushed him faster to get onto the van, causing his foot to get stuck in the gap where the ramp meets the van and his foot had bent back. LVN A said she assessed the resident's ankle and noted swelling around it. Resident #40 told LVN A he was having pain to his ankle and he was medicated and they ordered x-rays to ensure it was not fractured. <BR/>Interview with the DON on 06/26/24 at 3:20 PM revealed she was told about Resident #40 incident and they had called the doctor for x-rays to ensure his ankle was not broke. The DON stated she called the transportation company to find out what happened but said she had not heard back but would be calling them again for a statement. <BR/>2. Record review of Resident #36's, undated, admission Record reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had diagnoses which included diabetes, stroke, and muscle wasting.<BR/>Record review of Resident #36's quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Her Functional Status reflected she required total assistance with all of her ADLs except eating and oral hygiene. <BR/>Record review of Resident #36's care plan, dated 05/24/24, reflected the resident had behaviors of scratching and picking at her legs, and delusions involving staff and family. <BR/>Record review of Resident #36's nursing notes reflected documentation on 05/12/24 resident with sugar ants all over her bed, moved resident to bed A temporarily, residents left arm with red raised itchy bumps. This Nurse notified MD new T.O: Benadryl 25mg PO PRN q8hours. DON was also informed.<BR/>Interview on 06/25/24 at 10:28 AM with Resident #36 revealed she had ants in her bed a few weeks ago, and she had ant bites all over her legs and arms. The facility treated her room, and she had no problems since then. <BR/>Interview on 06/27//24 at 2:30 PM, the DON stated the incident with Resident #36 and the ants was not reported because the resident was able to tell them what happened. The DON did not feel reporting the injury to the resident was significant enough to rise to the level of reporting.<BR/>Record review of the facility's pest control logs for January-June 2024 reflected the facility was treated for ants twice a month.<BR/>3. Record review of Resident #9's face sheet, dated 06/27/24, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE].<BR/>Record review of Resident #9's quarterly MDS, dated [DATE], reflected she had a BIMS score of 03, which indicated cognition was severely impairment. She had active diagnoses which included chronic obstructive pulmonary disease (lung disease), dysphagia (difficulty swallowing), gastro-esophageal reflux disease (acid reflux), type 2 diabetes mellitus (high blood sugar) with diabetic neuropathy (nerve damage) and essential hypertension (high blood pressure). <BR/>Record review of Resident #9's care plan, revised on 05/07/24, reflected:<BR/>Focus: [Resident #9] is taking medication for the management of GERD (Gastroesophageal Reflux Disease). Goal: Will remain free from discomfort, complications or s/sx related to dx of GERD through review date. Interventions: Give medications as ordered. Monitor/document side effects and effectiveness. <BR/>Focus: [Resident #9] is on Pain medication Therapy r/t back, joint and muscle pain secondary to CVA (stroke) and DM (diabetic) Neuropathy. Goal: Will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions: Administer medication as ordered. <BR/>Record review of Resident #9's April 2024 MAR reflected: Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth one time a day for GERD ***DO NOT CRUSH*** and traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours for Pain were held on 04/22/24 and to see nurses' notes.<BR/>Record review of Resident #9's progress notes, dated 04/22/24 at 05:39 AM, by LNV A, reflected: <BR/>Resident was given wrong medications, resident was supposed to be give PANTOPRAZOLE SOD DR 40 MG TAB, and TRAMADOL HCL 50 MG tablet for 6am medication. Instead, was given ALPRAZolam Oral Tablet 0.5 MG, and HYDROCODONE- ACETAMIN 10-325 MG. Resident has no known allergies to the medications. Resident lying in bed, eyes closed, respirations even and unlabored vitals within normal ranges BP 121/52, P 63, O2 97, R 18, T 97.5. Dr. [Name] notified wants patient monitored for any reactions to medications, DON notified as well.<BR/>Interview on 06/25/24 at 2:55 PM with Resident #9 revealed he was doing well. Resident #9 did not appear to recall or know if he was given the wrong medication in April. <BR/>Interview on 06/26/24 at 4:32 PM with LVN A revealed she administered Resident #9 the wrong medications the morning of 04/22/24. She stated she was giving morning medication pass and was prepping another resident medication when a staff went up to her to ask her a question, she got distracted and gave the medications to Resident #9 instead of the other resident. She stated she administered Resident #9 a narcotic pain pill and a Xanax. She stated she made the mistake of not double checking the resident and ended up giving the medication to Resident #9. She stated she realized the mistake and notified the doctor and the DON. She stated Resident #9 was monitored for 72 hours. She stated Resident #9 was not allergic to the medications and there were no side effects to the medications. She stated she was in-serviced the same day (04/22/24) on medication errors. She stated the risk of giving a resident the wrong medication could lead to side effects or resident being allergic to it. <BR/>Interview on 06/27/24 at 2:02 PM with the DON revealed she could not recall all the details; however, LVN A administered Resident #9 the wrong medication back in April 2024. She stated LVN A contacted her right away and informed her she had given the wrong medication to Resident #9. She stated Resident #9 was placed on observation for 72 hours. She stated she in-serviced all the nursing staff on medication administration. The DON stated the risk of giving the wrong medication could lead to unconsciousness or an allergic reaction. The DON stated it was her and the Operational Manager responsibility to report any incidents to the state survey agency. She stated since there was no harm to Resident #9 and resident did not need to be sent to the hospital, they did not feel it needed to be reported to the state. <BR/>Interview on 06/27/24 at 3:49 PM with the Operations Manager revealed she was the Abuse Coordinator, and it was her and the DON responsibility to report to the State Survey Agency. She stated she could not recall if she was notified that Resident # 9 was given the wrong medication. She stated she was unsure if it was something that needed to be reported to the state, she stated she would have to look into it.<BR/>Review of the facility's undated policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation, or Mistreatment reflected the following:<BR/>Policy:<BR/>It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment .Resident must not be subjected to abuse by anyone, including, but not limited to Facility staff, other resident representatives, consultants, or volunteers, staff of other agencies serving the resident representatives, families, friends, or other individuals.<BR/> .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to:<BR/> .The State Survey Agency .

Based on observation and interview the facility failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records and failed to safeguard medical record information against loss, destruction, or unauthorized use for 1 of 1 facility.<BR/>Residents' medical records were stored in an unlocked room on the 3rd floor that was being remodeled. Medical record sheets were out of their files and scattered on the floor in multiple places in the room.<BR/>This failure could place resident identifiable information at risk of unauthorized use.<BR/>The findings were:<BR/>Observation on 5/9/23 at 9:20 a.m. revealed surveyors had been placed in a conference room on the 3rd floor. There were no residents on the floor as it was being remodeled and under construction.<BR/>Observation on 5/9/23 at 3:30 p.m. revealed construction workers were working on the 3rd floor and walking in the hallway. An unknown staff member was standing in the hallway waiting on the elevator.<BR/>Observation on 5/10/23 at 4:34 p.m. revealed on the 3rd floor directly across from the conference room hallway a door was open and revealed what appeared to be residents' records on the floor and in file boxes stacked in the room. There were boxes labeled medical records and boxes labeled 2015 and 2020 GA-GR and other boxes labeled with residents' names and dates and others not labeled. Observation further revealed signed Physician's Telephone order forms on the floor and other residents' medical records scattered on the floor. Some boxes were observed to be tilted and stacked up to 6 ft tall in different parts of the room and falling over. There were residents' medical records on the floor and scattered in the corner of the room between boxes. There was a bathroom and the light was on and the new floors in the room had been covered with paper protection and taped together at the seams. Multiple areas of the room had residents' medical records with diagnoses, medications, lab and x-ray results on the floor and footprints on them in one area as if they had been stepped on. Observed several boxes also labeled business office and what looked like thin folders with staff names as well. Many of the boxes were missing lids and had files sticking up out of them as if they had been gone through and not placed back in the box. The door did not have a lock.<BR/>Observation on 5/10/23 at 4:34 p.m. revealed there were several construction workers walking in the hallway on the 3rd floor. <BR/>In an interview on 5/10/23 at 4:45 p.m. the Administrator was notified of the opened and unlocked room with the medical records and stated he would take care of it.<BR/>Observation on 5/11/23 at 8:40 a.m. revealed a worker was changing the doorknob on the room with the medical records and replacing it with a doorknob that had a key lock.<BR/>In an interview on 05/11/23 at 1 p.m. Staff D stated the medical records in the room across from the conference room hallway were her shred records, and then stated the records in the room were from the previous facility owners and Staff D confirmed what the surveyor saw regarding 2015 and 2020 dates on boxes and stated again they were from previous facility owners and not current resident records. Staff D reported current residents' records were locked in her office and she and the Administrator were the only ones with keys to it. Staff D stated the medical records in the room on the 3rd floor should be locked and secured especially with the construction on the 3rd floor. Staff D stated the facility had contacted the previous facility owners to let them know the medical records were at the facility but had not heard anything back from them. Staff D stated the facility would not be shredding anything and would follow the medical records retention policy. <BR/>Observation on 5/11/23 at 3:00 p.m. revealed in the conference room with the surveyors had been a metal shopping cart style cart with accordion files, binders, and boxes. On the top of the cart was a resident's large medical record. Upon examining the accordion folder type file, there was no cover and noted it was a resident's medical record and the resident's name is on the accordion file. There was also a large file box that had a resident's name; handwriting and different forms could be seen sticking out. There were no residents by those names on current resident roster dated 5/9/23 for this survey. <BR/>Interview on 5/11/23 at 3:45 p.m. the DON and Staff D were informed of the cart in the conference room with resident's medical records in it. Staff D stated it might be from the audit and stated she would secure the records immediately.<BR/>Observation on 5/11/23 at 5:30 p.m. revealed the metal cart in the conference room with resident's medical records on it was gone from the conference room. <BR/>In an interview on 5/12/23 at 2:00 p.m. the Administrator stated the medical records that were in the room on the 3rd floor should have been secured. The Administrator further stated the facility's plan was to continue going through the medical records per retention policy and then calling the previous company again to ask them to collect their residents' and staff records. The Administrator stated the facility had a safe storage company they used and the previous company did not but if the records were sent to their safe storage company, they would be kept separate in case the company comes to get them.<BR/>Review of the facility HIPAA compliance policy and procedure dated January 2017 indicated, Policy Statement Protected Health Information (PHI) will be safeguarded against unauthorized use, access, or disclosure in accordance with federal and state laws to prevent access by unauthorized persons.Secure shall be defined as inaccessible to unauthorized individuals, protected shall be defined as safe from environmental damage.2. Store all documents containing PHI in a secure, locked location with limited access to authorized workforce members. 9. Keep records and other documents out of public view and reach. 16. Secure and protect all records and documents from damage, loss, or destruction when an alternative storage space is needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 6 residents (Resident #8) reviewed for safe and functional equipment.<BR/>The facility failed to ensure Resident #8's bed was in proper working condition. <BR/>This failure could place residents at risk for skin tears, injury, falls and discomfort during transfers. <BR/>Findings included:<BR/>Record review of Resident #8's face sheet, dated 06/27/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. <BR/>Record review of Resident #8's quarterly MDS, dated [DATE], reflected she had a BIMS score of 15, which indicated cognition was intact. Resident #8 had active diagnoses which included biliary cirrhosis (chronic liver disease), chronic pain syndrome, fibromyalgia (pain and tenderness all over the body). Resident #8 required the use of a wheelchair and required assistance of 2 or more helpers with bed mobility, toileting, transfers and dressing. <BR/>Record review of Resident #8's care plan, revised on 05/07/24, reflected:<BR/>Focus: ADL Self Care Performance Deficit r/t generalized weakness. Goal: Will safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene with modified independence through the review date. Interventions: Bed Mobility (Roll Left And Right, Sit To Lying, Lying To Sitting On Side Of Bed): Requires staff participation to reposition and turn in bed.<BR/>Focus: [Resident #8] has Liver Disease r/t Biliary Cirrhosis. Focus: Will be free from s/sx of liver complications, including infection, abnormal or unexplained bleeding, malnutrition, anemia, cognitive decline or mental status changes through review date. Interventions: Monitor/document/report to MD s/sx of complications: Malaise (discomfort), Fatigue (tiredness), Anorexia (eating disorder), Weight loss, Edema (fluid buildup), Nosebleeds, Bleeding gums, constipation or diarrhea, Ascites (fluid in abdomen, Altered LOC (level of consciousness), Confusion/disorientation.