HIGHLAND NURSING CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #6<BR/>FTag Initiation<BR/>01/10/25 03:31 PM Initiate F700 & F656 initiated d/t order for abdominal binder and fact that abdominal binder is not identified in the care plan and use of 1/2 side rail for positioning (not appropriate need for this resident). <BR/>Resident #33<BR/>FTag Initiation<BR/>01/10/25 10:39 AM Thorazine consent not signed, wrong resident and theo [NAME] res was not on thorazine<BR/>vns check was not on mar,

Resident #6<BR/>FTag Initiation<BR/>01/10/25 03:31 PM Initiate F700 & F656 initiated d/t order for abdominal binder and fact that abdominal binder is not identified in the care plan and use of 1/2 side rail for positioning (not appropriate need for this resident).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents [Resident #6] reviewed for care plans. <BR/>The facility failed to develop the appropriate care plan intervention of implementing an abdominal binder to prevent Resident #6 from pulling out her feeding-tube per physician's order. <BR/>This deficient practice could place resident at risk of trauma or injury. <BR/>The findings include:<BR/>Record review of Resident #6 face sheet dated 9/20/24 revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. Relevant diagnosis included Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance, bilateral below the knee amputee. <BR/>Record review of Resident #6 Quarterly MDS dated [DATE] revealed resident unable to complete BIMS assessment due to severe cognitive impairment. Resident #5 had functional limittion in rang of motion with impairment on both sides of upper extremity to include shoulder, elvow, wrist, hand. The MDS reealed resident was dependent. The BIMS assessment was unable to be completed due to Resident#6 severe cognitive impairment. Resident #6 was dependent and helper did all the effort in ADL needs. Resident did none of the effort to complete any of the ADL activities. <BR/>Record review of Resident #6 Care Plan (last updated 9/24/24) revealed absence of behavioral disturbance reflecting behavior of pulling out feeding tube or potential for injury related to pulling out feeding tube. <BR/>Record review of Resident #6 physician's orders reflected an order dated 1/20/16 apply abdominal binder to prevent pulling of G-tube all shifts.<BR/>During observation on 01/07/2025 at 10:55 AM Resident #6 was resting in bed, eyes closed with tube feeding connected and an abdominal binder was not in place. <BR/>During observation on 01/08/2025 at 11:05 AM Resident #6 was resting in bed, eyes closed with tube feeding connected and abdominal binder was not in place. <BR/>During an observation on 01/09//2025 at 2:20 PM Resident #6 was resting in bed, eyes were closed, and tube feeding was not running. An abdominal binder was not in place. <BR/>An interview on 01/09/25 AM with CNA A revealed Resident #6 has a tendency to pull out tube feeding which is why abdominal binder is placed on resident. CNA A stated she worked with resident on 01/08/25 and applied binder. CNA stated abdominal binders were located in the linen closets. <BR/>An interview on 01/09/25 at 10:25 AM with CNA B revealed staff used a binder to prevent Resident #6 from pulling out tube feeding. CNA B stated she has not worked with Resident #6 this week.<BR/>An interview on 01/10/25 at 8:00 AM with LVN E confirmed that resident had an order for an abdominal binder. LVN E stated CNA's apply binder daily and reapply after peri-care as needed. LVN confirmed Charge Nurse is responsible to ensure abdominal binder is in place. LVN stated the staff know about the binder and that she will put it on the nursing MAR so it will not be missed.<BR/>An interview on 01/10/25 at 8:22 AM with the DON confirmed that Resident #6 did have an order for an abdominal binder on at all shifts. DON confirmed that adverse effects to include trauma / injury to stoma site could occur if resident pulled feeding tube out.<BR/>A request for a policy on Care Plan development and implementation was made on 01/09/2025 at 9:00 AM and was not provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 27 medication administration opportunities with 15 errors resulting in a 55.56% medication error rate, for 4 of 4 residents (Residents #6, #7, #22, and #30) reviewed for medication administration.<BR/>1. LVN D administered Resident #6's medications by her gastronomy tube (often called a G tube, is a surgically placed device used to give direct access to a person's stomach for supplemental feeding, hydration, or medicine), contrary to professional standards by administering all the medications together rather than one by one, and late by 11 minutes.<BR/>2. LVN D administered Resident #30's medications by her gastronomy tube contrary to professional standards by administering all the medications together rather than one by one, and late by 50 minutes.<BR/>3. Medication Aide I did not administer Amlodipine 5mg to Resident #7 as prescribed by her physician. <BR/>4. Medication Aide I did not administer hydrochlorothiazide 25mg to Resident #22 as prescribed by his physician. <BR/>These deficient practices placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. <BR/>The findings included:<BR/>A record review of Resident #6's admission record dated 1/9/2025, revealed an admission date of 12/17/2020 with diagnoses which included hypertension (high blood pressure), diabetes (a person's difficulty using blood sugar in their cells) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). <BR/>A record review of Resident #6's quarterly MDS assessment dated [DATE] revealed Resident #6 was an [AGE] year-old female admitted for long term care and was unable to participate in a BIMS assessment which indicated severe cognitive impairment. Resident #6 was assessed with the need for a feeding tube (also known as a g-tube).<BR/>A record review of Resident #6's care plan dated 01/09/2025 revealed, potential for weight loss and dehydration r/t CVA, dementia, tube feeding . flush PEG tube (Feeding tubes, or PEG tubes, allow you to receive nutrition through your stomach) with water and post medication administration as ordered per physician for hydration. tube feeding . flush tube as ordered <BR/>A record review of Resident #6's physicians orders dated 1/9/2025 revealed the physician prescribed Resident #6 to receive medications which included metformin 500mg 1-tab PGT daily diagnoses diabetes mellitus type 2 at 8:00 AM and acetaminophen 500mg 1-tab PGT every 8 hours diagnosis generalized pain at 8:00 AM, 4:00 PM, and at midnight. Further review revealed the physician prescribed for Resident #6 to receive a water flush before and after each medication all shifts. <BR/>During an observation on 01/09/2025 at 9:11 AM revealed LVN D prepared and administered medications for Resident #6 per Resident #6's g-tube. LVN D crushed and mixed the prescribed acetaminophen, metformin, miralax, and her liquid multivitamin by flushing the medications with an unmeasured amount of water poured from a 9-ounce plastic cup. LVN D began by pouring water into the resident's G-tube, adding water to the medications, and pouring the medications together in to Resident #6's g-tube, and completed the administration by pouring the remainder of the water from the plastic cup without administering the medications individually and with a water flush in between all individual medications. <BR/>2. A record review of Resident #30's admission record dated 07/22/2024 revealed an admission date of 03/01/2022 with diagnoses which included gastronomy status (presence of a g-tube), dementia, and seizures (electrical storms of the brain). <BR/>A record review of Resident #30's quarterly MDS assessment dated [DATE] revealed Resident #30 was a [AGE] year-old female admitted for long term care and assessed with severely impaired cognition, could not communicate her needs. Resident #30 was assessed with the need for a feeding tube.<BR/>A record review of Resident #30's care plan dated 12/13/2024 revealed Resident #30 was quadriplegic (a symptom of paralysis that affects all a person's limbs and body from the neck down), NPO (Latin for nothing by mouth) and required enteral feeding (enteral administration is food or drug administration via the human gastrointestinal tract), Tube feeding . Resident has gastronomy tube . assess feeding tube placement, patency, and residual every shift and before and after administration of any fluids or medications. <BR/>A record review of Resident #30's physician order summary dated January 2025, revealed the physician prescribed Resident #30 would have her g-tube flushed with 15 ml of water before and after administration of medications. Further review revealed the physician prescribed Resident #30 to have 11 medications administered by her g-tube, at 8:00 AM, as follows:<BR/>Apixaban 5mg 1-tab PGT 2x daily crush tab and suspend in 60ml water 8:00 AM, 8:00 PM.<BR/>Escitalopram 5mg 1-tab PGT daily 8:00 AM. <BR/>Memantine 5mg 1-tab PGT daily 8:00 AM.<BR/>Tramadol 50mg 1-tab PGT 2x daily 8:00 AM / 8:00 PM.<BR/>Reglan 5mg/5ml 10mg PGT 3x daily 8:00 AM, 4:00 PM, midnight. <BR/>Aspirin 81 mg 1-tab PGT daily 8:00 AM.<BR/>Docusate sodium 100mg 1-tab PGT 2x daily 8 AM and 8 PM.<BR/>Sodium chloride 1 gram 1-tab PGT 3x daily 8:00 AM, 2:00 PM, 8:00 PM.<BR/>Simethicone 80mg 1-tab PGT 2x daily (may crush med) 8:00 AM, 8:00 PM.<BR/>Oxcarbazepine 300mg 1-tab PGT 2x daily 8:00 AM, 8:00 PM.<BR/>Miralax 17 grams powder 1 capful 2x daily 8 ounces of water.<BR/>During an observation on 1/9/2025 at 9:50 AM revealed LVN D prepared and administered medications for Resident #30 per Resident #30's g-tube. LVN D crushed, mixed, with water, and administered the following prescribed medications together and not separately - individually:<BR/>Apixaban 5mg 1-tab PGT 2x daily crush tab and suspend in 60ml water 8:00 AM, 8:00 PM.<BR/>Escitalopram 5mg 1-tab PGT daily 8:00 AM. <BR/>Memantine 5mg 1-tab PGT daily 8:00 AM.<BR/>Tramadol 50mg 1-tab PGT 2x daily 8:00 AM / 8:00 PM.<BR/>Reglan 5mg/5ml 10mg PGT 3x daily 8:00 AM, 4:00 PM, midnight. <BR/>Aspirin 81 mg 1-tab PGT daily 8:00 AM.<BR/>Docusate sodium 100mg 1-tab PGT 2x daily 8 AM and 8 PM.<BR/>Sodium chloride 1 gram 1-tab PGT 3x daily 8:00 AM, 2:00 PM, 8:00 PM.<BR/>Simethicone 80mg 1-tab PGT 2x daily (may crush med) 8:00 AM, 8:00 PM.<BR/>Oxcarbazepine 300mg 1-tab PGT 2x daily 8:00 AM, 8:00 PM.<BR/>Miralax 17 grams powder 1 capful 2x daily 8 ounces of water.<BR/>During an interview on 01/09/2025 at 9:40 AM, LVN D stated the physician's order for Resident #30 was for 15 ml of water to be flushed by the g-tube before and after medication administration. LVN D stated the 9-ounce plastic water cup was unmarked for measurement. <BR/>During an interview on 01/10/2024 at 11:20 AM, LVN D stated she had administered all medications mixed without a water flush in between each individual medication for Residents #6 and #30, on 1/9/2025, and did not have a response for why nor what effect the action could have had for residents. <BR/>3. A record review of Resident #7's admission record dated 7/22/2024 revealed an admission date of 07/07/2017 with diagnoses which included hypertension (high blood pressure).<BR/>A record review of Resident #7's quarterly MDS assessment dated [DATE] revealed Resident #7 was an [AGE] year-old female admitted for long term care with the diagnosis of hypertension and assessed with a BIMS score of 8 out of a possible 15 which indicated mild cognitive impairment. Further review revealed Resident #7 was assessed with the ability to usually understand others and could usually make her needs known. <BR/>A record review of Resident #7's care plan dated 10/18/2024 revealed Resident #7 was a fall risk with the intervention to assess medications for contributing factors. <BR/>A record review of Resident #7's physician's orders, dated January 2025, revealed the physician prescribed for Resident #7 to receive amlodipine 5 g daily at 8:00 AM with the stipulation hold for systolic blood pressure less than 100 or diastolic blood pressure less than 60.<BR/>During an observation and interview on 1/9/2025 at 8:54 AM revealed MA I prepared Resident #7's medications and checked Resident #7's blood pressure with a digital electronic blood pressure cuff. MA revealed the result was 102 systolic blood pressure (the pressure in your arteries when your heart beats) over 63 diastolic blood pressure (the pressure of blood in the arteries when the heart is resting between beats). MA I stated I will not give the (name brand for amlodipine) due to (Resident #7's name) low blood pressure. <BR/>4. A record review of Resident #22's admission record dated 7/22/2024 reveled an admission date of 6/29/2016 with diagnoses which included hypertension (high blood pressure).<BR/>A record review of Resident #22's quarterly MDS assessment dated [DATE] revealed Resident #22 was a [AGE] year-old male admitted for long term care, diagnosed with high blood pressure, and assessed with a BIMS score of 06 which indicated severe cognitive impairment. <BR/>A record review of Resident #22's care plan dated 10/11/2024 revealed, evaluate medications and diet for adverse interactions.<BR/>A record review of Resident #22's physician orders dated January 2025 revealed the physician prescribed for Resident #22 to receive hydrochlorothiazide 25mg daily at 10:00 AM. Further review of the order revealed no stipulations. <BR/>During an observation and interview on 1/10/2025 at 9:46 AM revealed MA I prepared medications for Resident #22 and prior to medication administration MA I checked Resident #22's blood pressure and stated the result was 99 SBP over 60 DBP with a pulse of 69 beats per minute. MA I stated she would not administer the amlodipine due to a low blood pressure. <BR/>During an interview on 1/10/2024 at 1:20 PM, LVN E stated she was the charge nurse and had not received a report from MA-I regarding Resident #22's low blood pressure and the resulting MA-I holding the hydrochlorothiazide. LVN E stated Resident #22 did not have stipulations on the hydrochlorothiazide administration and would assess Resident #22.<BR/>During an interview on 1/10/2025 at 11:23 AM, LVN E stated she did not have any standing physician orders for g-tube medication administration to reference for enteral flushes. LVN E stated Residents #6 and #30 did have orders for each medication to be administered separately with a water flush in between each medication administration. LVN E stated all nurses should know the professional standard for medication administration per g-tube was for each medication to be administered one at a time with a water flush in between each medication. <BR/>During an interview on 1/10/2025 at 1:30 PM the DON stated Residents #7 and #30 had physician orders for water flushes in between medication administration and the expectation was for all nurses to administer g-tube medications individually, flush the g-tube with 5-10 ml of water in between each medication, and to flush the g-tube with water before and after the whole medication administration. The DON stated medication aides should administer medications as prescribed by the physician and follow the parameters set by the physician. The DON stated if the medication had no stipulations / parameters then the medication should be administered per physicians' orders. The DON stated she had not received a report that Resident #22 had not received his hydrochlorothiazide this morning and stated if Resident #22's hydrochlorothiazide order did not have parameters it should have been administered with a blood pressure of 99 sbp / 63 dbp. The DON stated the risk for residents could be for residents not to receive the therapeutic effects of their medications.