HARMONY CARE AT GIDDINGS

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 7 residents (Residents #5 and #7) reviewed for care plans.<BR/>1. The facility failed to ensure the comprehensive care plan for Resident #5 included the need for a mechanical lift transfer with the assistance of 2 staff. <BR/>2. The facility failed to ensure Resident #7's comprehensive care plan included aggressive behaviors. <BR/>These failures could affect residents by placing them at risk of not receiving appropriate physical and psychosocial care. <BR/>Findings included:<BR/>Review of Resident #5's face sheet, dated 2/9/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that occurs when the right side of the brain was damaged, resulting in physical disabilities on the left side of the body), depression, unspecified (disorder than can impact your mood, thoughts and feelings, weight, sleeping habits, etc.) and pain. <BR/>Review of Resident #5's MDS admission Assessment, dated 07/22/24, reflected Resident #5 had a BIMS score of 10, which indicated her cognition was moderately impaired. Resident #5 required a mechanical lift with transfers. <BR/>Record review of Resident #5's Comprehensive Care Plan, revised, 09/12/24 reflected a focus area of ADL self-care performance the interventions listed included TRANSFER: the resident is able to: Requires total assist x1.<BR/>Review of Resident #7's face sheet, dated 2/9/25, reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of dementia severe with agitation (brain impairment of at least two brain functions with worry and anxiety) and schizoaffective disorder (a combination of schizophrenia, a mental health condition with symptoms of hallucinations or delusions mixed with mood disorder such as mania and depression)<BR/>Review of Resident #7's MDS Assessment, dated 1/31/25, reflected Resident #7 had a BIMS score of a 3, which indicated severe cognitive impairment. <BR/>Review of Resident #7's Comprehensive Care Plan, initiated, 1/28/25 reflected a focus area of a regular/mechanical soft diet. No other focused areas were included.<BR/>Review of progress Notes from previous facility included with admission paperwork, dated 1/13/25, revealed recent documentation of aggressive history for Resident #7 on 1/23/25 it was noted he had the behavior of grabbing and spitting on nurses. <BR/>During an interview on 2/8/25 at 12:48 pm, CNA F stated Resident #7 had been frequently aggressive with staff when they were providing care. He stated he knew of one incident in which Resident #7 was also aggressive with a peer. CNA F stated he did the best he could do to deal with the aggression and protect the other residents. <BR/>During an interview on 2/8/25 at 4:49 pm, CNA G stated she experienced Resident #7 being aggressive toward staff. CNA G stated she would, in the past, just back off from assisting him and try again later. <BR/>During an interview on 2/9/25 at 11:30 am the Adm stated the person responsible for care plans was a corporate nurse, and the DON added some of the nursing needs. He stated aggressive behaviors and transfer needs should be included in a resident's care plan. <BR/>During an interview on 2/10/25 at 9:30 am with the DON revealed that she was only able to add antibiotic treatments and falls to a care plan. She stated Resident #4's transfer needs with the mechanical lift and 2 staff should be on the care plan. Resident #7's aggression should also be addressed on the care plan. <BR/>During an interview on 2/10/25 at 9:10 am with Corporate LVN/DOR stated that day she was notified that the MDS nurse was out sick. It was her job to oversee all care plans at that facility, and others owned by the same corporation. The LVN/DOR stated she was not aware that Resident #4's care plan did not include her transfer requirements. She stated a mechanical lift always required the use of two staff members and should be included in the care plan. The LVN/DOR stated she was not familiar with Resident #7 but looking at his records they were close to being within the time, 21 days, that a comprehensive care plan was required. She stated the of the care plans was so they can provide the best care possible for the residents. <BR/>Review of the facility policy titled Lifting Machine, Using a Mechanical, revised 7/2017, reflected the following: At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.<BR/>Review of the facility's Care Plans, Comprehensive Person-Centered policy, revised March 2022, reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.<BR/>Policy Statement:<BR/>The interdisciplinary team is responsible for the development of resident care plans.<BR/>Policy Interpretation and Implementation:<BR/>1. Resident care plans are developed according to the timeframes and criteria established by &sect;483.21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 4 residents review for catheter care.<BR/>The facility failed to change Resident #1's foley catheter (a medical device used to drain urine from the bladder.) as ordered monthly on 04/09/2025 and 5/9/2025. Resident #1 was sent to the local ER on [DATE] due to fever and lethargy and was diagnosed with possible sepsis (is a life-threatening condition that occurs when the body has extreme response to infection).<BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/2025 at 4:19 pm and an IJ template was given. While the IJ was removed on 05/20/2025 at 7:01 pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This deficient practice could place residents at risk for hospitalization, coma and death.<BR/>Findings included:<BR/>Review of Resident # 1's face sheet dated 05/18/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Autistic disorder (is a developmental disorder that affects communication, behavior and social interaction, with symptoms typically appearing in early childhood), Hypertension (HTN - High blood pressure), Urinary retention, history of Urinary Tract Infections (UTI -occurs when bacteria get in the urinary system, often through the urethra, and begin to multiply in the bladder), Diabetes Mellitus type II (a chronic condition characterized by insulin resistance and elevated blood sugar levels).<BR/>Review of Resident #1's hospital discharge papers dated 4/1/2025 reflected: <BR/>Urinary retention<BR/>-multiple trials of foley removal without success<BR/>-continue foley<BR/>-continue Flomax<BR/>-3/10 foley replaced by urology. replace foley monthly.<BR/>Review of Resident #1's admission MDS dated [DATE] indicated he had a BIMS score of not conducted indicating severe cognitive impairment. Staff assessment of Mental Status reflected Resident #1 has short-term and long-term memory problems. Section H- Bladder and Bowel reflected Resident #1 had an indwelling catheter.<BR/>Review of Resident #1's MAR/TAR reflected:<BR/>CHANGE F/C 14fr 10cc Q MONTH AND PRN IF DISLOGED. one time a day starting on the 9th and ending on the 9th every month dated 04/03/2025 with start date of 04/09/2025.<BR/>Provide catheter care Q-shift/PRN every shift.<BR/>Review of Resident #1's Care Plan initiated 04/14/2025 reflected no plan of care for catheter, DM or Hypertension.<BR/>Review of Resident #1's TAR reflected his Foley was changed on 4/9/25 by MA E.<BR/>Review of Resident #1's TAR reflected his Foley was changed on 5/9/25 by MA A. <BR/>Review of Resident #1's progress notes written by LVN C dated 05/17/2025 at 1:39 pm reflected:<BR/>Resident transferred to ER due to difficult to arouse, decrease in urine output and low blood pressure.<BR/>Review of Resident #1 current hospital records dated 5/17/2025 reflected:<BR/>He was sent over from his nursing home for fever of 101, more lethargic than usual and his glucose reading was high. On arrival his serum glucose is around 478, sodium is 156, creatinine of 4. He is very lethargic and barely opens eyes. Initial work up shows likely diagnosis of DKA/ hyperosmolar diabetes (is a serious complication of diabetes, primarily occurring in individual with type 2 diabetes), possible sepsis, UTI (his foley was exchanged in ER, had brown urine with some pus in penile area), possible right lung pneumonia, with AKI.<BR/>During an interview on 05/19/2025 at 10:11 am MA A stated she did not change Resident #1's foley catheter because it was outside her scope of practice. MA A stated Resident #1's foley catheter order to change was on her MAR and she accidentally signed it. MA A also stated she did not tell the nurse who worked on 5/9/2025 about the foley catheter needing to be changed.<BR/>During an interview on 05/19/2025 at 11:04 am the DON stated, foley catheters were supposed to be changed once a month. The DON stated if foley catheters were not changed as ordered, the resident would get infection. The DON stated Resident #1's foley catheter was supposed to be changed around 5/09/2025 and the nurse was supposed to initial when it was changed. The DON stated staff did not document urine output because Resident #1 did not have orders to document urine output and Resident #1 did not have issues with output. The DON stated MAs cannot change foley catheters because it was not within their scope of practice. The DON reviewed Resident #1's TAR and noted that it was not changed on 4/9 and 5/9 but was initialed by MAs. The DON stated Resident #1's order for catheter change was revised on 5/10/2025 by LVN F to reflect on the nurse's TAR, according to the DON. <BR/>During an interview on 05/19/2025 at 11:43 am the NP stated Resident #1 had a foley catheter due to urinary retention. The NP stated she usually did not write orders for foley catheters, and she let the urologist deal with foley catheters. The NP stated she expected the facility to keep foley catheters clean and free from infection. The NP asked to step out and call the MD, came back later and stated she would not continue with the interview unless her MD was present.<BR/>During a phone interview on 05/19/2025 at 2:45 pm the MD stated, there was new evidence that indicated not to change the foley catheter monthly. The MD stated changing foley monthly, really did not make a difference in infection prevention. The MD stated the hospital may have said change the foley catheter monthly, but he disagreed with the urologist (are medical specialists who focus on the diagnosis and treatment of conditions related to the urinary tract and male reproductive system) . The MD stated Resident #1 would have to be scheduled for urology follow-up, maybe his foley catheter was difficult. <BR/>During an interview on 05/19/2025 at 1:35 pm, the Interim Administrator stated not changing the foley catheter as ordered can lead to possible infection. The Interim Administrator stated the CNAs were supposed to document urine output. The interim Administrator stated if Resident #1 had the foley catheter due to urinary retentions, it was important to document urine output.<BR/>Attempts was made to contact MA E on 05/19/2025 at 10:30 am but was unsuccessful.<BR/>Attempts was made to contact LVN F on 05/19/2025 at 12:21 pm but was unsuccessful .<BR/>Review of facility's policy titled Catheter Care; Urinary dated August 2022 reflected:<BR/>Purpose <BR/>The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. <BR/>Preparation<BR/>1. <BR/>Review the resident's care plan to assess for any special needs of the resident.<BR/>2. <BR/>Assemble the equipment and supplies as needed.<BR/>The VP for Operation, Interim Administrator and the DON were notified on 05/19/25 at 4:19 pm that an IJ had been identified and an IJ template was provided.<BR/>The following POR was approved on 05/20/25 at 12:51 pm.<BR/>F690<BR/>Immediate Jeopardy Removal Actions Taken<BR/>1. <BR/>Immediate Resident Response<BR/>o <BR/>Resident #1 was immediately transferred to the emergency room on 5/17/2025 due to fever, lethargy, and suspected sepsis.<BR/>o <BR/>A full head-to-toe assessment was conducted by licensed staff prior to transfer. (No skin breakdown, foley catheter intact) <BR/>o <BR/>Foley catheter was replaced in the ER. The resident was diagnosed with UTI, possible sepsis, AKI, and pneumonia.<BR/>o <BR/>Family and physician were notified immediately.<BR/>2. <BR/>Resident Safety Review<BR/>o <BR/>100% audit of all residents with Foley catheters completed on [5/19/2025] by the Director of Nursing (audit tool created to monitor foley catheter orders) (DON was in-serviced prior to completing audit on 5/19/2025 by CNO)<BR/>Reviewed orders for catheter care and replacement schedule. (Review of 1 resident with foley pre- discharged orders in PCC were reviewed by DON as resident #1 is in the hospital. ( No residents other than resident # 1 have a foley catheter. <BR/>Verified compliance with physician orders, TAR/MAR accuracy, and documented output as needed. <BR/>Any overdue changes were immediately completed by a licensed nurse. (Currently no residents in the facility with foley catheter orders) None are affected. <BR/>Any discrepancies in documentation were immediately addressed and corrected.<BR/>3. <BR/>Order Clarification & Physician Review<BR/>o <BR/>All current Foley catheter orders reviewed with attending physicians to ensure: By: CNO and DON 5/19/2025. <BR/>Specific frequency for changes (monthly, prn, etc.)<BR/>Whether urology follow-up is required.<BR/>Clear instructions on who is responsible (facility vs. specialist).<BR/>o <BR/>Physician orders revised accordingly and entered into EMR (1 resident total) (DON/ designee will monitor upon admission and weekly in Standards of care meeting).<BR/>4. <BR/>Scope of Practice Enforcement<BR/>o <BR/>Immediate education and competency check completed on 5/19/2025 for all medication aides (MAs) clarifying: ( DON completed education. Staff that were not present we called by the DON. Staff that could not be reached must be in-serviced prior to next scheduled shift. <BR/>MAs may not change Foley catheters.<BR/>MAs must report Foley orders to licensed nurses immediately.<BR/>MAs may not document, or initial Foley care they did not perform.<BR/>o <BR/>The MA involved was removed from the schedule pending retraining and counseling (In-service and posttest). ( Next scheduled shift for MA is 5/21/25 and she will not be allowed to work prior to the in-service and test for acknowledgement. <BR/>5. <BR/>Documentation & Tracking System Improvements<BR/>o <BR/>New Foley catheter tracking log implemented for all residents with catheters ( monitored by DON/ Designee.<BR/>o <BR/>TARs and MARs updated to reflect accurate task assignments and responsibilities. ( DON completed the task after in-service by CNO on 5/19/2025.<BR/>o <BR/>DON or designee to verify completion of catheter change orders date. (This will be reviewed after admission and weekly in Standards of Care meeting) (Continuously). <BR/>6. <BR/>Care Planning & Assessment<BR/>o <BR/>Resident #1's care plan updated by DON immediately to reflect catheter management needs.<BR/>o <BR/>100% audit of care plans (foley catheter audit ) for all catheterized residents completed by DON to ensure individualized interventions for infection prevention, hydration, and output monitoring (3 resident's care plans were updated). (This will be tracked in the weekly Standards of care meeting)<BR/>o <BR/>Facility policy updated to require catheter care plans within 24 hours of admission. ( DON will be responsible and the CNO will provide oversight weekly X 6 weeks and then monthly. <BR/>7. <BR/>Staff Education<BR/>o <BR/>In-service conducted for all licensed nurses and MAs by DON (in-service and posttest) on: ( DON will provide continuous training with new hires, agency, and staff who were not present to ensure compliance is met and sustained.<BR/>Foley catheter management per HHSC/CMS standards.<BR/>Identifying early signs of UTI and sepsis.<BR/>Documentation protocols and scope of practice.<BR/>o <BR/>DON and ADON re-trained on oversight responsibility for order reconciliation, scope of practice enforcement, and task delegation (in-service by CNO) ( By verbal and written acknowledgement of training.<BR/>8. <BR/>Quality Assurance and Monitoring<BR/>o <BR/>Daily (clinical morning meeting) review for 14 days (continuously in weekly Standards of care meeting) of:<BR/>Catheter care orders.<BR/>Documentation of changes.<BR/>Correct scope of task completion.<BR/>o <BR/>QA team to review catheter log weekly and monitor compliance during rounds. (Monthly in QAPI meeting indefinitely-as long as there are residents with foley catheters)<BR/>o <BR/>Findings reviewed in monthly QAPI meetings.<BR/>9. <BR/>Leadership Accountability<BR/>o <BR/>MA involved received documented disciplinary counseling. (DON via phone on 5/20/25) All MAs and nurses have been in-serviced by DON via in person or phone. ( Post test was sent via phone after in-service by DON to the staff who were not present at the time of the in-person training. All staff will be required to acknowledge the education was given by presenting the signed posttest prior to the next scheduled shift.<BR/>o <BR/>DON received education on catheter care orders, identifying signs of UTI and sepsis, and documentation protocols and scope of practice. <BR/>Chief Nursing Officer providing oversight (5/19/25 daily X 10 days in person, then weekly X 4 remotely, and then monthly remotely and prn to ensure continued compliance with the plan.<BR/>The Surveyor monitored the POR on 05/20/2025 from 1:00 pm to 7:00 pm as follows:<BR/>During interviews on 05/20/2025 from 1:00 pm -7:00 pm, three LVNs (LVN B, C and D), 1 RN (RN D) from all shifts stated they had been in-serviced by the DON and the Interim Administrator/ CNO<BR/>During interviews on 05/20/2025 from 1:00 pm -7:00 pm, two MAs (MA A and B), from all shifts, they both stated they had been in-serviced by the DON and the Interim Administrator/ CNO that MAs and Nurses were responsible for documenting on the MAR. They stated MAs were responsible for documenting in the MAR non-nursing responsibilities. Nurses were responsible for documenting in the MAR nursing responsibilities, such as catheter care. They were trained on MAR documentation. They learned to notify the charge nurse or DON if they observed incorrect entries or nursing responsibilities in the MAR. They stated if they accidentally checked off performing nursing responsibilities, such as ointment, on the MAR, they would strike out and notify nurse on duty. They stated they knew it was important to notify the nurse whenever they observe nursing responsibilities on the MA's MAR. They stated It's important because it could be abuse or neglect. Resident won't get attention they need as ordered from the doctor. Resident needs to get their treatment. Residents won't get what they need, such as wound care or ointment. Residents could not receive a medication or treatment if the MAR was checked off as received but they did not receive.