<BR/>Observation and interview on 06/25/24 at 10:18 AM revealed Resident #8 sitting in her wheelchair. She stated she was doing well. Resident #8 stated she had been at the facility for 3 months and her bed had not been fixed. She stated her bed did not go up or down. Observed Resident #8 use the bed remote to adjust the end of the bed, however, it would only make a noise and would not move. She stated she would like to be able to elevate her legs at night due to her edema while lying in bed. She stated she needed her bed to work. Resident #8 stated she told the staff and a maintenance person but could not recall names. <BR/>Interview on 06/27/24 at 1:50 PM with CNA G revealed she was the CNA assigned to Resident #8. She stated a couple of weeks ago Resident #8 mentioned to her that her bed was not working. She stated she notified the Maintenance Director and she believed the Maintenance Director looked at it but she was unsure if he fixed it. She stated when Resident #8 went to bed they elevated her legs with pillows. <BR/>Interview on 06/27/24 at 2:42 PM with RN H revealed Resident #8 had not mentioned anything to her regarding her bed not working. She stated Resident #8 was able to voice her needs and the resident was known to report any concerns to management. She stated she had not noticed Resident #8's bed not working, she stated they elevated Resident #8 legs with pillows at night. She stated there was no risk to the resident since the resident legs were being elevated with pillows. She stated as far as she knew the bed was working last week. <BR/>Interview on 06/27/24 at 2:50 PM with the DON revealed she was not aware Resident #8's bed was not working. She stated staff had not mentioned anything to her regarding Resident #8's bed. She stated they had an online system where they log any maintenance concerns and they choose the priority. She stated all staff were responsible to notify maintenance. <BR/>Interview on 06/27/24 at 3:51 PM with the Operations Manager revealed Resident #8 had not mentioned anything to her regarding her bed. She stated all staff were responsible to notify maintenance of any environmental concerns. She stated they had an online system staff used to input work orders and maintenance staff were responsible to review the report. She stated all staff had access to it. She stated she had not seen anything regarding Resident #8 bed. <BR/>Interview on 06/27/24 at 4:48 PM with the Maintenance Director revealed about a month ago Resident #8 mentioned something about her bed not working. He stated he went to check the bed and the head of the bed was working properly. He stated he was unaware the end of the bed was the part that was not working. He stated they had an online system where staff were able to input any work order s and he reviewed it daily . <BR/>Record review of facility Work Orders from 04/01/24 - 06/21/24 revealed no orders pertaining Resident #8's bed. <BR/>Record review of the facility's, undated, policy titled Environmental Service reflected the following: <BR/>It is the policy of this facility to maintain a clean and comfortable environment .3. When a maintenance issue arises, the resident, staff member or family member must put in a work order at the front desk with the receptionist.<BR/>4. <BR/>The maintenance department will complete the work order or find a resolution within 72 hours from the time it was reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program so the facility was free of pests and rodents for 1 of 1 facility kitchen and 1 (Resident #36) of 5 residents reviewed for pest control.<BR/>1. Resident #36 repored her bed was infested with ants and she had numerous bites to her arms and legs. <BR/>2. There were multiple gnats observed in the kitchen food preparation area, storage area room, dishwasher room and floor drain<BR/>This failure could place residents at risk of a decreased quality of life and cross contamination of food.<BR/>Findings include:<BR/>1. Record review of Resident #36's, undated, admission Record reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had with diagnoses that which included diabetes, stroke, and muscle wasting.<BR/>Record review of Resident #36's quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Her Functional Status reflected she required total assistance with all of her ADLs except eating and oral hygiene. <BR/>Record review of Resident #36's care plan, dated 05/24/24, reflected the resident had behaviors of scratching and picking at her legs, and delusions involving staff and family. <BR/>Record review of Resident #36's nursing notes reflected documentation on 05/12/24 resident with sugar ants all over her bed, moved resident to bed A temporarily, residents left arm with red raised itchy bumps. This Nurse notified MD new T.O.: Benadryl 25mg PO PRN q8hours. DON was also informed.<BR/>Interview and observation on 06/25/24 at 10:28 AM revealed Resident #36 stated she had ants in her bed a few weeks ago, and she had ant bites all over her legs and arms. The facility treated her room, and she had no problems since then. Observed Resident #36 extremities and had no visible bite marks. <BR/>Interview on 06/27//24 at 2:30 PM, the DON stated the incident with Resident #36 and the ants was not reported because the resident was able to tell them what happened. The DON did not feel reporting the injury to the resident was significant enough to rise to the level of reporting .<BR/>Record review of the facility's pest control logs for January- June 2024 reflected the facility was treated for ants twice a month.<BR/>2. Observation of kitchen area on 06/25/24 at 8:43 AM revealed several gnats in the kitchen food prep area, storage area room and dishwasher room. No food was observed in the prep area. <BR/>Follow-up observation of kitchen area on 06/25/24 at 10:33 AM revealed staff prepping for lunch, staff were waving their hands in the air to move the gnats. Food was observed on the steam table; however, the food was covered. <BR/>Interview on 06/25/24 at 11:28 AM with [NAME] revealed they have had an issue with gnats for a couple of months however, it had gotten better. He stated pest control went out about once or twice a month and was treating them. He stated they tried to always keep the kitchen clean to reduce the gnats. He stated the risk of having pests in the kitchen was it could get in the residents' foods.<BR/>Interview on 06/25/24 at 11:23 AM with the Dietary Supervisor revealed pest control service went by yesterday (06/24/24) to treat the gnats. She stated the gnats used to be worse, and they come and go. She stated maintenance had been addressing the gnats and ensuring pest control services went out. She stated the risk of having pests in the kitchen would be pests getting in the resident's food.<BR/>Interview on 06/25/24 at 11:36 AM with the Maintenance Supervisor revealed pest control service went out twice a month or as needed. He stated they had a drip system in place where they pour a chemical in the dishwasher room drains. He stated they were responsible to treat and notify the pest control service company when needed. He stated he had not had any complaints regarding pests in the facility . <BR/>Record review of Pest Control Service Invoices, for 03/04/24 through 06/24/24, reflected evidence of treatment for pests in the kitchen.<BR/>Record review of the facility's Physical Environment policy, revised May 2007, reflected the following: It is the policy of this facility to provide an environment free of pests. 1. The facility will have a pest control contract that provides frequent treatment of the environment for pests. 2. The pest control visits will occur at least monthly. 3. It will allow for additional visits when a problem is detected. 4. Monitoring of the environment will be done by the facility's staff. 5. Pest control problems will be reported promptly to the administrator.

**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 and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 1 of 6 residents (Resident #6) reviewed for resident rights, in that: <BR/> ADON B was engaged in a personal telephone conversation on a cell phone while feeding Resident #6, instead of socializing with the resident during care. <BR/>This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity and self-worth.<BR/>The findings included:<BR/>Record review of Resident #6's face sheet dated 3/22/2023 revealed an admission date of 11/16/2021 with readmission date of 2/23/2023 with diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness and paralysis that occurs after a stroke, aphasia following cerebral infarction (loss of ability to understand or express speech after brain damage caused by a stroke), and type 2 diabetes mellitus. <BR/>Record review of Resident #6's significant change in status MDS dated [DATE] revealed Resident #6 had a BIMs score of 8 (scale of 0-15) which indicated a moderate cognitive impairment. <BR/>Record review of Resident #6's significant change in status MDS dated [DATE] revealed Resident #6 required extensive assistance with eating which included one person physical assistance to eat. <BR/>Record review of Resident #6's Care Plan dated 11/16/2021, last revised on 11/29/2022 revealed the resident had an ADL self-care performance deficit with interventions which included: Eating: requires extensive assistance with one person staff participation with feeding. <BR/>Record review of Resident #6's Care Plan dated 1/13/2022 revealed the resident had disruptive verbal behaviors which included: yells out for assistance or attention/company with interventions which included: Staff with respond to resident and socialize during care as able. <BR/>During an observation on 3/21/2023 at 12:35 p.m., ADON B was heard engaging in personal conversation while in Resident #6's room. Upon further observation, ADON was observed feeding Resident #6 his lunch meal. Resident #6 was sitting up in bed, he was awake, alert and able to interact and respond to conversation with simple responses. ADON B's cell phone was observed on Resident #6's bedside table, directly beside the meal tray. ADON's cell phone was lit up on an active call with Wifey was observed with the phone on speaker. <BR/>During an interview on 3/21/2023 at 12:38 p.m. Resident #1 was able to engage in conversation about his food preferences but was not able to answer detailed interview questions due to his cognitive status. <BR/>During an interview on 3/21/2023 at 1:24 p.m., ADON B stated she was on a personal call with her mother in Resident #6's room while she was feeding Resident #6. She stated she knew she should not have answered the call, but it was her mother whom she described as very demanding. ADON B stated she did not know the facility policy for personal cell phone use while in a resident room or while providing feeding assistance. ADON B stated she did not want to be on a personal call while feeding a resident, but it was her mom and her mom just kept talking. <BR/>During a follow-up interview on 3/21/2023 at approximately 3:30 p.m. Resident #6 was unable to recall lunch and was unable to state his preferences for care due to his cognitive status. <BR/>During an interview on 3/22/2023 at 3:13 p.m., the DON stated her expectation was that staff do not use personal cell phones while providing nursing care or interacting with residents. The DON stated staff should step out of the room or away from the resident if the phone call was an emergency. The DON stated it was important for staff to provide the residents with their full attention, especially during feeding to ensure the resident's safety. <BR/>Record review of a facility policy, titled Personal Cell Phone/Electronic Communication Device use by Employees (undated) revealed: To ensure the safety and security of the therapeutic treatment environment and to ensure patient and employee privacy and confidentiality. Use of personal cell phones/electronic communication devices by facility employees is to be used only in rare situations while employees are working. Employees may use cell phones/electronic communication devices during their shift but recommended only during lunch or break periods (unless specifically authorized by a supervisor for work-related purpose or other rate situation related to their personal family needs). Personal cell phones/electronic communication devices are recommended to be turned off and stored during working hours . <BR/>Record review of a facility policy, titled Resident Rights (undated) revealed: The Resident has the right: 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 1 of 6 residents (Resident #5) reviewed for medication administration in that: <BR/>MA A left Resident #5's medication at the bedside without ensuring the resident consumed the medication. <BR/>This deficient practice could affect residents and place them at risk of not receiving the therapeutic dosage and drug diversion.<BR/>The findings included:<BR/>Record review of Resident #5's face sheet dated 3/23/2023 revealed an admission date of 1/20/2020 with readmission date of 1/07/2022 with diagnoses which included: personal history of urinary tract infections, gastro-esophageal reflux disease without esophagitis, and mechanical loosening of internal right hip prosthetic joint subsequent encounter. <BR/>Record review of Resident #5's quarterly MDS, dated [DATE] revealed a BIMs score of 15 (scale of 0-15) which indicated the resident was cognitively intact. <BR/>Record review of Resident #5's Care Plan dated 12/19/2022 stated: Administer medication as ordered. <BR/>Record review of Resident #5's Order Summary for March 2023 revealed physician orders for the administration of the following medication:<BR/>-simethicone tablet (used to treat gas) with a start date of 9/26/2022. Give 2 tablets by mouth 3 times a day for gas. <BR/>-gabapentin capsule (anticonvulsant medication often used off label to treat nerve pain) 100 mg with a start date of 1/08/2022. Give 1 capsule by mouth 3 times a day related to pain in right hip. <BR/>-macrodantin capsule (nitrofurantoin macrocrystal) (antibiotic used to treat UTI's) 100 mg with a start date of 12/11/2022. Give 1 capsule by mouth one time a day for prophylactic for multiple UTI's. <BR/>-florastor capsule (probiotic used to support digestive health) with a start date of 9/19/2022. Give 1 capsule by mouth two times a day for stomach (sic). <BR/>During an observation/interview on 3/21/2023 at 9:58 a.m. Resident #5 was observed in her bed with the head of the bed elevated, utilizing her personal cell phone. On the bedside table directly beside Resident #5's bed were two medication cups with pills in them. Medication cup #1 had two nickel sized white round pills. Medication cup #2 had one capsule that contained a beige bead like substance, one oblong pill and one round tablet. Resident #5 quickly took the medication cups and consumed the contents of medication cup while this surveyor was observing. Resident #5 stated the two round nickel sized pills in medication cup #1 were gas pills. She stated the pills in medication cup #2 was one pill for her stomach, one antibiotic. She stated she did not know what the 3rd pill was used for right now. Resident #5 stated it was her fault the medication was at the bedside. She stated MA A gave her the medication and she did not take them right away because she was busy playing on her phone. <BR/>During an interview on 3/22/2023 at 11:47 a.m., MA A stated confirmation that she had left Resident #5's medication at the bedside without ensuring the resident consumed the medication on 3/21/2023. MA A stated she does not normally leave medication at the bedside, but Resident #5 was complaining of an upset stomach and waited to eat something before taking her morning medication. MA A stated she normally makes sure the resident swallows the pills but on 3/21/2023 she was called out of the room for something and left the pills with the resident. MA A stated she estimated the time the medication was left on the beside to be approximately 20 minutes. MA A stated Resident #5 was not cleared to self-administer medications. MA A identified the medication as: simethicone gas pills which were nickel size round white tablets, florastor a probiotic which was a capsule with beige colored beads, gabapentin, and nitro mac an antibiotic used to treat a UTI. MA A stated she was trained and knew she was supposed to stay in the room with the resident until she swallowed the pills. <BR/>During an interview on 3/22/2023 at 4:15 p.m., the DON stated her expectations for medication administration was for staff to remain in the resident room until medications were taken (consumed). The DON stated it was important for staff to ensure the medication was consumed to ensure a dosage of medication was not missed and so someone else could not get a hold of the medication. <BR/>Record review of a facility policy, titled Administration of Medications (undated) revealed: 2. Medications must be given in accordance with the resident's service plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the nursing staff were licensed to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 of 21 staff (Staff C) reviewed for licensure. <BR/>The facility failed to ensure Staff C was appropriately supervised as a Graduate Vocational Nurse (GVN) and maintained a valid nursing license to practice nursing, as