<BR/>During an interview on 01/10/2025 at 4:40 PM, the Administrator stated he agreed with the DON on her expectations for g-tube medication administration and other medication administration practices. <BR/>A policy for g-tube medication and medication errors was requested on 1/10/2025 and as of 1/16/2025 was not provided. <BR/>A record review of the United States of America's National Library of Medicine website, titled Preventing Errors When Drugs Are Given Via Enteral Feeding Tubes, https://pmc.ncbi.nlm.nih.gov/articles/PMC3875244/#:~:text=Appropriate%20administration%20techniques%20must%20be,drugs%20through%20enteral%20feeding%20tubes accessed 01/10/2025, revealed, Preventing Errors When Drugs Are Given Via Enteral Feeding Tubes Problem: Giving medications through a feeding tube can be fraught with errors that occur more often than they are reported or recognized. These mistakes are often the result of administering drugs that are incompatible with administration via a tube, of not preparing the medications properly, and of using faulty techniques. These inaccuracies can result in an occluded feeding tube, a reduced drug effect, or drug toxicity. These potential adverse outcomes can lead to patient harm or even death. FAULTY PREPARATION - Oral medications that are intended to be taken by mouth must be prepared for enteral administration. Tablets must be crushed and diluted, capsules must be opened so the contents can be diluted, and even many commercially available liquid forms of drugs should be further diluted before being administered enterally-a practice not well known to all practitioners. WRONG ADMINISTRATION TECHNIQUE - Most nurses rely primarily on their own experience and on that of their coworkers for information about preparing and administering enteral medications. Because few nurses rely on pharmacists, nutritionists, or printed guidelines, a variety of improper techniques and an overall lack of consistency have often been the result. The most common improper administration techniques include mixing multiple drugs together to give at the same time and failing to flush the tube before giving the first drug and between giving subsequent drugs. Safe Practice Recommendation: Within each organization, an interdisciplinary team of nurses, pharmacists, nutritionists, and physicians should work together to develop protocols for administering drugs through enteral feeding tubes. Protocols should address using appropriate dosage forms; preparing the drugs for enteral administration; administering each drug separately; diluting the drugs as appropriate; and flushing the feeding tube before, between, and after drug administration.<BR/>A record review of the United States of America's National Library of Medicine website, titled, Hydrochlorothiazide https://medlineplus.gov/druginfo/meds/a682571.html Accessed 1/10/2025, revealed Why is this medication prescribed? Hydrochlorothiazide is used alone or in combination with other medications to treat high blood pressure. Hydrochlorothiazide is used to treat edema (fluid retention; excess fluid held in body tissues) caused by various medical problems, including heart, kidney, and liver disease and to treat edema caused by using certain medications including estrogen and corticosteroids. Hydrochlorothiazide is in a class of medications called diuretics ('water pills'). It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine. High blood pressure is a common condition and when not treated, can cause damage to the brain, heart, blood vessels, kidneys, and other parts of the body. Damage to these organs may cause heart disease, a heart attack, heart failure, stroke, kidney failure, loss of vision, and other problems. How should this medicine be used? Hydrochlorothiazide comes as a tablet, capsule, and solution (liquid) to take by mouth. It usually is taken once or twice a day. When used to treat edema, hydrochlorothiazide may be taken daily or only on certain days of the week. Follow the directions on your prescription label carefully and ask your doctor or pharmacist to explain any part you do not understand. Take hydrochlorothiazide exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. Hydrochlorothiazide controls high blood pressure but does not cure it. Continue to take hydrochlorothiazide even if you feel well. Do not stop taking hydrochlorothiazide without talking to your doctor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 diseases and infections, which must include, at a minimum, the following elements: A. Standard and transmission-based precautions to be followed to prevent spread of infections, and B. The hand hygiene procedures to be followed by staff involved in direct resident contact; for 2 of 2 residents reviewed for incontinent care and medication administration (Residents #6 and #30) reviewed for standard and transmission-based precautions for infection control and prevention.<BR/>1. On 1/9/2025, CNA A and CNA J assisted Resident #6 with incontinent care and failed to change gloves with hand hygiene in between glove changes after touching handling Resident #6's soiled linens and supplies prior to touching handling Resident #6's clean linens and supplies. <BR/>2. On 1/9/2025, LVN D failed to change gloves with hand hygiene after touching handling Resident #6's clothing and furniture prior to administering Resident #6's medications. <BR/>3. LVN D failed to doff a potentially contaminated PPE gown prior to exiting Resident #6's room and wore the potentially soiled PPE gown in the hallway. <BR/>4. On 1/9/2025, LVN D failed to change gloves with hand hygiene after touching handling Resident #30's clothing and furniture prior to administering Resident #30's medications. <BR/>5. LVN D failed to doff a potentially contaminated PPE gown prior to exiting Resident #30's room and wore the potentially soiled PPE gown in the hallway. <BR/>6. The facility failed to store oxygen concentrator equipment in a clean room and stored the oxygen concentrator equipment in a bathroom. <BR/>These failures could place residents at risk for harm by cross-contamination. <BR/>The findings included:<BR/>A record review of Resident #6's admission record dated 1/9/2025, revealed an admission date of 12/17/2020 with diagnoses which included hypertension (high blood pressure), diabetes (a person's difficulty using blood sugar in their cells) and dementia (A group of symptoms that affects memory, thinking and interferes with daily life). <BR/>A record review of Resident #6's quarterly MDS assessment dated [DATE] revealed Resident #6 was an [AGE] year-old female admitted for long term care and was unable to participate in a BIMS assessment which indicated severe cognitive impairment. Resident #6 was assessed with the need for a feeding tube (AKA a g-tube).<BR/>A record review of Resident #6's care plan dated 01/09/2025 revealed, at risk for covid-19 virus . follow strict CDC guidelines <BR/>A record review of Resident #6's physicians orders dated 1/9/2025 revealed the physicians' prognosis for Resident #6 was guarded. <BR/>During an observation on 1/9/2025 at 10:57 AM revealed CNA A and CNA J assisted Resident #6 with incontinent care by donning PPE to include gowns and gloves. CNA A was observed to position and disrobe Resident #6 and continued to dispense cleansing wipes from the clean wipes package, clean Resident #6's genitalia and buttocks with multiple wipes kept atop of Resident #6's soiled under-pad, changed gloves without hand hygiene in between glove changes, and proceeded to remove the soiled linen and under pads, and then provided clean linen and adult briefs with the same soiled contaminated gloves. CNA A then doffed the gloves without performing hand hygiene and exited Resident #6 room. <BR/>During an observation on 1/9/2025 at 11:17 AM, CNA A stated she changed gloves after every 3 to 4 wipes. CNA A stated she should have sanitized her hands after changing gloves, and improper hand hygiene was a risk for causing infections and cross contaminations or getting stool into Resident #6's vagina.<BR/>2. An observation and interview on 1/9/2025 at 9:11 AM revealed LVN D administered medications to Resident #6 via her g-tube. LVN D donned gloves without providing hand hygiene prior to donning, handled medication cart and keys, and entered Resident #6's room and assessed Resident #6's blood pressure, exited Resident #6 room without doffing the gloves and or performing hand hygiene, nor disinfecting the blood pressure cuff, and proceeded to prepared Resident #6's medications with the same gloves. LVN D donned PPE to include a gown and continued with the same gloves. LVN D was observed to handle Resident #6's person, clothing, furniture, and enteral piston syringe and then proceeded to administer Resident #6's medications via her g-tube while not changing gloves with hand hygiene prior to the medication administration. After the medication administration LVN D was observed to exit Resident #6's room without doffing the gown, doffed the gloves without providing hand hygiene, and continued into the hallway and entered a bathroom to wash Resident #6's enteral piston syringe and performed hand hygiene. LVN D continued in the hallway and reentered Resident #6's room to replace the piston syringe in the package, exited Resident #6's room and doffed the gown without performing hand hygiene. LVN D stated she should have changed gloves with hand hygiene before administering Resident #6's g-tube medications and stated the potential harm for residents was infections. <BR/>3. A record review of Resident #30's admission record dated 07/22/2024 revealed an admission date of 03/01/2022 with diagnoses which included gastronomy status (presence of a g-tube), dementia, and seizures (electrical storms of the brain). <BR/>A record review of Resident #30's quarterly MDS assessment dated [DATE] revealed Resident #30 was a [AGE] year-old female admitted for long term care and assessed with a severely impaired cognition, could not communicate her needs. Resident #30 was assessed with the need for a feeding tube.<BR/>A record review of Resident #30's care plan dated 12/13/2024 revealed Resident #30 was quadriplegic (a symptom of paralysis that affects all a person's limbs and body from the neck down), NPO (Latin for nothing by mouth) and required enteral feeding (enteral administration is food or drug administration via the human gastrointestinal tract), Tube feeding . Resident has gastronomy tube . assess feeding tube placement, patency, and residual every shift and before and after administration of any fluids or medications. <BR/>A record review of Resident #30's physicians orders dated 1/9/2025 revealed the physicians' prognosis for Resident #30 was guarded.<BR/>During an observation on 1/9/2025 at 9:48 AM revealed LVN D donned gloves without performing hand hygiene, prepared Resident #30's medications, doffed the gloves without hand hygiene, donned new gloves, entered Resident #30's room, recognized she was missing a piston syringe and a PPE gown, exited the room while continuing with the same gloves, walked to the supply cabinet closet in the hallway, donned a gown and returned to Resident #30's bedside with the same gloves. LVN D was observed to administer Resident #30's medications with the same gloves. After LVN D administered Resident #30's medications she was observed to exited Resident #30's room, without doffing the gown and gloves, continued in the hallway to the bathroom where she doffed the gloves provided hand hygiene and washed the piston syringe. LVN D continued with the same gown in the hallway and returned to Resident #30's room to replace the piston syringe and doffed the gown. <BR/>4. During daily observations from 1/7/2025 through 1/10/2025 revealed the A Hallway public bathroom for staff and visitors. Further daily observations revealed the bathroom housed 2 clean oxygen concentrators covered with plastic translucent bags. The bags were labeled cleaned 1/6/2025 and 12/2/24.<BR/>During an interview on 1/8/2025 at 1:20 PM, LVN E stated the clean oxygen concentrators were available for resident-use and were stored in the staff and visitors public restroom due to lack of space with in the facility. <BR/>During an interview on 01/10/2025 at 2:00, the DON stated the expectation for infection control and prevention was for staff to follow standard precautions for all residents and enhanced barrier precautions for residents with g-tubes. The DON stated standard precautions were for staff to perform glove changes when going from a dirty to clean scenario and to perform hand hygiene in between all glove changes and when gloves are doffed. The DON continued to state all PPE must not be worn in the hallways and should be doffed in the enhanced barrier precautions room. The DON stated the nursing staff were trained per CDC guidelines for standard and enhanced barrier precautions. <BR/>During an interview on 1/10/2025 at 5:00 PM, the Administrator stated he agreed with the DON's expectations for infection control and prevention. <BR/>A policy for infection control was requested on 1/10/2025 and was not provided upon exit on 1/10/2025.<BR/>A record review of the United States of America's Centers for Disease Control and Preventions website titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings. <BR/>https://www.cdc.gov/infection-control/hcp/core-practices/index.html<BR/>Accessed 1/10/2025, revealed, Use Standard Precautions to care for all patients in all settings. Standard Precautions include:<BR/>5a. Hand hygiene<BR/>5b. Environmental cleaning and disinfection . <BR/>5f. Reprocessing of reusable medical equipment between each patient or when soiled Standard Precautions are the basic practices that apply to all patient care, regardless of the patient's suspected or confirmed infectious state, and apply to all settings where care is delivered. These practices protect healthcare personnel and prevent healthcare personnel or the environment from transmitting infections to other patients. <BR/>5a. Hand Hygiene . <BR/>Use an alcohol-based hand rub or wash with soap and water for the following clinical indications:<BR/>Immediately before touching a patient.<BR/>Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices.<BR/>Before moving from work on a soiled body site to a clean body site on the same patient.<BR/>After touching a patient or the patient's immediate environment.<BR/>After contact with blood, body fluids or contaminated surfaces.<BR/>Immediately after glove removal.<BR/>Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled.<BR/>Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered.<BR/>Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. 5d. Risk Assessment with Appropriate Use of Personal Protective Equipment . <BR/>Ensure proper selection and use of personal protective equipment (PPE) based on the nature of the patient interaction and potential for exposure to blood, body fluids and/or infectious material:<BR/>Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur.<BR/>Wear a gown that is appropriate to the task to protect skin and prevent soiling of clothing during procedures and activities that could cause contact with blood, body fluids, secretions, or excretions.<BR/> . Remove and discard PPE . upon completing a task before leaving the patient's room or care area. Do not use the same gown or pair of gloves for care of more than one patient. Remove and discard disposable gloves upon completion of a task or when soiled during the process of care. Ensure that healthcare personnel have immediate access to and are trained and able to select, put on, remove, and dispose of PPE in a manner that protects themselves, the patient, and others