<BR/>During an interview on 05/20/2025 at 3:40 pm the DON stated she was in-serviced on 05/19/25 by the CNO. She learned about the types of orders, expectations, what to look for when reviewing orders, admissions/readmissions process, new procedures, scope of practices for MAs and nurses, following orders, and reviewing and revising care plans. She also reviewed orders for catheter care and replacement schedule on 05/19/25 and found there were no residents other than Resident #1 who had a foley catheter. She reviewed Resident #1's EHR and verified compliance with physician orders, TAR/MAR accuracy, and urinary output documentation on 05/19/25. There were no overdue changes that immediately needed to be completed by a licensed nurse during review and verification. She also did not identify any discrepancies in documentation. Attending physicians, her and the CNO reviewed all current foley catheter orders on 05/19/25 for frequency for changes in output, urology follow-up, and who was responsible for changing. MD became oversight for ensuring urinary output documented, urology follow-ups were made, and foley catheters were changed according to orders. She started and completed the audit of all residents with foley catheters on 05/19/25 and found there were no residents with foley pre-discharged orders in EHR other than Resident #1. Resident #1's physician orders were revised and entered in EHR on 05/19/25 . She provided immediate education and competency checks by phone and in-person to the MAs on 05/19/25 regarding MAs not changing foley catheters, reporting foley orders to licensed nurses immediately, and not documenting or initialing foley care they did not perform. All MAs have been reached by in-person or phone before their next scheduled shift. MA involved was removed from the schedule. She reached out to the MA involved and the MA was scheduled to visit the facility to receive counseling and retraining on 05/21/25. She initiated and was monitoring a new foley catheter tracking log on 05/19/25. No discrepancies and errors observed. She updated Resident #1's TAR/MAR to reflect task assignments and responsibilities after being trained by the CNO on 05/19/25. There were no other residents. She was to start verifying completion of catheter change orders date and review after Resident #1's readmission and weekly. She updated Resident #1's care plan to reflect catheter management needs on 05/20/25. She completed an audit of all catheterized residents' care plans to ensure interventions were included and implemented and was tracking weekly. The DON stated the CNO updated the facility's policy to reflect requiring catheter care plans within 24 hours of admission and overseeing weekly for next 6 weeks and then monthly thereafter. She in-serviced all licensed nurses and MAs and gave post-tests to them regarding foley catheter management, documentation protocols, and identifying early signs of UTI and sepsis. CNO retrained her and had her sign written acknowledgment on oversight responsibility for order reconciliation, scope of practice enforcement, and task delegation on 05/19/25. QA was reviewing daily for 14 days and then weekly on catheter care orders, documentation of changes, and correct scope of task completion. QA team also reviewing catheter log weekly to monitor compliance during rounds and findings monthly in QAPI meeting. CNO was overseeing from 05/19/25, daily for the next 10 days in person, weekly for the next four weeks, and then monthly remotely and as needed to ensure compliance.<BR/>During an interview on 05/20/2025 at 5:18pm Interim Administrator/CNO stated she in-serviced the DON on 05/19/25 regarding order reconciliation, ensuring orders were in nurses' MAR, ensuring orders for foley care and monitoring were in place, ensuring MAs notifying nurses of any orders in their MAR, and DON reviewing and tracking any discrepancies and errors and correcting. The Interim Administrator/CNO stated the DON signed an acknowledgement of receiving the in-service before performing the audit of residents with foley catheters. The Interim Administrator/CNO stated she, the DON, and MD reviewed current residents' foley catheter orders on 05/19/25 and found no other discrepancies and errors. The Interim Administrator/CNO stated she and the DON discussed with the MD the IJs as well. The Interim Administrator/CNO stated she in-serviced the DON on updating TARs and MARs to reflect accurate task assignments and responsibilities on 05/19/25 before the DON updated the TARs and MARs. DON signed an acknowledgement of receiving the in-service before updating the TARs and MARs. She was overseeing weekly for the next 6 weeks to ensure facility policy was updated and followed regarding catheter care plans were required within 24 hours of admission. She in-serviced the DON on oversight responsibility for order reconciliation, scope of practice enforcement, and task delegation. DON signed an acknowledgement of receiving the in-service before initiating oversight responsibility for order reconciliation, scope of practice enforcement, and task delegation. She oversaw to ensure processes completed daily for the next 10 days in person, then weekly for four weeks remotely, and then monthly remotely and as needed to ensure continued compliance.<BR/>Review of facility's in-services dated 05/19/2025 reflected the following:<BR/> Facility had an ADHOC QAAC for identification of deficient practice.<BR/>DON: Foley Catheter Review: Foley Catheter Policy presented by the Interim Administrator/CNO and signed by the DON.<BR/>Nurses: Foley catheter, Foley catheter management/policy and procedure, identify early signs of UTI and sepsis, documentation presented by the Interim Administrator/CNO and the DON; signed by LVN B and LVN F and via phone for LVN C and RN D. <BR/>Medication Aides: Foley Catheter: MAs may not change foley catheter, MAs must report foley catheter orders to nurse, MAs may not document or initial on foley catheter, presented by the Interim Administrator/CNO and the DON; signed by MA A, MA E via phone.<BR/>Education to Physician/NP on MARs/TARs on new/readmissions. Weekly Review of high-risk residents regardless of payer. LOA residents require same level of care as skilled. MD stated and acknowledged understanding of medication process and foley catheter orders to be specified if would like catheter changed monthly. <BR/>Nursing: Scope of Practice/ Medication Administration presented by the DON via phone for MA F.<BR/>Foley Catheter test completed on 05/19/2025 by Nurses including the DON, LVN B, LVN C via phone, RN D via phone, MA E via phone, LVN F <BR/>Review of facility's in-services dated 05/20/2025 reflected the following:<BR/>Foley Catheter management, notification of change in condition to nurse, where to document output dated 05/20/2025 presented by the DON signed by CNAs . <BR/>Review of Facility's Indwelling (Foley) Catheter Insertion policy, revised 05/19/25, reflected the policy was updated to required care plan updates with foley catheter within 24 hours of admission, verify resident specific output orders related to diagnosis for foley catheter insertion, and verify resident specific foley change orders with physician monthly or PRN for occlusions and dislodgement.<BR/>DON audit of all residents with foley catheters, completed on 05/19/25, reflected Resident #1 was the only resident. Orders for catheter care and replacement schedule were reviewed and present. Foley change frequency was ordered. Foley changed as ordered. Care plan reflected foley use. Tracking log was used for foley catheter care residents.<BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/2025 at 4:19 pm and an IJ template was given. While the IJ was removed on 05/20/2025 at 7:01 pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 4 residents review for pharmacy services.<BR/>The facility failed to carry out Resident #1's orders from the hospital for insulin to control his blood glucose. Resident #1 was sent to the local ER on [DATE] due to fever and lethargy and was diagnosed with Diabetes Ketone Acidosis (DKA-Diabetes Ketone Acidosis is serious and can be life threatening. DKA is when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy (with a blood serum level of 478. Normal blood serum glucose levels:<BR/>Fasting blood glucose 70 to 99 mg/dL. Random blood glucose: generally, it should be 125 mg/dL.) .<BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/2025 at 4:19 pm and an IJ template was given. While the IJ was removed on 05/20/2025 at 7:01pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This deficient practice could place residents at risk for high blood glucose, hospitalization, coma and death.<BR/>Findings included:<BR/>Review of Resident # 1's face sheet dated 05/18/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Autistic disorder (is a developmental disorder that affects communication, behavior and social interaction, with symptoms typically appearing in early childhood), Hypertension (HTN - High blood pressure), Urinary retention, history of Urinary Tract Infections (UTI -occurs when bacteria get in the urinary system, often through the urethra, and begin to multiply in the bladder), Diabetes Mellitus type II (a chronic condition characterized by insulin resistance and elevated blood sugar levels).<BR/>Review of Resident #1's hospital discharge orders dated 4/1/2025 reflected: <BR/>Insulin NPH Hum/Reg 70/30 (Trade name: Novolin 70/30)<BR/>15 Units Subcutaneous before Breakfast and Dinner<BR/>Review of Resident #1's hospital discharge papers dated 4/1/2025 reflected: <BR/>Type 2 diabetes mellitus uncontrolled with hyperglycemia (high blood sugar level), A1c 7.5%<BR/>- <BR/>Home regimen; NPH 70/30 15 units b.i.d.<BR/>- <BR/>continue at l0u BID due to hypoglycemia <BR/>- <BR/>sliding scale insulin, monitor for hypoglycemia<BR/>Review of Resident #1's admission MDS dated [DATE] indicated he had a BIMS score of not conducted indicating severe cognitive impairment. Staff assessment of Mental Status reflected Resident #1 has short-term and long-term memory problems. Section I- Active Diagnoses reflected Resident #1 had Diabetes Mellitus. Section N- Medications did not indicate Resident #1 was on insulin. <BR/>Review of Resident #1's initial physician/NP narrative note written by the MD dated 05/04/2025 reflected:<BR/>Type 2 Diabetes Mellitus with Foot Ulcer<BR/>Continue insulin regimen as prescribed. Monitor glucose levels and foot ulcer healing.<BR/>Review of Resident #1's Care Plan initiated 04/14/2025 reflected no plan of care for a catheter, DM.<BR/>Review of Resident #1's progress notes written by NP dated 05/04/2025 reflected:<BR/>Type 2 Diabetes Mellitus with Foot Ulcer<BR/>Continue insulin regimen as prescribed. Monitor glucose levels and foot ulcer healing.<BR/>Chief Complaint<BR/>Management of chronic medical conditions including the ones listed above.<BR/>Review of Resident #1's MAR/TAR reflected no orders for Insulin or blood sugar checks for the months of April and May 2025. <BR/>Review of Resident #1's progress notes written by LVN C dated 05/17/2025 at 1:39 pm reflected:<BR/>Resident transferred to ER due to difficult to arouse, decrease in urine output and low blood pressure.<BR/>Review of Resident #1's current hospital records dated 5/17/2025 reflected:<BR/>He was sent over from his nursing home for fever of 101, more lethargic than usual and his glucose reading was high. On arrival his serum glucose is around 478, sodium is 156, creatinine of 4. He is very lethargic and barely opens eyes. Initial work up shows likely diagnosis of DKA/ hyperosmolar diabetes ( is a serious complication of diabetes, primarily occurring in individual with type 2 diabetes), possible sepsis (is a life threatening condition that occurs when the body has extreme response to infection), UTI (his foley (foley- a medical device that helps drain urine from the bladder when you can't pee on your own) was exchanged in ER), had brown urine with some pus in penile area, possible right lung pneumonia, with AKI.<BR/>Normal blood serum glucose levels:<BR/>Fasting blood glucose 70 to 99 mg/dL <BR/>Random blood glucose: generally, it should be 125 mg/dL.<BR/>Medlineplus https://medlineplus.gov.ency/article <BR/>During an interview on 05/19/2025 at 10:01 am LVN B stated he was not aware of Resident #1 needing accu checks (accu check refer to the use of a glucometer to test a patient's blood sugar level) or insulin.<BR/>During an interview on 05/19/2025 at 11:04 am the DON stated, she knew Resident #1 was diabetic from his referral papers that were faxed over. The DON stated she reviewed Resident #1's admission papers and she didn't see Resident #1 was on Insulin. The DON stated she participated in Resident #1's admission assessments and reviewed his orders from the referral papers sent in February 2025. The DON stated she did not put Resident #1's orders in Point Click Care (PCC- a web based EHR that helps long-term care provider manage the complete lifecycle of a resident care). The DON stated Resident #1 was admitted to the facility with only 2 pieces of paper. The DON stated she called the local hospital for Resident #1's hospital records and was told the records would be faxed over. The DON stated she did not follow up to find out if Resident #1's hospital records were faxed or document that she had called for the hospital records. The DON stated she did not see Resident #1 showing signs or symptoms of Hypo (low) or Hyperglycemia (high blood glucose). The DON stated if a Resident was supposed to get insulin and did not get the insulin, the resident would have hyperglycemia which can lead to DKA and coma.<BR/>During an interview on 05/19/2025 at 11:43 am the NP stated, Resident #1 was seen once a month because he was non-funded ( no Payal source). The NP stated she had seen Resident #1 twice since he was admitted to the facility. The NP stated she visited with Resident #1 on 5/17/2025. She said he was not responding well, he was unresponsive, and she ordered for him to be sent to the ER for further evaluation. The NP stated she documented on 05/04/2025 that Resident #1 should continue insulin regimen as prescribed, monitor glucose levels and foot ulcer healing based on the MD's previous documentation and Resident #1's hospital records. The NP stated she did not review Resident #1's MAR/TAR for his glucose reading during her visits. The NP stated she did not have access to PCC to put in orders. The NP stated if a resident was ordered insulin and did not get the insulin as ordered, the resident can go into DKA or hyperosmolarity (blood is more concentrated than normal due to dehydration). The NP stated, generally, you want the serum blood glucose around 80 and not more than 200, and 400 plus serum blood glucose can indicate uncontrol diabetes/blood sugar. The NP stated she ordered labs on 5/4/2025 but was not able to get the lab done due to Resident #1's funding. The NP stated she gave the lab ordered sheet to the DON and spoke with the MD regarding that. The NP stated, if the insulin was ordered from the hospital for Resident #1, Resident #1 should have gotten the insulin as ordered. <BR/>During a phone interview on 05/19/2025 at 12:15 pm RN D stated he worked with Resident #1 but could not remember putting Resident #1's orders in the EMR upon admission. RN D stated he did not recall Resident #1 having orders for accu checks or insulin. RN D stated he had never given Resident #1 insulin or checked his blood glucose level.<BR/>During an interview on 05/19/2025 at about 12:41 pm, the DON stated the NP gave her a sheet with orders for labs for Resident #1, but the labs were not completed due to Resident's payment source (LOA-Letter of Agreement). The DON stated Resident #1 contract with the hospital only pay for room and boarding only. <BR/>During an interview on 05/19/2025 at 1:35 pm, the Interim Administrator stated when a resident is being admitted from the hospital, the admitting nurse was responsible to call the hospital for clarification of orders. She stated, if the Resident was transported to the facility without hospital papers, the admitting nurse is responsible to contact the hospital for discharge papers and follow up on the papers. The Interim Administrator stated the DON was responsible to ensure the nurses were following all orders. The Interim Administrator stated for a resident who was ordered insulin and did not get the insulin, the resident's blood glucose would be high. The Interim Administrator stated the facility missed the insulin order for Resident #1, it was a mistake, and they were working on fixing the problem. The Interim Administrator stated for a Resident with LOA funding, the facility gets paid a flat rate per day through the hospital contract. The Interim Administrator also stated the facility would pay for labs because the Resident had to be taken care of. The Interim Administrator stated that was a misunderstanding. The Interim Administrator stated the MD should be able to see and treat every Resident regardless of their payment source.<BR/>During a phone interview on 05/19/2025 at 2:45 pm the MD stated he had just reviewed Resident #1's chart and the insulin and accu checks were an error on their part. He stated it was an oversight not looking for the accu check and the insulin administration. The MD stated his office should have realized that Resident #1's insulin was held. The MD stated he was told by the NP that the DON said the insulin was discontinued due to insurance problem/ LOA. The MD stated the facility should have continued with Resident #1's accu checks and stopped the 70/30 insulin when the blood glucose was stable. The MD stated his NP should have asked the facility to monitor Resident #1's blood glucose reading regardless of payment source. The MD stated DKA was considered life threatening, but we can bring the Resident/Patient back from it. He stated DKA can also be triggered by acute infection, but again, the blood glucose should have been monitored before the facility can decide on keeping Resident #1 on the insulin or not. <BR/>Review of Resident #1's Letter of Agreement dated 04/01/2025 reflected the following: <BR/>Obligations of Facility<BR/>a. Facility shall provide quality service to patient without discriminating of the basis of<BR/>source of payment, gender, nationality, ethnicity, age, or handicap.<BR/>b. Facility shall invoice Hospital by the 15th of each month for services to patient. An<BR/>itemized statement will accompany each invoice.<BR/>c. Facility agrees to provide the following services to the Patient:<BR/>i. Nursing Care<BR/>ii. Physical Therapy<BR/>iii. Speech Therapy<BR/>iv. Occupation Therapy<BR/>d. Facility agrees to provide the medications prescribed by transferring physician. A list of the prescribed medications is located in Exhibit A and is included by reference herein.<BR/>Review of facility's policy titled Reconciliation of Medications on admission dated July 2017 reflected: <BR/>Purpose <BR/>The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. <BR/>Preparation<BR/>1. <BR/>Gather the information needed to reconcile the medication list:<BR/>a. <BR/>Approved medication reconciliation form.<BR/>b. <BR/>Discharge summary from referring facility.<BR/>c. <BR/>admission order sheet.<BR/>d. <BR/>All prescription and supplement information obtained from the resident/family during the medication history; and<BR/>e. <BR/>Most recent medication administration record (MAR), if this is a readmission.<BR/>2. <BR/>Find a quiet place that is free from distractions.<BR/>General Guidelines<BR/>1. <BR/>Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care.<BR/>2. <BR/>Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process.<BR/>3. <BR/>Medication reconciliation helps to ensure that all medications, routes and dosages on the list are appropriate for the resident and his/her condition, and do not interact in a negative way with other medications/supplements on the list.<BR/>4. <BR/>Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team.<BR/>Steps in the Procedure<BR/>3. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources).<BR/>4. <BR/>List the dose, route and frequency for all medications.<BR/>5. <BR/>Review the list carefully to determine if there are discrepancies/conflicts.<BR/>c. <BR/>There is a medication listed on the discharge summary for which there is no diagnosis or condition to support the use of the medication.<BR/>6. <BR/>If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example:<BR/>a. <BR/>Contact the nurse from the referring facility.<BR/>b. <BR/>Contact the physician from the referring facility.<BR/>c. <BR/>Discuss with the resident or family.<BR/>d. <BR/>Contact the resident's primary physician in the community.<BR/>e. <BR/>Contact the resident's secondary physician(s) in the community.<BR/>f. <BR/>Contact the community pharmacy used by the resident; or<BR/>g. <BR/>Contact the admitting and/or Attending Physician.<BR/>The VP for Operation, Interim Administrator and the DON were notified on 05/19/25 at 4:19 pm that an IJ had been identified and an IJ template was provided.<BR/>The following POR was approved on 05/20/25 at 12:51 pm.<BR/>F755<BR/>Immediate Jeopardy Removal Actions Taken<BR/>1. <BR/>Immediate Clinical Response<BR/>o <BR/>Resident #1 was immediately transferred to the hospital upon identification of altered mental status and signs of sepsis and hyperglycemia on 5/17/2025.<BR/>o <BR/>Full head-to-toe nursing assessment completed and documented prior to transfer.<BR/>o <BR/>Family and physician were notified promptly.<BR/>2. <BR/>Resident Review & Safety Measures<BR/>o <BR/>100% audit of all current residents with diabetes diagnoses was conducted on [5/19/2025] by Director of Nursing. (Documented on audit tool developed for new admit medication reconciliation) DON was in-serviced before completing audit by Chief Nursing Officer. <BR/>o <BR/>Review included MAR/TAR, physician orders, care plans, and hospital discharge records for insulin, glucose monitoring, or diabetic care needs.