a result Staff C worked on 28 occasions without a valid nursing license. <BR/>These failures placed residents at the facility at risk of not receiving care and services from staff who are properly trained and supervised. <BR/>The findings included: <BR/>Record review of the staff roster provided by the facility listed Staff C, as a Licensed Vocational Nurse, with a hire date of [DATE]. <BR/>Record review of Staff C's employee file revealed a job application for employment. GVN was handwritten into the space for position desired. The question, do you currently hold a valid professional license or certification was marked yes and a box X mark indicated a LVN/LPN license and was signed by Staff C on [DATE]. Staff C indicated her previous job experience was working for another rehab facility as a GVN from 7/22 to 10/22. <BR/>Record review of Staff C's employee file revealed a Texas Board of Nursing licensure verification for Staff C dated Tuesday, [DATE], at 1:13 p.m. The report indicated Staff C, from the Board of Nursing had a Grad Permit Pre-Exam as a LVN/LPN with a current license that was issued on [DATE] and expired [DATE] for Staff C. The report stated, This permit is issued until the applicant meets all of the licensure requirements for a permanent license. <BR/>Record review of the website on https://txbn.boardsofnursing.org/licenselookup for verification of nursing license revealed that Staff C was issued a Board of Nursing- Grad Permit Pre Exam on [DATE] with expiration date of [DATE]. The license was listed a Inactive. <BR/>Record review of a facility document titled Labor Hours Report for Staff C revealed Staff C had worked on the following dates after her license expired: <BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>2/022023<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>[DATE]<BR/>for a total of 221.63 hours on 28 days before surveyor intervention. <BR/>Record review of the facility schedule for [DATE] revealed Staff C was scheduled to work on the date of surveyor entrance to the facility from 6 am-2 p.m. <BR/>During an interview on [DATE] at 2:05 p.m. Staff C stated she was hired as a GVN (graduate vocational nurse (pre-exam)) in October or November of 2022. She stated she presented the facility with her nursing license number but did not present documentation or proof of licensure to the facility. Staff C stated she took the LVN NCLEX (licensing exam) in January of 2023 and failed the examination. Staff C stated she was not licensed as a LVN. Staff C stated she thought her license expired in 4/2023 and was unaware that it had expired in January of 2023. Staff C stated she was supposed to work today ([DATE]) but had called in. She stated the last time she worked in the facility was Friday [DATE]. <BR/>During an interview on [DATE] at 5:12 p.m., ADON B stated new nurses upon hired are trained on the floor. ADON B stated she had the new staff demonstrate with stuff (nursing procedures) they had (residents who requrired the specific procedure) and for stuff (nursing procures that were unable to be performed for current residents) they did not have she verbally walked them threw the stops of care. She stated observations of new staff would include catheters, peri-care, tube feedings and medications. She stated observations she did not make of new staff were trach and ventilators because those things were not readily available in the facility. ADON B stated new staff gets 3 days of orientation and then she asks them if they feel competent. She stated she could give extra training if they indicate they need it. ADON B stated she was not doing another different with any of the staff and not doing anything extra for any staff members. <BR/>During an interview on [DATE] at 3:15 p.m., the DON stated Staff C was a GVN who had not yet taken her nursing license exam. The DON stated she was not aware that Staff C's GVN permit had expired. She stated the HR person, who no longer works at the facility must have obtained the document indicating a LVN permit license that expired 4/2023. The DON stated since she became the DON in February, she had not looked any anyone's license unless there was a problem. She stated she had not looked or verified Staff C's license. The DON stated license verification was an HR responsibility and she left approximately 3 weeks ago. The DON stated it was also an HR responsibility to monitor the nursing staff license. The DON stated it was her responsibility, along with the ADON to monitor clinical's. The DON stated she did not have any monitoring in place for a Staff C (as a GVN) because she had already been at the facility for a while before the DON got to the facility. The DON stated she watched Staff C, and she was a good nurse. The DON stated she did not document the observations of Staff C. The DON stated she had not done anything extra with Staff C and had not assigned her a preceptor. The DON stated she did not know what training had occurred when Staff C first came to the facility, but she had already been there over 3 months. The DON stated it was a liability for staff to work without a license. The DON stated Staff C technically did not have a license to treat patients and the license was what gives a person the right to treat patients. The DON stated Staff C had no disciplinary action or complaints that she was aware of at this time. <BR/>During an interview on [DATE] at 4:05 p.m., the DON with the Corporate Compliance Nurse stated since Staff C had failed her licensing exam the Texas Board of Nursing likely rescinded her license. <BR/>During an interview on [DATE] at 4:07 p.m., the Administrator stated he was not aware Staff C had failed her licensing exam. The Administrator stated just last week she was telling him she was preparing for the exam and getting ready to test (date unknown). <BR/>During a follow-up interview on [DATE] at 4:36 p.m., Staff C stated the DON had called her (after surveyor intervention) and told her the license was expired. Staff C stated she had previously talked to the HR Director (name and date unknown) who told her she could continue to work until she failed the test 3 times. Staff C stated she was under the impression she had one year from being given the GVN license. Staff C stated she had never seen a copy of her license and only had her license number. Staff C stated her nursing school also told her she had one year to work. Staff C stated she looked up her nursing license online in January, but she could not remember the date. Staff C stated she had graduated from a local nursing school in [DATE]. Staff C stated as of the date of this intervention she had still never received her test results in the mail from the Board of Nursing even though she knew she had failed. Staff C stated she had no malicious intent. She stated because she spoke with ADON B and the HR director she thought she was okay to continue to work. <BR/>During an interview on [DATE] at 5:01 p.m. Staff C stated when she was first hired, she trained with ADON B for approximately one week. She stated ADON had her return demonstrated some things (unknown) and gave her verbal instructions. Staff C stated she was not given any facility policies or procedures or any written guidelines, guidebooks, or training materials. Staff C stated after the one week of training, ADON B told her to ask the nurse she was working with, or she could call her if she had any questions. Staff C stated at the time she was hired the facility had a temporary DON (name unknown) who told her she could ask questions and bring any forms to her to make sure they were filled out correctly. Staff C stated no one at the facility had been assigned to her as a preceptor and no one was signing off on her work. She stated the current DON gave her in-service training that included all staff but did not give her any special instructions as a GVN. <BR/>During an interview on [DATE] at 3:36 p.m., ADON B stated she never asked Staff C when she was testing for her LVN exam and Staff C had never discuss testing with her. ADON B stated Staff C did not tell her she had failed her licensing exam. ADON B stated she thought HR was supposed to keep up with licensed staff. <BR/>During an interview on [DATE] at 4:26 p.m., the Administrator stated he did not know Staff C had failed her licensing exam. He stated it was new to him that a GVN's license ends the day they fail the test. <BR/>Record review of a facility document, titled Graduate Nurse (undated) revealed: Qualifications: Permit/Certificates and Licenses: Must possess an active permit to practice as a graduate Vocational Nurse valid in this state. This document was bland and was not signed. <BR/>Record review of a facility document, titled License Vocational Nurse/Licensed Practical Nurse (undated) revealed: Qualifications: Certificates and Licenses: Must possess an active license to practice as a Licensed Vocational Nurse or a Licensed Practical Nurse valid in this state. This document was blank and was not signed. <BR/>During an interview on [DATE] at 10:39 a.m., the DON stated the facility did not have a signed job description for Staff C. <BR/>Record review of a facility document, titled Verification of Licenses (undated) revealed: It is the policy of the company to verify that all employees in positions which require licensure or certification, have a current license or other authorization to practice in the state(s) in which they work. 6. The department manager or designee should monitor expiration dates of all licenses and credentials and notify employees in advance of such dates. 9. The employee must notify his or her supervisor if his or her license is no longer valid based on state recommendation. <BR/>During an interview on [DATE] at 10:23 a.m., the DON stated the facility did not have a policy for GVN's, LVN's or nursing staff. <BR/>Review of the Board of Nursing Rules and Guidelines Governing the Graduate Vocational Nurse Candidates and Newly Licensed Vocational Nurse at https://www.bon.texas.gov/practice_guidelines.asp.html#:~:text=Rule%20217.3%20%28a%29%20%283%29%2C%20Temporary%20Authorization%20to%20Practice%2C,under%20the%20direct%20supervision%20of%20a%20licensed%20nurse as viewed on [DATE] revealed: In accordance with Rule 217.3(a): A new graduate who completes an accredited basic nursing education program within the United States, its Territories, or Possessions and who applies for initial licensure by examination in Texas may be temporarily authorized to practice nursing as a graduate vocational nurse (GVN) pending the results of the licensing examination. This temporary authorization is not renewable and will expire the earliest date of any of the following: (1) when the candidate passes the NCLEX-PN&reg; test; (2) when the candidate fails the NCLEX-PN&reg; test; (3) or on the 75th day following the effective date of the temporary authorization [217.3(2)]. Expired or Invalid Permission to Practice: New graduates may not continue to practice as GVNs after failing the NCLEX-PN&reg; , even if the expiration date of the temporary permission to practice has not expired. Employers must follow-up on the results of the new graduate's test results, either by asking to see the new graduate's test results, monitoring the issuance of a license using the automated phone line or utilizing the on-line licensure verification process on the Board's web page. If the new graduate is allowed to continue to practice after receiving notice of failing the NCLEX-PN&reg; , both the nurse manager and the new graduate may be subject to disciplinary action by the Board. Integration of the GVN, GN, or Newly Licensed Nurse into Practice: Both the graduate nurse (GVN or GN) and the newly licensed nurse are in a transitional process from student to professional. As a novice practitioner, the GVN, GN or new LVN or RN is inexperienced and not fully integrated into his/her professional nursing role and setting. The Board believes it is essential during this transitional period for the new graduate or newly licensed nurse to seek and receive direction, supervision, consultation, and collaboration from experienced nurses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review revealed the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 Residents (Resident #2) whose records were reviewed for accuracy of assessments, in that: <BR/>Resident #2's MDS reflected that he required extensive assistance by 1 person for transfers but he actually required extensive assistance by 2 persons.<BR/>This deficient practice could affect any resident and could contribute to residents not receiving care and services as needed.<BR/>The findings were:<BR/>Review of Resident #2's face sheet, dated 1/23/23, revealed he was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy and repeated falls. <BR/>Review of Resident #2's admission quarterly MDS, dated [DATE], revealed his BIMS was 8 (out of 15) indicative of severe cognitive impairment; he required extensive assistance by 1 person for bed mobility and transfers; he was unsteady moving from sitting to standing position, on and off the toilet and surface to surface transfer and only able to stabilize with staff assistance.<BR/>Review of Resident #2's Care Plan, revised 11/8/22, revealed he required extensive assistance by 2 persons for bed mobility and transfers. Resident #2 was identified as being a fall risk and interventions included: anticipate and meet needs, avoid rearranging furniture, be sure the call light is within reach and encourage to use it to call for assistance as needed, educate resident and caregivers about safety reminders and what to do if a fall occurs, maintain a clear pathway, free of obstacles. Further review revealed Resident #2 had a fall on 1/13/23 and the interventions included: Call don't fall signs next to bed, check range of motion<BR/>, monitor/document /report to MD for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, neuro-checks as ordered and vital signs as ordered.<BR/>Interview on 1/20/23 at 3:20 PM with LVN E revealed Resident #2 was confused and required extensive assistance with transfers by 2 persons because he was not able to bare weight and was not able to pivot. <BR/>Interview on 1/20/23 at 3:31 PM with CNA K revealed Resident #3 had been a 1 person assist for transfers but noted when she transferred him he was dead weight. CNA K stated it seemed to her like he had a decline in condition but did not tell LVN E about the change. <BR/>Interview on 1/23/23 at 12:50 PM with the MDS Coordinator revealed Resident #2 required extensive assistance by 2 persons for transfers. He stated anytime a resident required extensive assistance they would assign the task to two staff. The MDS Coordinator reviewed Resident #2's quarterly MDS, dated [DATE] and his Care Plan revised on 11/8/22 and stated the MDS should reflect extensive assistance by 2 persons for transfers. He further stated that the POC used by the aides self-populated with the information inputted into MDS. Therefore, Resident #2's POC would provide the aides with wrong information and could contribute to the aides not providing the care Resident #2 needed and potentially contribute to avoidable falls. The MDS Coordinator stated he used the RAI as a policy for completed the MDS assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to the ensure the resident received assistance devices to prevent accidents and the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance for 2 of 5 Residents (Resident #1 & Resident #2) whose records were reviewed for falls.<BR/>1. Resident #1 had 4 falls within 24 hours upon admission related to nursing staff not providing Resident #1's fall history through report, lack of staffing and staff not initiating appropriate safety interventions to keep Resident #1 as safe as possible. As a result, he sustained multiple fractures.<BR/>2. Resident #2 had a history of falling out of his wheelchair. Nursing staff failed to ensure his wheelchair was in the locked position and placed away from his bed to prevent further falls.<BR/>These deficient practices could affect any resident and potentially contributed to avoidable falls and injuries.<BR/>The findings were:<BR/>1. Review of Resident #1's face sheet, dated 1/19/23, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified Dementia and Chronic Systolic (congestive) Heart Failure.