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, it was determined the facility failed to ensure each resident was provided the right to a dignified existence, self-determination, for 2 of 6 residents reviewed for Resident rights (Resident #1 and #2).<BR/>The facility failed ensure Resident #1 and #2's guardian the right to choose Hospice Company C to evaluate these residents for their eligibility for hospice; instead of Hospice Company D. <BR/>This failure could place residents at risk of their responsible party not being involved in their medical care and treatment.<BR/>Findings included:<BR/>1. Record review of Resident #1's clinical record , date not legible, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses to include dementia (a loss of cognitive functioning that interferes with daily life and activities) without behavioral disturbances. It further revealed Resident #1's guardian was Guardian A. <BR/>Record review of Resident #1's BIMS, dated 09/24/2024, revealed Resident #1's BIMS score was 8 out of 15, indicating moderate cognitive impairment.<BR/>Record Review of Resident #1's clinical records, dated 07/02/24 at 03:11 PM, reflected a fax to Doctor B with subject to include, As per [Guardian A] request resident evaluation for [Hospice Company C]<BR/>Record Review of Resident #1's Nurse's Notes, dated 07/08/24 at 1:00 PM , author signature not legible, reflected Received call from [Doctor B] states [Hospice Company D] screened [Resident #1] and [Resident #1] doesn't qualify for hospice services . [Doctor B] states he did not give order for [Hospice Company C]<BR/>2. Record review of Resident #2's clinical record, dated 07/22/24, revealed Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses to include dementia (a loss of cognitive functioning that interferes with daily life and activities). It further revealed Resident #2's guardian was Guardian A.<BR/>Record review of Resident #2's BIMS, dated 11/22/2024, revealed Resident #2's BIMS score was 6 out of 15, indicating severe cognitive impairment.<BR/>Record Review of Resident #2's clinical records, dated 07/02/24 at 03:43 PM, reflected a fax to Doctor B with subject to include, As per [Guardian A] request resident evaluation for [Hospice Company C]<BR/>Record Review of Resident #2's Nurse's Notes, dated 07/08/24 at 01:00 PM, author signature not legible, reflected Received call from [Doctor B] states [Hospice Company D] screened [Resident #2] and [Resident #2] doesn't qualify for hospice services . [Doctor B] states he did not give order for [Hospice Company C] to eval [Resident #2].<BR/>Written communication with Guardian A for both Resident #1 and #2, dated 12/04/24 at 11:48 AM, reflected, I had to have a meeting with [Doctor B] and he did not believe hospice was appropriate. I am not asking for [Doctor B] to assess or provide any services to the Ward. All [Doctor B] has to do is request [Hospice Company C] come out and assess for hospice services. <BR/>Written communication with Guardian A, dated 12/06/24 at 11:16 AM, reflected, I am not aware of the visits being unofficial. I had requested hospice services for my Wards and verified that [Hospice Company C] was in contract. I am simply asking for the facility and [Doctor B] sign the order for [Hospice Company C] to evaluate. [Hospice Company C] will evaluate and determine if hospice is appropriate.<BR/>During an interview and record review on 12/04/24 at 1:45 PM, LVN E revealed she remembered hearing about Resident #1's and #2's interest in hospice placement. She knew she was waiting for Hospice Company D. She did not recall anything about Hospice Company C. LVN E further revealed if the resident did not select a hospice company, they were told to use Hospice Company D, as was observed to be written on a paper that was hung up at the nurse's station . She revealed residents had the right to choose what hospice company they would like.<BR/>During an interview on 12/04/24 at 3:39 PM, RN F revealed Hospice Company C came to the facility and concluded Residents #1 and #2 did not qualify for hospice services. RN F further revealed she let Guardian A know Hospice Company C came in unofficially to assess residents. RN F was aware Guardian A wanted Hospice Company C to evaluate Residents #1 and #2 instead of Hospice Company D. <BR/>Record Review of the facility's policy Resident Rights, dated April 2008, reflected You have the right to make your own choices regarding personal affairs, care, benefits, and services.<BR/>Record Review of the facility's policy Hospice Services, dated 12/03/24, reflected Our facility has entered into a contractual agreement for hospice services to ensure that residents who wish to participate in a hospice program may do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made for 2 of 2 (Residents #1 and#2) residents. <BR/>1.The facility failed to report on 3 separate elopement incidents Resident #1 elopement from the facility, no injuries. <BR/>2. The facility failed to report and submit Resident #2's left knee fracture, intake #379566 allegation of unknown origin. <BR/>These failures could place residents at risk for not having allegations of abuse or neglect reported to the State Agency to ensure that allegations are fully investigated.<BR/>The findings were: <BR/>1. Record review of Resident #1's admission Record dated [DATE] revealed she was admitted on [DATE] with diagnoses of vascular dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain.), severe cognitive impairment, anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome.) state and mood disorder (any of a group of mental conditions characterized by persistent disturbance of mood, especially in the form of depression or euphoria or a combination of these true clinical depression is a mood disorder, which can interfere with everyday life for an extended time. <BR/>Record review of Resident #1's admission MDS dated [DATE] revealed section C Cognitive Patterns BIMS score 99, severely impaired. <BR/>Record review of Resident #1's care plan dated [DATE] revealed resident walks, eats independently, had adequate vision, continent of bladder, communicates verbally, frequent disorientation, place, and time, wander guard, elopement risk. <BR/>Record review of an incident report dated [DATE] at 6 PM documented Resident #1 went out the laundry room gate and was brought back by staff and Resident was placed on 15-minute observations for safety. Resident #1 was observed by staff on a continuous basis after she returned to the facility by LVN A. Resident #1 was gone from facility less than 30 minutes.<BR/>Record review of an incident report dated [DATE] at 7:25 AM documented Resident #1 eloped from the facility last seen at 10 AM, notified police, APS (adult protective service), family no signs of point of exit. Resident #1 had her wander guard on her wrist and was brought back by police by LVN B. Resident #1 was gone from facility less than 30 minutes.<BR/>Record review of an incident report dated [DATE] at 2:05 PM documented dietary manager C called the facility by phone saying that she saw Resident #1 walking down the side street away from the facility and brought her back, wander guard was on wrist and was working by LVN B. Resident #1 was gone from facility less than 30 minutes.<BR/>Record review of all 3 incident reports for Resident #1 was documented she had no injures, the medical director, guardian, family, Administrator/DON, and APS were called. On one of the incidents reports the facility notified the police. All the incident reports included a head-to-toe assessment, vitals, and 15-minute checks. Wander guard check, changed locks, locked room window and continue to search for an alternate placement with a secure unit.<BR/>Interview on 9/202023 at 1:41 PM with LVN B, she stated staff knew to keep a close eye on Resident #1 because she had eloped before from the building. LVN B stated Resident #1 was in the dining room ([DATE] at 7:25 AM) for breakfast and then the next minute between checking meal trays, Resident #1 was gone from her sight. LVN B stated she told staff to start looking for Resident #1 inside and outside the facility. She notified the Administrator, and police. Staff drove around the facility, and could not find Resident #1, after about 30 minutes the police brought her back to facility. LVN B stated staff monitored Resident #1 every 15 minutes and had her wander guard bracelet on her wrist. LVN B stated she was not sure how Resident #1 left the facility. LVN B stated the second time she knew Resident #1 eloped and was brought back to facility by cook C after she saw Resident #1 walking away from the facility. LVN B stated one of the new interventions were to have the psychiatrist review her medications and prescribed a mood medication that has helped. <BR/>Interview on [DATE] at 4:14 PM with RN supervisor stated she had spoken to Resident #1's guardian, and they had both been searching for placement for Resident #1 in a locked unit for Resident #1's safety, since she first eloped in [DATE]. RN supervisor stated Resident #1 was monitored by staff and will continue to have 1:1 monitoring by staff 24 hours until she can be discharged to a locked unit facility. <BR/>Interview on [DATE] at 4:55 PM with LVN A, stated Resident #1 left the building ([DATE] at 6 PM), she was missing for about 10-15 minutes and was found and brought back with no injuries. LVN A stated they started 15-minute check on Resident #1 and LVN A liked to keep Resident #1 with her to keep her busy. LVN A stated Resident #1's wander guard bracelet was still on her. LVN A stated Resident #1 was alert and orientated times 2-3 depending on time of day. <BR/>Interview on [DATE] at 3:55 PM with the DON stated Resident #1 had eloped from the facility 3 times and had interventions in place for her, such as wander guard bracelet, 1:1 monitoring, 15-minute checks, medication reviews, psychiatrist medication review, her room window had an alarm, at night staff were right outside door while she slept and was care planned. The DON stated Resident #1 was an APS case and had brought Resident #1 to facility. The facility had reported to APS about Resident #1's elopements and being at this facility, that was not a locked unit, and was a safety risk due to her elopement. The DON stated Resident #1's guardian and administrative staff had been searching for a locked unit facility but were unsuccessful due to no finances available for her room and board. <BR/>Interview on [DATE] at 5:15 PM with Administrator/DON stated Resident #1's elopements were from 15 minutes to 30 minutes. After the last elopement, the facility started to monitor Resident #1 more closely to include 1:1 supervision. Each incident the Maintenance supervisor walked around the perimeter of the building to look for clues of how Resident #1 might have left the facility. <BR/>2. Record review of Resident #2's admission Record dated [DATE] revealed she was admitted on [DATE] and was discharged on [DATE], with diagnoses of dementia, Alzheimer's disease, Breast Cancer, paranoid delusional and depressive disorder. Resident # 2 was on hospice service and died in [DATE]. <BR/>Record review of Resident #2's mobile x-ray dated [DATE] of left femur finding were, A displaced fracture of the left femoral neck is present. Diffuse osteopenia is present. The age of the fracture is indeterminate. <BR/>Record review of incident #379566, date of incident was [DATE] at 11:30 AM, date and time the facility first learned of the incident was [DATE] at 12:15 PM, and the incident was reported findings was on [DATE] at 5:44 PM and submitted to STATE on [DATE]. This incident involved an unwitnessed fracture to Resident #2's left femoral neck.<BR/>Interview on [DATE] at 5:57 PM with the Administrator stated he was not sure why I did not report to the STATE until [DATE]. Interview with the Administrator stated when looking at his phone, to see date he should have submitted and reported Resident #2's incident, provider email from the STATE was documented [DATE].