<BR/>o <BR/>Any missing or incorrect orders were immediately clarified with the physician and implemented. (1 resident)<BR/>o <BR/>Any residents found without current diabetic monitoring or medication orders received immediate physician review. (All medications for non-funded residents will be ordered through the pharmacy and charged in the same manner as a skilled resident, facility's responsibility). (All care plans were audited, with 2 updates made to care plans )<BR/>3. <BR/>Hospital Discharge Order Reconciliation<BR/>o <BR/>A new protocol was implemented effective immediately:<BR/>A licensed nurse and the DON or designee will review all hospital discharge papers at time of admission or return to ensure all orders are entered correctly into the EMR (PCC). (Medication reconciliation form )<BR/>The receiving nurse must confirm medication orders, follow-up appointments, and labs on all new and readmitted resident. (This will be tracked daily in the clinical morning meeting by the DON/Designee) Any additional education will be provided to the DON if there are any discrepancies.)<BR/>Orders will be reviewed by the DON or designee on all admission and noted as reviewed in the EMR. (Within 24 hours after admission) <BR/>4. <BR/>Physician/Nurse Practitioner Notification and Oversight<BR/>o <BR/>The facility's Medical Director and NP were re-educated by the Chief Nurse Officer 5/19/25 on the responsibility to review MAR/TAR and hospital discharge notes on every visit.<BR/>o <BR/> The facility implemented a process that requires weekly NP review of high-risk residents, including diabetic and non-funded residents. (Medications will be ordered from the pharmacy and cost occurred outside of LOA will be supported by the facility. NP review will be monitored by use of change of condition form) ( Change of condition forms on PCC will be reviewed daily in clinical stand up by DON / Designee to ensure compliance.<BR/>5. <BR/>Education and Training<BR/>o <BR/>Emergency in-service conducted on May 19th, 2025, by Director of Nurses to all licensed nursing staff on: ( DON was provided training prior to in-servicing others by CNO. <BR/>Importance of following hospital discharge orders.<BR/>Recognizing signs/symptoms of hypo/hyperglycemia.<BR/>Diabetic care management and documentation requirements.<BR/>Immediate reporting of missing or unclear orders. (in-service and posttest)<BR/>o <BR/>Re-education for DON and ADON on responsibilities during admission/re-admission. (By: CNO) 5/19/25) <BR/>6. <BR/>Monitoring and Quality Assurance<BR/>o <BR/>Indefinite Daily audits of all new admissions and re-admissions to ensure:<BR/>Hospital discharge orders are obtained, reviewed, and implemented timely. Daily review in clinical morning meeting). <BR/>Medication orders are entered into the EMR correctly.<BR/>o <BR/>All audits are reviewed by the Administrator or Regional Nurse Consultant daily.<BR/>o <BR/>Ongoing Monthly QA audits will be conducted thereafter and tracked via QAPI.<BR/>7. <BR/>Accountability and Leadership Oversight<BR/>o <BR/>DON educated on policy and procedure. ( By: CNO policy reviewed, and DON acknowledged understanding with verbal and written acknowledgment. <BR/>o <BR/>Additional coverage and oversight by Chief Nursing Officer ( Weekly X 6 weeks then monthly. <BR/>The Surveyor monitored the POR on 05/20/2025 from 1:00pm to 7:00 pm as follows:<BR/>During interviews on 05/20/2025 from 1:00 pm -7:00 pm, three LVNs ( LVN B, C and D), 1 RN (RN D) from all shifts stated they had been in-serviced by the DON and the Interim Administrator/ CNO and they learned about the types of orders, expectations, what to look for when reviewing orders, admissions/readmissions process, new procedures, scope of practices for MAs and nurses, following orders, review residents EHR and verified compliance with physician orders, review MAR/TAR, physician orders, care plans, and hospital discharge records for insulin, glucose monitoring, or diabetic care needs. They all stated the DON would review orders on all admissions and comparing to EHR to ensure completed within 24 hours of admission.<BR/>During an interview on 05/20/2025 at 3:40 pm the DON stated she completed a full audit of all current residents with diabetes diagnoses on 05/19/25. Review included MAR/TAR, physician orders, care plans, and hospital discharge records for insulin, glucose monitoring, or diabetic care needs. The DON stated the CNO in-serviced her before completing the audit on 05/19/25. The DON stated Resident #1 was identified as the only resident with missing or incorrect orders that was immediately clarified with the physician on 05/19/25. The DON stated there were no residents identified as requiring immediate physician review because none were without current diabetic monitoring and medication orders. New protocol immediately implemented by her and licensed nurses on 05/19/25 on reviewing all hospital discharge papers at the time of admission and readmission. The DON stated there were no new admissions nor readmissions since 05/19/25. The DON stated she was conducting daily tracking to ensure receiving nurse confirmed receiving discharge papers and orders at time of admission and readmission. The DON stated she was also reviewing orders on all admissions and comparing to EHR to ensure completed within 24 hours of admission. The DON stated the MD and NP were re-educated by the CNO on 05/19/25 to review MAR/TAR and hospital discharge notes on every visit. The facility also started having NP review weekly high-risk residents on 05/19/25. The DON stated she immediately in-serviced and gave post-tests on all licensed nursing staff on 05/19/25 on importance of following hospital discharge orders, recognizing signs/symptoms of hypo/hyperglycemia, diabetic care management and documentation requirements, and immediate reporting of missing or unclear orders. She was also trained before the in-service by the CNO on 05/19/25. The DON stated the CNO re-educated her on admission/readmission process on 05/19/25. Indefinite daily audits of all new admissions and re-admissions to ensure hospital discharge orders are obtained, reviewed, and implemented timely and medication orders are entered into the EHR correctly. QAPI was conducting monthly reviews thereafter. The DON stated she was educated by the CNO and signed an acknowledgement of the policies and procedures regarding medication administration, physician orders for diabetic's process, and admission/readmission process. CNO would oversee weekly for the next six weeks and then monthly.<BR/>During an interview on 05/20/2025 at 5:18pm Interim Administrator/CNO stated she in-serviced the DON on the importance of admission/readmission process and responsibilities, following hospital discharge orders, recognizing signs/symptoms of hypo/hyperglycemia, diabetic care management and documentation requirements, immediate reporting of missing or unclear orders on 05/19/25. The Interim Administrator/CNO stated the DON also signed an acknowledgement on 05/19/25 before in-servicing the remainder of staff on 05/19/25. The Interim Administrator/CNO stated she reviewed the policy and DON signed acknowledging policy and procedure reviewed on processes. The Interim Administrator/CNO stated she oversaw to ensure processes completed weekly for the next 6 weeks and then monthly.<BR/>Review of facility's in-services dated 05/19/2025 reflected the following:<BR/> Facility had an ADHOC QAAC for identification of deficient practice.<BR/> DON: Review Medication orders on admission: following hospital discharge orders, recognizing symptoms of hypo/hyperglycemia, Diabetes care/ management, reporting missing/unclear orders presented by the Interim Administrator/CNO and signed by the DON.<BR/>Nurses: Medication Administration: following hospital discharge orders, recognizing symptoms of hypo/hyperglycemia, Diabetes care/ management, reporting missing/unclear orders presented by the Interim Administrator/CNO and the DON; signed by LVN B and LVN F and via phone for LVN C and RN D. <BR/>Education to Physician/NP on MARs/TARs on new/readmissions. Weekly Review of high-risk residents regardless of payer. LOA residents require same level of care as skilled. MD stated and acknowledged understanding of medication process, missed dosage of medication due to transcription error presented by the Interim Administrator and the DON signed by Interim Administrator and the DON on behalf of the MD and the NP .<BR/>Abuse, Neglect and Physician Orders quiz completed by Nurses including the DON, LVN B, LVN C via phone, RN D via phone, MA E via phone, LVN F <BR/>Administering Medications policy, revised April 2019, reflected DON was reeducated on policy. <BR/>Abuse, neglect and physician's orders post-tests were completed by licensed nurses. <BR/>DON audit of all residents with diabetes diagnoses, conducted 05/19/25, reflected the DON reviewed MAR/TAR reflecting accurate orders, ensured medication reconciliation, diagnosis of diabetes, physician orders, care plans reflect diabetes, glucose monitoring and diabetic care needs, hospital discharge orders reviewed, and insulin ordered and administered as ordered. <BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/2025 at 4:19 pm and an IJ template was given. While the IJ was removed on 05/20/2025 at 7:01pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 5 residents (Residents #1 and #2) reviewed for infection control.<BR/>The facility failed to ensure Resident #1 was placed on Isolation after she tested COVID-19 (Coronavirus 2019) positive in the hospital on [DATE]. <BR/>The facility failed to have signage on Resident #1's door that reflected PPE was required for infection control.<BR/>The facility failed to removed Resident #2 from a COVID-19 positive room even though she tested negative for COVID.<BR/>These failures could place residents at risk for infection, or hospitalization.<BR/>Findings included:<BR/>According to the intakes received by HHSC, The facility is not practicing infection control. They are not quarantining the covid positive Residents. [Resident #3] is next door to [Resident #1], and she is Covid Positive. The staff are not wearing PPEs, gloves or gowns. The staff are saying the Resident's covid test results are negative. This is false. The Complainant is concerned Covid will spread to other Residents due to the facility lack of infection Control, and on [DATE], [Resident #1] was sent to the local hospital due to loss of appetite, body aches and cough .The Resident came back from the hospital a couple of hours later. The Complainant assisted EMS with getting the Resident back into the facility and overheard an EMT tell [LVN A] that [Resident #1] had COVID. [Resident #1] is not receiving treatment, and there is not even isolation sign on her door. The complainant fears the illness will spread to other Residents. There Complainant is not aware of other active COVID-19 cases in the facility, but there are several Residents with similar symptom.[sic] <BR/>Review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Systemic Lupus Erythematosus unspecified (a chronic autoimmune disease in which the body's immune system mistakenly attacks healthy tissues in many parts of the body), nontraumatic intracranial hemorrhage (bleeding within the intracranial vault including the brain), Cognitive communication deficit, Acute respiratory failure with hypoxia (Hypoxia is low level of oxygen in the body tissue).<BR/>Review of Resident #1's Quarterly MDS Assessment, dated [DATE], reflected Resident #1 had a BIMS score of 10, which indicated she had moderate cognitive impairment. <BR/>Review of Resident #1's Comprehensive Care Plan dated [DATE] reflected Resident #1 had an ADL self-care.<BR/>performance deficit, had impaired cognitive function/dementia or impaired thought processes, had altered respiratory status/difficulty breathing.<BR/>Review of Resident #1's progress noted dated [DATE] at 9:51 am written by LVN A reflected, minimally responding to verbal and tactile stimulation, very clammy and diaphoretic. New order received: IV 1L 100ml/hr. CBC,<BR/>CMP, UA, chest Xray.<BR/>Review of Resident #1's progress noted dated [DATE] at 1:36 pm written by LVN A reflected, doc notified of COC, resident appears to be lethargic, clammy, and diaphoretic. to receive from doc: CBC, CMP, UA, chest Xray, IV NS 1000mL at 100mL/h.<BR/>Review of Resident #1's progress notes dated [DATE] at 9:00am written by the DON reflected, LATE ENTRY<BR/>Note Text: Spoke with nurse at hospital notified at this time that resident was given test for Covid which was NEGATIVE. Also notified that MD seen no need for IV placement. Resident is not dehydrated. Resident sent back to facility with no medications ordered.<BR/>Review of Resident #1's clinical records from [DATE] through [DATE] did not reflected Resident #1 was COVID positive. It did not reflect Resident #1 was isolated due to COVID and was being monitor. It did not reflect Resident #1 was being treated for COVID 19.<BR/>Review of Resident #2's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] with readmission date of [DATE]. Resident #2 had diagnoses which included Metabolic Encephalopathy (a condition characterized by brain dysfunction caused by systemic metabolic disturbances. Symptoms make include confusion, memory loss, loss of consciousness), Urinary tract infection, Dysphagia (difficulty swallowing) following unspecified cerebrovascular disease (group of conditions that affect blood flow and blood vessels in the brain).<BR/>Review of Resident #2's admission MDS Assessment, dated [DATE], reflected Resident #2 had a BIMS score of 1, which indicated she had severe cognitive impairment. <BR/>Review of Resident #2's Comprehensive Care Plan initiated [DATE] reflected Resident #2 required staff assistance for<BR/>meeting emotional, intellectual, physical, and social needs related to diagnosis of Dementia, Resident is at risk for infection related to risk of COVID-19, and also at risk for social isolation r/t infection control practices implemented by CDC and CMS guidelines to limit visitation, communal dining, and group activities. Community transmission of COVID-19.<BR/>Review of Resident #2's progress notes dated [DATE] written by the DON reflected:<BR/>Late Entry: created [DATE] @1:43 pm<BR/>Note Text: Tested for covid NEGATIVE.<BR/>Review of Resident #2's clinical records did not indicate Resident #2 was moved to another room due to roommate being tested positive for COVID-19<BR/>Review of facility's infection control logs for the months of January, February and March of 2025 did not reflected Resident #1 or any other Resident had COVID-19.<BR/>During an interview on [DATE] at 12:10 pm, LVN A stated she was not in the facility when Resident #1 was transferred to the local Hospital ER on [DATE] and assumed Resident #1 had a changed of condition that is why she was sent to the hospital. LVN A stated she was the assigned nurse when Resident #1 returned from the ER on [DATE] and Resident #1 was not in any Respiratory distress, Resident #1 was at baseline. LVN A stated EMT to her Resident #1 was COVID positive and she told the EMS staff that was not true, Resident #1 was not COVID positive because nurse to nurse report from the hospital and was told Resident #1 was COVID negative. LVN A stated EMS gave her Resident #1's hospital papers and it indicated Resident #1 was COVID negative. LVN A stated she told the DON what the EMS staff had said about Resident #1 being COVID positive and put Resident #1's hospital records in the medical records box. LVN A stated since she had been at the facility from 06/2024 to [DATE], no Resident had tested positive for COVID-19 so there was no need to isolate a Resident.<BR/>During an interview on [DATE] at 12:36 am LVN B stated she was not the nurse on duty who sent Resident #1 to the ER on [DATE]. LVN B stated she had not seen Resident #1 with change of condition, no coughing, no running nose. LVN B stated as far as she can recall, there has been no resident with s/s of covid or tested positive for covid. If someone test positive for covid we have to put them on isolation, let the DON and the Administrator know, they will take it from there and notified whoever.<BR/>During an interview on [DATE] at 12:47pm, Resident #1's family stated, she was told by facility's staff that Resident #1 was sent to the ER to get IV started because they were having trouble starting an IV. Resident #1's family also stated facility staff told her Resident #1 was COVID negative. Family also stated if Resident #1 had COVID, the nurses and the DON did not tell her.<BR/>During an interview on [DATE] at 1:04 pm, CNA C stated he had worked with Resident #1 and was never told she was COVID-19 positive. CNA C stated since he had worked in the facility from 12/2024, no resident had tested positive for COVID-19; No Resident had been put on isolation due to COVID-19. <BR/>During an interview on [DATE] at 1:37 pm, the Medical Record staff stated when a resident comes from the hospital, the nurses give him the resident's hospital records, and it is scanned into PCC. The Medical Record staff stated he did not get hospital records for Resident #1's hospital visit on [DATE]. He stated he was aware that Resident #1 went to the hospital on [DATE] but there were no records. <BR/>During an interview on [DATE] at 1:45 pm, CNA D stated she was usually assigned with Resident #1. CNA stated she could not recall if Resident #1 had signs and symptoms of COVID 19. CNA D stated Resident #1 told her she was COVID positive around the time the resident was sent to the ER. CNA D stated there was a rumor in the facility that Resident #1 was COVID positive but there was nothing done to treat Resident #1. CNA D stated Resident #1 had a roommate, the roommate was never removed from the room and Resident #1 was never isolated.<BR/>During an interview on [DATE] at 2:38 pm, the DON stated she was in the facility when Resident #1 was being sent to the ER on [DATE] due to IV placement. She stated she got nurse-to-nurse report from the hospital on [DATE] regarding Resident #1 was being transfer back to the facility. The DON stated she was also told Resident #1 was COVID negative and Resident #1 did not need IV fluids based on labs done at the hospital. The DON stated she was in the facility when Resident #1 got back, and EMS did not provide hospital papers. The DON said she did not hear EMS say Resident #1 was covid positive. The DON stated, Resident #1's family stated Resident #1 was COVID negative. The DON stated she heard the staff say Resident #1 was positive for COVID, but they did not re-test Resident #1 to confirm because there were no covid test in the facility. The DON stated the COVID test in the facility were all expired. The DON stated, if a Resident was COVID positive, they had to isolate the resident, notify family and the Doctor, test roommate and or remove from the room depending on the test result. <BR/>During an interview with on [DATE] at 2:00 pm, Resident #1 stated she recalled going to the ER for IV meds. Resident #1 stated while in the hospital, they swapped her nose for COVID, and they try to say she had COVID. Resident #1 stated she did not think she had COVID because she did not feel the same as when she had COVID before and was surprised. <BR/>Requested Hospital records for Resident #1's hospital stay on [DATE] from the Administrator and the Hospital.<BR/>Received Resident #1's hospital records on [DATE].<BR/>Reviewed of Resident #1's hospital records dated [DATE] reflected the following:<BR/>COVID-19 confirmed, Cough unspecified-confirmed, fever unspecified-confirmed.<BR/>Chief Complaint-Nausea-Patient is a [AGE] year-old female who comes to the emergency department by EMS from [Nursing Home] complaining of flulike symptoms, of cough, congestions fever, running nose for 2 days. The Nursing home staff was concerned she might be dehydrated and called EMS to have her evaluated. She is speaking in full sentences, alert and oriented without distress.Vital signs stable. Denies any other symptoms.