<BR/>Review of Resident #1's admission assessment, dated 12/30/22 at 3:49 PM, revealed Resident #1 was alert 1-2, understood had memory loss which caused agitation and impulsiveness, complained of dizziness in past 3 days, wore glasses, had moderate hearing impairment, no use of assuasive device noted, history of falls, unable to determine weight bearing limitations and it was noted he had limited range of motion on both legs and feet. Further review revealed LVN F completed the assessment.<BR/>Review of Resident #1's 5-day MDS, dated [DATE], revealed he had vision impairment; his BIMS was 00 (out of 15) indicative of severe cognitive impairment; he exhibited inattention and disorganized thinking; transfers only happened once or twice by 1 person; he was not steady moving from seated to standing position, moving off and on the toilet and surface to surface transfer; he used a wheelchair for mobility; was incontinent of urine; he had a fall in the last month, 2-6 months, fracture related to a fall in the last 6 months prior to admission and he had a fall since admission; he had one fall with no injury and one fall with a major injury.<BR/>Review of Resident #1's 48-hour Care Plan, dated 12/30/22, revealed he was a risk for falls related to history of falls, generalized weakness, poor safety awareness and impulsiveness and the intervention implemented was to keep needed items water, etc., in reach.<BR/>Review of Resident #1's incident log revealed he had a fall on 12/30/22 at 19:51 (7:51 PM), at 12/31/22 at 0:00 (!2 PM) and on 12/31/22 at 10:03 AM. <BR/>Review of incident report for Resident #1, dated 12/30/22 at 7:51 PM revealed, This writer was called due to roommate hollering. Upon entering the room resident was one foot away from mattress, head pointed towards the wall and feet over by the privacy curtain and laying on the floor on stomach but favoring the right side. Right arm was folded under the resident. Resident still has red slip grip socks from hospital and the roommates bedside table was pulled away from the wall and the small refrigerator was knocked over on the floor. This writer and CNA attempted to assist the resident up but stated that he wanted a moment to lay on the floor because he was in a great deal of pain. Does attempt to explain what he was trying to do but gets lost in thought and cannot recall the right words so he stops explaining and sighs heavily. Immediate action taken: Resident stood himself up and walked himself back to bed and laid down, covered himself and keeps saying, there was something I was going to do. Injury Type: Unable to Determine. Injury Location: Right hand palm. Level of pain based on observing the resident was a 5. Mental Status: Oriented to Person. Notes: Resident has history of falls due to impulsivity. Further review revealed LVN F completed this report.<BR/>Review of Resident #1's order summary for December 2022 revealed an order dated 12/30/22 for an x-ray to the right shoulder and right hand due to fall and complaint to pain one time only until 12/31/22.<BR/>Review of an X-ray report for Resident #1, dated 12/30/22, revealed no acute fracture or dislocation of right shoulder and no acute fracture or dislocation of right hand.<BR/>Interview on 1/19/23 at 11:30 AM with Resident #1's RP revealed she was not happy with the fact Resident #1 fell within 2 hours upon admission and then fell again later. She stated Resident #1 had a history of falling at home because he could not walk on his own and he had severe Dementia. She stated she let nursing staff know about his history of falling. The RP stated she did not believe they took care of him the way he needed. Furthermore, she did not believe he would be safe if he returned to the facility so she secured alternative placement.<BR/>Interview on 1/19/23 at 1:15 PM with LVN F revealed she admitted Resident #1 on a Friday and no one was with him upon admission from the hospital. He did not have any visitors. A family member called about a visit and she let him know Resident #1's roommate went to bed early and told the son if he visited it would have to be a quick visit or he could visit early next morning. LVN F stated Resident #1 had a communication deficit (lack of expressive language) and would get agitated. She stated the bed was in the lowest position and the urinal was at bedside within reach. She demonstrated how to use the call light; had it pinned to his gown and provided the bed remote. LVN F stated Resident #1 was a 2 person assist and not able bare weight; he could not stand for long without his knees buckling. She stated Resident #1 was thin but tall. He could follow commands and seemed to understand. LVN F stated Resident #1 fell within 2 hours after admission before dinnertime. She had put him to bed about 2 hours prior to the fall and he was talking on the phone. LVN F stated Assistant MS saw Resident #1 on the floor and told her. LVN F stated she talked with Resident #1's RP about the fall and she stated Resident #1 had fallen at home. LVN F stated Resident #1 was sleeping by the time she left at 10 PM. She stated Resident #1 requested that she leave the overhead light on. LVN F stated she asked the MS about fall mats and he told her she could find them in central supply. She stated she did not implement fall mats.<BR/>Interview on 1/19/23 at 2:13 PM with CNA G revealed she was on duty on 12/30/22 from 2 PM to 10 PM when Resident #1 fell. She stated LVN F told her he was a fall risk. She stated fall protocol usually required the use of a low bed in the lowest position, fall mat, call within reach and more frequent visual checks. She stated she was not sure if the bed was in the lowest position and there was not a fall mat in place. She stated the call light was clipped to Resident #1's gown ad he had 2 urinals by the bedside. CNA B stated Resident #1 got up twice during the shift and did not seem to understand what he was doing. She stated the first time she caught Resident #1 up and she put him back to bed. CNA G stated she thought Resident #1 fell after dinner between 6 PM to 7 PM and had checked on him about an hour before he fell. Resident #1 was found on the floor and he did not say how he fell. He seemed confused. She stated she alerted LVN F who came right away. CNA G stated she thought Resident #1 sustained an injury but could not remember what type of injury.<BR/>Interview on 1/19/23 at 2:35 PM with LVN F revealed she did not get a fall mat from central supply and did not have the CNA get a fall mat because they were the only ones on duty. She stated she did not implement a fall mat. She stated typically there were 2 aides on duty but was not sure if someone called in or what happened. She stated there were three or four other residents who were a fall risk so it made it difficult for her and the 1 aide to complete tasks and do as many visual checks as required on the residents who were a fall risk.<BR/>Interview on 1/19/23 at 6:10 PM with LVN F revealed she did not know Resident #1 was a fall risk until he fell. She stated she knew she would be getting a new admission but nursing staff including the AM nurse did not provide any descriptive information about Resident #1. She stated the hospital nurse also did not tell her in report that Resident #1 was a fall risk. She clarified that she asked the MS about the mats to ensure they were available as needed. She stated she did not know enough about Resident #1 to determine whether the use of a fall mat was beneficial or a safety hazard. LVN F confirmed Resident #1 was not able to bare weight and was unsteady on his feet. However, stated he continued to try and walk on his own and was concerned a mat would be more of a safety hazard. LVN F further stated that she believed Resident #1 was going to fall no matter what because he was so unsteady on his feet and could not bare weight for long.<BR/>Review of incident report for Resident #1, dated 12/31/22 at 0:00 (12 PM) revealed CNA found resident sitting on floor. Immediate action taken: Assessed had small abrasion to forehead. Cleansed with normal saline and pat dried. Bleeding stopped. Vital signs 103/66, 76, 18, 98.2, 97 RM air, Assisted back to bed. Neuros started again. Mental Status: Oriented to Person. Further review revealed the family representative, the resident physician and DON were notified of the incident. Further review revealed LVN D completed this report.<BR/>Review of Fall Risk Evaluation dated 12/31/22 0:00 (12 PM) revealed Resident #1 was a high risk for falls with a score of 18. He was noted to be disoriented x 2, had poor vision with or without glasses, history of 3 or more falls in the past 3 months and he had balance problems while standing/walking.<BR/>Review of incident reports for Resident #1 did not reveal an incident report dated 12/31/22 at 2:05 AM.<BR/>Review of Fall Risk Evaluation dated 12/31/22 2:05 AM revealed Resident #1 was a high risk for falls with a score of 18. He was noted to be disoriented x 2, had poor vision with or without glasses, history of 3 or more falls in the past 3 months, he had balance problems while standing/walking and requires use of assistive devices (i.e., cane, walker or wheelchair).<BR/>Review of incident report for Resident #1, dated 12/31/22 at 4:30 AM revealed Resident #1's roommate came yelling down hall that resident was on his side and going to fall again. Resident observed holding onto wheelchair very unsteady gait. 'I immediately ran to his side. Resident stated, hurry up get me to bed. Immediate action taken: Resident had to be eased to sitting position too heavy to try continuing to walk to bed as he was not following direction, please slow down and let go of wheelchair. Abrasion to back observed/scratch. Has swelling to head in between eyebrows. Redness to right hip observed. Injury Type: Abrasion. Injury Location: scapula. Mental Status: Oriented to Person. Notes: Abrasion noted to right hip and abrasion to upper back/scratch, swelling now in between eyebrows. NP notified, requested X-RAY to head and Right hip. Further review revealed the family representative, the resident physician and DON were notified of the incident. Further review revealed LVN D completed this report.<BR/>Review of Fall Risk Evaluation dated 12/31/22 4:30 AM revealed Resident #1 was a high risk for falls with a score of 15. He was noted to be disoriented x 3, had adequate vision, history of 3 or more falls in the past 3 months and he had balance problems while standing/walking.<BR/>Review of Resident #1's order summary for December 2022 revealed an order dated 12/31/22 for STAT X-RAY to right hand, digits, wrist and forearm.<BR/>Review of an X-ray report for Resident #1, dated 12/31/22, revealed acute fracture of distal radius of the right forearm; acute fracture of distal radius of the right wrist and of the 5th digit at the PIP joint.<BR/>Review of hospital transfer form dated 12/31/22 revealed Resident #1 was transferred to the hospital at 2:44 PM.<BR/>Interview on 1/20/23 at 8:10 AM with LVN D revealed she worked at the overnight shift and worked on 12/30/22 and 12/31/22. She stated Resident #1 was extremely confused, impulsive and did not retain instruction. She stated Resident #1 was difficult to redirect based on impulsiveness. He also seemed anxious and she suspected it was because he was in a new environment. LVN D stated Resident #1 had his first fall during her shift around midnight. She stated the CNA on duty reported Resident #1 was sitting next to his bed. She assessed Resident #1, started neurochecks and transferred him back into bed. LVN D stated the bed was in the lowest position and she educated Resident #1 about using the call light to ask for assistance. She encouraged Resident #1 to allow them to help him so he would not fall. LVN D stated she changed Resident #1 and continued to encourage him to use the call light before getting up. She stated later on in the shift the roommate came out into the hallway yelling that Resident #1 was up and was going to fall. She ran to the room and saw Resident #1 using the roommate's wheelchair to ambulate. He was walking towards his bed but was extremely wobbly. LVN D stated she walked up beside Resident #1 and held on to his arm. He was clinching on to the wheelchair and she attempted to lock the wheelchair cut could not reach to secure the lock. LVN D stated it was not a good situation and was afraid they were both going to fall. She was able to get Resident #1 to release the wheelchair and she eased him down to the floor. The roommate reported that Resident #1 darted up from the bed and fell trying to get to the restroom and hit his head prior to her entering the room. LVN D stated upon assessment she noted redness to his right hip and ordered x-rays. She passed on the events that took place during her shift, in report, to the morning nurse, LVN E LVN D stated she notified the RP about the falls and she stated he fell at the hospital. The RP said Resident #1 had really bad Dementia. LVN D stated Resident #1 required 1 on 1 supervision and was probably a good candidate for a memory care unit. LVN D stated LVN F told her in report she did not use a fall mat because it would be a tripping hazard. She stated based on her experience with Resident #1 the one night she believed he was going to fall no matter what. She also thought a fall mat would probably have been more of a safety/trip hazard because he was on a mission to get up and go. Although, she stated it might have cushioned his fall. LVN D stated she talked with the ADON and DON both and they did not instruct her to implement any other interventions than were already in place: bed to the lowest position, clipped the call light to his gown, continue to instruct to use it and increase visual checks.<BR/>Interview on 1/20/23 at 9:21 AM with the ADM revealed the Admissions Coordinator would round on the residents in the hospital and get as much information as possible prior to admission. He stated it became obvious very quickly that they were not going to be able to meet his needs in the facility due to Resident #1's impulsivity and not following directives.<BR/>Interview on 1/20/23 at 10:41 AM with the Admissions Coordinator (AC) revealed he started working for the facility during October 2022. He stated he was also an LVN. The AC stated he would get a referral from the hospital, review the clinical documents, visit the patient at the hospital, talk to the aide, nurse and doctor per availability to determine any special needs/equipment the patient might need. He would also talk with family. The AC stated he would present the patient information to the IDT team (department heads) including ADON, DON, ADM, Rehab Director, MDS Coordinator and the SW. The AC stated Resident #1 was referred for skilled nursing for PT/OT with the plan to return home. He had a history of falls at home and had fallen in the hospital 3 times. The hospital had him on 1 on 1 supervision for a period of time but when he visited Resident #1 he was not on 1 to 1 supervision any longer. The AC stated he talked to the nurse who stated Resident #1 was no longer trying to get out of bed. He also spoke with the case manager, with Resident #1 and the RP around 12/22/22 to 12/23/22. He stated he was in contact with the case manager off and on until Resident #1 was ready to be released to determine his discharge plan. The AC stated Resident #1 seemed really nice, able to answer questions, was always in bed, calm and progressing in therapy at the hospital. Resident #1 did not display any agitation or behavior issues and was compliant with treatments per report from nursing. He stated the case manager stated Resident #1 had been on 1 on 1 supervision and it was discontinued on 12/22/23. The AC stated he was not sure if the supervision was continuous but the nurse told him they would be taking him off 1 to 1 supervision. The AC stated per his own experience the Resident would need to be off 1 to 1 supervision 24 hours prior to placement. The AC stated there was not a facility policy that he knew of regarding the supervision and he had not received direction from the nursing facility. The AC stated he presented Resident #1's information to the IDT team on 12/23/22 or 12/24/22. He stated he did not remember everyone who attended the IDT meeting but again stated it was usually the department heads. The IDT reached a consensus that they would accept Resident #1 but stated the admission took place at the end of the month after they secured the contract with Resident #1's insurance provider. <BR/>Interview on 1/20/23 at 1:06 PM with LVN H revealed she worked on 12/30/22 from 6 AM to 2 PM. She stated she knew Resident #1 was admitted on 12/3022 but it was not on her shift. LVN H stated she was not provided any information about Resident #1 including that he had a history of falling. <BR/>Interview on 1/20/23 at 1:43 PM with the Interim DON stated she knew Resident #1 was being admitted but was not sure if she was part of the IDT meeting when staff discussed his appropriateness for placement. She stated the day of admission the floor nurse would receive an admission packet. The first shift nurse would pass on in report that they were expecting a new admission if the resident did not arrive during the first shift and so on. The admitting nurse would document the resident's admission in the 24- hour report and any significant information.