<BR/>Interview on [DATE] at 6:04 PM with the Administrator stated he used the Abuse, Neglect, and Exploitation, Misappropriation of Resident property provider letter for a resource to know when to report an incident with residents. The Administrator confirmed after surveyor intervention, he was using an old provider letter on reporting Abuse, Neglect, and Exploitation, Misappropriation of Resident property to the STATE. The provider letter he was using was dated 2014, this one stated if the resident was not missing for longer than 8 hours, he did not have to report to the STATE. The surveyor showed him the provider letter in reporting Abuse, Neglect, and Exploitation, Misappropriation of Resident property and other Incidents dated [DATE]. The Administrator looked at his phone, (intakes list) to see which day he was supposed to submit the provider investigation and was dated for [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving resident neglect are investigated for 2 of 16 resident (Residents #8 and #17) reviewed for reporting neglect, in that: <BR/>The facility failed to investigate an incident when Resident #8 and #17 were observed in the dining room to be using profanity toward each other after Resident #17 threw a liquid-filled cup at Resident #8. <BR/>This failure could place the residents at risk for uninvestigated allegations of abuse, neglect, and injuries. <BR/>The findings were: <BR/>Observation on 11/29/2023 at 10:41 AM revealed Resident #17 yelling in the dining room toward Resident #8 calling Resident #8 a [expletive] and a [expletive] before throwing a cup of liquid toward her. Further observation revealed Resident #8 responded by calling Resident #17 a [expletive]. Following this, the Assistant AD and LVN B were observed to separate the residents and attempt to deescalate the situation. Resident #8 was observed stating I won't take this [expletive] while being assisted by wheelchair away from the dining room. <BR/>Record review of Resident #8's face sheet reflected a [AGE] year-old female with an original admission date of 10/16/2015 and a primary diagnosis of Type 2 Diabetes Mellitus Without Complications. <BR/>Record review of Resident #17's face sheet reflected a [AGE] year-old female with an original admission date of 05/04/2016 and a primary diagnosis of Type 2 Diabetes Mellitus Without Complications. <BR/>Interview on 11/30/2023 at 9:26 AM, the Assistant AD stated she has been at the facility since 2006 originally but has left and returned since then. The Assistant AD stated she was present when Resident #17 threw water at Resident #8 but did not remember what caused the event to occur. The Assistant AD stated after the water was thrown, she attended to Resident #17 attempting to calm her down before taking her to her room. The Assistant AD stated similar events such as this have occurred in the last year but never where an object was thrown but have generally included profanity on a weekly frequency. The Assistant AD stated Resident's #19, #18, and #27 had been disinterested in attending activities due to the frequency of profanity and yelling exhibited by Residents #17 and #8. The Assistant AD stated following the event, she did not inform or report the incident to anyone due to her believing LVN B would take appropriate action as LVN B was the senior staff present. <BR/>Interview on 11/30/2023 at 9:40 AM, Resident #8 stated Resident #17 threw hot cocoa at her because she is crazy. Resident #8 stated Resident #17 also called her a [expletive] and a [expletive] and felt Resident #17 did not make [her] feel too good. Resident #8 stated no one had come to ask her what happened, including the ADM or the ADON. Resident #8 stated <BR/>Interview on 11/30/2023 at 9:46 AM, LVN B stated that she was present when Resident #17 threw what she thought to be chocolate milk at Resident #8. LVN B stated that Resident #17 had delusions regularly and felt emotionally threatened spontaneously. LVN B stated Resident #8 did not express any pain after the incident. LVN B stated that the incident she informed the ADON of the de-escalation and the prevention of harm. LVN B stated that she did not complete an incident report as the protocol for completing an incident report was only after an injury has occurred. LVN B stated profanity was a frequent occurrence and incident reports were not made for each instance. LVN B stated examples of reportable instances of abuse included talking ugly, threatening, or misappropriation. LVN B stated this was an example of talking ugly but felt because this occurred so frequently that no further action needed to be taken. LVN B stated the thrown beverage could not have been hot as the staff do not serve hot beverages to residents. LVN B stated the reportability of incidents are determined on a case-by-case basis. <BR/>Interview on 11/30/2023 at 10:02 AM, with ADON stated she was informed of the incident by LVN B and was told that Resident #17 and Resident #8 were speaking ugly to one another but was not informed of any thrown item or profanity. The ADON stated incident reports were only completed when actual harm occurred and that when objects are thrown it was on a case-by-case basis as to whether they are reportable. The ADON stated the expectation when incidents occurred was that staff present were to complete an incident report and inform the abuse and neglect coordinator to which he would investigate the allegation to confirm findings. <BR/>Attempted interview on 11/30/2023 at 10:14 AM, with Resident #17 was unsuccessful due to the resident being non-interviewable. <BR/>Interview on 11/30/2023 at 10:37 AM, Resident #19 stated she was the resident council president and she decided to no longer attend activities due to feelings of discomfort due to Resident #8 using profanity and shouting during bingo. Resident #19 stated she had never been interviewed by the ADM about these instances or if she felt safe in the facility and preferred to just stay in her room during activities. <BR/>Interview on 11/30/2023 at 10:42 AM, Resident #18 stated she did not like to go to activities because of the shouting and occasional anger displayed by other unnamed residents. Resident #18 stated she has never been interviewed about these instances or asked if she had ever felt safe in the facility. <BR/>Interview on 11/30/2023 at 2:40 PM, the ADM stated he was informed of the incident involving Resident #17 and Resident #8 in the evening of 11/29/2023. The ADM stated he did not submit a self-reported incident to HHSC as he was not aware of the reportability of this incident. The ADM stated he was not informed of the use of profanity during the incident and that it was his expectation that instances of verbal confrontation be reported to himself so that they may be reported to HHSC. The ADM stated instances of verbal confrontation could be examples of verbal abuse and should therefore be reported to HHSC as per their facility policy. The ADM stated following the event he did not interview the victims or any other residents of their feelings of safety or for pertinent evidence pertaining to the incident as he would normally do during an investigation of abuse and neglect. The ADM stated a report was to be made based on the findings presented by the survey team.<BR/>Record review of the Abuse and Neglect policy, dated 08/2011, reflected instances of abuse, neglect, or exploitation were to be reported to the Abuse and Neglect Coordinator so they may be reported and investigated by the ANE Coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 12 residents (Resident #4 and #20) whose assessments were reviewed in that:<BR/>1. Resident #4's most recent Quarterly MDS assessment dated [DATE] did not accurately reflect the resident's oral/dental status and oxygen use.<BR/>2. Resident #20's most recent annual MDS assessment dated [DATE] did not accurately reflect the resident's ability to maintain personal hygiene.<BR/>This failure could place residents at-risk for inadequate care due to inaccurate assessments.<BR/>The findings included:<BR/>1. Record review of Resident #4's face sheet, dated 9/6/23 revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia with behavioral disturbance, hypertension (high blood pressure), angina pectoris (condition marked by severe chest pain caused by inadequate blood supply to the heart), heart failure, glaucoma (a condition of increased pressure within the eyeball causing gradual loss of sight), depressive disorder and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs).<BR/>Record review of Resident #4's physician orders for November 2023 revealed the following:<BR/>-Oxygen 2-5 liters via mask via concentrator all shifts with order date 3/8/22 and no end date<BR/>Record review of Resident #4's comprehensive care plan, dated 9/6/23 revealed the resident required assistance with oral hygiene related to dementia and visual deficit as evidenced by missing some teeth and lack of hygiene awareness. Further review of Resident #4's comprehensive care plan revealed the resident had ineffective breathing patterns related to COPD (chronic obstructive pulmonary disease; disease that cause airflow blockage and breathing-related problems), asthma, frequent upper respiratory infections and decreased lung compliance as evidence by shortness of breath and labored respirations with interventions that included continuous oxygen therapy at 2-5 liters every shift.<BR/>Record review of Resident #4's most recent quarterly MDS assessment, dated 9/6/23 revealed the resident was cognitively intact for daily decision-making skills. Further review of Resident #4's quarterly MDS assessment revealed section L - Oral/Dental Status was blank and section O - Special Treatments and Programs under oxygen treatments was blank. <BR/>Observation and interview on 11/27/23 at 10:19 a.m. revealed Resident #4 sitting up in bed with the O2 concentrator operating via nasal canula at 2 liters. Resident #4 stated she always used the oxygen concentrator. <BR/>Observation on 11/28/23 at 9:18 a.m. revealed Resident #4 was sitting up in a wheelchair and the O2 concentrator was operating via nasal canula at 2 liters.<BR/>During a follow-up observation and interview on 11/28/23 at 9:24 a.m., Resident #4 stated she had all her teeth removed over a period of time. Resident #4 revealed she had worn dentures, but they did not fit. Resident #4 was observed with several missing teeth.<BR/>Observation on 11/29/23 at 8:13 a.m. revealed Resident #4 sitting up in a wheelchair and the O2 concentrator was operating via nasal canula at 2 liters.<BR/>During an interview on 11/30/23 at 11:02 a.m., the DON revealed Resident #4 had some teeth but was not aware the resident wore dentures or partials. The DON confirmed Resident #4's most recent quarterly MDS assessment, dated 9/6/23 section L - Oral/Dental Status and section O- Special Treatments and Programs under oxygen treatments were blank. The DON revealed she was responsible for completing the MDS assessments and revealed Resident #4's quarterly MDS assessment was inaccurate and did not reflect the resident. The DON revealed it was important to complete the MDS accurately because it could affect the resident's treatment management. The DON revealed the facility referred and followed the Resident Assessment Instrument to complete MDS assessments. <BR/>2. Record review of Resident #20's face sheet, dated 6/22/23 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included anxiety, hypertension (high blood pressure), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), encephalopathy (a broad term for any brain disease that alters brain function or structure), diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), chronic viral hepatitis C (long-term infection of the liver that could lead to complications such as cirrhosis, liver failure, and liver cancer).<BR/>Record review of Resident #20's most recent annual MDS assessment, dated 8/30/23 revealed the resident was cognitively intact for daily decision-making skills. Further review of Resident #20's annual MDS assessment, under Section GG - Functional Abilities and Goals, sub-section GG0130 Self-Care, I. Personal Hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) was blank. <BR/>Record review of Resident #20's comprehensive care plan, dated 8/30/23 revealed the resident had Activity of Daily Living impairment related to coordination deficit, upper body weakness, visual disturbance/deficit, limited endurance, activity intolerance, limited range of motion, pain, uncontrolled movements, difficulty with dressing/bathing/grooming/hygiene/toileting.<BR/>During an observation and interview on 11/27/23 at 11:05 a.m., Resident #20 stated she styled her hair with a flat iron. Resident #20 was observed with a flat iron and a blow dryer at the bedside. Resident #20 stated she had burned her finger several times trying to reach the back of her hair with the flat iron. Resident #20 was observed with a round, red mark on the inner 2nd finger on the middle joint of the left hand that appeared to measure the size of a pea. Resident #20 was observed with a slight tremor to the right hand. <BR/>During a follow up observation and interview on 11/28/23 at 9:35 a.m., Resident #20 stated she had used the blow dryer to dry her hair after her shower yesterday, 11/27/23. Resident #20 again stated she had been burning her finger with the flat iron and needed to get a pair of gloves or staff to help her. Resident #20 was observed with the flat iron and the blow dryer at the bedside. Resident #20 stated she had asked staff for help with the blow dryer and the flat iron but they are busy.<BR/>During an interview on 11/29/23 at 1:57 p.m., LVN B revealed Resident #20 had tremors mostly to her hands, maybe the right hand. LVN B stated she was aware Resident #20 used the flat iron and the resident had revealed to her she had burnt her finger, but had not showed it to me. LVN B then stated, I did ask to see the burn but there was nothing there. LVN B revealed the resident first got the flat iron on 11/17/23, but had asked Resident #20 not to use the flat iron because of safety reasons. LVN B revealed the flat iron should have been added to Resident #20's care plan due to safety reasons. <BR/>During an interview on 11/29/23 at 2:18 p.m., the DON revealed Resident #20 could not have the flat iron in her room due to safety reasons. The DON revealed she was responsible for completing the MDS assessments and revealed Resident #20's annual MDS assessment was inaccurate and did not reflect the resident. The DON revealed it was important to complete the MDS accurately because it could affect the resident's treatment management. The DON revealed the facility referred and followed the Resident Assessment Instrument to complete MDS assessments. <BR/>Record review of CMA MDS 3.0 Manual dated 10/2019 revealed: The RAI process has multiple regulatory requirements. Federal regulations at 42 CVR 483.20 (b)(1)(xviii), (g) and (h) require that: 1. The assessment accurately reflects the resident's status. 2. A registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals 3. The assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. In addition, an accurate assessment requires collecting information from multiple sources .should include the resident's medical record, physician and family/guardian .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents [Resident #6] reviewed for care plans. <BR/>The facility failed to develop the appropriate care plan intervention of implementing an abdominal binder to prevent Resident #6 from pulling out her feeding-tube per physician's order. <BR/>This deficient practice could place resident at risk of trauma or injury. <BR/>The findings include:<BR/>Record review of Resident #6 face sheet dated 9/20/24 revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. Relevant diagnosis included Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance, bilateral below the knee amputee. <BR/>Record review of Resident #6 Quarterly MDS dated [DATE] revealed resident unable to complete BIMS assessment due to severe cognitive impairment. Resident #5 had functional limittion in rang of motion with impairment on both sides of upper extremity to include shoulder, elvow, wrist, hand. The MDS reealed resident was dependent. The BIMS assessment was unable to be completed due to Resident#6 severe cognitive impairment. Resident #6 was dependent and helper did all the effort in ADL needs. Resident did none of the effort to complete any of the ADL activities. <BR/>Record review of Resident #6 Care Plan (last updated 9/24/24) revealed absence of behavioral disturbance reflecting behavior of pulling out feeding tube or potential for injury related to pulling out feeding tube. <BR/>Record review of Resident #6 physician's orders reflected an order dated 1/20/16 apply abdominal binder to prevent pulling of G-tube all shifts.