<BR/>Lab results-2019 Coronavirus SARS-CoV-2Ra positive on [DATE] at 11:42 am<BR/>ED Course: Patient is a [AGE] year-old female who comes to the emergency department complaining of generalized flulike symptoms and cough for the past few days. Denies any Nausea or vomiting to me. No clinical evidence of dehydration. Vital signs are stable. Patient is COVID positive, and symptoms have been going on for the past few days. Unable to get a list of her medications and without this I do not feel comfortable prescribing Paxlovid at this time due to possible interactions with her other medications. Patient is asymptomatic and hemodynamically stable at this time. Recommended continued supportive care, fluid hydration orally and close outpatient follow-up with PCP with droplet precaution at the nursing home to avoid spread of the virus to other residents. <BR/>During an interview on [DATE], LVN A stated she and the DON sent Resident #1 out to the hospital on [DATE] for IV placement. LVN A stated Resident #1 had a change of condition, the MD and Resident #1's family were notified. LVN A stated she called EMS and explained why Resident #1 was being sent to the ER. LVN A stated she was still at work on [DATE] when Resident #1 returned from the ER. LVN A stated she did not get report for the hospital regarding Resident #1, the DON got report. LVN A stated the EMS staff told her Resident #1 was COVID positive and she did not take them seriously because the 2 EMS personnels did not want to be there and was just doing the job to get pay. LVN A looked at Resident #1's printed hospital records and stated those were the same records Resident #1 came back from the hospital with on [DATE]. LVN A stated if the hospital records indicated Resident #1 was COVID positive, then she was COVID positive. LVN A stated Resident #1 was sent to the ER for IV placement due to dehydration, not COVID test and was tested by the hospital due to protocol. LVN A stated she came back to the facility at the end of my shift I was ready to go home. I have life outside of work, I come and do my job and leave. I passed report on to the incoming shift that Resident #1 was COVID positive, I don't recall speaking with the DON that Resident #1 was COVID positive, I did not notify the MD, I passed it on in report and went to my Kids. LVN A stated, I am assuming we isolate if a Resident was COVID positive, roommate has to be tested and removed from the room, staff wear full PPEs. LVN A stated she did not test Resident #1's roommate for COVID, she did not know what happened to Resident #1's roommate. LVN A stated she left, went home, not sure if she worked the days following because she had taken some days off. LVN A stated isolation is to prevent them from passing on to somebody else. PPEs included gowns, N95 mask/face shield and gloves.<BR/>During an interview on [DATE] at 09:38 am the DON stated Resident #1 was sent to the ER on [DATE] due to showing signs and symptoms of dehydration such as low blood pressure and dry lips. The DON stated the facility tried to start an IV but was unsuccessful, MD was notified, and Resident was transferred to the hospital. The DON stated LVN A said Resident #1 was sent back without hospital papers. The DON stated Resident #1 should have had hospital records and the admitting nurse is responsible to review the hospital records and give to medical record personnel to enable all staff working with the resident to have access to the records. DON stated she did not see Resident #1's hospital records until [DATE]. The DON stated COVID POSITIVE precautions were isolation, verify the test by retesting, notify families and all parties, test the roommate, if negative they are to be removed from the room, don PPEs such as gowns, gloves, face shield, N95 mask, the sign on the door. The DON stated Resident #1 was not COVID positive, but the roommate was tested negative and moved to another room. <BR/>During an interview on [DATE] at 10:36 am, Resident #1 stated her roommate had been in the room the entire time and had not been moved to another room. Resident #1 stated staff had not been wearing gowns and mask to care for her when she came back from the hospital.<BR/>During an interview on [DATE] from 10:42 am through 1:09 pm CNA D, CNA F, CMA G, CNA H, CNA I, Housekeeper J and Housekeeper K all stated Resident #1 was never isolated when she returned from the hospital. They stated there had not been any communication of COVID positive resident in the facility around the time Resident#1 went to the hospital. They all stated it was never passed in report that Resident #1 had COVID. They all stated Resident #1's roommate was never moved to another room. They stated they were never in-serviced on COVID positive in the last 60 days. <BR/>During an interview on [DATE] at 11:55 am, the Administrator said he first heard Resident #1 went out to the ER on [DATE] during their regular morning meeting due to him being off work. The Administrator stated he was not made aware by the DON that Resident #1 tested positive for COVID 19. The Administrator stated if a resident was COVID positive, the expectation was to isolate the resident and monitor, do not have to put them on another hall, follow infection control precautions. The Administrator stated, if the positive resident had a roommate, the roommate should be tested and quarantine when negative. The Administrator stated the DON have details on the facility's policy on COVID, he did not know. The Administrator stated COVID positive should be communicated with other staff caring for the residents for precautions. The Administrator stated he never saw Resident #1's hospital records until [DATE]. The Administrator stated, when a resident was transferred from the hospital, their hospital records are scanned into the system by the Medical Record staff. The Administrator stated the nurses were supposed to review the records for updates, changes and update the Resident's medical records. The Administrator stated he expected the nurses to take into serious consideration what EMS tells them to familiarize themself with the resident, if not done, they will not know how to properly care for the Residents. The Administrator stated they have not isolated any resident for COVID since he had been at the facility due to not having covid positive resident. The Administrator stated it was the expectation for the staff to call the hospital to get paperwork/records, to follow up from the hospital, for continuity of care. He stated, not following the steps for taking precautions could have caused an outbreak, bigger problems, potential to affect other Residents and staff. He stated the DON was supposed to ensure that there were covid tests in facility.<BR/>During an interview on [DATE] at 2:57 pm, LVN L stated he usually got report from LVN A due to them being on the same rotation. LVN L stated he had never gotten report from LVN A indicating Resident #1 was COVID positive. LVN L stated Resident #1 has never been isolated due to COVID-19 and her roommate had been in the room the entire time. LVN L stated if a Resident tested positive for COVID-19, they are to be isolated in a room by themselves or with another covid positive Resident. Staff would wear full PPE such as N95 mask, gown, gloves, face shield, sign place on the door. LVN L stated if Resident #1 tested positive, it would have been good communicating it to staff that provide care for the resident to prevent the spread of the virus.<BR/>Review of facility's policy titled Infection Prevent and Control Program updated 04/2024 reflected: <BR/>1. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals<BR/>and is an integral part of the quality assurance and performance improvement program.<BR/>2. The elements of the infection prevention and control program consist of coordination/oversight, policies/<BR/>procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of<BR/>infection, and employee health and safety.<BR/>Policies and Procedures<BR/>Policies and procedures are utilized as the standards of the infection prevention and control program.<BR/>The infection prevention and control committee, Medical Director, Director of Nursing Services, and<BR/>other key clinical and administrative staff review the infection control policies at least annually. The<BR/>review will include:<BR/>(1) Updating or supplementing policies and procedures as needed;<BR/>(2) Assessment of staff compliance with existing policies and regulations; and<BR/>(3) Any trends or significant problems since the previous review.<BR/>Prevention of Infection<BR/>a. Important facets of infection prevention include:<BR/>(1) identifying possible infections or potential complications of existing infections;<BR/>(2) instituting measures to avoid complications or dissemination;<BR/>(3) educating staff and ensuring that they adhere to proper techniques and procedures;<BR/>(4) enhancing screening for possible significant pathogens;<BR/>(5) immunizing residents and staff to try to prevent illness;<BR/>(6) implementing appropriate isolation precautions when necessary; and<BR/>(7) following established general and disease-specific guidelines such as those of the Centers for Disease<BR/>Control (CDC).<BR/>Requested facility's COVID policy on [DATE] and [DATE] from the Administrator and policy was never given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #5) of 7 residents reviewed for resident rights. <BR/>The facility failed to honor Resident #5's request of being assisted out of bed on 02/09/25.<BR/>This failure could place resident at risk for depression, diminished quality of life and isolation. <BR/>Findings included: <BR/>Review of Resident #5's face sheet, dated 02/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that occurs when the right side of the brain is damaged, resulting in physical disabilities on the left side of the body), depression, unspecified (disorder than can impact your mood, thoughts and feelings, weight, sleeping habits, etc.) and pain. <BR/>Review of Resident #5's MDS admission Assessment, dated 07/22/2024, reflected Resident #5 had a BIMS score of a 10, which indicated her cognition was moderately impaired. Resident #5 required a mechanical lift with transfers. <BR/>Review of Resident #5's Comprehensive Care Plan , revised on 07/29/2024, reflected Resident #5 had a focused area of depression. The interventions included encourage Resident #5 to be an active participant in decision making. Encourage Resident #5 to be involved in activities of choice and preferences. <BR/>During an observation on 2/9/25 from 8:15 am until 9:10 am revealed Resident #5 remained in her bed. Resident #5 was eating breakfast while in her room alone. <BR/>During an interview on 2/9/25 at 8:58 am with Resident #5 revealed that she had wanted to get up this morning prior to breakfast time. Resident #5 stated she was told by staff that they could not get her up. Resident #5 stated she liked to get up and eat in the dining room with other people. She stated it makes her mad and sad to be told she cannot get up out of bed. Resident #5 stated it happens all the time that they tell her she cannot get up. <BR/>During an interview on 2/9/25 at 9:00 am with CNA A revealed she was unable to get Resident #1 out of bed because they did not have a clean sling to use for her. They are waiting for the laundry to get finished washing and drying the sling. <BR/>In a follow-up interview on 2/10/25 at 9:20 am with CNA A, she stated on average she would guess it happened about one time a week that a sling is not available for Resident #5 to get up. <BR/>During an interview on 2/9/25 at 9:10 am with Laundry Aide B revealed the sling needed to get Resident #5 out of bed had not been put in the washing machine yet. She stated that the current load had 16 more minutes than she would wash the sling and set it outside to air dry. The amount of time it would take depended on how fast it dried outside and the weather. <BR/>During an interview on 2/10/25 at 9:50 am with the Adm revealed he was not aware that Resident #5 was not being assisted to get out of bed because of the lack of a sling. He stated soon after the observation yesterday another sling was found. He also had talked to the laundry person and told her if a sling were needed, she could dry it in the dryer. The Adm stated it should not be happening that Resident #5 was told a sling was not available to get her up. He stated all residents have the right to get out of bed when they asked. <BR/>Review of a facility In-service Training Report dated 11/11/24, with the topics to be covered including resident rights. The in-service contents covered included a document titled Resident Rights which included The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 7 residents (Residents #5 and #7) reviewed for care plans.<BR/>1. The facility failed to ensure the comprehensive care plan for Resident #5 included the need for a mechanical lift transfer with the assistance of 2 staff. <BR/>2. The facility failed to ensure Resident #7's comprehensive care plan included aggressive behaviors. <BR/>These failures could affect residents by placing them at risk of not receiving appropriate physical and psychosocial care. <BR/>Findings included:<BR/>Review of Resident #5's face sheet, dated 2/9/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that occurs when the right side of the brain was damaged, resulting in physical disabilities on the left side of the body), depression, unspecified (disorder than can impact your mood, thoughts and feelings, weight, sleeping habits, etc.) and pain. <BR/>Review of Resident #5's MDS admission Assessment, dated 07/22/24, reflected Resident #5 had a BIMS score of 10, which indicated her cognition was moderately impaired. Resident #5 required a mechanical lift with transfers. <BR/>Record review of Resident #5's Comprehensive Care Plan, revised, 09/12/24 reflected a focus area of ADL self-care performance the interventions listed included TRANSFER: the resident is able to: Requires total assist x1.<BR/>Review of Resident #7's face sheet, dated 2/9/25, reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of dementia severe with agitation (brain impairment of at least two brain functions with worry and anxiety) and schizoaffective disorder (a combination of schizophrenia, a mental health condition with symptoms of hallucinations or delusions mixed with mood disorder such as mania and depression)<BR/>Review of Resident #7's MDS Assessment, dated 1/31/25, reflected Resident #7 had a BIMS score of a 3, which indicated severe cognitive impairment. <BR/>Review of Resident #7's Comprehensive Care Plan, initiated, 1/28/25 reflected a focus area of a regular/mechanical soft diet. No other focused areas were included.<BR/>Review of progress Notes from previous facility included with admission paperwork, dated 1/13/25, revealed recent documentation of aggressive history for Resident #7 on 1/23/25 it was noted he had the behavior of grabbing and spitting on nurses. <BR/>During an interview on 2/8/25 at 12:48 pm, CNA F stated Resident #7 had been frequently aggressive with staff when they were providing care. He stated he knew of one incident in which Resident #7 was also aggressive with a peer. CNA F stated he did the best he could do to deal with the aggression and protect the other residents. <BR/>During an interview on 2/8/25 at 4:49 pm, CNA G stated she experienced Resident #7 being aggressive toward staff. CNA G stated she would, in the past, just back off from assisting him and try again later. <BR/>During an interview on 2/9/25 at 11:30 am the Adm stated the person responsible for care plans was a corporate nurse, and the DON added some of the nursing needs. He stated aggressive behaviors and transfer needs should be included in a resident's care plan. <BR/>During an interview on 2/10/25 at 9:30 am with the DON revealed that she was only able to add antibiotic treatments and falls to a care plan. She stated Resident #4's transfer needs with the mechanical lift and 2 staff should be on the care plan. Resident #7's aggression should also be addressed on the care plan. <BR/>During an interview on 2/10/25 at 9:10 am with Corporate LVN/DOR stated that day she was notified that the MDS nurse was out sick. It was her job to oversee all care plans at that facility, and others owned by the same corporation. The LVN/DOR stated she was not aware that Resident #4's care plan did not include her transfer requirements. She stated a mechanical lift always required the use of two staff members and should be included in the care plan. The LVN/DOR stated she was not familiar with Resident #7 but looking at his records they were close to being within the time, 21 days, that a comprehensive care plan was required. She stated the of the care plans was so they can provide the best care possible for the residents. <BR/>Review of the facility policy titled Lifting Machine, Using a Mechanical, revised 7/2017, reflected the following: At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.<BR/>Review of the facility's Care Plans, Comprehensive Person-Centered policy, revised March 2022, reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.<BR/>Policy Statement:<BR/>The interdisciplinary team is responsible for the development of resident care plans.<BR/>Policy Interpretation and Implementation:<BR/>1. Resident care plans are developed according to the timeframes and criteria established by &sect;483.21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for one of five residents (Resident #14) reviewed for dignity. The facility failed to speak to Resident #14 in a way that promoted her dignity and self-worth. This failure could place residents at risk of a decline in their sense of dignity, level of satisfaction with life, and feeling of self-worth.Findings include: Record review of Resident #14's face sheet, dated 07/17/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14 had diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition where a person exhibits symptoms of dementia, but the specific type of dementia was not identified, and the severity had not been specified. Dementia- a loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) , senile degeneration of the brain, not elsewhere classified (a decline in mental abilities like memory, reasoning, and judgement), and anxiety disorder ( excessive, persistent, and uncontrollable feelings of worry, fear, and unease), and Wernicke's encephalopathy (caused by vitamin B1 deficiency, primarily affecting the brain and nervous system). Record review of Resident #14's admission MDS, dated [DATE], reflected the resident had a BIMS score of 9, which indicated her cognition was moderately impaired. Resident #9 did not have any physical or verbal behavior symptoms directed toward others. She had senile degeneration of the brain, Wernicke's encephalopathy, anxiety disorder and non-Alzheimer's dementia (is various types of dementia that are not caused by Alzheimer's disease [(a progressive brain disorder that slowly destroys memory and thinking skills, ultimately interfering with daily life]). Record review of Resident #14's Comprehensive Care Plan, with a revision date of 06/30/2025, reflected Resident #9 had signs and symptoms of anxiety. Interventions: Allow Resident #14 to voice thoughts and feelings. Explore with resident the reason of anxiety. Psych services as ordered. Resident #14 resides in the secure unit. She was at risk for elopement and needed reduced stimuli and a controlled environment. Resident #14's dignity will be maintained and will be safe in the secured unit. Interventions: Monitor frequently to assure residents safety. Explain all procedures, suing terms/ gestures resident can understand. Call by name when given care. Record review of Resident #14's skin assessment and safe survey, on 07/17/2025 at 4:00 PM, dated 07/17/2025, there were no concerns with skin assessments and the resident did not have any psychosocial negative outcomes. She was calm and did not recall the incident. Observation on 07/17/2025 at 12:15 PM, the state surveyor was entering the secured unit and heard someone in a loud tone state you need to sit in your chair. The hallway revealed staff and residents in the dining room. The State Surveyor was approximately 200 feet from the dining room. Upon entering the dining room CNA G and CNA H were passing out trays. Observation on 07/17/2025 at 12: 30 PM to 12:40 PM revealed CNA G remained in the hall when the State Surveyor exited the secure unit and within 3 minutes found the Corporate Nurse and explained what occurred on the secure unit with CNA G. Another DON from a sister facility immediately went to the unit and walked with CNA G to the