<BR/>Interview on 1/20/23 at 2:10 PM with the ADON revealed she was part of the IDT meeting when they discussed Resident #1's placement. She stated she was not sure who all attended but usually it included the DON, SW, therapy, ADM and the BOM. The ADON stated she told LVN H know about Resident #1's admission on [DATE]. LVN H worked the 6 AM to 2 PM shift. The ADON stated she would have provided specifics about Resident #1 including that he was a fall risk. LVN H should have passed the information on in report to LVN F. The ADON stated LVN F asked about implementing a fall mat after Resident #1 fell the first time but she advised her to wait until therapy assessed him. She stated Resident #1 was referred for therapy services with the focused areas being strength and mobility. The ADON stated nursing staff would have to get clearance from management before implementing a floor mat. She stated the interventions in place for Resident #1 included clipping the call light to his gown and increasing rounding on him. She stated they did not put the bed in the lowest position because he was a tall man and would often get up on his own. She stated Resident #1 did not have the strength to get up from the bed in the lowest position and it would be considered a restraint.<BR/>Interview on 1/20/23 at 3:10 PM with the ADM revealed they conducted a fall management in-service on 12/31/22 for the nurses. He stated they had not provided another in-service since to include the CNA's or other staff.<BR/>Interview on 1/20/23 at 3:15 PM with the SC revealed a CNA called in 12/30/22 for the 2 PM to 10 PM shift. He stated they had to make some changes to the assignments and LVN F and CNA G were the only two staff working the hall from 2 PM to 10 PM shift. The SC stated it would have made it difficult to complete normal tasks and to provide the level of supervision Resident #1 required in addition to the 3 or 4 other residents on the hall that were also a fall risk. He stated the census was probably like over 30 residents.<BR/>Interview on 1/20/23 at 4 PM with the Interim DON revealed a fall risk assessment was completed for every resident upon admission and after any fall. She stated nursing staff were to gather information to determine the root cause of the fall. Nursing staff was supposed to ask the who, what, when, where and why and implement interventions according to the root cause analysis.<BR/>Interview on 1/20/23 at 4:09 PM with the Staffing Coordinator (SC) revealed he worked the second floor from 10 PM to 6 AM as a CNA on 12/31/22. He stated upon beginning his shift he would usually make a sweep of all residents, checking on residents to ensure they were in their room, in bed and were ok. He remembered Resident #1 talking to himself and fidgeting with his gown. He asked the Resident if he was ok and the Resident said yes. The SC stated he completed his sweep and then started with incontinent care. He stated Resident #1's roommate came out and asked for help while he was in another resident room by the nurse's station. The SC stated Resident #1 was lying on the floor on his right side by the roommate's bed . Resident #1 said I'm hurting but could not say what happened. The SC stated there was not a fall mat in place. The bed was in the lowest position about 1 foot off the floor. He stated the nurse responded and assessed Resident #1 while on the floor. He and the nurse transferred Resident #1 to bed and the Resident complained of pain to his wrist. The SC stated after the second fall he answered the call light. The roommate was out in the hallway yelling for help. The SC stated when he entered the room he saw Resident #1 crawling on the floor. He stepped out of the room to get the nurse to help and when they returned Resident #1 had put himself back to bed. The SC stated Resident #1 was very confused. The roommate reported he saw Resident #1 crawling on the floor when he woke up. The SC stated he had checked in on Resident #1 about an hour before he was observed crawling on the floor. He stated Resident #1 was wide awake and restless. The SC stated he would round on residents every two hours and in between changing residents. He stated the nurse would also make her own rounds. The SC could not remember if the nurse told him Resident #1 was a fall risk. He stated the fall protocol required they put the resident bed to the lowest position, ensure the environment was clutter free and a fall mat was used if it was not a safety hazard. The SC further stated Resident #1 had the call light clipped to his gown and his overhead light was on. The SC stated Resident #1 was not able to walk and during transfer he was able to bare weight for a short time. He stated the nurse did not implement the use of the fall mat after the additional 2 falls. <BR/>Interview on 1/20/23 at 4:40 PM with the Interim DON revealed she assumed her position on 12/27/22 or 12/28/22. She stated she reviewed Resident #1's hospital documentation after it was faxed to the facility and stated Resident #1 had 3 falls while at the hospital related to impulsivity. She stated Resident #1 had heart failure and his heart was operating at 30 %. The Interim DON stated LVN F called her late in the evening after Resident #1 had his first fall. She understood Resident #1 was using his bedside table to walk and he fell into the roommate's mini refrigerator. The nurse educated Resident #1 on the use of the call light. She stated X-rays were ordered and they were negative for any fractures. The Interim DON stated staff found Resident #1 sitting next to his bed after his 2nd fall and LVN D reported she guided Resident #1 to the floor which was considered to be his 3rd fall. LVN D stated Resident #1 was using his roommate's wheelchair/ to ambulate and was very unsteady. Interim DON stated the last two falls took place during the overnight shift. She stated Resident #1 had 3 falls altogether while at the facility. The Interim DON stated a 2nd set of X-rays were positive for a fracture but was not sure about the exact location. She stated the interventions in place for Resident #1 included: call light was clipped to his gown; he had 2 urinals at bedside and his overnight light was on. She stated nursing staff believed Resident #1 required 1 to 1 supervision because he was determined to get up and walk. He was able to ambulate somewhat; not safely but he could walk. Interim DON stated they obviously could not provide 1 to 1 supervision. Furthermore, nursing staff was not convinced using a fall mat was a safe intervention which she discussed with nursing staff. The Interim DON stated she did not know who received Resident #1's clinical's to determine whether he was appropriate for placement. <BR/>Interview on 1/23/23 at 1:39 PM with the SC revealed he confirmed that on Saturday, 12/31/22, he found Resident #1 on the floor after the first fall during the night shift; later he observed Resident #1 crawling on the floor and then LVN D called him over to Resident #1's room to help transfer Resident #1 to bed after reporting she had lowered him to the floor. The SC stated technically Resident #1 had 3 falls during the night shift.<BR/>Interview on 1/23/23 at 1:42 PM with Resident #4 revealed he remembered Resident #1 after cueing. He stated Resident #1 kept falling. He would get out of bed and would hold on to everything to keep from falling but he fell anyway. Resident #4 stated Resident #1 was not steady and could not walk very good. He stated Resident #1 knocked his mini refrigerator over from on top of his dresser. Resident #4 stated Resident #1 did not want to be in bed. Resident #4 stated he kept calling staff for help because it usually took staff over an hour to respond when he used the call light. He stated the staff responded to his call for help.<BR/>2. Review of Resident #2's face sheet, dated 1/23/23, revealed he was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy and repeated falls. <BR/>Review of Resident #2's admission quarterly MDS, dated [DATE], revealed his BIMS was 8 (out of 15) indicative of severe cognitive impairment; he required extensive assistance by 1 person for bed mobility and transfers; he was unsteady moving from sitting to standing position, on and off the toilet and surface to surface transfer and only able to stabilize with staff assistance.<BR/>Review of Resident #2's Care Plan, revised 11/8/22, revealed he required extensive assistance by 2 persons for bed mobility and transfers. Resident #2 was identified as being a fall risk and interventions included: anticipate and meet needs, avoid rearranging furniture, be sure the call light is within reach and encourage to use it to call for assistance as needed, educate resident and caregivers about safety reminders and what to do if a fall occurs, maintain a clear pathway, free of obstacles. Further review revealed Resident #2 had a fall on 1/13/23 and the interventions included: Call don't fall signs next to bed, check range of motion, monitor/document /report to MD for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, neuro-checks as ordered and vital signs as ordered. <BR/>Review of an incident report, dated 1/13/23, revealed LVN E heard Resident #2 yelling out for nurse at 6:30 AM. She found him on the floor laying on his left side with wheelchair beside him. The wheelchair brakes were not locked. The Resident was wearing non-skid socks. Resident #2 was able to make his needs known and stated he hit his head on the floor. Resident #2's description: I don't know, I just fell. Immediate Action Taken: assessed Resident #2 and observed bump on left side of forehead and purple discoloration to left knee upon sitting Resident #2 up. Resident #2 denied pain. He was assisted to the wheelchair by 2 persons and neurochecks initiated. It was noted he did not have any injuries. Further review revealed LVN E notified Resident #2's physician, family member and the DON about the incident.<BR/>Observation on 1/18/23 at 2:05 PM revealed Resident #2 sitting in a wheelchair by the nurse's station. Further observation revealed he had bruising over his left eye. Interview with Resident #2's family member revealed Resident #3 had a fall.<BR/>Observation and interview on 1/20/23 at 11:40 AM revealed Resident #2 was lying in bed on his left side with eyes closed and his bed in a low position. The wheelchair was a couple of feet from the bedside. Interview with CNA I revealed she worked Monday through Friday from 8 AM to 5 PM. She stated she noted bruising over Resident #2's left eye on Monday, 1/17/23, and did not know if he had a fall. She stated the nurse did not say anything to her. CNA I stated Resident #2 was able to make his needs known, would use his call light to ask for assistance, was a 1 or 2 person assist with transfers. She stated the following interventions were used when a resident was identified as being a fall risk: call light within reach, low bed to lowest position and talk to nurse about using a fall mat. LVN I stated she would think Resident #2 was a fall risk because she had seen him try to self-transfer without assistance. She stated he was unsteady on his feet. Further observation revealed Resident #2's bed was not in the lowest position. She stated Resident #2 would sit up and the bed was in the position which allowed him to sit up and place his feet on the floor. CNA I stated there was no fall mat and his call light (touch pad) was placed underneath his left hand.<BR/>Observation and interview on 1/20/23 at 1:06 PM revealed Resident #2 was lying in bed on his left side with eyes closed and his bed in a low position. The wheelchair was a couple of feet from the bedside. Interview with LVN H revealed Resident #2 was a fall risk per nursing report. He required assistance with transfers and stated he was able to pivot at one point but not so much anymore. LVN H stated she was aware Resident #2 had bruising over his left eye but did not talk to CNA I about his fall history because it took place earlier in the month. She stated the information would be available in Resident #2's POC. She stated this was the program the aides documented on which provided them with resident ADL information and any special circumstances. LVN H stated the aides should report any change of condition to them when they noted any changes. She stated CNA I should have reported the bruising over Resident #2's left eye if she had not noted the bruising during her previous shift. LVN H stated she understood LVN E found Resident #2 on the floor by the bed but was not sure if he fell out of the bed or the wheelchair. She did not know all of the details and had not looked at his chart. LVN H stated a low bed to the lowest position would be utilized if Resident #2 fell from the bed and if he fell from the wheelchair then it should be positioned out of the reach/sight from Resident #2 and in the locked position. Further observation revealed Resident #2's bed was not in the lowest position, his wheelchair was by his bedside in front of the night stand, his call light was under his left hand and the bed remote was on the floor. LVN H further stated the wheelchair was not in the locked position and a safety hazard if Resident attempted to transfer to the wheelchair. <BR/>Interview on 1/20/23 at 1:20 PM with CNA J revealed she and CNA I were working together on the same hall. She stated she did not know Resident #2 had fallen and had not noted the bruising to his forehead. She stated she would ask the nurse on duty of any new resident changes upon returning from her days off. CNA J review[TRUNCATED]

Observation, interview and record review revealed the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen.<BR/>1. The floors in the kitchen had food debris on them throughout the kitchen; on the floors in the chemical/storage area and the floors had a greasy appearance to them. The tile was stained underneath the 3 -compartment sink by the stove.<BR/>2. The air vent partitions were a rust color and the vent covers had built up lent on them throughout the kitchen and dishwashing room. Some of the vent covers were modified by using duct tape and zip ties.<BR/>3. There were dirty cooking trays piled up on the 3- compartment sink and inside the sink of the dishwasher. There were black stains on the walls in the dishwashing room.<BR/>4. In the chemical/storage room there were multiple brown (filthy) mop heads inside a food bin; there were empty boxes, empty grease containers, a pot full of used grease on the floor; the 3 metal shelving units had built up lent; the floor mat was overturned onto the bottom shelf of one of the shelving units and looked dirty.<BR/>5. [NAME] A and DA B had hair coming out of the hairnet and baseball cap on the side of their head. DA B was not wearing a beard guard.<BR/>6. The convection oven and the two ovens on the stove had built up burned food debris on the walls.<BR/>These deficient practices could affect resident who ate their meals prepared in the kitchen and could contribute to cross contamination and the spread of foodborne illnesses.