<BR/>During observation on 01/07/2025 at 10:55 AM Resident #6 was resting in bed, eyes closed with tube feeding connected and an abdominal binder was not in place. <BR/>During observation on 01/08/2025 at 11:05 AM Resident #6 was resting in bed, eyes closed with tube feeding connected and abdominal binder was not in place. <BR/>During an observation on 01/09//2025 at 2:20 PM Resident #6 was resting in bed, eyes were closed, and tube feeding was not running. An abdominal binder was not in place. <BR/>An interview on 01/09/25 AM with CNA A revealed Resident #6 has a tendency to pull out tube feeding which is why abdominal binder is placed on resident. CNA A stated she worked with resident on 01/08/25 and applied binder. CNA stated abdominal binders were located in the linen closets. <BR/>An interview on 01/09/25 at 10:25 AM with CNA B revealed staff used a binder to prevent Resident #6 from pulling out tube feeding. CNA B stated she has not worked with Resident #6 this week.<BR/>An interview on 01/10/25 at 8:00 AM with LVN E confirmed that resident had an order for an abdominal binder. LVN E stated CNA's apply binder daily and reapply after peri-care as needed. LVN confirmed Charge Nurse is responsible to ensure abdominal binder is in place. LVN stated the staff know about the binder and that she will put it on the nursing MAR so it will not be missed.<BR/>An interview on 01/10/25 at 8:22 AM with the DON confirmed that Resident #6 did have an order for an abdominal binder on at all shifts. DON confirmed that adverse effects to include trauma / injury to stoma site could occur if resident pulled feeding tube out.<BR/>A request for a policy on Care Plan development and implementation was made on 01/09/2025 at 9:00 AM and was not provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 2 of 2 residents (Resident #1 and #13) reviewed for enteral feeding tubes in that:<BR/>1. LVN A did not rinse or discard the medication syringe after administering medications into Resident #1's enteral feeding tube.<BR/>2. LVN A did not rinse or discard the medication syringe after administering medications into Resident #13's enteral feeding tube.<BR/>These failures could place residents at risk for complications of enteral feeding.<BR/>The findings included:<BR/>1. Record review of Resident #1's face sheet, dated 10/27/22 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included seizures/convulsions, anxiety, cerebral palsy (physical disability that affects movement and posture), osteoporosis (condition that causes bones to become weak and brittle). Further review of Resident #1's face sheet, under the Diet section revealed the resident was a tube feeder.<BR/>Record review of Resident #1's most recent quarterly MDS assessment, dated 10/20/23 revealed the resident was severely cognitively impaired for daily decision-making skills and required a feeding tube.<BR/>Record review of Resident #1's physician's orders for November 2023 revealed the following:<BR/>- Start Jevity 1.5, 50 cc per hour via feeding pump, up at 10:00 a.m. and down at 6:00 a.m. Flush 200 cc water every 4 hours via g-tube. Discontinue bolus of formula and water bolus, with order date 11/21/23 and no end date.<BR/>- Carbamazepine 200 mg/10 ml, 15 ml via peg tube two times daily for seizure/convulsion with order date 8/2/22 and no end date.<BR/>-Clonazepam 1 mg, 1 tablet via peg tube two ties daily for seizure/convulsion with order date 10/23/23 and no end date.<BR/>Record review of Resident #1's comprehensive care plan, dated 7/11/23 revealed the resident required a feeding tube related to potential for aspiration with interventions that included to assess feeding tube placement, patency and residual every shift and before and after administration of any fluids or medications. <BR/>Observation on 11/28/23 at 9:45 a.m., during the medication pass, revealed LVN B, after administering Resident #1's Carbamazepine and Clonazepam medication, removed the medication syringe from the resident's feeding tube and placed it back into the plastic sleeve. LVN B did not discard or rinse the medication syringe after use.<BR/>2. Record review of Resident #13's face sheet, dated 12/23/20 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included vascular dementia with delusion (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), schizoaffective disorder (a mental health problem characterized by mood symptoms), hypertension (high blood pressure) and confusion.<BR/>Record review of Resident #13's most recent discharge MDS assessment, dated 8/6/23 revealed the resident was moderately impaired for daily decision-making skills.<BR/>Record review of Resident #13's physician's orders for November 2023 revealed the following:<BR/>- Send Resident #13 to emergency room for peg tube placement with order date 11/24/23 and no end date.<BR/>- Isosource 1.5 calorie, 250 ml every 4 hours via peg tube bolus four times daily with order date 11/27/23 and no end date.<BR/>- Oxcarbazepine 300 mg three times daily for mood stabilization with order date 8/9/22 and no end date.<BR/>- Oxcarbazepine 150 mg three times daily for mood disorder with order date 5/16/23 and no end date.<BR/>Record review of Resident #13's comprehensive care plan, dated 4/18/23 revealed the resident had a chewing problem with a potential for aspiration and weight loss related to oral abscesses, ill-fitting dentures, broken, loose, carious or missing teeth and mouth pain.<BR/>Observation on 11/29/23 at 1:28 p.m., during the medication pass, revealed LVN B, after administering Resident #13's Oxcarbazepine medication, removed the medication syringe from the resident's feeding tube and placed it back into the plastic sleeve. LVN B did not discard or rinse the medication syringe after use.<BR/>During an interview on 11/29/23 at 1:38 p.m., LVN B revealed the medication syringe would have been washed if it were dirty such as with residual (gastric contents.) LVN B further revealed, in the care of Resident #1 and Resident #13, the water flush used at the end of the medication administration into the medication syringe would have been enough to have cleansed the medication syringe. LVN B revealed the facility policy was once the medication syringe was flushed with water at the end of medication administration, then the medication syringe was considered clean.<BR/>During an interview on 11/29/23 at 2:10 p.m., the DON revealed the medication syringe used for administering feedings and medications were to be washed after each use to remove residue and it was considered best nursing practice, it's part of the process for germs and what not. The DON further revealed, even with water flushes, the medication syringe could still have possible residue and should be rinsed after use.<BR/>Record review of the facility policy and procedure titled Policy for giving medications per Peg Tube, revision date 11/29/23 revealed in part, .Clean the (medication) syringe immediately after each use - failure to do so may result in the syringe becoming contaminated with dry feed or medication which may cause problems if mix with fresh fluids .clean the barrel and plunger with warm soapy only (sic) .Rinse the barrel and plunger in cold tap water then place in a paper towel to dry .store in a dry container or zip lock bag .Note: This process will help eliminate the risks of tube obstructions, altered drug responses and chemical incompatibilities .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #4) reviewed for respiratory care in that:<BR/>The facility failed to ensure Resident #4 had an oxygen sign posted outside her bedroom.<BR/>This deficient practice could place residents at risk for inadequate care.<BR/>The findings included:<BR/>Record review of Resident #4's face sheet, dated 9/6/23 revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia with behavioral disturbance, hypertension (high blood pressure), angina pectoris (condition marked by severe chest pain caused by inadequate blood supply to the heart), heart failure, glaucoma (a condition of increased pressure within the eyeball causing gradual loss of sight), depressive disorder and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs).<BR/>Record review of Resident #4's physician orders for November 2023 revealed the following:<BR/>-Oxygen 2-5 liters via mask via concentrator all shifts with order date 3/8/22 and no end date<BR/>Record review of Resident #4's comprehensive care plan, dated 9/6/23 revealed the resident had ineffective breathing patterns related to COPD (chronic obstructive pulmonary disease; disease that cause airflow blockage and breathing-related problems), asthma, frequent upper respiratory infections and decreased lung compliance as evidence by shortness of breath and labored respirations with interventions that included continuous oxygen therapy at 2-5 liters every shift.<BR/>Record review of Resident #4's most recent quarterly MDS assessment, dated 9/6/23 revealed the resident was cognitively intact for daily decision-making skills. <BR/>Observation and interview on 11/27/23 at 10:19 a.m. revealed Resident #4 sitting up in bed with the O2 concentrator operating via nasal canula at 2 liters. Resident #4 revealed she always used the oxygen concentrator. Further observation revealed there was no oxygen in use sign outside the resident's room or anywhere in the resident's room.<BR/>Observation on 11/28/23 at 9:18 a.m. revealed Resident #4 sitting up in a wheelchair in her room with the O2 concentrator operating via nasal canula at 2 liters. Further observation revealed there was no oxygen in use sign outside the resident's room or anywhere in the resident's room.<BR/>Observation on 11/29/23 at 8:13 a.m. revealed Resident #4 sitting up in a wheelchair and the O2 concentrator was operating via nasal canula at 2 liters. Further observation revealed there was no oxygen in use sign outside the resident's room or anywhere in the resident's room.<BR/>During an observation and interview on 11/29/23 at 1:47 p.m., the charge nurse, LVN B revealed she had been responsible for ensuring the oxygen concentrators were clean and the tubing was labeled with a date and the setting on the concentrator was operating per the physician's orders. LVN B stated Resident #4 did not have an oxygen in use sign outside of the resident's room and should have had the sign because it was used to alert others about the potential for a fire hazard. <BR/>During an interview on 11/29/23 at 2:26 p.m., the DON revealed it was the responsibility of the nurse to ensure the oxygen concentrators were clean, were operating per the physician's orders and a sign posted outside of the resident's room that alerted others the resident was using oxygen. The DON revealed the oxygen sign was important because it alerted those going into the resident's room that the resident was on oxygen and to use caution because it could be flammable.<BR/>Record review of the facility policy and procedure titled, Policy for Oxygen Concentrators, undated, revealed in part, .A sign must be posted on the door of resident's room advising staff and visitors to not smoke while in the room .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made for 2 of 2 (Residents #1 and#2) residents. <BR/>1.The facility failed to report on 3 separate elopement incidents Resident #1 elopement from the facility, no injuries. <BR/>2. The facility failed to report and submit Resident #2's left knee fracture, intake #379566 allegation of unknown origin. <BR/>These failures could place residents at risk for not having allegations of abuse or neglect reported to the State Agency to ensure that allegations are fully investigated.<BR/>The findings were: <BR/>1. Record review of Resident #1's admission Record dated [DATE] revealed she was admitted on [DATE] with diagnoses of vascular dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain.), severe cognitive impairment, anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome.) state and mood disorder (any of a group of mental conditions characterized by persistent disturbance of mood, especially in the form of depression or euphoria or a combination of these true clinical depression is a mood disorder, which can interfere with everyday life for an extended time. <BR/>Record review of Resident #1's admission MDS dated [DATE] revealed section C Cognitive Patterns BIMS score 99, severely impaired. <BR/>Record review of Resident #1's care plan dated [DATE] revealed resident walks, eats independently, had adequate vision, continent of bladder, communicates verbally, frequent disorientation, place, and time, wander guard, elopement risk. <BR/>Record review of an incident report dated [DATE] at 6 PM documented Resident #1 went out the laundry room gate and was brought back by staff and Resident was placed on 15-minute observations for safety. Resident #1 was observed by staff on a continuous basis after she returned to the facility by LVN A. Resident #1 was gone from facility less than 30 minutes.<BR/>Record review of an incident report dated [DATE] at 7:25 AM documented Resident #1 eloped from the facility last seen at 10 AM, notified police, APS (adult protective service), family no signs of point of exit. Resident #1 had her wander guard on her wrist and was brought back by police by LVN B. Resident #1 was gone from facility less than 30 minutes.<BR/>Record review of an incident report dated [DATE] at 2:05 PM documented dietary manager C called the facility by phone saying that she saw Resident #1 walking down the side street away from the facility and brought her back, wander guard was on wrist and was working by LVN B. Resident #1 was gone from facility less than 30 minutes.<BR/>Record review of all 3 incident reports for Resident #1 was documented she had no injures, the medical director, guardian, family, Administrator/DON, and APS were called. On one of the incidents reports the facility notified the police. All the incident reports included a head-to-toe assessment, vitals, and 15-minute checks. Wander guard check, changed locks, locked room window and continue to search for an alternate placement with a secure unit.