front office. CNA G wrote a statement, and she was immediately terminated upon further investigation. Interview on 07/17/2025 at 12:20 PM, CNA H stated CNA G did speak in a loud tone when speaking to Resident #14 in the dining room approximately 12:15 PM on 07/17/2025. She stated CNA G stated, you need to sit in your chair. She stated Resident #14 did not respond to CNA G. CNA H stated Resident #14 did not become upset after CNA H spoke to her in a loud tone. Interview on 07/17/2025 at 12:25 PM, CNA G stated she did speak in a loud tone when she stated sit in your chair when she spoke to Resident #14. CNA G stated, I did use a loud tone and was expected to use a softer tone when speaking to a resident. She stated, I can understand this was not the correct tone of voice to use when speaking to residents. CNA G stated she was in-service on abuse and neglect. She did not remember the date. Interview on 07/17/2025 at 2:05 PM, the Corporate Nurse stated CNA G was immediately terminated. She stated anyone using a loud tone when speaking to a resident was not tolerated in the facility. She stated there was a potential a resident may become more anxious and effect a resident's dignity if a staff used a loud tone when speaking to a resident. The Corporate Nurse stated to prevent this from happening again she felt terminating CNA G was in the best interest of the residents in the facility. She stated they wanted to ensure extra precautions were taken to prevent potential neglect or abuse. She stated the physician, ombudsman, family and HHSC were immediately contacted about the incident with Resident #14. The Corporate Nurse stated safety checks and skin assessments were completed on all residents on the secure unit and there were no concerns. She stated an investigation into the incident had begun and the full investigation would be completed within 5 days and submitted to HHSC. The Corporate Nurse stated the facility would not tolerate any rude tone being used when speaking to any of the residents. Interview on 07/17/2025 at 2:30 PM, the DON from the sister facility stated Resident #14 did not have any psychosocial negative outcomes from CNA G speaking to her in a rude tone. She stated Resident #14 was calm and did not display any anxious behavior such as worried expression, wringing her hands or pacing. She stated CNA G was immediately removed from the secure unit and terminated. She stated she instructed nurses to complete skin assessments and safety checks on all residents on the secure unit. The DON stated the skin assessments and safety checks were being completed as a precaution. She stated when staff used a rude tone with a resident this affected a resident's dignity. Interview on 07/17/2025 at 2:45 PM, . Resident #14 stated she did not like for anyone to speak to her very loud. Resident #14 stated no one had spoken to her in a loud tone or yelled at her. She stated no one was rude or mean to her. Resident #14 stated she wanted to see her family. She kept talking about her family. Resident #14 was calm and smiling. She stated, talk to someone else about all of this because I am fine here. Resident #14 stated she felt safe and was not afraid to live in the facility. She stated she did not want to talk anymore and stated come back next week for another visit. Record review of the facility's, undated Resident Rights policy reflected All residents have the right to be treated with dignity and respect, regardless of age, disability, race, ethnicity, religion, sexual orientation, gender identity, or socioeconomic status. Staff will interact with residents in a manner that promotes their self-esteem and self-worth, using preferred names and titles honoring their personal preferences. Record review of the facility's Identifying Types of Abuse Policy, dated June 2023, reflected verbal abuse includes but not limited to the use of oral, written, or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples: name calling, swearing, threatening harm , trying to frighten the resident, racial slurs, etc .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident# 12 and Resident #16) reviewed for ADL care. The facility failed to ensure Resident #12, and Resident # 16's nails were cleaned, and did not have rough edges. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings include: 1. Record review of Resident #12's face sheet, dated 07/17/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included Type 2 diabetes mellitus without complications (a disorder where the body either does not produce enough insulin or cannot properly use the insulin it produces, leading to high blood sugar levels), lack of coordination (the inability to smoothly and efficiently combine movements of different body parts. It can manifest as clumsiness, unsteadiness, or difficulty with tasks such as buttoning a shirt), and anxiety disorder (conditions characterized by excessive fear, worry, and apprehension that can interfere with daily activities). Record review of Resident #12's Annual MDS, dated [DATE], reflected the resident had a BIMS score of 15, which indicated his cognition was intact. Resident #12 required partial/moderate assistance (helper does less than half the effort) with personal hygiene, and showers. He required supervision/or touching assistance (helper provides verbal cues and/or touching as resident completes activity) with the following: dressing, toileting, and oral hygiene. Record review of Resident #12's Comprehensive Care Plan, with completion date of 06/30/2025, reflected Resident # 12 required one staff assistance with bathing, dressing, grooming and hygiene. Observation and interview on 07/15/2025 at 11:01 AM, revealed Resident #12 was in his room sitting in his wheelchair. He had a blackish/ brownish substance underneath the middle and ring fingernails on his right hand. Resident #12's middle fingernail on his right hand was uneven around the edges. Resident #12 stated he requested for his nails to be cleaned and filed a few days ago. He did not recall the date or who he asked to clean his nails. Resident #12 stated the person explained he would receive nail care on Sunday (07/20/2025). He stated he did not recall the ladies name when he requested his nails to be cleaned and filed. 2. Record review of Resident # 16's face sheet, dated 07/17/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #16 had diagnoses which included paraplegia, unspecified (partial or complete paralysis of both legs and often the lower trunk, with the specific cause or extent of the impairment not being clearly defined), lack of coordination (the inability to smoothly and efficiently combine movements of different body parts. It can manifest as clumsiness, unsteadiness, or difficulty with tasks such as buttoning a shirt), and contracture of left hand (a condition where the tissue under the skin of the palm thickens and tightens, causing one or more fingers to bend towards the palm and making it difficult to straighten them). Record review of Resident #16's Quarterly MDS Assessment, dated 06/09/2025, reflected Resident #16 had a BIMS score of 11, which indicated her cognitive status was moderately impaired. Resident #16 required set up assistance with personal hygiene, oral hygiene, and upper body dressing. She required partial/moderate assistance with showers (helper does less than half the effort). Record review of Resident #16's Comprehensive Care Plan, with completion date of 06/30/2025, reflected Resident #16 had an ADL self-care performance deficit related to disease process and impaired balance. Intervention: Bathing/Showering- check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Observation and interview on 07/15/2025 at 11:15 AM, revealed Resident #16 was in her room sitting in her wheelchair. She had a blackish/ brownish substance underneath the middle ring and fore fingernails on her right hand. Resident #16's ring and middle fingernail on her right hand were uneven around the edges. She stated on Saturday (07/12/2025) she asked a nurse if she would clean her nails. Resident #16 did not recall the nurse's name, and the nurse stated her nails would be cleaned and trimmed on Sunday (07/13/2025). She stated no one cleaned her nails on Sunday (07/13/2025). In an interview on 07/15/2025 at 2:00 PM, LVN F stated the nurses were responsible for residents with diagnosis of diabetes with nail care such as trimming, cleaning, filing. He stated the CNAs were responsible for all other residents' nail care. LVN F stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill, such as stomach problems nausea and vomiting. LVN F stated if a resident refused any type of care, the nurse would document the refusal in the nurse's notes. He stated Resident #12 and Resident #16 did not refuse nail care. He stated no one reported to him Resident #16 or Resident #12 refused nail care. LVN F stated he had worked with Resident #12 and Resident #16 for several weeks. He stated he was in- serviced on nail care, however, he did not recall the date. In an interview on 06/19/2025 at 9:20 AM, CNA G stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA G stated the residents' nails were usually cleaned on Sundays, their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as vomiting and diarrhea. She stated a resident may cause a skin tear if their fingernails were not smooth. CNA G stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 12 and Resident #16, and they did not refuse nail care. CNA G stated she did not know the last time these residents' nails were trimmed or cleaned. She stated if any resident refused care it was reported to the nurse and the nurse would document the refusal in the nurses note. In an interview on 06/19/25 at 10:30 AM, CNA C stated the nurses and the CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. She stated it was the CNAs' responsibility to clean and trim all other residents' nails during showers or as needed. She stated if there was a blackish substance underneath the resident's nails, there was a possibility the substance had bacteria. CNA C stated if a resident swallowed the bacteria there was a possibility a resident may become ill with stomach problems such as vomiting. CNA C stated she was in-serviced on nail care; however, she did not recall the date. She stated she had given care to Resident #12 and Resident #16. She stated she was not aware of Resident #12 or Resident #16 refusing nail care. In an interview on 07/17/25 at 09:36 AM, the Corporate Nurse stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become ill with stomach issues such as vomiting and nausea if they ingested the blackish/ brownish substance. She stated the CNAs were responsible for all residents' nails such as cleaning, trimming, and filing except for the residents with diabetes (a disease that occurs when your blood sugar, is too high). She stated for any resident with a diagnosis of diabetes the nurse was responsible for these residents' fingernails. The Corporate Nurse stated the nurse supervisor was responsible for monitoring CNAs giving ADL care which included nail care and the DON was responsible for monitoring the nurse supervisors. Record review of the facility's Policy on Activities of Daily Living, dated 03/2018, reflected Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated, and revised as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two of five residents ( Resident # 15 and Resident #25) reviewed for activities. The facility failed to provide Resident #15 and Resident #25 in room activities on the dates of 07/01/2025 thru 7/17/2025. This failure could place residents at risk for boredom, depression, and diminished quality of life. Based on interview, observation and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two of five residents ( Resident # 15 and Resident #25) reviewed for activities. The facility failed to provide Resident #15 and Resident #25 in room activities on the dates of 07/01/2025 thru 7/17/2025. This failure could place residents at risk for boredom, depression, and diminished quality of life. Findings included:Review of Resident #15's Face Sheet, dated 07/17/2025, reflected an [AGE] year-old female admitted on [DATE] with a diagnosis of Parkinson's disease without dyskinesia, without mention of fluctuations (motor symptoms like tremors, rigidity and slowness of movement. Dyskinesia- disease symptoms where involuntary movements are absent, and there are no significant variations in symptom throughout the day), muscle wasting and atrophy, not elsewhere classified, unspecified site (muscles that lose their nerve supply and waste away), and unspecified asthma (a respiratory condition marked by spasms in the lungs, causing difficulty in breathing).Review of Resident #15's admission MDS Assessment, dated 09/21/2024, reflected Resident #15 had a BIMS score of 15 which indicated her cognition was intact. Resident #15's activity preference was the following:1. Reading books or newspaper.2. Listening to music.3. Being around animals.4. Keeping up with the news.5. Do favorite activities.6. Go outside to get fresh air when the weather is good.7. Do things in groups of people.8. Participating in religious services or practices. Review of Resident #15's Quarterly MDS Assessment, dated 06/10/2025, reflected Resident #15 had a BIMS score of 15 which indicated Resident #15's cognition was intact. Review of Resident #15's Comprehensive Care Plan, dated 06/30/2025, reflected Resident #15 required in rom activity related to resident not participating in activities. Intervention: Activity Director will assess the resident's interest and create the activity plan. Review of Resident #15's Activity Initial Assessment, dated 09/16/2024, reflected Resident #15 preferred activities in her room. Review of Resident #15's Activity In room Participation Record, dated July 2025, reflected Resident #15 did not receive any in room activities from 07/01/2025 thru 07/17/2025. Observation and interview on 07/16/2025 at 2:20 PM, revealed Resident # 15 was in her room watching television. She stated she was tired of watching television every day. Resident #15 stated she did want activities in her room and wanted activity director to visit her and assist her with doing activities. Resident #15 stated she was receiving activities from the Activity Director at one time; however, she had not been getting activities in her room from the Activity Director over the past several weeks. Resident #15 stated she did get bored sometimes. She stated she did not want to attend group activities. Review of Resident #25's Face Sheet, dated 07/17/2025, reflected a 68- year-old male was admitted on [DATE] and readmitted on [DATE] with a diagnoses of unspecified dementia, unspecified severity, with other behavioral disturbance (a condition where a person exhibits symptoms of dementia, but the specific type of dementia was not identified, and the severity had not been specified. Dementia- a loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities with behaviors such as agitation - characterized by restlessness, and anxiety - feelings of fear worry, unease , and apprehension), cognitive communication deficit ( difficulties in communication that arise from impairments in cognitive functions like attention, memory reasoning, and problem-solving), and lack of coordination ( the inability to smoothly and efficiently control movements). Review of Resident #25's Annual MDS, dated [DATE], reflected Resident #25 had a BIMS score of 7 which indicated his cognition was moderately impaired. Resident #25's activity preference was participating in religious services or practices. Review of Resident #25's Quarterly MDS, dated [DATE], reflected Resident #25 had a BIMS score of 8 which indicated his cognition was moderately impaired. Review of Resident #25's Comprehensive Care Plan Assessment, with a completion date of 06/30/2025, reflected Resident #25 was at risk for pain, impaired physical mobility, and inflammation in affected joints. Intervention: Encourage socialization and involvement in activities. Resident #15 required in room activity. Intervention: Activity Director will assess the resident's interest and create activity plan. Review of Resident #25's Activity In room Participation Record, dated July 2025, reflected Resident #15 did not receive any in room activities from 07/01/2025 thru 07/17/2025. Review of The Activity Director's Personnel record on 07/17/2025, reflected she was a certified Activity Director. Observation and interview on 07/17/2025 at 9:10 AM, Resident #25 was sitting in his room lying in bed. He was staring at the wall in front of him. There was not any stimulation on in his room. Resident #25 stated he sometimes gets bored and wished someone come in and talk to him. He stated he did not remember when anyone came in and talked to him or offered him activity. Resident #25 stated he did not want to attend group activities. He stated he did not enjoy being around a group. Resident #25 stated he was tired and come back tomorrow and talk to him. Interview on 07/16/2025 at 8:30 AM, the Activity Director stated Resident #15, and Resident #25 did not receive in room activities from 07/01/2025 thru 07/17/2025. The Activity Director stated she was expected to ensure all residents received activities based on their preferences and their physical abilities. She stated if a was not coming out of their room, the residents were to be provided in room activities. The Activity Director stated she provided in room activities at least twice a week. She stated there was not an excuse why Resident #15 and Resident #25 did not receive in room visits. The Activity Director stated if a resident was not receiving activities on a consistent basis there was a potential a resident may become bored, depressed, or have a decline in their quality of life. Interview on 07/17/2025 at 8:45 AM, The Corporate Nurse stated she expected in room activities be provided to the residents needing these type of activities. She stated if the if a resident was not receiving in room activities there was a possibility a resident may become depressed, bored, and isolated. She stated the Activity Director was responsible for all activities in the facility. The Corporate Nurse stated the Administrator quit on 07/01/2025 and the facility was in the process of hiring a new administrator. She stated the Administrator would be responsible for monitoring the Activity Director and she was going to assign someone (she did not know who at the time of the interview) to monitor activity programs until an administrator was hired. Review of the Facility Activity Programs Policy, dated 06/2018, reflected Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident.Policy Interpretation and Implementation1. The activities program is provided to support the well-being of residents and to encourage both independence and community interaction.2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.3. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities.4. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health.5. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs.6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs.7. Our activity programs consist of individual, small group and large group activities that are designed to meet the needs and interests of each resident. Activity programs include activities that promote:1. self-esteem.2. comfort.3. pleasure.4. education.5. creativity.6. success; and7. independence.8. All activities are documented in the resident's medical record.9. Activities participation for each resident is approved by the attending physician based on information in the resident's comprehensive assessment.10. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g., bed bound or visually impaired residents). Individualized and group activities are provided that:1. reflect the schedules, choices and rights of the residents.2. are offered at hours convenient to the residents, including evenings, holidays and weekends.3. reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents.4. appeal to men and women, as well as those of various age groups residing in the facility; and5. incorporate family, visitor and resident ideas of desired appropriate activities.11. Residents are encouraged, but not required, to participate in scheduled activities.12. Adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met.