<BR/>Review of an audit conducted by the Dietician, dated 12/28/22, revealed there were many areas of the kitchen that points were deducted because the kitchen was not in compliance including; the floors were dirty, there were boxes and items on the floor in the storage areas, air vents had dust, shelving units had dust and staff did not always wear hairnets while in the kitchen. <BR/>Interview on 1/18/23 at 11:13 AM with the Dietician revealed she conducted an audit of the kitchen on 12/28/22 to include the cleanliness of the kitchen. She stated she inquired about the kitchen sanitation including the condition of the floor under the 3- compartment sink. She stated she noted the tile under the sink was stained and there were areas in the kitchen that had not been swept. The Dietician stated there were other areas of concern and stated she provided the DM with a written report. <BR/>Observation on 1/18/23 at 11:30 AM revealed the DM, 1 [NAME] 3 Dietary Aides were on duty. The following was noted during the kitchen observation: the floors throughout the kitchen, the chemical/supply room and in the dishwashing room were full of debris. There was a built- up greasy appearance on the floors and there were stains on the tile in multiple areas including under the 3- compartment sink closest to the stove. There were dirty cooking trays and pots in the 3 compartment sink. There was food debris behind the stove, the convection oven, deep fryer and the prep tables along the far wall and under the prep tables positioned in front of the stove. There were multiple used/brown/filthy mop heads in a food storage bin in the chemical/supply room. There was a rubber floor mat overturned onto the bottom shelf on one of the shelving units. There were 3 shelving units that had built up lent on them. In the dishwashing room, there were black stains along the wall. There were multiple dirty cooking sheets and dishes in the sink for the dishwasher. The air vent metal partitions on the ceiling holding the ceiling panels in place throughout the kitchen were a rust color and the vent covers had built up lent on them,. There were two air vents over the prep table in front of the stove. The vent covers had built up lent on them. Further observation revealed black residue on the walls of the convection oven and on the walls in the two ovens of the stove. It appeared like burnt up burned food residue. <BR/>Observation on 1/18/23 at 11:45 AM revealed the [NAME] and two Dietary Aides wore hairnets. The two Dietary Aides had hair coming out of the hairnet along the sides and the back of their head. <BR/>Interview on 1/18/23 at 11:50 AM with the DM revealed he had worked at the facility for about 60 days. He toured the kitchen with the Surveyor and stated staff was supposed to clean in between breakfast and lunch meals. He stated based on the amount of dirty dishes at the 3-compartment sink and in the sink for the dishwasher, it looked like staff did not clean after the breakfast meal. He stated kitchen staff was also supposed to sweep and spot mop as needed and at the end of the day. The DM further stated one of the DA's and pointed to DA B had swept and mopped the floors this morning. Interview with the DA B at this same time, revealed he had just arrived to the facility and had not done any cleaning. Then the DM stated that it did not look like the floors had been swept or mopped based on the amount of food debris behind the appliances and the greasy appearance on the floor. The DM stated he had a deep cleaning schedule but could not find it at the time. He stated night staff was supposed to deep clean the ovens and ensure the floors were clean but further stated the night cook called in yesterday evening. The DM stated staff was to deep clean all appliances at least once weekly but after looking inside the convection oven and in the two ovens on the stove, he stated the ovens did not look like they had been cleaned in a long while. The DM stated there was black burnt food debris in the all the ovens. The DM pointed out two vent covers that he had to modify by using duct tape and zip ties to hold the covers in place. He stated the MS was responsible for cleaning the vents covers. He stated that he saw maintenance staff clean them maybe 1 month ago. The DM stated the lent on the vent covers that were over the steam table could blow into the food and contaminate the food possibly making residents sick. <BR/>Interview on 1/18/23 at 12:15 PM with the MS revealed he was responsible for replacing the filters inside the vents in the kitchen and repair broken kitchen equipment. He stated he was not responsible for cleaning the vent covers. He stated the kitchen staff was solely responsible for cleaning the kitchen since he had been in his position for 3 years. <BR/>Interview on 1/19/23 at 10:45 AM with DA B revealed he worked from 12 PM to 7:30 or 8 PM. He stated he would sweep and mop the floor in the main kitchen area, wipe down all stations, break down and clean the dishwasher, and would take out the trash before leaving for the day. DA B stated they did not have a morning DA and the DM had been filling this position. He stated he was allowed to use a baseball cap instead of a hairnet. He wore a mask but not a beard guard. DA B stated he understood the purpose of the hairnet and beard guard was to ensure facial hair from falling into the food while prepping the meal trays. DA B stated he had hair that was longer than the bottom of his baseball cap and he confirmed he was not wearing a beard guard. He stated if hair fell into the food it could make residents sick. DA B reviewed the deep cleaning schedule for the week of 1/16/23. He stated the DM had him initial the log yesterday and he mistakenly initialed on Tuesday, 1/17/23, but stated he did not work on 1/17/23. He stated he meant to initial on 1/18/23. <BR/>Interview on 1/19/23 at 10:59 AM with [NAME] A revealed she had worked at the facility for about 1 year. She stated as a [NAME] she was responsible for sweeping, mopping, wiping down the steam table, 3 compartment sink and organizing different areas in the kitchen. [NAME] A stated the DA was supposed to wash dishes between the breakfast and lunch meals but they did not have a morning DA and the DM was filling the position. [NAME] A stated the dishes were not washed after the breakfast meal on 1/18/23. [NAME] A stated not all kitchen staff followed the cleaning schedule and the DM did not enforce it. She stated no one listened and there were no consequences which was why the kitchen was dirty on 1/18/23 [NAME] A stated the vent covers in the kitchen were clean once since she had been working and it was done while the previous DM was working. [NAME] A also stated she understood the hairnet was designed to keep hair from falling in the food. She stated her hair was coming out on the sides of her head and on the back of her head. She stated she would take it on and off when she used the bathroom and sometimes was in a hurry. [NAME] A stated if hair fell in the food it could contaminate the food and make the residents sick. [NAME] A also stated the DM had her initial the cleaning schedule yesterday, 1/18/23, but stated she had not completed tasks per the cleaning schedule. <BR/>Interview on 1/19/23 at 12:15 PM with the ADM revealed he had observed the kitchen on 1/18/23 and believed the debris on the floor was a result of kitchen staff actively working in the kitchen. He state he talked with the DM about the audit completed by the Dietician on 12/28/22 and the DM was supposed to be working on cleaning and making necessary changes to the areas that were marked as not done including cleaning the floors. He stated he provided the DM with guidance according to his job description as part of his training. The ADM stated the DM was fairly new to the facility but had many years of experience as a DM in long term care. <BR/>Review of a facility policy, Cleaning and Disinfection of Kitchen Equipment, undated, read in part: Purpose: To provide information on how to clean and disinfect kitchen equipment. This may include food prep areas, tables, sinks, ovens, floors and other kitchen equipment. Procedure: Equipment used for food preparation must be wiped with a facility-approved cleaning supplies after each use and when visibly soiled.<BR/>Review of the job description for Dietary Supervisor, dated 12/27/21, read in part: Position Summary: To direct the overall operation of the Dietary Department in accordance with current applicable federal, state, and local standards, guidelines and regulations governing the facility and as may be directed by the Administrator and Dietician. To assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner. As the Dietary Supervisor, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. <BR/> <BR/> <BR/> <BR/> <BR/> <BR/>

**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 and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 1 of 6 residents (Resident #6) reviewed for resident rights, in that: <BR/> ADON B was engaged in a personal telephone conversation on a cell phone while feeding Resident #6, instead of socializing with the resident during care. <BR/>This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity and self-worth.<BR/>The findings included:<BR/>Record review of Resident #6's face sheet dated 3/22/2023 revealed an admission date of 11/16/2021 with readmission date of 2/23/2023 with diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness and paralysis that occurs after a stroke, aphasia following cerebral infarction (loss of ability to understand or express speech after brain damage caused by a stroke), and type 2 diabetes mellitus. <BR/>Record review of Resident #6's significant change in status MDS dated [DATE] revealed Resident #6 had a BIMs score of 8 (scale of 0-15) which indicated a moderate cognitive impairment. <BR/>Record review of Resident #6's significant change in status MDS dated [DATE] revealed Resident #6 required extensive assistance with eating which included one person physical assistance to eat. <BR/>Record review of Resident #6's Care Plan dated 11/16/2021, last revised on 11/29/2022 revealed the resident had an ADL self-care performance deficit with interventions which included: Eating: requires extensive assistance with one person staff participation with feeding. <BR/>Record review of Resident #6's Care Plan dated 1/13/2022 revealed the resident had disruptive verbal behaviors which included: yells out for assistance or attention/company with interventions which included: Staff with respond to resident and socialize during care as able. <BR/>During an observation on 3/21/2023 at 12:35 p.m., ADON B was heard engaging in personal conversation while in Resident #6's room. Upon further observation, ADON was observed feeding Resident #6 his lunch meal. Resident #6 was sitting up in bed, he was awake, alert and able to interact and respond to conversation with simple responses. ADON B's cell phone was observed on Resident #6's bedside table, directly beside the meal tray. ADON's cell phone was lit up on an active call with Wifey was observed with the phone on speaker. <BR/>During an interview on 3/21/2023 at 12:38 p.m. Resident #1 was able to engage in conversation about his food preferences but was not able to answer detailed interview questions due to his cognitive status. <BR/>During an interview on 3/21/2023 at 1:24 p.m., ADON B stated she was on a personal call with her mother in Resident #6's room while she was feeding Resident #6. She stated she knew she should not have answered the call, but it was her mother whom she described as very demanding. ADON B stated she did not know the facility policy for personal cell phone use while in a resident room or while providing feeding assistance. ADON B stated she did not want to be on a personal call while feeding a resident, but it was her mom and her mom just kept talking. <BR/>During a follow-up interview on 3/21/2023 at approximately 3:30 p.m. Resident #6 was unable to recall lunch and was unable to state his preferences for care due to his cognitive status. <BR/>During an interview on 3/22/2023 at 3:13 p.m., the DON stated her expectation was that staff do not use personal cell phones while providing nursing care or interacting with residents. The DON stated staff should step out of the room or away from the resident if the phone call was an emergency. The DON stated it was important for staff to provide the residents with their full attention, especially during feeding to ensure the resident's safety. <BR/>Record review of a facility policy, titled Personal Cell Phone/Electronic Communication Device use by Employees (undated) revealed: To ensure the safety and security of the therapeutic treatment environment and to ensure patient and employee privacy and confidentiality. Use of personal cell phones/electronic communication devices by facility employees is to be used only in rare situations while employees are working. Employees may use cell phones/electronic communication devices during their shift but recommended only during lunch or break periods (unless specifically authorized by a supervisor for work-related purpose or other rate situation related to their personal family needs). Personal cell phones/electronic communication devices are recommended to be turned off and stored during working hours . <BR/>Record review of a facility policy, titled Resident Rights (undated) revealed: The Resident has the right: 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review revealed the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 Residents (Resident #2) whose records were reviewed for accuracy of assessments, in that: <BR/>Resident #2's MDS reflected that he required extensive assistance by 1 person for transfers but he actually required extensive assistance by 2 persons.<BR/>This deficient practice could affect any resident and could contribute to residents not receiving care and services as needed.<BR/>The findings were:<BR/>Review of Resident #2's face sheet, dated 1/23/23, revealed he was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy and repeated falls. <BR/>Review of Resident #2's admission quarterly MDS, dated [DATE], revealed his BIMS was 8 (out of 15) indicative of severe cognitive impairment; he required extensive assistance by 1 person for bed mobility and transfers; he was unsteady moving from sitting to standing position, on and off the toilet and surface to surface transfer and only able to stabilize with staff assistance.<BR/>Review of Resident #2's Care Plan, revised 11/8/22, revealed he required extensive assistance by 2 persons for bed mobility and transfers. Resident #2 was identified as being a fall risk and interventions included: anticipate and meet needs, avoid rearranging furniture, be sure the call light is within reach and encourage to use it to call for assistance as needed, educate resident and caregivers about safety reminders and what to do if a fall occurs, maintain a clear pathway, free of obstacles. Further review revealed Resident #2 had a fall on 1/13/23 and the interventions included: Call don't fall signs next to bed, check range of motion<BR/>, monitor/document /report to MD for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, neuro-checks as ordered and vital signs as ordered.<BR/>Interview on 1/20/23 at 3:20 PM with LVN E revealed Resident #2 was confused and required extensive assistance with transfers by 2 persons because he was not able to bare weight and was not able to pivot. <BR/>Interview on 1/20/23 at 3:31 PM with CNA K revealed Resident #3 had been a 1 person assist for transfers but noted when she transferred him he was dead weight. CNA K stated it seemed to her like he had a decline in condition but did not tell LVN E about the change. <BR/>Interview on 1/23/23 at 12:50 PM with the MDS Coordinator revealed Resident #2 required extensive assistance by 2 persons for transfers. He stated anytime a resident required extensive assistance they would assign the task to two staff. The MDS Coordinator reviewed Resident #2's quarterly MDS, dated [DATE] and his Care Plan revised on 11/8/22 and stated the MDS should reflect extensive assistance by 2 persons for transfers. He further stated that the POC used by the aides self-populated with the information inputted into MDS. Therefore, Resident #2's POC would provide the aides with wrong information and could contribute to the aides not providing the care Resident #2 needed and potentially contribute to avoidable falls. The MDS Coordinator stated he used the RAI as a policy for completed the MDS assessments.