<BR/>Interview on 9/202023 at 1:41 PM with LVN B, she stated staff knew to keep a close eye on Resident #1 because she had eloped before from the building. LVN B stated Resident #1 was in the dining room ([DATE] at 7:25 AM) for breakfast and then the next minute between checking meal trays, Resident #1 was gone from her sight. LVN B stated she told staff to start looking for Resident #1 inside and outside the facility. She notified the Administrator, and police. Staff drove around the facility, and could not find Resident #1, after about 30 minutes the police brought her back to facility. LVN B stated staff monitored Resident #1 every 15 minutes and had her wander guard bracelet on her wrist. LVN B stated she was not sure how Resident #1 left the facility. LVN B stated the second time she knew Resident #1 eloped and was brought back to facility by cook C after she saw Resident #1 walking away from the facility. LVN B stated one of the new interventions were to have the psychiatrist review her medications and prescribed a mood medication that has helped. <BR/>Interview on [DATE] at 4:14 PM with RN supervisor stated she had spoken to Resident #1's guardian, and they had both been searching for placement for Resident #1 in a locked unit for Resident #1's safety, since she first eloped in [DATE]. RN supervisor stated Resident #1 was monitored by staff and will continue to have 1:1 monitoring by staff 24 hours until she can be discharged to a locked unit facility. <BR/>Interview on [DATE] at 4:55 PM with LVN A, stated Resident #1 left the building ([DATE] at 6 PM), she was missing for about 10-15 minutes and was found and brought back with no injuries. LVN A stated they started 15-minute check on Resident #1 and LVN A liked to keep Resident #1 with her to keep her busy. LVN A stated Resident #1's wander guard bracelet was still on her. LVN A stated Resident #1 was alert and orientated times 2-3 depending on time of day. <BR/>Interview on [DATE] at 3:55 PM with the DON stated Resident #1 had eloped from the facility 3 times and had interventions in place for her, such as wander guard bracelet, 1:1 monitoring, 15-minute checks, medication reviews, psychiatrist medication review, her room window had an alarm, at night staff were right outside door while she slept and was care planned. The DON stated Resident #1 was an APS case and had brought Resident #1 to facility. The facility had reported to APS about Resident #1's elopements and being at this facility, that was not a locked unit, and was a safety risk due to her elopement. The DON stated Resident #1's guardian and administrative staff had been searching for a locked unit facility but were unsuccessful due to no finances available for her room and board. <BR/>Interview on [DATE] at 5:15 PM with Administrator/DON stated Resident #1's elopements were from 15 minutes to 30 minutes. After the last elopement, the facility started to monitor Resident #1 more closely to include 1:1 supervision. Each incident the Maintenance supervisor walked around the perimeter of the building to look for clues of how Resident #1 might have left the facility. <BR/>2. Record review of Resident #2's admission Record dated [DATE] revealed she was admitted on [DATE] and was discharged on [DATE], with diagnoses of dementia, Alzheimer's disease, Breast Cancer, paranoid delusional and depressive disorder. Resident # 2 was on hospice service and died in [DATE]. <BR/>Record review of Resident #2's mobile x-ray dated [DATE] of left femur finding were, A displaced fracture of the left femoral neck is present. Diffuse osteopenia is present. The age of the fracture is indeterminate. <BR/>Record review of incident #379566, date of incident was [DATE] at 11:30 AM, date and time the facility first learned of the incident was [DATE] at 12:15 PM, and the incident was reported findings was on [DATE] at 5:44 PM and submitted to STATE on [DATE]. This incident involved an unwitnessed fracture to Resident #2's left femoral neck.<BR/>Interview on [DATE] at 5:57 PM with the Administrator stated he was not sure why I did not report to the STATE until [DATE]. Interview with the Administrator stated when looking at his phone, to see date he should have submitted and reported Resident #2's incident, provider email from the STATE was documented [DATE].<BR/>Interview on [DATE] at 6:04 PM with the Administrator stated he used the Abuse, Neglect, and Exploitation, Misappropriation of Resident property provider letter for a resource to know when to report an incident with residents. The Administrator confirmed after surveyor intervention, he was using an old provider letter on reporting Abuse, Neglect, and Exploitation, Misappropriation of Resident property to the STATE. The provider letter he was using was dated 2014, this one stated if the resident was not missing for longer than 8 hours, he did not have to report to the STATE. The surveyor showed him the provider letter in reporting Abuse, Neglect, and Exploitation, Misappropriation of Resident property and other Incidents dated [DATE]. The Administrator looked at his phone, (intakes list) to see which day he was supposed to submit the provider investigation and was dated for [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 diseases and infections, which must include, at a minimum, the following elements: A. Standard and transmission-based precautions to be followed to prevent spread of infections, and B. The hand hygiene procedures to be followed by staff involved in direct resident contact; for 2 of 2 residents reviewed for incontinent care and medication administration (Residents #6 and #30) reviewed for standard and transmission-based precautions for infection control and prevention.<BR/>1. On 1/9/2025, CNA A and CNA J assisted Resident #6 with incontinent care and failed to change gloves with hand hygiene in between glove changes after touching handling Resident #6's soiled linens and supplies prior to touching handling Resident #6's clean linens and supplies. <BR/>2. On 1/9/2025, LVN D failed to change gloves with hand hygiene after touching handling Resident #6's clothing and furniture prior to administering Resident #6's medications. <BR/>3. LVN D failed to doff a potentially contaminated PPE gown prior to exiting Resident #6's room and wore the potentially soiled PPE gown in the hallway. <BR/>4. On 1/9/2025, LVN D failed to change gloves with hand hygiene after touching handling Resident #30's clothing and furniture prior to administering Resident #30's medications. <BR/>5. LVN D failed to doff a potentially contaminated PPE gown prior to exiting Resident #30's room and wore the potentially soiled PPE gown in the hallway. <BR/>6. The facility failed to store oxygen concentrator equipment in a clean room and stored the oxygen concentrator equipment in a bathroom. <BR/>These failures could place residents at risk for harm by cross-contamination. <BR/>The findings included:<BR/>A record review of Resident #6's admission record dated 1/9/2025, revealed an admission date of 12/17/2020 with diagnoses which included hypertension (high blood pressure), diabetes (a person's difficulty using blood sugar in their cells) and dementia (A group of symptoms that affects memory, thinking and interferes with daily life). <BR/>A record review of Resident #6's quarterly MDS assessment dated [DATE] revealed Resident #6 was an [AGE] year-old female admitted for long term care and was unable to participate in a BIMS assessment which indicated severe cognitive impairment. Resident #6 was assessed with the need for a feeding tube (AKA a g-tube).<BR/>A record review of Resident #6's care plan dated 01/09/2025 revealed, at risk for covid-19 virus . follow strict CDC guidelines <BR/>A record review of Resident #6's physicians orders dated 1/9/2025 revealed the physicians' prognosis for Resident #6 was guarded. <BR/>During an observation on 1/9/2025 at 10:57 AM revealed CNA A and CNA J assisted Resident #6 with incontinent care by donning PPE to include gowns and gloves. CNA A was observed to position and disrobe Resident #6 and continued to dispense cleansing wipes from the clean wipes package, clean Resident #6's genitalia and buttocks with multiple wipes kept atop of Resident #6's soiled under-pad, changed gloves without hand hygiene in between glove changes, and proceeded to remove the soiled linen and under pads, and then provided clean linen and adult briefs with the same soiled contaminated gloves. CNA A then doffed the gloves without performing hand hygiene and exited Resident #6 room. <BR/>During an observation on 1/9/2025 at 11:17 AM, CNA A stated she changed gloves after every 3 to 4 wipes. CNA A stated she should have sanitized her hands after changing gloves, and improper hand hygiene was a risk for causing infections and cross contaminations or getting stool into Resident #6's vagina.<BR/>2. An observation and interview on 1/9/2025 at 9:11 AM revealed LVN D administered medications to Resident #6 via her g-tube. LVN D donned gloves without providing hand hygiene prior to donning, handled medication cart and keys, and entered Resident #6's room and assessed Resident #6's blood pressure, exited Resident #6 room without doffing the gloves and or performing hand hygiene, nor disinfecting the blood pressure cuff, and proceeded to prepared Resident #6's medications with the same gloves. LVN D donned PPE to include a gown and continued with the same gloves. LVN D was observed to handle Resident #6's person, clothing, furniture, and enteral piston syringe and then proceeded to administer Resident #6's medications via her g-tube while not changing gloves with hand hygiene prior to the medication administration. After the medication administration LVN D was observed to exit Resident #6's room without doffing the gown, doffed the gloves without providing hand hygiene, and continued into the hallway and entered a bathroom to wash Resident #6's enteral piston syringe and performed hand hygiene. LVN D continued in the hallway and reentered Resident #6's room to replace the piston syringe in the package, exited Resident #6's room and doffed the gown without performing hand hygiene. LVN D stated she should have changed gloves with hand hygiene before administering Resident #6's g-tube medications and stated the potential harm for residents was infections. <BR/>3. A record review of Resident #30's admission record dated 07/22/2024 revealed an admission date of 03/01/2022 with diagnoses which included gastronomy status (presence of a g-tube), dementia, and seizures (electrical storms of the brain). <BR/>A record review of Resident #30's quarterly MDS assessment dated [DATE] revealed Resident #30 was a [AGE] year-old female admitted for long term care and assessed with a severely impaired cognition, could not communicate her needs. Resident #30 was assessed with the need for a feeding tube.<BR/>A record review of Resident #30's care plan dated 12/13/2024 revealed Resident #30 was quadriplegic (a symptom of paralysis that affects all a person's limbs and body from the neck down), NPO (Latin for nothing by mouth) and required enteral feeding (enteral administration is food or drug administration via the human gastrointestinal tract), Tube feeding . Resident has gastronomy tube . assess feeding tube placement, patency, and residual every shift and before and after administration of any fluids or medications. <BR/>A record review of Resident #30's physicians orders dated 1/9/2025 revealed the physicians' prognosis for Resident #30 was guarded.<BR/>During an observation on 1/9/2025 at 9:48 AM revealed LVN D donned gloves without performing hand hygiene, prepared Resident #30's medications, doffed the gloves without hand hygiene, donned new gloves, entered Resident #30's room, recognized she was missing a piston syringe and a PPE gown, exited the room while continuing with the same gloves, walked to the supply cabinet closet in the hallway, donned a gown and returned to Resident #30's bedside with the same gloves. LVN D was observed to administer Resident #30's medications with the same gloves. After LVN D administered Resident #30's medications she was observed to exited Resident #30's room, without doffing the gown and gloves, continued in the hallway to the bathroom where she doffed the gloves provided hand hygiene and washed the piston syringe. LVN D continued with the same gown in the hallway and returned to Resident #30's room to replace the piston syringe and doffed the gown. <BR/>4. During daily observations from 1/7/2025 through 1/10/2025 revealed the A Hallway public bathroom for staff and visitors. Further daily observations revealed the bathroom housed 2 clean oxygen concentrators covered with plastic translucent bags. The bags were labeled cleaned 1/6/2025 and 12/2/24.<BR/>During an interview on 1/8/2025 at 1:20 PM, LVN E stated the clean oxygen concentrators were available for resident-use and were stored in the staff and visitors public restroom due to lack of space with in the facility. <BR/>During an interview on 01/10/2025 at 2:00, the DON stated the expectation for infection control and prevention was for staff to follow standard precautions for all residents and enhanced barrier precautions for residents with g-tubes. The DON stated standard precautions were for staff to perform glove changes when going from a dirty to clean scenario and to perform hand hygiene in between all glove changes and when gloves are doffed. The DON continued to state all PPE must not be worn in the hallways and should be doffed in the enhanced barrier precautions room. The DON stated the nursing staff were trained per CDC guidelines for standard and enhanced barrier precautions. <BR/>During an interview on 1/10/2025 at 5:00 PM, the Administrator stated he agreed with the DON's expectations for infection control and prevention. <BR/>A policy for infection control was requested on 1/10/2025 and was not provided upon exit on 1/10/2025.<BR/>A record review of the United States of America's Centers for Disease Control and Preventions website titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings. <BR/>https://www.cdc.gov/infection-control/hcp/core-practices/index.html<BR/>Accessed 1/10/2025, revealed, Use Standard Precautions to care for all patients in all settings. Standard Precautions include:<BR/>5a. Hand hygiene<BR/>5b. Environmental cleaning and disinfection . <BR/>5f. Reprocessing of reusable medical equipment between each patient or when soiled Standard Precautions are the basic practices that apply to all patient care, regardless of the patient's suspected or confirmed infectious state, and apply to all settings where care is delivered. These practices protect healthcare personnel and prevent healthcare personnel or the environment from transmitting infections to other patients. <BR/>5a. Hand Hygiene . <BR/>Use an alcohol-based hand rub or wash with soap and water for the following clinical indications:<BR/>Immediately before touching a patient.<BR/>Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices.<BR/>Before moving from work on a soiled body site to a clean body site on the same patient.<BR/>After touching a patient or the patient's immediate environment.<BR/>After contact with blood, body fluids or contaminated surfaces.<BR/>Immediately after glove removal.<BR/>Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled.<BR/>Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered.<BR/>Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. 5d. Risk Assessment with Appropriate Use of Personal Protective Equipment . <BR/>Ensure proper selection and use of personal protective equipment (PPE) based on the nature of the patient interaction and potential for exposure to blood, body fluids and/or infectious material:<BR/>Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur.<BR/>Wear a gown that is appropriate to the task to protect skin and prevent soiling of clothing during procedures and activities that could cause contact with blood, body fluids, secretions, or excretions.<BR/> . Remove and discard PPE . upon completing a task before leaving the patient's room or care area. Do not use the same gown or pair of gloves for care of more than one patient. Remove and discard disposable gloves upon completion of a task or when soiled during the process of care. Ensure that healthcare personnel have immediate access to and are trained and able to select, put on, remove, and dispose of PPE in a manner that protects themselves, the patient, and others