Based on observation, interview, and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for facility service safety and preparation for one of one kitchen. <BR/>The facility failed to ensure Dietary [NAME] A properly sanitized hands between tasks.<BR/>This failure could place the residents, who received food from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life.<BR/>Findings included: <BR/>Observation of the kitchen on 03/09/2023 at 9:25 AM revealed the Dietary [NAME] A was using oven mitts and checked on food cooking in the oven. When she heard the knock at the door, she turned around and the surveyor asked if she had a hair net. Dietary [NAME] A stated yes and picked up a dirty wet rag and washed her hands with the rag. She walked toward the hair nets at the other locked entrance door and placed the hair net in the surveyor's hand. She walked with the surveyor to the sink and the surveyor washed both hands. She stood by the surveyor until hand washing was completed. She returned to the stove and looked at the vegetables she was preparing for lunch. Dietary [NAME] A touched her clothes and side of her hair in the small open area of the hair net with all her fingers on her right hand. She walked to a shelf and opened a large container with different types of ladles. She reached for a ladle and touched the section of the ladle used to place inside the cooking pot. She returned to the stove and put the same ladle into the cooking pot with California vegetable medley being prepared and began to stir the food. The dietary cook A did not properly sanitize or wash hands between these tasks.<BR/>In an interview on 03/09/2023 at 9:35 AM the Dietary [NAME] A stated she did use the wet rag to wash her hands. She stated she did touch her clothes and her hair. She stated her hair felt lose underneath the hair net. She stated it was required for her to wash hands at the sink in between tasks or anytime her hands may be dirty. She stated she did not follow how she was trained to wash her hands. She stated anytime her hands touched anything dirty or if it was a possibility her hands were dirty, she was expected to use the sink in the kitchen with soap and water to sanitize her hands. She also stated she had been in serviced on hand hygiene and she was aware of proper hand hygiene. She stated she was not thinking when she washed her hands with the disinfectant rag. She stated the rag was dirty and had disinfectant on it to clean the prep tables and sink. She stated she did not wash, sanitize, or wear gloves after she washed her hands when she first entered the kitchen around 6:00 AM today. <BR/>In an interview on 03/09/2023 at 9:50 AM the Dietary Manager stated it was her responsibility to monitor hand hygiene in the kitchen. She stated she had stepped out of the kitchen for several minutes during this incident. She stated all staff was expected to follow proper hand hygiene protocol. She stated dietary cook was expected to wash her hands in the sink in between tasks and whenever her hands were contaminated by touching objects or anything may not be clean. She stated if she touched her clothing and hair, she was expected to wash her hands immediately. She stated touching inside of the ladle had potential of cross contamination of bacteria on her hands onto the ladle. She stated if the ladle in the vegetables on the stove was the ladle, she touched the ladle would be considered contaminated. She stated she had in-serviced staff on hand hygiene in the kitchen. She also stated if the food was contaminated a resident may become sick with a virus, could have diarrhea or vomiting and become dehydrated. She stated there was a possibility a resident may need hospital care. <BR/>In an interview on 03/09/2023 at 2:45 PM the Director of Nurses stated all staff was expected to use proper hand hygiene protocol including dietary staff. She stated anytime the staff's hands were contaminated they were expected to immediately wash their hands at the designated sink using soap and water. She also stated the dietary staff was expected to follow their hand hygiene protocol/policy. She stated if a dietary staff's hands were potentially contaminated and touched any type of utensils and used the utensils in the pan while cooking there was a possibility bacteria would transfer from the utensil to the food. She stated residents had potential of becoming ill with some type of gastrointestinal virus. She stated there was a potential a resident be admitted to the hospital with certain type of viral infections. She also stated it was her responsibility to monitor all sanitation including hand hygiene in the kitchen. <BR/>Record Review of Dietary [NAME] A's time sheet for 03/09/2023 reflected dietary cook clocked in for the day at 5:46 AM. <BR/>Record review of the Safety Data Sheet of Sink and Surface Cleaner Sanitizer (not dated) reflected wash hands thoroughly after handling. In case of hand contact rinse with plenty of water. If swallowed rinse mouth and get medical attention if symptoms occur. Keep out of reach of children. <BR/>Record review of Facility Policy titled Employee Sanitation dated 2018 reflected the nutrition and food service employees of the facility will practice good sanitation practices in accordance with state and US Food Codes to minimize the risk of infection and food borne illness. Employees must wash their hands and exposed portions of their arms at designated hand washing facilities at the following times:<BR/>1. Immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles.<BR/>2. During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks. <BR/>3. After engaging in other activities that contaminate hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow guidelines for mandatory electronic submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 4 quarters reviewed for payroll data information (Quarter 1 2024).<BR/>The facility failed to submit PBJ staffing information to CMS for the 1st quarter ([DATE] to March 30) of fiscal year 2024.<BR/>This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.<BR/>Findings included:<BR/>Review of the facility's Civil Rights Survey Report dated 05/28/2024 (Form 3761) indicated the following:<BR/>3 RNs <BR/>7 LVNs <BR/>9 Direct Care Staff<BR/>6 Dietary<BR/>4 Housekeeping & Laundry <BR/>7 All Others<BR/>Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report) 1705 D FY Quarter 1 2024 (October 1-December 31), dated 05/22/2024, indicated the following entry: Metric Failed to Submit Data for the Quarter, Result Triggered Definition Triggered = No Data Submitted for Quarter.<BR/>In an interview on 05/30/2023 at 1:20 PM the Administrator stated the corporate office was in charge of reporting the CMS PBJ staffing data. She stated the pervious company was responsible for reporting the 1st quarter staffing information and it was not done. She stated the new corporate office did report the 2nd order. <BR/>Review of the facility's policy (undated) reflected Policy Statement: Direct care staffing information is reported electronically to CMS through the Payroll-Based Journal system. Policy Interpretation and Implementation:<BR/>1. Complete and accurate direct care staffing information is reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS. 8. Technical specifications for uploading data directly from a payroll or time and attendance system will be accessed through: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html.9. Direct care staffing information is submitted on the schedule specified by CMS, but no less frequently than quarterly. 10. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows:<BR/>Fiscal Quarter <BR/>Date Range <BR/>Submission Deadline<BR/>1 <BR/>October 1 - December 31 <BR/>February 14<BR/>2 <BR/>January 1 - March 31 <BR/>May 15<BR/>3 <BR/>April 1 - June 30 <BR/>August 14 <BR/>4 <BR/>July 1 - September 30 <BR/>November 14

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 5 residents (Residents #1 and #2) reviewed for infection control.<BR/>The facility failed to ensure Resident #1 was placed on Isolation after she tested COVID-19 (Coronavirus 2019) positive in the hospital on [DATE]. <BR/>The facility failed to have signage on Resident #1's door that reflected PPE was required for infection control.<BR/>The facility failed to removed Resident #2 from a COVID-19 positive room even though she tested negative for COVID.<BR/>These failures could place residents at risk for infection, or hospitalization.<BR/>Findings included:<BR/>According to the intakes received by HHSC, The facility is not practicing infection control. They are not quarantining the covid positive Residents. [Resident #3] is next door to [Resident #1], and she is Covid Positive. The staff are not wearing PPEs, gloves or gowns. The staff are saying the Resident's covid test results are negative. This is false. The Complainant is concerned Covid will spread to other Residents due to the facility lack of infection Control, and on [DATE], [Resident #1] was sent to the local hospital due to loss of appetite, body aches and cough .The Resident came back from the hospital a couple of hours later. The Complainant assisted EMS with getting the Resident back into the facility and overheard an EMT tell [LVN A] that [Resident #1] had COVID. [Resident #1] is not receiving treatment, and there is not even isolation sign on her door. The complainant fears the illness will spread to other Residents. There Complainant is not aware of other active COVID-19 cases in the facility, but there are several Residents with similar symptom.[sic] <BR/>Review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Systemic Lupus Erythematosus unspecified (a chronic autoimmune disease in which the body's immune system mistakenly attacks healthy tissues in many parts of the body), nontraumatic intracranial hemorrhage (bleeding within the intracranial vault including the brain), Cognitive communication deficit, Acute respiratory failure with hypoxia (Hypoxia is low level of oxygen in the body tissue).<BR/>Review of Resident #1's Quarterly MDS Assessment, dated [DATE], reflected Resident #1 had a BIMS score of 10, which indicated she had moderate cognitive impairment. <BR/>Review of Resident #1's Comprehensive Care Plan dated [DATE] reflected Resident #1 had an ADL self-care.<BR/>performance deficit, had impaired cognitive function/dementia or impaired thought processes, had altered respiratory status/difficulty breathing.<BR/>Review of Resident #1's progress noted dated [DATE] at 9:51 am written by LVN A reflected, minimally responding to verbal and tactile stimulation, very clammy and diaphoretic. New order received: IV 1L 100ml/hr. CBC,<BR/>CMP, UA, chest Xray.<BR/>Review of Resident #1's progress noted dated [DATE] at 1:36 pm written by LVN A reflected, doc notified of COC, resident appears to be lethargic, clammy, and diaphoretic. to receive from doc: CBC, CMP, UA, chest Xray, IV NS 1000mL at 100mL/h.<BR/>Review of Resident #1's progress notes dated [DATE] at 9:00am written by the DON reflected, LATE ENTRY<BR/>Note Text: Spoke with nurse at hospital notified at this time that resident was given test for Covid which was NEGATIVE. Also notified that MD seen no need for IV placement. Resident is not dehydrated. Resident sent back to facility with no medications ordered.<BR/>Review of Resident #1's clinical records from [DATE] through [DATE] did not reflected Resident #1 was COVID positive. It did not reflect Resident #1 was isolated due to COVID and was being monitor. It did not reflect Resident #1 was being treated for COVID 19.<BR/>Review of Resident #2's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] with readmission date of [DATE]. Resident #2 had diagnoses which included Metabolic Encephalopathy (a condition characterized by brain dysfunction caused by systemic metabolic disturbances. Symptoms make include confusion, memory loss, loss of consciousness), Urinary tract infection, Dysphagia (difficulty swallowing) following unspecified cerebrovascular disease (group of conditions that affect blood flow and blood vessels in the brain).<BR/>Review of Resident #2's admission MDS Assessment, dated [DATE], reflected Resident #2 had a BIMS score of 1, which indicated she had severe cognitive impairment. <BR/>Review of Resident #2's Comprehensive Care Plan initiated [DATE] reflected Resident #2 required staff assistance for<BR/>meeting emotional, intellectual, physical, and social needs related to diagnosis of Dementia, Resident is at risk for infection related to risk of COVID-19, and also at risk for social isolation r/t infection control practices implemented by CDC and CMS guidelines to limit visitation, communal dining, and group activities. Community transmission of COVID-19.<BR/>Review of Resident #2's progress notes dated [DATE] written by the DON reflected:<BR/>Late Entry: created [DATE] @1:43 pm<BR/>Note Text: Tested for covid NEGATIVE.<BR/>Review of Resident #2's clinical records did not indicate Resident #2 was moved to another room due to roommate being tested positive for COVID-19<BR/>Review of facility's infection control logs for the months of January, February and March of 2025 did not reflected Resident #1 or any other Resident had COVID-19.<BR/>During an interview on [DATE] at 12:10 pm, LVN A stated she was not in the facility when Resident #1 was transferred to the local Hospital ER on [DATE] and assumed Resident #1 had a changed of condition that is why she was sent to the hospital. LVN A stated she was the assigned nurse when Resident #1 returned from the ER on [DATE] and Resident #1 was not in any Respiratory distress, Resident #1 was at baseline. LVN A stated EMT to her Resident #1 was COVID positive and she told the EMS staff that was not true, Resident #1 was not COVID positive because nurse to nurse report from the hospital and was told Resident #1 was COVID negative. LVN A stated EMS gave her Resident #1's hospital papers and it indicated Resident #1 was COVID negative. LVN A stated she told the DON what the EMS staff had said about Resident #1 being COVID positive and put Resident #1's hospital records in the medical records box. LVN A stated since she had been at the facility from 06/2024 to [DATE], no Resident had tested positive for COVID-19 so there was no need to isolate a Resident.<BR/>During an interview on [DATE] at 12:36 am LVN B stated she was not the nurse on duty who sent Resident #1 to the ER on [DATE]. LVN B stated she had not seen Resident #1 with change of condition, no coughing, no running nose. LVN B stated as far as she can recall, there has been no resident with s/s of covid or tested positive for covid. If someone test positive for covid we have to put them on isolation, let the DON and the Administrator know, they will take it from there and notified whoever.<BR/>During an interview on [DATE] at 12:47pm, Resident #1's family stated, she was told by facility's staff that Resident #1 was sent to the ER to get IV started because they were having trouble starting an IV. Resident #1's family also stated facility staff told her Resident #1 was COVID negative. Family also stated if Resident #1 had COVID, the nurses and the DON did not tell her.<BR/>During an interview on [DATE] at 1:04 pm, CNA C stated he had worked with Resident #1 and was never told she was COVID-19 positive. CNA C stated since he had worked in the facility from 12/2024, no resident had tested positive for COVID-19; No Resident had been put on isolation due to COVID-19. <BR/>During an interview on [DATE] at 1:37 pm, the Medical Record staff stated when a resident comes from the hospital, the nurses give him the resident's hospital records, and it is scanned into PCC. The Medical Record staff stated he did not get hospital records for Resident #1's hospital visit on [DATE]. He stated he was aware that Resident #1 went to the hospital on [DATE] but there were no records. <BR/>During an interview on [DATE] at 1:45 pm, CNA D stated she was usually assigned with Resident #1. CNA stated she could not recall if Resident #1 had signs and symptoms of COVID 19. CNA D stated Resident #1 told her she was COVID positive around the time the resident was sent to the ER. CNA D stated there was a rumor in the facility that Resident #1 was COVID positive but there was nothing done to treat Resident #1. CNA D stated Resident #1 had a roommate, the roommate was never removed from the room and Resident #1 was never isolated.<BR/>During an interview on [DATE] at 2:38 pm, the DON stated she was in the facility when Resident #1 was being sent to the ER on [DATE] due to IV placement. She stated she got nurse-to-nurse report from the hospital on [DATE] regarding Resident #1 was being transfer back to the facility. The DON stated she was also told Resident #1 was COVID negative and Resident #1 did not need IV fluids based on labs done at the hospital. The DON stated she was in the facility when Resident #1 got back, and EMS did not provide hospital papers. The DON said she did not hear EMS say Resident #1 was covid positive. The DON stated, Resident #1's family stated Resident #1 was COVID negative. The DON stated she heard the staff say Resident #1 was positive for COVID, but they did not re-test Resident #1 to confirm because there were no covid test in the facility. The DON stated the COVID test in the facility were all expired. The DON stated, if a Resident was COVID positive, they had to isolate the resident, notify family and the Doctor, test roommate and or remove from the room depending on the test result. <BR/>During an interview with on [DATE] at 2:00 pm, Resident #1 stated she recalled going to the ER for IV meds. Resident #1 stated while in the hospital, they swapped her nose for COVID, and they try to say she had COVID. Resident #1 stated she did not think she had COVID because she did not feel the same as when she had COVID before and was surprised. <BR/>Requested Hospital records for Resident #1's hospital stay on [DATE] from the Administrator and the Hospital.<BR/>Received Resident #1's hospital records on [DATE].<BR/>Reviewed of Resident #1's hospital records dated [DATE] reflected the following:<BR/>COVID-19 confirmed, Cough unspecified-confirmed, fever unspecified-confirmed.<BR/>Chief Complaint-Nausea-Patient is a [AGE] year-old female who comes to the emergency department by EMS from [Nursing Home] complaining of flulike symptoms, of cough, congestions fever, running nose for 2 days. The Nursing home staff was concerned she might be dehydrated and called EMS to have her evaluated. She is speaking in full sentences, alert and oriented without distress.Vital signs stable. Denies any other symptoms.