Based on observation and interview the facility failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records and failed to safeguard medical record information against loss, destruction, or unauthorized use for 1 of 1 facility.<BR/>Residents' medical records were stored in an unlocked room on the 3rd floor that was being remodeled. Medical record sheets were out of their files and scattered on the floor in multiple places in the room.<BR/>This failure could place resident identifiable information at risk of unauthorized use.<BR/>The findings were:<BR/>Observation on 5/9/23 at 9:20 a.m. revealed surveyors had been placed in a conference room on the 3rd floor. There were no residents on the floor as it was being remodeled and under construction.<BR/>Observation on 5/9/23 at 3:30 p.m. revealed construction workers were working on the 3rd floor and walking in the hallway. An unknown staff member was standing in the hallway waiting on the elevator.<BR/>Observation on 5/10/23 at 4:34 p.m. revealed on the 3rd floor directly across from the conference room hallway a door was open and revealed what appeared to be residents' records on the floor and in file boxes stacked in the room. There were boxes labeled medical records and boxes labeled 2015 and 2020 GA-GR and other boxes labeled with residents' names and dates and others not labeled. Observation further revealed signed Physician's Telephone order forms on the floor and other residents' medical records scattered on the floor. Some boxes were observed to be tilted and stacked up to 6 ft tall in different parts of the room and falling over. There were residents' medical records on the floor and scattered in the corner of the room between boxes. There was a bathroom and the light was on and the new floors in the room had been covered with paper protection and taped together at the seams. Multiple areas of the room had residents' medical records with diagnoses, medications, lab and x-ray results on the floor and footprints on them in one area as if they had been stepped on. Observed several boxes also labeled business office and what looked like thin folders with staff names as well. Many of the boxes were missing lids and had files sticking up out of them as if they had been gone through and not placed back in the box. The door did not have a lock.<BR/>Observation on 5/10/23 at 4:34 p.m. revealed there were several construction workers walking in the hallway on the 3rd floor. <BR/>In an interview on 5/10/23 at 4:45 p.m. the Administrator was notified of the opened and unlocked room with the medical records and stated he would take care of it.<BR/>Observation on 5/11/23 at 8:40 a.m. revealed a worker was changing the doorknob on the room with the medical records and replacing it with a doorknob that had a key lock.<BR/>In an interview on 05/11/23 at 1 p.m. Staff D stated the medical records in the room across from the conference room hallway were her shred records, and then stated the records in the room were from the previous facility owners and Staff D confirmed what the surveyor saw regarding 2015 and 2020 dates on boxes and stated again they were from previous facility owners and not current resident records. Staff D reported current residents' records were locked in her office and she and the Administrator were the only ones with keys to it. Staff D stated the medical records in the room on the 3rd floor should be locked and secured especially with the construction on the 3rd floor. Staff D stated the facility had contacted the previous facility owners to let them know the medical records were at the facility but had not heard anything back from them. Staff D stated the facility would not be shredding anything and would follow the medical records retention policy. <BR/>Observation on 5/11/23 at 3:00 p.m. revealed in the conference room with the surveyors had been a metal shopping cart style cart with accordion files, binders, and boxes. On the top of the cart was a resident's large medical record. Upon examining the accordion folder type file, there was no cover and noted it was a resident's medical record and the resident's name is on the accordion file. There was also a large file box that had a resident's name; handwriting and different forms could be seen sticking out. There were no residents by those names on current resident roster dated 5/9/23 for this survey. <BR/>Interview on 5/11/23 at 3:45 p.m. the DON and Staff D were informed of the cart in the conference room with resident's medical records in it. Staff D stated it might be from the audit and stated she would secure the records immediately.<BR/>Observation on 5/11/23 at 5:30 p.m. revealed the metal cart in the conference room with resident's medical records on it was gone from the conference room. <BR/>In an interview on 5/12/23 at 2:00 p.m. the Administrator stated the medical records that were in the room on the 3rd floor should have been secured. The Administrator further stated the facility's plan was to continue going through the medical records per retention policy and then calling the previous company again to ask them to collect their residents' and staff records. The Administrator stated the facility had a safe storage company they used and the previous company did not but if the records were sent to their safe storage company, they would be kept separate in case the company comes to get them.<BR/>Review of the facility HIPAA compliance policy and procedure dated January 2017 indicated, Policy Statement Protected Health Information (PHI) will be safeguarded against unauthorized use, access, or disclosure in accordance with federal and state laws to prevent access by unauthorized persons.Secure shall be defined as inaccessible to unauthorized individuals, protected shall be defined as safe from environmental damage.2. Store all documents containing PHI in a secure, locked location with limited access to authorized workforce members. 9. Keep records and other documents out of public view and reach. 16. Secure and protect all records and documents from damage, loss, or destruction when an alternative storage space is needed.

Observation, interview and record review revealed the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen.<BR/>1. The floors in the kitchen had food debris on them throughout the kitchen; on the floors in the chemical/storage area and the floors had a greasy appearance to them. The tile was stained underneath the 3 -compartment sink by the stove.<BR/>2. The air vent partitions were a rust color and the vent covers had built up lent on them throughout the kitchen and dishwashing room. Some of the vent covers were modified by using duct tape and zip ties.<BR/>3. There were dirty cooking trays piled up on the 3- compartment sink and inside the sink of the dishwasher. There were black stains on the walls in the dishwashing room.<BR/>4. In the chemical/storage room there were multiple brown (filthy) mop heads inside a food bin; there were empty boxes, empty grease containers, a pot full of used grease on the floor; the 3 metal shelving units had built up lent; the floor mat was overturned onto the bottom shelf of one of the shelving units and looked dirty.<BR/>5. [NAME] A and DA B had hair coming out of the hairnet and baseball cap on the side of their head. DA B was not wearing a beard guard.<BR/>6. The convection oven and the two ovens on the stove had built up burned food debris on the walls.<BR/>These deficient practices could affect resident who ate their meals prepared in the kitchen and could contribute to cross contamination and the spread of foodborne illnesses.<BR/>Review of an audit conducted by the Dietician, dated 12/28/22, revealed there were many areas of the kitchen that points were deducted because the kitchen was not in compliance including; the floors were dirty, there were boxes and items on the floor in the storage areas, air vents had dust, shelving units had dust and staff did not always wear hairnets while in the kitchen. <BR/>Interview on 1/18/23 at 11:13 AM with the Dietician revealed she conducted an audit of the kitchen on 12/28/22 to include the cleanliness of the kitchen. She stated she inquired about the kitchen sanitation including the condition of the floor under the 3- compartment sink. She stated she noted the tile under the sink was stained and there were areas in the kitchen that had not been swept. The Dietician stated there were other areas of concern and stated she provided the DM with a written report. <BR/>Observation on 1/18/23 at 11:30 AM revealed the DM, 1 [NAME] 3 Dietary Aides were on duty. The following was noted during the kitchen observation: the floors throughout the kitchen, the chemical/supply room and in the dishwashing room were full of debris. There was a built- up greasy appearance on the floors and there were stains on the tile in multiple areas including under the 3- compartment sink closest to the stove. There were dirty cooking trays and pots in the 3 compartment sink. There was food debris behind the stove, the convection oven, deep fryer and the prep tables along the far wall and under the prep tables positioned in front of the stove. There were multiple used/brown/filthy mop heads in a food storage bin in the chemical/supply room. There was a rubber floor mat overturned onto the bottom shelf on one of the shelving units. There were 3 shelving units that had built up lent on them. In the dishwashing room, there were black stains along the wall. There were multiple dirty cooking sheets and dishes in the sink for the dishwasher. The air vent metal partitions on the ceiling holding the ceiling panels in place throughout the kitchen were a rust color and the vent covers had built up lent on them,. There were two air vents over the prep table in front of the stove. The vent covers had built up lent on them. Further observation revealed black residue on the walls of the convection oven and on the walls in the two ovens of the stove. It appeared like burnt up burned food residue. <BR/>Observation on 1/18/23 at 11:45 AM revealed the [NAME] and two Dietary Aides wore hairnets. The two Dietary Aides had hair coming out of the hairnet along the sides and the back of their head. <BR/>Interview on 1/18/23 at 11:50 AM with the DM revealed he had worked at the facility for about 60 days. He toured the kitchen with the Surveyor and stated staff was supposed to clean in between breakfast and lunch meals. He stated based on the amount of dirty dishes at the 3-compartment sink and in the sink for the dishwasher, it looked like staff did not clean after the breakfast meal. He stated kitchen staff was also supposed to sweep and spot mop as needed and at the end of the day. The DM further stated one of the DA's and pointed to DA B had swept and mopped the floors this morning. Interview with the DA B at this same time, revealed he had just arrived to the facility and had not done any cleaning. Then the DM stated that it did not look like the floors had been swept or mopped based on the amount of food debris behind the appliances and the greasy appearance on the floor. The DM stated he had a deep cleaning schedule but could not find it at the time. He stated night staff was supposed to deep clean the ovens and ensure the floors were clean but further stated the night cook called in yesterday evening. The DM stated staff was to deep clean all appliances at least once weekly but after looking inside the convection oven and in the two ovens on the stove, he stated the ovens did not look like they had been cleaned in a long while. The DM stated there was black burnt food debris in the all the ovens. The DM pointed out two vent covers that he had to modify by using duct tape and zip ties to hold the covers in place. He stated the MS was responsible for cleaning the vents covers. He stated that he saw maintenance staff clean them maybe 1 month ago. The DM stated the lent on the vent covers that were over the steam table could blow into the food and contaminate the food possibly making residents sick. <BR/>Interview on 1/18/23 at 12:15 PM with the MS revealed he was responsible for replacing the filters inside the vents in the kitchen and repair broken kitchen equipment. He stated he was not responsible for cleaning the vent covers. He stated the kitchen staff was solely responsible for cleaning the kitchen since he had been in his position for 3 years. <BR/>Interview on 1/19/23 at 10:45 AM with DA B revealed he worked from 12 PM to 7:30 or 8 PM. He stated he would sweep and mop the floor in the main kitchen area, wipe down all stations, break down and clean the dishwasher, and would take out the trash before leaving for the day. DA B stated they did not have a morning DA and the DM had been filling this position. He stated he was allowed to use a baseball cap instead of a hairnet. He wore a mask but not a beard guard. DA B stated he understood the purpose of the hairnet and beard guard was to ensure facial hair from falling into the food while prepping the meal trays. DA B stated he had hair that was longer than the bottom of his baseball cap and he confirmed he was not wearing a beard guard. He stated if hair fell into the food it could make residents sick. DA B reviewed the deep cleaning schedule for the week of 1/16/23. He stated the DM had him initial the log yesterday and he mistakenly initialed on Tuesday, 1/17/23, but stated he did not work on 1/17/23. He stated he meant to initial on 1/18/23. <BR/>Interview on 1/19/23 at 10:59 AM with [NAME] A revealed she had worked at the facility for about 1 year. She stated as a [NAME] she was responsible for sweeping, mopping, wiping down the steam table, 3 compartment sink and organizing different areas in the kitchen. [NAME] A stated the DA was supposed to wash dishes between the breakfast and lunch meals but they did not have a morning DA and the DM was filling the position. [NAME] A stated the dishes were not washed after the breakfast meal on 1/18/23. [NAME] A stated not all kitchen staff followed the cleaning schedule and the DM did not enforce it. She stated no one listened and there were no consequences which was why the kitchen was dirty on 1/18/23 [NAME] A stated the vent covers in the kitchen were clean once since she had been working and it was done while the previous DM was working. [NAME] A also stated she understood the hairnet was designed to keep hair from falling in the food. She stated her hair was coming out on the sides of her head and on the back of her head. She stated she would take it on and off when she used the bathroom and sometimes was in a hurry. [NAME] A stated if hair fell in the food it could contaminate the food and make the residents sick. [NAME] A also stated the DM had her initial the cleaning schedule yesterday, 1/18/23, but stated she had not completed tasks per the cleaning schedule. <BR/>Interview on 1/19/23 at 12:15 PM with the ADM revealed he had observed the kitchen on 1/18/23 and believed the debris on the floor was a result of kitchen staff actively working in the kitchen. He state he talked with the DM about the audit completed by the Dietician on 12/28/22 and the DM was supposed to be working on cleaning and making necessary changes to the areas that were marked as not done including cleaning the floors. He stated he provided the DM with guidance according to his job description as part of his training. The ADM stated the DM was fairly new to the facility but had many years of experience as a DM in long term care. <BR/>Review of a facility policy, Cleaning and Disinfection of Kitchen Equipment, undated, read in part: Purpose: To provide information on how to clean and disinfect kitchen equipment. This may include food prep areas, tables, sinks, ovens, floors and other kitchen equipment. Procedure: Equipment used for food preparation must be wiped with a facility-approved cleaning supplies after each use and when visibly soiled.