Based on record review and interview, the facility failed to include as part of its QAPI program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program, for 9 of the 16 staff members (the AADM, the DON, LVN C, LVN D, CNA E, CNA F, CNA G, CNA H, CNA I) reviewed for mandatory training, in that: <BR/>Nine staff members (the AADM, the DON, LVN C, LVN D, CNA E, CNA F, CNA G, CNA H, CNA I) reviewed for mandatory training had not received training regarding the facility's QAA-QAPI program. <BR/>This failure could place residents at risk of receiving inadequate care from staff who are unfamiliar with the facility's QAPI program. <BR/>The findings included: <BR/>Record review of employee files reflected the following employees had not received training regarding the QAPI program:<BR/>-AADM was hired on 11/20/1986 <BR/>-DON hired on 10/16/2023<BR/>-LVN C, hired on 8/22/2011<BR/>-LVN D, hired on 06/27/2016<BR/>-CNA E, hired on 04/25/2017<BR/>-CNA F, hired on 03/17/2016<BR/>-CNA G, hired on 11/20/1986<BR/>-CNA H, hired on 05/04/2005<BR/>-CNA I, hired on 01/19/2016<BR/>Interview 11/30/2023 at 3:16 PM, the ADON stated she was not aware of staff being required to be trained in any manner related to QAPI and could not find training related to QAPI for other staff. The ADON stated she had only known of the committee members to be trained on QAPI or QAA.<BR/>Interview on 11/30/2023 at 4:16 PM, the ADM stated he was not the QA point-of-contact and was not aware other staff members apart from the committee members were required to be trained on QAA and QAPI. The ADM stated he believed the QA plan and associated processes related to QAPI were helpful to staff. The ADM stated he did not understand the risk associated with staff being untrained on QAPI. The ADM stated the facility did not have a policy related to QAPI training or who was required to be trained on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #6<BR/>FTag Initiation<BR/>01/10/25 03:31 PM Initiate F700 & F656 initiated d/t order for abdominal binder and fact that abdominal binder is not identified in the care plan and use of 1/2 side rail for positioning (not appropriate need for this resident). <BR/>Resident #33<BR/>FTag Initiation<BR/>01/10/25 10:39 AM Thorazine consent not signed, wrong resident and theo [NAME] res was not on thorazine<BR/>vns check was not on mar,

Based on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 3 medication carts (the medication aide cart) reviewed for supervision and security.<BR/>The Medication cart was left unsupervised and unsecured for 25 minutes by an unknown staff member. <BR/>This failure could place residents at risk for harm by not receiving the therapeutic effects of their medications. <BR/>The findings included:<BR/>During an observation on 1/9/2025 at 10:30 AM revealed the medication cart was left unsupervised and unsecured and positioned in the A hall by Resident #4's room. Continued observation from 10:30 AM until 10:55 AM revealed Resident #4 and Resident #20, housekeepers, and CNAs walked freely in the hallway back and forth past the unattended and unsecured medication cart.<BR/>During an observation and interview on 1/9/2025 at 10:56, LVN D was alerted to the unsecured and unattended medication cart. LVN D was observed to lock the cart and stated the medication cart was not her assigned cart for the day and MA I was assigned to the medication cart. LVN D stated MA I was, on a break most likely.<BR/>During an interview on 1/9/2025 at 3:00 PM, the DON stated all medication carts should be secured when not in use. The DON stated the risk for residents could be uncontrolled medications, unsecured <BR/>During an interview on 1/10/2025 at 5:00 PM, the Administrator stated he agreed with the DON's expectations for secured medication carts.<BR/>A policy was requested on 1/10/2025 and had not been received by exit on 1/10/2025.<BR/>A record review of the CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services website:<BR/>https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/Downloads/LewinGroup.pdf<BR/>accessed 1/19/2025 revealed, . Medication carts must be supervised at all times by the nurse administering medications. When medication carts are not in use, they must be stored in a designated locked area with all drawers locked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #6<BR/>FTag Initiation<BR/>01/10/25 03:31 PM Initiate F700 & F656 initiated d/t order for abdominal binder and fact that abdominal binder is not identified in the care plan and use of 1/2 side rail for positioning (not appropriate need for this resident). <BR/>Resident #33<BR/>FTag Initiation<BR/>01/10/25 10:39 AM Thorazine consent not signed, wrong resident and theo [NAME] res was not on thorazine<BR/>vns check was not on mar,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY<BR/>Environment<BR/>01/09/25 02:35 PM poor lighting in shower rooms. a and b, resident little stated she used shower and she could use a better light, and could be warmer, the heater in a and b were not working. <BR/>01/09/25 05:36 PM pm [NAME] stated laundry door gap ok, ok for concern and no tag for door gap, shower curtain in between dirty and clean, and toilet on pedestal, <BR/>Resident #19<BR/>FTag Initiation<BR/>01/10/25 01:31 PM no light in shwr and bump on ramp.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY<BR/>Environment<BR/>01/09/25 02:35 PM poor lighting in shower rooms. a and b, resident little stated she used shower and she could use a better light, and could be warmer, the heater in a and b were not working. <BR/>01/09/25 05:36 PM pm [NAME] stated laundry door gap ok, ok for concern and no tag for door gap, shower curtain in between dirty and clean, and toilet on pedestal, <BR/>Resident #19<BR/>FTag Initiation<BR/>01/10/25 01:31 PM no light in shwr and bump on ramp.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assess each resident annually using the Minimum Data Set form specified by the state and approved by CMS for 1 of 16 residents (Resident #26) reviewed for annual assessments, in that:<BR/>Resident #26's Annual MDS Assessment was not completed within 366 days of the previous annual assessment.<BR/>This failure could place residents at-risk of not having their assessments completed timely.<BR/>The findings were: <BR/>Record review of Resident #26's face sheet reflected a [AGE] year-old resident with an original admission date of 02/08/2019 and a primary diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (paralysis of partial or total body function on one side of the body).<BR/>Record review of Resident #26's last annual MDS assessment reflected a completion date of 10/26/2022. The proceeding MDS assessment was due dated 10/27/2023, however it was dated opened on 11/20/2023. <BR/>Interview on 11/29/2023 at 2:41 PM, the DON stated she had begun working at the facility on 10/26/2023 and was responsible for completing MDS assessments. The DON stated she was not sure why the MDS assessments were being completed late and was told by the ADM that she was to complete the late ones. The DON stated the expectation was for MDS assessments to be completed in the prescribed timeframes by the RAI Manual. The DON stated the risks associated with not completing the assessments timely were that changes in condition could potentially be overlooked. <BR/>Interview on 11/30/2023 at 2:40 PM, the ADM stated he was aware of the Annual MDS Assessment for Resident #26 having been completed late and stated it was due to the former MDS Coordinator leaving their position at the facility. The ADM stated it was his expectation that MDS assessments be completed timely as to reduce the risk of changes in condition be overlooked.<BR/>Record review of the RAI (Resident Assessment Instrument) Manual OBRA Assessment Summary, dated 10/2019, reflected, The Annual assessment is an OBRA comprehensive assessment for a resident that must be completed at least every 366 days following the previous OBRA comprehensive assessment.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: <BR/>The facility failed to obtain pasteurized eggs for the purpose of serving undercooked eggs for residents. <BR/>These failures could place residents at risk for cross-contamination and foodborne illness. <BR/>The findings included: <BR/>Observation and interview on 11/29/2023 at 3:51 PM revealed four (4) cartons of unpasteurized eggs stored in the reach-in refrigerator in the kitchen. The DM stated five (5) of the thirty-three (33) residents eat fried and/or over-easy eggs for breakfast. The DM stated she was aware of the presence of the unpasteurized eggs and the risks associated with serving them undercooked to residents such as foodborne illness. The DM stated she did not have a precise reason the facility had purchased only unpasteurized eggs. <BR/>Interview on 11/29/2023 at 4:12 PM, the ADM stated that he had spoken with the DM. The ADM stated he was aware of the risk associated to residents with undercooked unpasteurized eggs. <BR/>Interview on 11/29/2023 at 4:29 PM, Resident #19 stated she received over-easy eggs daily and described the yolk of the egg being runny in texture. Resident #19 stated she had not had any gastrointestinal concerns or issues recently. <BR/>Interview on 11/30/2023 at 2:40 PM, the ADM stated he was not aware of the usage of unpasteurized eggs in the kitchen and stated he was fearful of the potential for gastrointestinal issues developing in residents, as some eat undercooked eggs. The ADM stated he did not have an explicit expectation for egg types and stated his future expectation was that the facility would purchase both pasteurized and unpasteurized eggs, and only utilize the pasteurized eggs for undercooked eggs. The ADM stated the facility did not have a specific policy on the acquisition of food products or on food storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #6<BR/>FTag Initiation<BR/>01/10/25 03:31 PM Initiate F700 & F656 initiated d/t order for abdominal binder and fact that abdominal binder is not identified in the care plan and use of 1/2 side rail for positioning (not appropriate need for this resident). <BR/>Resident #33<BR/>FTag Initiation<BR/>01/10/25 10:39 AM Thorazine consent not signed, wrong resident and theo [NAME] res was not on thorazine<BR/>vns check was not on mar,

Based on record review and interview, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 14 staff (the DOR) reviewed for background screenings, in that: <BR/>The facility had failed to complete an Employee Misconduct Registry search for the DOR. <BR/>This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. <BR/>The findings included: <BR/>Record review of the facility Key Personnel roster, dated 11/28/2023, reflected an unknown hire date for the DOR. <BR/>Record review of the DOR's Personnel File reflected no evidence of a completed Employee Misconduct Registry search.<BR/>Interview on 11/30/2023 at 2:40 PM, the ADM stated the DOR was contracted with the facility and provided services onsite to the residents as a Physical Therapist. The ADM stated he was not aware that contracted staff were required to also be searched on the employee misconduct registry and stated he understood the risk associated with not searching frequent visitors providing health services on the employee misconduct registry.<BR/>Record review of the Abuse and Neglect policy, dated 08/2011, reflected all staff on site prior to hire and annually are to be searched for criminal history and past misconduct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assess each resident quarterly using the Minimum Data Set form specified by the state and approved by CMS for 3 of 16 residents (Resident #12, #26, and #28) reviewed for quarterly assessments, in that: <BR/>Resident #12, #26, and #28's quarterly MDS Assessment was not completed within 92 days of the previous quarterly assessment. <BR/>This failure could place residents at-risk of not having their assessments completed timely. <BR/>The findings were: <BR/>Record review of Resident #12's face sheet reflected an [AGE] year-old resident with an original admission date of 01/17/2019 and a primary diagnosis of schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania.)<BR/>Record review of Resident #12's most recent MDS Assessment, dated 7/31/2023, reflected the due date of the next Quarterly MDS Assessment was to be completed on 10/31/2023. Further review reflected the Quarterly MDS Assessment due on 10/31/2023 had not been started. <BR/>Record review of Resident #26's face sheet reflected a [AGE] year-old resident with an original admission date of 02/08/2019 and a primary diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (paralysis of partial or total body function on one side of the body). <BR/>Record review of Resident #26's most recent MDS Assessment, dated 7/27/2023, reflected the due date of the next Quarterly MDS Assessment was to be completed on 10/27/2023. Further review reflected the Quarterly MDS Assessment due on 10/27/2023 had been started on 11/10/2023. <BR/>Record review of Resident #28's face sheet reflected a [AGE] year-old resident with an original admission date of 01/15/2019 and a primary diagnosis of seizures/convulsions.<BR/>Record review of Resident #28's most recent MDS Assessment, dated 7/28/2023, reflected the due date of the next Quarterly MDS Assessment was to be completed on 10/28/2023. Further review reflected the Quarterly MDS Assessment due on 10/28/2023 had not been started. <BR/>Interview on 11/29/2023 at 2:41 PM, the DON stated she had begun working at the facility on 10/26/2023 and was responsible for completing MDS assessments. The DON stated she was not sure why the MDS assessments were being completed late and was told by the ADM that she was to complete the late ones. The DON stated the expectation was for MDS assessments to be completed in the prescribed timeframes by the RAI Manual. The DON stated the risks associated with not completing the assessments timely were that changes in condition could potentially be overlooked. <BR/>Interview on 11/30/2023 at 2:40 PM, the ADM stated he was aware of the Quarterly MDS Assessment for Residents #12, #26, and #28 having been completed late and stated it was due to the former MDS Coordinator leaving their position at the facility. The ADM stated it was his expectation that MDS assessments be completed timely as to reduce the risk of changes in condition be overlooked. <BR/>Record review of the RAI (Resident Assessment Instrument) Manual OBRA Assessment Summary, dated 10/2019, reflected, The Annual assessment is an OBRA comprehensive assessment for a resident that must be completed at least every 366 days following the previous OBRA comprehensive assessment.