<BR/>Lab results-2019 Coronavirus SARS-CoV-2Ra positive on [DATE] at 11:42 am<BR/>ED Course: Patient is a [AGE] year-old female who comes to the emergency department complaining of generalized flulike symptoms and cough for the past few days. Denies any Nausea or vomiting to me. No clinical evidence of dehydration. Vital signs are stable. Patient is COVID positive, and symptoms have been going on for the past few days. Unable to get a list of her medications and without this I do not feel comfortable prescribing Paxlovid at this time due to possible interactions with her other medications. Patient is asymptomatic and hemodynamically stable at this time. Recommended continued supportive care, fluid hydration orally and close outpatient follow-up with PCP with droplet precaution at the nursing home to avoid spread of the virus to other residents. <BR/>During an interview on [DATE], LVN A stated she and the DON sent Resident #1 out to the hospital on [DATE] for IV placement. LVN A stated Resident #1 had a change of condition, the MD and Resident #1's family were notified. LVN A stated she called EMS and explained why Resident #1 was being sent to the ER. LVN A stated she was still at work on [DATE] when Resident #1 returned from the ER. LVN A stated she did not get report for the hospital regarding Resident #1, the DON got report. LVN A stated the EMS staff told her Resident #1 was COVID positive and she did not take them seriously because the 2 EMS personnels did not want to be there and was just doing the job to get pay. LVN A looked at Resident #1's printed hospital records and stated those were the same records Resident #1 came back from the hospital with on [DATE]. LVN A stated if the hospital records indicated Resident #1 was COVID positive, then she was COVID positive. LVN A stated Resident #1 was sent to the ER for IV placement due to dehydration, not COVID test and was tested by the hospital due to protocol. LVN A stated she came back to the facility at the end of my shift I was ready to go home. I have life outside of work, I come and do my job and leave. I passed report on to the incoming shift that Resident #1 was COVID positive, I don't recall speaking with the DON that Resident #1 was COVID positive, I did not notify the MD, I passed it on in report and went to my Kids. LVN A stated, I am assuming we isolate if a Resident was COVID positive, roommate has to be tested and removed from the room, staff wear full PPEs. LVN A stated she did not test Resident #1's roommate for COVID, she did not know what happened to Resident #1's roommate. LVN A stated she left, went home, not sure if she worked the days following because she had taken some days off. LVN A stated isolation is to prevent them from passing on to somebody else. PPEs included gowns, N95 mask/face shield and gloves.<BR/>During an interview on [DATE] at 09:38 am the DON stated Resident #1 was sent to the ER on [DATE] due to showing signs and symptoms of dehydration such as low blood pressure and dry lips. The DON stated the facility tried to start an IV but was unsuccessful, MD was notified, and Resident was transferred to the hospital. The DON stated LVN A said Resident #1 was sent back without hospital papers. The DON stated Resident #1 should have had hospital records and the admitting nurse is responsible to review the hospital records and give to medical record personnel to enable all staff working with the resident to have access to the records. DON stated she did not see Resident #1's hospital records until [DATE]. The DON stated COVID POSITIVE precautions were isolation, verify the test by retesting, notify families and all parties, test the roommate, if negative they are to be removed from the room, don PPEs such as gowns, gloves, face shield, N95 mask, the sign on the door. The DON stated Resident #1 was not COVID positive, but the roommate was tested negative and moved to another room. <BR/>During an interview on [DATE] at 10:36 am, Resident #1 stated her roommate had been in the room the entire time and had not been moved to another room. Resident #1 stated staff had not been wearing gowns and mask to care for her when she came back from the hospital.<BR/>During an interview on [DATE] from 10:42 am through 1:09 pm CNA D, CNA F, CMA G, CNA H, CNA I, Housekeeper J and Housekeeper K all stated Resident #1 was never isolated when she returned from the hospital. They stated there had not been any communication of COVID positive resident in the facility around the time Resident#1 went to the hospital. They all stated it was never passed in report that Resident #1 had COVID. They all stated Resident #1's roommate was never moved to another room. They stated they were never in-serviced on COVID positive in the last 60 days. <BR/>During an interview on [DATE] at 11:55 am, the Administrator said he first heard Resident #1 went out to the ER on [DATE] during their regular morning meeting due to him being off work. The Administrator stated he was not made aware by the DON that Resident #1 tested positive for COVID 19. The Administrator stated if a resident was COVID positive, the expectation was to isolate the resident and monitor, do not have to put them on another hall, follow infection control precautions. The Administrator stated, if the positive resident had a roommate, the roommate should be tested and quarantine when negative. The Administrator stated the DON have details on the facility's policy on COVID, he did not know. The Administrator stated COVID positive should be communicated with other staff caring for the residents for precautions. The Administrator stated he never saw Resident #1's hospital records until [DATE]. The Administrator stated, when a resident was transferred from the hospital, their hospital records are scanned into the system by the Medical Record staff. The Administrator stated the nurses were supposed to review the records for updates, changes and update the Resident's medical records. The Administrator stated he expected the nurses to take into serious consideration what EMS tells them to familiarize themself with the resident, if not done, they will not know how to properly care for the Residents. The Administrator stated they have not isolated any resident for COVID since he had been at the facility due to not having covid positive resident. The Administrator stated it was the expectation for the staff to call the hospital to get paperwork/records, to follow up from the hospital, for continuity of care. He stated, not following the steps for taking precautions could have caused an outbreak, bigger problems, potential to affect other Residents and staff. He stated the DON was supposed to ensure that there were covid tests in facility.<BR/>During an interview on [DATE] at 2:57 pm, LVN L stated he usually got report from LVN A due to them being on the same rotation. LVN L stated he had never gotten report from LVN A indicating Resident #1 was COVID positive. LVN L stated Resident #1 has never been isolated due to COVID-19 and her roommate had been in the room the entire time. LVN L stated if a Resident tested positive for COVID-19, they are to be isolated in a room by themselves or with another covid positive Resident. Staff would wear full PPE such as N95 mask, gown, gloves, face shield, sign place on the door. LVN L stated if Resident #1 tested positive, it would have been good communicating it to staff that provide care for the resident to prevent the spread of the virus.<BR/>Review of facility's policy titled Infection Prevent and Control Program updated 04/2024 reflected: <BR/>1. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals<BR/>and is an integral part of the quality assurance and performance improvement program.<BR/>2. The elements of the infection prevention and control program consist of coordination/oversight, policies/<BR/>procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of<BR/>infection, and employee health and safety.<BR/>Policies and Procedures<BR/>Policies and procedures are utilized as the standards of the infection prevention and control program.<BR/>The infection prevention and control committee, Medical Director, Director of Nursing Services, and<BR/>other key clinical and administrative staff review the infection control policies at least annually. The<BR/>review will include:<BR/>(1) Updating or supplementing policies and procedures as needed;<BR/>(2) Assessment of staff compliance with existing policies and regulations; and<BR/>(3) Any trends or significant problems since the previous review.<BR/>Prevention of Infection<BR/>a. Important facets of infection prevention include:<BR/>(1) identifying possible infections or potential complications of existing infections;<BR/>(2) instituting measures to avoid complications or dissemination;<BR/>(3) educating staff and ensuring that they adhere to proper techniques and procedures;<BR/>(4) enhancing screening for possible significant pathogens;<BR/>(5) immunizing residents and staff to try to prevent illness;<BR/>(6) implementing appropriate isolation precautions when necessary; and<BR/>(7) following established general and disease-specific guidelines such as those of the Centers for Disease<BR/>Control (CDC).<BR/>Requested facility's COVID policy on [DATE] and [DATE] from the Administrator and policy was never given.

Based on observations, interviews, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 dining rooms and 1 of 1 shower room reviewed for environment.<BR/>The facility failed to ensure the dining room was free of flies during the resident meal service on 05/28/2024 at 12:15 PM.<BR/>The facility failed to ensure the shower room was free of roaches and water bugs on 05/29/2024 at 1:15 PM.<BR/>These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live. <BR/>Findings included:<BR/>Observation on 05/28/2024 at 12:15 PM revealed one resident swatting a fly off of her food. The fly landed in her dessert cup and was stuck on the inside. Another resident had a fly land on her drink cup several times. <BR/>Observation on 05/29/2024 at 1:15 PM in the shower room of a small brown roach crawling toward the commode and a water bug (a large insect that can bite and prefers very wet environments) approximately one-inch-long crawling on the wall above the linen cart. <BR/>In an interview on 05/30/2024 at 4:35 PM the ADM stated she and the MS did the pest control for the facility. She stated they used over the counter products, and she was not aware of any live roaches, but she had seen dead roaches. She stated they sprayed around the outside of the building one time a month. She stated a commercial pest control company had quit coming to the facility and she did not know why. <BR/>In an anonymous staff interview on 05/30/2024 at 12:34 PM they stated there were water bugs in the facility and the infestation was worse in the summer. They stated there were a lot of flies everywhere in the building and especially in the dining room. <BR/>In an interview on 05/30/2024 at 12:39 PM MA I stated she had been at the facility since the end of January. Stated there are a lot of flies in the dining room and at the nurse's station. She stated she had not observed crawling insects, but she did not go into the shower room. <BR/>In an interview on 05/30/2024 at 3:50 PM the DON stated her expectation was that the facility would be pest free. She stated insects could contaminate food. She stated she had not seen any roaches, but she had seen flies in the dining room.<BR/>In an interview on 05/30/2024 at 4:30 PM the ADM stated her expectation was that the facility would be pest free which she stated was not realistic. She stated food that insects landed on could be contaminated. She stated she obtained the pest control chemicals from the local big chain store, or the hardware store and the chemicals were stored outside in the storage room. She stated she and her MS sprayed the pest control products monthly and as needed. She stated she did not know why the pest control company quit coming and stated the company she worked for had taken over the facility November 1st, 2023.<BR/>Record review of an undated facility policy and procedure titled Pest Control reflected Purpose: to provide an environment free of pests. Policy: 1. The facility will have pest control that provides frequent treatment of the environment for pests. It will allow for periodic treatment when a problem is detected. There will be emphasis on the pest control in the kitchens, cafeterias, laundries, loading docks, construction activities and other areas prone to infestation. Monitoring of the environment will be done by the facility's staff. Pest control problems will be reported promptly. Screens will be maintained in all windows that open to the outside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #5) of 7 residents reviewed for resident rights. <BR/>The facility failed to honor Resident #5's request of being assisted out of bed on 02/09/25.<BR/>This failure could place resident at risk for depression, diminished quality of life and isolation. <BR/>Findings included: <BR/>Review of Resident #5's face sheet, dated 02/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that occurs when the right side of the brain is damaged, resulting in physical disabilities on the left side of the body), depression, unspecified (disorder than can impact your mood, thoughts and feelings, weight, sleeping habits, etc.) and pain. <BR/>Review of Resident #5's MDS admission Assessment, dated 07/22/2024, reflected Resident #5 had a BIMS score of a 10, which indicated her cognition was moderately impaired. Resident #5 required a mechanical lift with transfers. <BR/>Review of Resident #5's Comprehensive Care Plan , revised on 07/29/2024, reflected Resident #5 had a focused area of depression. The interventions included encourage Resident #5 to be an active participant in decision making. Encourage Resident #5 to be involved in activities of choice and preferences. <BR/>During an observation on 2/9/25 from 8:15 am until 9:10 am revealed Resident #5 remained in her bed. Resident #5 was eating breakfast while in her room alone. <BR/>During an interview on 2/9/25 at 8:58 am with Resident #5 revealed that she had wanted to get up this morning prior to breakfast time. Resident #5 stated she was told by staff that they could not get her up. Resident #5 stated she liked to get up and eat in the dining room with other people. She stated it makes her mad and sad to be told she cannot get up out of bed. Resident #5 stated it happens all the time that they tell her she cannot get up. <BR/>During an interview on 2/9/25 at 9:00 am with CNA A revealed she was unable to get Resident #1 out of bed because they did not have a clean sling to use for her. They are waiting for the laundry to get finished washing and drying the sling. <BR/>In a follow-up interview on 2/10/25 at 9:20 am with CNA A, she stated on average she would guess it happened about one time a week that a sling is not available for Resident #5 to get up. <BR/>During an interview on 2/9/25 at 9:10 am with Laundry Aide B revealed the sling needed to get Resident #5 out of bed had not been put in the washing machine yet. She stated that the current load had 16 more minutes than she would wash the sling and set it outside to air dry. The amount of time it would take depended on how fast it dried outside and the weather. <BR/>During an interview on 2/10/25 at 9:50 am with the Adm revealed he was not aware that Resident #5 was not being assisted to get out of bed because of the lack of a sling. He stated soon after the observation yesterday another sling was found. He also had talked to the laundry person and told her if a sling were needed, she could dry it in the dryer. The Adm stated it should not be happening that Resident #5 was told a sling was not available to get her up. He stated all residents have the right to get out of bed when they asked. <BR/>Review of a facility In-service Training Report dated 11/11/24, with the topics to be covered including resident rights. The in-service contents covered included a document titled Resident Rights which included The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 7 residents (Residents #5 and #7) reviewed for care plans.<BR/>1. The facility failed to ensure the comprehensive care plan for Resident #5 included the need for a mechanical lift transfer with the assistance of 2 staff. <BR/>2. The facility failed to ensure Resident #7's comprehensive care plan included aggressive behaviors. <BR/>These failures could affect residents by placing them at risk of not receiving appropriate physical and psychosocial care. <BR/>Findings included:<BR/>Review of Resident #5's face sheet, dated 2/9/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that occurs when the right side of the brain was damaged, resulting in physical disabilities on the left side of the body), depression, unspecified (disorder than can impact your mood, thoughts and feelings, weight, sleeping habits, etc.) and pain. <BR/>Review of Resident #5's MDS admission Assessment, dated 07/22/24, reflected Resident #5 had a BIMS score of 10, which indicated her cognition was moderately impaired. Resident #5 required a mechanical lift with transfers. <BR/>Record review of Resident #5's Comprehensive Care Plan, revised, 09/12/24 reflected a focus area of ADL self-care performance the interventions listed included TRANSFER: the resident is able to: Requires total assist x1.<BR/>Review of Resident #7's face sheet, dated 2/9/25, reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of dementia severe with agitation (brain impairment of at least two brain functions with worry and anxiety) and schizoaffective disorder (a combination of schizophrenia, a mental health condition with symptoms of hallucinations or delusions mixed with mood disorder such as mania and depression)<BR/>Review of Resident #7's MDS Assessment, dated 1/31/25, reflected Resident #7 had a BIMS score of a 3, which indicated severe cognitive impairment. <BR/>Review of Resident #7's Comprehensive Care Plan, initiated, 1/28/25 reflected a focus area of a regular/mechanical soft diet. No other focused areas were included.