<BR/>Review of the job description for Dietary Supervisor, dated 12/27/21, read in part: Position Summary: To direct the overall operation of the Dietary Department in accordance with current applicable federal, state, and local standards, guidelines and regulations governing the facility and as may be directed by the Administrator and Dietician. To assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner. As the Dietary Supervisor, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. <BR/> <BR/> <BR/> <BR/> <BR/> <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 1 Resident (Resident #3) who was observed for services.<BR/>Nursing staff failed to ensure that Resident #3's call light was within reach preventing him from calling for assistance.<BR/>This deficient practice could affect any resident and could contribute to resident not receiving the needed services. <BR/>The findings were:<BR/>Review of Resident #3's face sheet, dated 1/19/23, revealed he was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis (paralysis) following Cerebral Infarction (Stroke) affecting left non-dominant side and Cognitive Communication Deficit. <BR/>Review of Resident #3's quarterly MDS, dated [DATE] revealed his BIMS was 12 (out of 15) indicating some cognitive impairment; he required limited assistance with eating and had limited range of motion to his upper and lower extremities on one side.<BR/>Review of Resident #3's Care Plan, dated 10/4/22, revealed he had an ADL Self Care Performance Deficit related to muscle weakness, cognitive impairment and hemiparesis. One of the staff interventions included: required supervision/set up to limited assistance by one staff participation to eat.<BR/>Observation on 1/20/23 at 2:45 PM revealed Resident #3 was lying in bed. He easily engaged in conversation but his speech was not clear. Resident #3 stated sometimes it would take nursing staff up to an hour to answer the call light. He stated he wanted ice and water but stated he could not reach the call light. Resident #3 stated sometimes nursing staff would not place the call light close to him. Further observation revealed Resident #3's specialized wheelchair was parked beside the bed. The call light was dangling along the wall behind the wheelchair closer to bed A and not within Resident #3's reach. <BR/>Interview on 1/20/23 at 3 PM with LVN C revealed he was walking down the hall and motioned him into the room. LVN C stated he was not sure why the call light was by bed A and not clipped to Resident #3's sheet (in bed B). He stated the aides usually clipped the call light to the sheet so Resident #3 could reach it. He stated Resident #3 was able to use the call light and would use it to get staff assistance. Resident #3 asked LVN C if he would fill up his jug with ice and water. LVN C stated having a call light ensured Resident #3 would have his needs met.<BR/>Review of facility policy, Care and Treatment, undated, read in part: It is the policy of this facility to ensure the safety and comfort of the resident and to assist in continuity of care and to identify potential change in condition. Staffing is assigned due to the acuity of care. 3. Note positioning, proper placement of Foley, IV's, feeding tube, restraint application & call lights are within resident's reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide comfortable and safe temperature levels between a range of 71 to 81 degrees Fahrenheit for one of ten residents (Resident #2) reviewed for environment.<BR/>The facility failed to ensure Resident #2's room remained at a comfortable temperature.<BR/>This failure could place residents at risk of experiencing decreased comfort and could affect the well-being of residents. <BR/>Findings include:<BR/>Record review of Resident #2's MDS, dated [DATE], reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included hypertension (high blood pressure), anxiety disorder, and chronic obstructive pulmonary disease. <BR/>Observation and interview on 06/25/24 at 10:40 AM with Resident #2 revealed he was in his room sitting in his bed. The resident said his room had been hot for a while and he had let the Maintenance Assistant know but the AC in his room had not been fixed. Observation of the thermostat on the wall of his room showed the temperature in the room was 80 degrees Fahrenheit. Resident #2 said he had a fan in his room but said it was not helping him keep cool. <BR/>Observation on the following dates and times with an ambient thermometer in Resident #2's room revealed the following:<BR/>06/25/24 at 2:28 PM - 80 degrees<BR/>06/26/24 at 3:28 PM - 82 degrees <BR/>Interview on 06/27/24 at 5:02 PM with the Maintenance Assistant revealed Resident #2 told him multiple times that his AC was not working, and one of those dates was 06/14/24. The Maintenance Assistant stated every time he checked Resident #2's AC, it was running good. The Maintenance Assistant said when he checked with his thermometer, the temperature out of the vent was 66 degrees. He stated he did not know why Resident #2's room was reading 80 degrees. The Maintenance Assistant further stated he told the Maintenance Director of Resident #2's AC but did not state when. <BR/>Interview on 06/27/24 at 5:02 PM with the Maintenance Director revealed he was made aware today, 06/27/24, that Resident #2's AC was not working. The Maintenance Director said they had just called in an AC repairman who was still at the facility and he would have Resident #2's AC checked out. <BR/>Interview on 06/27/24 at 3:42 PM with the Operations Manager revealed she was not made aware Resident #2's AC was not working. She said risks of a hot room could cause the resident to feel uncomfortable in his room.<BR/>Record review of the facility's, undated, policy titled Environmental Service reflected the following: <BR/>It is the policy of this facility to maintain a clean and comfortable environment . 2. Temperatures in the common areas must remain between 70F-78F.

Based on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 5 of 5 residents (confidential residents) reviewed for resident rights. The facility failed to ensure staff distributed mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. These findings included: During a confidential resident council meeting, 5 of 5 residents present stated that they do not get mail on Saturdays, if mail comes on Saturday, it is not given out until Monday. During an interview via phone call on 8/7/2025 at 10:00 am Receptionist D-stated she worked weekends and the mail on the weekends usually comes in bulk and has a rubber band on it. She stated she does not go through the mail, and she puts it in the drawer for them to distribute on Monday. During a staff interview on 8/7 2025 at 11:12 am Receptionist C -stated that she worked Monday through Friday and every third weekend. She stated that on weekends, the mail is put in the drawer for distribution on Monday by the social worker. During a staff interview on 8/7 2025 at 11:17 am HR-stated mail is supposed to be distributed on Saturdays. She said she was not sure why it was not being done. She stated it is the residents right to receive their mail on Saturdays. During a staff interview on 8/7 2025 at 11:40 am SS -stated that residents should get their mail on Saturday. She stated they should be holding the facility mail and giving resident mail to activities for distribution. Record review of Resident Mail Policy revealed, When mail is delivered to the facility for residents, it is given to Activities Dept. Activities Dept. will hand deliver to resident rooms day of delivery.

Based on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 3 of 4 waste receptacles in that: <BR/>There were two waste receptacles filled with waste that did not have tight fitting lids and one waste receptacle was overfilled and could not be closed outside the facility.<BR/>These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents.<BR/>The findings included:<BR/>Observation on 05/10/2023 at 08:50 a.m. revealed there were four waste receptacles next to the dumpster outside the facility. One receptacle was closed with a lid; one receptacle could not be closed because the amount of waste in plastic bags inside the receptacle surpassed the top of the receptacle; one receptacle was overflowing with waste in plastic bags beyond the top and did not have a lid; and one receptacle was filled approximately 1/4th with loose waste and debris not sealed in a plastic bag. There were gnats too numerous to count flying around the dumpster and waste receptacles.<BR/>Interview on 05/10/2023 at 9:12 a.m. with the Maintenance Director revealed the dumpster was usually emptied daily; however, the company that empties it did not come the day prior due to the weather. The Maintenance Director further stated his Maintenance Resource Advisor observed the previous day that the Dumpster was full and there was trash around the dumpster that needed to be disposed of properly.<BR/>Interview on 05/10/2023 at 9:23 a.m. with the Administrator revealed he was aware there were waste receptacles without tight-fitting lids next to the dumpster that contained waste and that could potentially cause the proliferation of rodents and pests.<BR/>Interview on 05/10/2023 at 9:27 a.m. with the DM revealed she was not aware there were waste receptacles without lids that were full of waste that morning, and this could contribute to the spread of disease from rodents and pests.<BR/>Review of facility policy 4-25 Waste Disposal, 2013, revealed, 1. Prior to disposal, all waste shall be kept in leak-proof, non-absorbent, fireproof containers that are kept covered. 2. These containers are emptied as often as necessary throughout the day. Trash bags shall be sealed prior to removing them from the facility. Trash will be deposited into a sealed container outside the premises.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 5-501.13 (A) Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables and for use with materials containing FOOD residue shall be durable, cleanable, insect-and rodent-resistant, leakproof, and nonabsorbent. 5-501.112 Outside Storage Prohibitions. (A) REFUSE receptacles not meeting the requirements specified under 5-501.13(A) such as receptacles that are not rodent-resistant, unprotected plastic bags and paper bags, or baled units that contain materials with FOOD residue may not be stored outside. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility to ensure a new resident was not admitted with a mental disorder, unless the state mental health authority determined, based on an independent physical and mental evaluation performed by a person or entity other then the State mental health authority prior to admission for one of six residents (Resident #63) reviewed for Preadmission Screening and Resident Review (PASRR) screening . <BR/>The Social Worker failed to ensure Resident #63's PL1 was accurate with the proper metal illness diagnosis when he was admitted .<BR/>This failure could place residents at risk of not receiving specialized services. <BR/>Findings included:<BR/>Record review of Resident #63's MDS, dated [DATE], reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included schizoaffective disorder, schizophrenia and depression. <BR/>Record review of Resident #63's care plan, revised on 11/27/24, reflected the resident was at risk for impaired cognitive function/dementia or impaired thought processes related to schizoaffective disorder. Interventions included social services to provide psychosocial support as needed. <BR/>Record review of Resident #63's PASRR Level 1 Screening, dated 10/19/23, reflected NO had been marked for the question if there was evidence or an indicator the individual had a mental illness. <BR/>Interview on 06/26/24 at 3:15 PM with the Social Worker revealed she was responsible for looking at the PASSR Level 1 Screenings before residents were admitted . She stated she did not read through Resident #63's clinical records prior to being admitted so she did not see the resident had a diagnosis of schizophrenia. The Social Worker further said Resident #63 should have been referred to case management for a PASRR Evaluation because the resident could have been overseen for services from the Local Authority . <BR/>Record review of the facility's policy titled PASRR, revised January 2022, reflected the following:<BR/> .Policy: The facility will designate an individual to follow up on ALL residents that received a PASRR Level 1 screening. If Facility serves a resident with a positive PASRR Level 1 screening, the facility MUST obtain A PASRR Level II evaluation from the Local Authority or have documented attempts to follow up with the Local Authority to obtain PASRR Level II evaluation.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #92) reviewed for privacy, in that: CNA E and CNA F did not close completely Resident #92's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.The findings include: Record review of Resident #92's face sheet, dated 08/07/2025, revealed an admission date of 01/09/2025, with diagnoses which included: Wernicke's encephalopathy (brain and memory disorder due to a lack of vitamin B1), Dysphagia (difficulty swallowing), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), and Asthma (Long-term inflammatory disease of the airways restricting airflow). Record review of Resident #92's Quarterly MDS assessment, dated 07/08/2025, revealed the resident had a BIMS score of 08, indicating she was moderately cognitively impaired. Resident #92 was always incontinent of bladder and bowel and, required total assistance with her ADLs. Record review of Resident #92's care plan, dated 01/17/2025, revealed a problem of has ADL Self Care Performance Deficit related to Wernicke's encephalopathy, Muscle weakness, with an intervention of Toileting Hygiene: Dependent. Observation on 08/07/2025 at 3:24 p.m. revealed CNA E and CNA F did not completely close the privacy curtains while they provided incontinent care for Resident #92, exposing the resident who could be seen if somebody entered the room. The privacy curtain was broken and was blocked on the rail, it could only be halfway closed. During an interview with CNA E and CNA F on 08/07/2025 at 3:38 p.m., CNA F confirmed the privacy curtains was not completely closed while they provided care for Resident #92 but it should have been to protect the resident's privacy. They did not know how long the privacy curtain had been broken. They confirmed they received resident rights training within the year. During an interview with the DON on 08/07/2025 at 3:40 p.m., she said privacy must be provided during care and Resident #92's privacy curtains should have been closed completely. She said she provided training, the staff received training on resident rights within the year and they do staff skills checks annually and as needed. Review of a policy, titled Resident Rights, undated, revealed They also will have the right to privacy, maintain privacy curtains for dressing and when providing care.