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 medication carts (Treatment/Medication Cart) in that:<BR/>The facility failed to ensure expired mediations were not found on the Treatment/Medication cart.<BR/>This deficient practice could affect residents who received medications or treatments and could result in less potent or adverse effects. <BR/>The findings included: <BR/>Observation on 11/29/23 at 10:54 a.m. of the inspection of the Treatment/Medication Cart with LVN B revealed the following:<BR/>- 1 open tube of moisturizing wound hydrogel with expiration date 3/29/2022<BR/>- 2 open packages of Oil Emulsion Non-Adherent Dressings with expiration date 11/2022<BR/>- 1 open box of anti-diarrheal 2 mg tablets with expiration date 9/2023<BR/>- 2 open tubes of antimicrobial skin and wound gel with expiration date 5/11/2023<BR/>- 1 bottle of sterile saline 0.9% with expiration date 1/28/2023<BR/>During an interview on 11/29/23 at 11:08 a.m., LVN B revealed she routinely checked the Treatment/Medication cart for expired medications but did not check items used for wound treatments such as gauze. LVN B revealed it was important to dispose of expired items from the Treatment/Medication cart because someone else using the cart could use the expired items and the residents would not receive the intended effect from the expired items.<BR/>During an interview on 11/29/23 at 3:55 p.m., the DON revealed it was LVN B's responsibility to ensure the Treatment/Medication cart did not have any expired items in the cart because LVN B provided the treatments to the residents during the day shift as no treatments were scheduled for the night shift. The DON further revealed, LVN B was responsible for ensuring the Treatment/Medication cart was stocked for the weekend treatment nurse. The DON revealed the facility could not store expired medications in the cart or anywhere because it could cause a negative reaction or may not be therapeutic if the expired item was used on a resident. The DON revealed, anything used from a medication cart should be checked before use, including the expiration date.<BR/>Record review of the facility policy and procedure titled, Policy for Medication Storage, undated, revealed in part, .All medications must be stored in a secured place, according with manufacturer .Medications must be checked at least monthly and those medications that are expired or close to be expired, must be taken to Director of Nursing's office to be destroyed when pharmacist comes to the facility, which occurs on a monthly basis .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to provide the required square footage per resident (80 square feet per resident) in 20 of 28 bed rooms (Rooms 1, 2, 3, 4, 5 , 6, 8, 12, 13, 14, 15, 16, 17, 18, 21, 23, 25, 26, 27, and 28) reviewed for square foot, in that: <BR/>Rooms 1, 2, 3, 4, 5 , 6, 8, 12, 13, 14, 15, 16, 17, 18, 21, 23, 25, 26, 27, and 28 did not have the required 80 square feet per resident.<BR/>This deficient practice could place residents who reside in those rooms at-risk for the restriction of the amount of resident care equipment and residents' personal effects that could be accommodated in these rooms.<BR/>The findings were:<BR/>Record review of Form 3740, dated 09/23/2022, Bed Classification Section C revealed that resident Rooms 1, 2, 3, 4, 5 , 6, 8, 12, 13, 14, 15, 16, 17, 18, 21, 23, 25, 26, 27, and 28 were all designated as double occupancy rooms (2 residents per room). Further review revealed rooms [ROOM NUMBER] were triple occupancy rooms (3 residents per room).<BR/>During an interview with the Administrator on 09/23/2022 at 9:00 a.m., the Administrator confirmed Rooms 1, 2, 3, 4, 5 , 6, 8, 12, 13, 14, 15, 16, 17, 18, 21, 23, 25, 26, 27, and 28 did not provide the required 80 square feet per resident and their size measurements had not changed since the previous year. The Administrator requested for the room waiver to remain in effect. The Administrator confirmed the following size measurements for the resident rooms under the room size waiver: <BR/>1. Resident room [ROOM NUMBER] measurements were 12.04 feet by 12 feet for a total of 144.8 square feet. This was a double occupancy room which provided 72.24 square feet per resident. <BR/>2. Resident Room # 2 measurements were 12.08 feet by 11.92 feet for a total of 143.99 square feet. This was a double occupancy room which provided 72 square feet per resident.<BR/>3. Resident Room # 3 measurements were 12.08 feet by 11.92 feet for a total of 144.48 square feet. This was double occupancy room which provided 72.24 square feet per resident. <BR/>4. Resident Rooms # 4 and # 5 measurements were 12.04 feet by 11.96 feet for a total of 144 square feet. These resident rooms were double occupancy rooms which provided 72 square feet per resident. <BR/>5. Resident Room # 6 had two different size areas. The measurements of these areas were 12.3 feet by 10.6 feet for a total of 128.63 square feet and the second area was 6.7 feet by 4.5 feet for a total of 29.08 square feet. The total square footage of these two areas in resident room [ROOM NUMBER] was 157.71 square feet. This room was a double occupancy room which provided 78.86 square feet per resident.<BR/>6. Resident Room # 8 had two different size areas. The measurements of these areas were 12.4 feet by 10.4 feet for a total of 127.37 square feet and the second area was 6.8 feet by 4.9 feet for a total of 31.68 square feet. The total square footage of these two areas in resident room [ROOM NUMBER] was 159.05 square feet. This room was a double occupancy room which provided 79.53 square feet per resident.<BR/>7. Resident room [ROOM NUMBER] had two different size areas. The measurements of these areas were 12.08 feet by 10.25 feet for a total of 123.82 square feet and the second area was 6.58 feet by 4.67 feet for a total of 30.73 square feet. The total square footage of these 2 areas in resident room [ROOM NUMBER] was 154.55 square feet. This room was a double occupancy room which provided 77.28 square feet per resident.<BR/>8. Resident room [ROOM NUMBER] had 2 different size areas. The measurements of these areas were 12.2 feet by 10.3 feet for a total of 124.75 square feet and the second area was 6.8 feet by 4.6 feet for a total of 30.02 square feet. The total square footage of these 2 areas in resident room [ROOM NUMBER] was 154.77 square feet. This room was a double occupancy room which provided 77.39 square feet per resident.<BR/>9. Resident Room # 14 had two different size areas. The measurements of these areas were 12.2 feet by 10.5 feet for a total of 126.82 square feet and the second area was 6.8 feet by 4.6 feet for a total of 30.02 square feet. The total square footage of these two areas in resident room [ROOM NUMBER] was 156.84 square feet. This room was a double occupancy room which provided 78.42 square feet per resident.<BR/>10. Resident Room # 15 measurements were 12.08 feet by 11.92 feet for a total of 143.99 square feet. This was a double occupancy room which provided 72 square feet per resident.<BR/>11. Resident Rooms # 16 and # 17 measurements were 12.04 feet by 11.96 feet for a total of 144 square feet. These resident rooms were double occupancy rooms which provided 72 square feet per resident.<BR/>12. Resident Room # 18 had two different size areas. The measurements of these areas were 18 feet by 11.8 feet which equaled 210.06 square feet and the second area was 5.2 feet by 4.3 feet which equaled 21.97 square feet. The total square footage of these two areas in resident room [ROOM NUMBER] was 232.03 square feet. This room was a triple occupancy room which provided 77.34 square feet per resident.<BR/>13. Resident Room # 21 measurements were 20.67 feet by 10.34 feet for a total of 213.72 square feet. This was a triple occupancy room which provided 71.24 square feet per resident.<BR/>14. Resident Room # 23 measurements were 20.83 feet by 10.58 feet for a total of 220.4 square feet. This was a triple occupancy room which provided 73.47 square feet per resident.<BR/>15. Resident Room # 25 measurements were 12 feet by 12 feet for a total of 144 square feet. This was a double occupancy room which provided 72 square feet per resident.<BR/>16. Resident Room # 26 measurements were 12.04 feet by 11.98 feet for a total of 144 square feet. This was a double occupancy room which provided 72 square feet per resident.<BR/>17. Resident Room # 27 measurements were 12.02 feet by 11.98 feet for a total of 144 square feet. This was a double occupancy room which provided 72 square feet per resident.<BR/>18. Resident Room # 28 measurements were 12.04 feet by 12.04 feet for a total of 144.96 square feet. This was a double occupancy room which provided 72.48 square feet per resident.

Based on observation and interviews, the facility failed to ensure the resident received care and services safely and that the physical layout of the facility maximized resident independence and did not pose a safety risk, with housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and adequate and comfortable lighting levels in all areas; for 2 of 2 shower rooms (A hall shower and B hall shower) reviewed for trip hazards and lighting.<BR/>1. The facility failed to have adequate safe lighting for the showers as evidenced by the B Hall shower having a shower stall with no light fixture within the shower stall and the A hall shower stall having no functioning light bulb in the fixture within the shower stall.<BR/>2. The facility failed to ensure there was no trip hazard in the A hall shower room as evidenced by the A hall shower stall had an inclined ramp up to the shower stall with a tile bump atop of the ramp. <BR/>These failures could place residents at risk for injuries by not having adequate lighting and trip hazards.<BR/>The findings included:<BR/>Daily observations beginning on 1/7/2025 at 10:45 AM through 1/10/2025 at 3:00 PM revealed the facility had a census of 34 with 2 shower rooms within the facility, located in A hall and B hall. An observation of the B hall shower room revealed a shower stall with an inclined ramp up into the shower stall, the stall appeared dark and was dimly illuminated by the nearby fluorescent ceiling lamp. Further observation revealed no light fixture within the shower stall. Observation of the A hall shower room revealed a shower stall with an inclined ramp which led up into the shower stall. The ramp presented with a tiled and curved bump atop of the ramp. <BR/>An observation and interview on 1/10/2025 at 11:34 AM revealed the Maintenance Director reviewed the B hall shower room. The Maintenance Director stated the shower stall did not have a light fixture. The Maintenance Director stated the shower stall had an inclined ramp up into the shower stall, the stall appeared dark and was dimly illuminated by the nearby fluorescent ceiling lamp.<BR/>An observation and interview on 1/10/2025 at 11:41 AM revealed the Maintenance Director reviewed the A hall shower room. The Maintenance Director stated the shower stall did have a light fixture with a burned-out bulb and was not aware when the bulb may have burned-out. The Maintenance Director stated the shower stall had an inclined ramp which led up into the shower stall. The ramp presented with a tiled curved bump atop of the ramp. The Maintenance Director stated the curved bump tile may have been added to the top of the ramp to prevent water from draining down on to the floor when the drain may clog. The Maintenance Director stated he was not aware if this tiled bump would be a safety risk to anyone.<BR/>An observation and interview on 1/10/2025 at 1:34 PM revealed hospice CNA K prepared linens and clothing for a Resident's shower in the A hall shower room and stated a light within the shower stall would allow her to better serve her residents with their skin assessments and ensure hygiene. CNA K stated the bump atop of the ramp made it difficult to push or pull residents over the bump, into the shower stall, and would often startle residents when the bump was overtaken.<BR/>An observation and interview on 1/10/2025 at 2:20 PM revealed CNAs A and J reviewed the A hall shower room and stated the bump atop of the ramp had caused near trip hazards for them as they pushed or pulled residents over the bump. CNAs A and J stated there were several residents who used the shower by themselves, and the poor light and the bump could place them at risk for falling.<BR/>During an interview on 01/10/2024 at 4:00 PM, the DON stated the poor lighting in the shower rooms should be corrected, and the tile curved bump atop of the A hall shower room ramp would be reviewed for safety and necessity. <BR/>During an interview on 1/10/2025 at 5:00 PM, the Administrator stated he agreed with the DON assessment of the shower rooms. <BR/>A policy was requested on 1/10/2025 and was not provided to the survey team before exit.

Based on an interview and record review, the facility failed to ensure that the facility's infection preventionist attended the QAA/QAPI meetings, for 1 of 1 facility, reviewed for QAA/QAPI.<BR/>The facility failed to ensure the infection preventionist attended their QAA and QAPI meetings for any month since the last annual survey (09/23/2022). <BR/>This failure could place residents at risk for quality deficiencies being unidentified and a lack of appropriate plans of action developed or implemented.<BR/>The findings included: <BR/>Record review of the facility's QAA/QAPI standing members list reflected the infection preventionist was not a member. <BR/>Interview on 11/30/2023 at 3:16 PM, the ADON stated the QAA/QAPI committee met quarterly and that LVN B, the Infection Preventionist, was not a part of these meetings. The ADON stated she was not aware that the Infection Preventionist was a required member of the committee. The ADON stated she understood the risk of not having the Infection Preventionist as a committee member as infection control concerns may not be brought to the committee. <BR/>Interview on 11/30/2023 at 3:39 PM, LVN B stated she was the facility Infection Preventionist. LVN B stated she was not a member of the QAA/QAPI Committee and had never attended a QAA/QAPI meeting. LVN B stated she was never informed of the requirement of the Infection Preventionist being a member of the committee. <BR/>Interview on 11/30/2023 at 4:16 PM, the ADM stated he was aware of the Infection Preventionist not being a QAA/QAPI committee member. The ADM stated he was not aware of the requirement of the Infection Preventionist being part of the committee. The ADM stated he was unsure of the risks posed by not having the Infection Preventionist be a member. The ADM stated the facility did not have a policy associated with QAA/QAPI, and the Plan did not state specific membership.