<BR/>Review of progress Notes from previous facility included with admission paperwork, dated 1/13/25, revealed recent documentation of aggressive history for Resident #7 on 1/23/25 it was noted he had the behavior of grabbing and spitting on nurses. <BR/>During an interview on 2/8/25 at 12:48 pm, CNA F stated Resident #7 had been frequently aggressive with staff when they were providing care. He stated he knew of one incident in which Resident #7 was also aggressive with a peer. CNA F stated he did the best he could do to deal with the aggression and protect the other residents. <BR/>During an interview on 2/8/25 at 4:49 pm, CNA G stated she experienced Resident #7 being aggressive toward staff. CNA G stated she would, in the past, just back off from assisting him and try again later. <BR/>During an interview on 2/9/25 at 11:30 am the Adm stated the person responsible for care plans was a corporate nurse, and the DON added some of the nursing needs. He stated aggressive behaviors and transfer needs should be included in a resident's care plan. <BR/>During an interview on 2/10/25 at 9:30 am with the DON revealed that she was only able to add antibiotic treatments and falls to a care plan. She stated Resident #4's transfer needs with the mechanical lift and 2 staff should be on the care plan. Resident #7's aggression should also be addressed on the care plan. <BR/>During an interview on 2/10/25 at 9:10 am with Corporate LVN/DOR stated that day she was notified that the MDS nurse was out sick. It was her job to oversee all care plans at that facility, and others owned by the same corporation. The LVN/DOR stated she was not aware that Resident #4's care plan did not include her transfer requirements. She stated a mechanical lift always required the use of two staff members and should be included in the care plan. The LVN/DOR stated she was not familiar with Resident #7 but looking at his records they were close to being within the time, 21 days, that a comprehensive care plan was required. She stated the of the care plans was so they can provide the best care possible for the residents. <BR/>Review of the facility policy titled Lifting Machine, Using a Mechanical, revised 7/2017, reflected the following: At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.<BR/>Review of the facility's Care Plans, Comprehensive Person-Centered policy, revised March 2022, reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.<BR/>Policy Statement:<BR/>The interdisciplinary team is responsible for the development of resident care plans.<BR/>Policy Interpretation and Implementation:<BR/>1. Resident care plans are developed according to the timeframes and criteria established by &sect;483.21.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 out of 8 residents reviewed for comfortable and safe temperature levels. <BR/>The facility failed to ensure the dining area was within 71-81 degrees Fahrenheit . <BR/>This failure could place residents susceptible to loss of body heat and an uncomfortable setting.<BR/>Findings included:<BR/>Observation on 01/17/2024 at 10:50 a.m., revealed a personal use thermometer on top of a piano in the dining room, the temperature observed was at 67 degrees Fahrenheit. Further observations revealed no residents in the dining room. <BR/>Observation on 01/17/2024 at 10:53 a.m., revealed dining room thermostat set at 73 degrees Fahrenheit, and temperature at 67 degrees Fahrenheit. <BR/>Observation on 01/17/2024 at 12:01 p.m., revealed dining room thermostat set at 73 degrees Fahrenheit, and temperature at 68 degrees Fahrenheit while residents were eating lunch.<BR/>Interview on 01/17/2024 at 10:43 a.m., Resident #1 stated that the dining room. Can be really cold, and that, it (dining room) is okay right now, but at night it can get cold. <BR/>Interview on 01/17/2024 at 10:46 a.m., CNA A stated that the hallways and the residents' rooms are warm, and if residents state it is cold, we respect the residents' concerns and request and we, put up the temperatures., if residents ask for blankets, we give them blankets and assure they are comfortable. CNA A reiterated that the hallways and rooms are good, the dining room is the area that gets cold, we try to keep them warm by offering the blankets and for extra layers of clothing.<BR/>During an observation and interview in the dining room on 01/17/2024 at 11:41 a.m., Resident #2 stated she chose to eat lunch today in the dining room. Resident #1 stated the temperature in the dining room is not bad right now, although it is cold that I wear sweaters and layers. Observation revealed the personal use thermometer on top of the piano temperature at 68 degrees Fahrenheit. <BR/>Interview on 01/17/2024 at 11:47 a.m., Resident #3 stated that it does get cold in the dining room. especially at night. <BR/>Interview on 01/17/2024 at 11:50 a.m., Resident #4 stated that it is cold in the dining room, Resident #4 further stated, she usually puts on her jacket and hat, and it would be ok, since it got cold outside it will get cold in the dining room. <BR/>Interview on 01/17/2024 at 01:59 p.m., Resident #5 stated that she chooses to eat in her room because she noticed temperatures are warmer down in her hallway compared to the dining room, Resident #5 stated the dining room can be cold, especially during the winter and at night.<BR/>Interview on 01/17/2024 at 02:39 p.m., the ADON stated that the dining hall and nursing station uses the same HVAC system. The ADON stated that to her knowledge, the system is working for that area, and at this time we are not able to provide temperature logs for the building, the ADON added if residents express concerns on the facility temperatures being cold, we, turn up the heat, offer and give blankets to our residents. The ADON commented on the temperatures in the dining hall and stated, I think it is the window or the door used to our courtyard, is where the cold air comes in, the door leads to the designated area where residents smoke during the designated smoking times, and that door is also used by staff to access the outside area. The ADON added that the dining room is emptied after the dinner service for cleaning. <BR/>Interview on 01/17/2024 at 03:37 p.m., the ADM stated that at this time she is not able to provide the temperature logs for the facility, and that no residents have informed her of the temperatures of the dining hall. The ADM added that to her knowledge the HVAC system for that area is working. The ADM commented on the temperatures in the dining hall and stated, we have residents that smoke during the designated times, some residents use wheelchairs so it may take some time to get them ready and safely escort the residents to the area, the door is left open to escort the residents out to the area and also back in. <BR/>Review of the facility's Quality of Life-Homelike Environment policy, no date, reflected a policy statement that Resident are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy reflected, <BR/>2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: <BR/>G. Comfortable temperatures

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remains free of accidents and hazards for one (1) (Resident #1) of four (4) residents reviewed for accidents and hazards.<BR/>The facility failed to properly supervise Resident #1 and as a result she had a cigarette lighter stored in her room.<BR/>This deficient practice placed residents at risk for accidents resulting in injuries or hospitalization related to burns or fire.<BR/>Findings include:<BR/>Review of Resident #1's face sheet dated 1/3/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Personal History of Lung Cancer, Muscle Wasting and Atrophy, Dementia (age related memory loss) and Paraplegia (partial paralysis).<BR/>Review of Resident #1's MDS dated [DATE] reflected a BIMS of 11, indicating moderate cognitive impairment. Review of Section G, Functional status revealed resident was limited assistance with eating; extensive assistance with transfers, mobility, dressing and personal hygiene; extensive assistance with toilet use and bathing. Resident # 1 required one person assistance with all activities except transfers where she was a two person assist.<BR/>Review of Resident #1's Care Plan dated 11/5/2023 revealed Resident #1 was a smoker with interventions: Instruct resident about smoking risks and hazards and about smoking cessation aids that are available; Instruct resident about the facility policy on smoking: locations, times, safety concerns; Notify charge nurse immediately if it was suspected resident has violated facility smoking policy; Observe clothing and skin for signs of cigarette burns.<BR/>Record review of Resident #1's smoking safety screens dated 11/18/2023 and 1/3/2024 revealed Resident #1 was safe to smoke with supervision.<BR/>During an observation on 1/3/2024 at 12:55 pm of the outside smoking area, Resident #4 was observed smoking a cigarette. There was no staff in the area and Resident #4 did not have a smoking apron on his person.<BR/>During an observation on 1/3/2024 at 1:00 pm in the facility common room, the ADON approached Resident #4 and asked him if he had a lighter on him. Resident #4 replied that he did and produced the lighter out of his pocket. The ADON asked him for the lighter and the resident handed it to her. <BR/>During an observation on 1/3/2024 at 1:35 pm of the outside smoking area, 3 residents were observed to be smoking with one staff in attendance. Two residents were observed wearing smoking aprons.<BR/>During an interview on 1/3/2024 at 11:35 am, RN-A stated she had been working at the facility for 3 to 4 months and she had not witnessed any issues with residents being unsafe or not following the smoking policy. RN - A stated smoking materials were locked up in the medication room and the smoking aprons were also kept in the medication room. She stated when it was time for the residents' smoke break, the designated staff would hand out cigarettes to the residents and take them outside of the dining room to smoke. She stated staff would hand out the Aprons to the supervised smokers and light their cigarettes for them.<BR/>During an interview on 1/3/2024 at 12:55 pm, Resident #4 he stated he had gotten cigarettes from then nurse and went outside and lit his own cigarettes. He produced a lighter from out of his coat pocket and showed this investigator.<BR/>During an interview on 1/3/2024 at 1:10 pm AD stated Resident #4 had completed a smoking safety screen and was determined to be an unsupervised smoker; Resident #4 could smoke outside unsupervised in the designated smoking area, could go without an apron and could have a cigarette lighter on his person.<BR/>During an interview on 1/3/2024 at 1:15 pm, Resident #1 stated RN -A had just come in the room and asked her if she had a lighter in her possession and if so, could she give it to her. Resident # 1 stated she handed her lighter to RN-A. Resident #1 stated she had kept the lighter in her dresser drawer when she was not using it and had kept it there for several weeks. Resident #1 stated she was familiar with the facility's smoking policy. She stated she could only smoke at the designated times out back, and she had to be supervised and she had to wear an apron. She stated she would get her cigarettes from the staff and the cigarettes were kept in a lock box in the medication room. She stated she knew she was not supposed to have a lighter in her room, but she likes having her own lighter.<BR/>During an interview on 1/3/2023 at 1:40 pm, RN- A stated the ADON had asked her to go around and ask all the smokers if they had lighters. She stated she went to Resident #1 and Resident #1 initially denied it but then told RN-A the lighter was in her top drawer. RN-A retrieved the lighter and held on to it until Resident #1 went out to smoke a short while later. RN -A stated when the residents came back in from their smoke break, the lighter was put in the lock box in the medication room. <BR/>During an interview on 1/3/2024 at 2:45 pm, the AD stated she had been working at this facility since 11/27/2023. She stated they have no residents that wander and no intrusive residents currently at this facility. She stated there have been no incidents involving close calls with lighters since she had been here. She stated the facility currently had no residents on continuous oxygen and that none of the residents that smoke had roommates. She stated if a resident passed their smoking safety screen, they could smoke independently in the designated smoking area and were allowed per the facility policy to keep smoking material on their person. She stated they had one resident who was an independent smoker, and that resident was allowed to keep a lighter on his person, but the cigarettes were still locked up in the medication room.<BR/>During an interview on 1/3/2024 at 3:17 pm, the Activity Director stated the facility held a resident council meeting on 11/2/2023 and the local Ombudsman came to the meeting to talk to the residents about their rights and review the facility smoking policy. She stated the Ombudsman discussed smoking break times, smoking safety and went over the entire smoking policy. She stated Resident #1 attended this council meeting. She stated she frequently takes the smokers out for their smoke breaks and the supervised smokers were very good about wearing their smoking aprons and abiding by the policy. She stated she had not witnessed any unsafe encounters while supervising the residents on their smoke breaks.<BR/>During an interview with the AD and RDCO (Regional Director of Clinical Operations) on 1/3/2024 at 5:30 pm, the AD stated they were not able to find the smoking behavior contract for Resident #1 but was sure she signed one when she was admitted . The DON stated there had been no safety incidents with any of the smokers since she had been here. Corporate Staff stated the definition of smoking materials in the facility's smoking policy includes all tobacco products and lighters.<BR/>During an interview with the AD on 1/3/2024 at 6:45 pm, she stated her expectations of staff, when they take residents out for smoke breaks, was that the residents that required supervision, the staff would be the one to light their cigarettes and then hold onto the lighter until they came back inside and then the lighter went in the lock box in the medication room. She stated Resident #1 having a lighter in her room did not meet her expectations and that a resident could potentially burn themselves or burn someone else, or even start a fire.<BR/>Review of Resident #4's Smoking - Safety Screen dated 11/11/2023 revealed Resident #4 is Safe to smoke without supervision. Resident is able to demonstrate task without difficulty.<BR/>Review of facility smoke break sign, undated, posted at the nurses station revealed Designated Smoking times 8:30 am, 11:00 am, 1:30 pm, 3:30 pm, 7:00 pm, 9:00 pm Further the sign stated No one is to smoke in the front of the building. A member of the staff is to accompany Residents to monitor safety. Please be sure cigarette butts are out when discarded, empty ashtray before lighting cigarettes. Thank you<BR/>Review of the facility Incident/Accident Report date 1//3/2024 revealed no incidents involving smoking, burns or lighters for the period of 7/4/2023 to 1/3/2024.<BR/>Review of facility staff in-service record dated 5/15/2023 revealed residents requiring supervision should not light their own cigarettes. Staff should light cigarettes and keep the lighter. Further it stated, supervised resident: Resident #1.<BR/>Review of facility Resident Council Minutes dated 11//2/23 at 10:15 am in the dining room revealed Resident #1 was in attendance at the meeting and topics were Resident Rights, Meals, Care Plans, Family Council and Smoking Policy.<BR/>Review of undated facility policy Nursing Policies and Procedures Stated under Smoking Safety - Resident Assessment #9 Smoking materials for residents who are determined by the interdisciplinary team as needing assistance with smoking, and for residents who use or reside in a room with oxygen use, will be stored by the nursing staff beginning at the time of admission, when purchased by the residents and/or received from family or other visitors; #10 Smoking materials for residents who are determined by the interdisciplinary team as safe for independent smoking may be managed by the resident, but must be stored on their person or in a locked box inaccessible to other residents.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 out of 8 residents reviewed for comfortable and safe temperature levels. <BR/>The facility failed to ensure the dining area was within 71-81 degrees Fahrenheit . <BR/>This failure could place residents susceptible to loss of body heat and an uncomfortable setting.<BR/>Findings included:<BR/>Observation on 01/17/2024 at 10:50 a.m., revealed a personal use thermometer on top of a piano in the dining room, the temperature observed was at 67 degrees Fahrenheit. Further observations revealed no residents in the dining room. <BR/>Observation on 01/17/2024 at 10:53 a.m., revealed dining room thermostat set at 73 degrees Fahrenheit, and temperature at 67 degrees Fahrenheit. <BR/>Observation on 01/17/2024 at 12:01 p.m., revealed dining room thermostat set at 73 degrees Fahrenheit, and temperature at 68 degrees Fahrenheit while residents were eating lunch.<BR/>Interview on 01/17/2024 at 10:43 a.m., Resident #1 stated that the dining room. Can be really cold, and that, it (dining room) is okay right now, but at night it can get cold. <BR/>Interview on 01/17/2024 at 10:46 a.m., CNA A stated that the hallways and the residents' rooms are warm, and if residents state it is cold, we respect the residents' concerns and request and we, put up the temperatures., if residents ask for blankets, we give them blankets and assure they are comfortable. CNA A reiterated that the hallways and rooms are good, the dining room is the area that gets cold, we try to keep them warm by offering the blankets and for extra layers of clothing.<BR/>During an observation and interview in the dining room on 01/17/2024 at 11:41 a.m., Resident #2 stated she chose to eat lunch today in the dining room. Resident #1 stated the temperature in the dining room is not bad right now, although it is cold that I wear sweaters and layers. Observation revealed the personal use thermometer on top of the piano temperature at 68 degrees Fahrenheit. <BR/>Interview on 01/17/2024 at 11:47 a.m., Resident #3 stated that it does get cold in the dining room. especially at night. <BR/>Interview on 01/17/2024 at 11:50 a.m., Resident #4 stated that it is cold in the dining room, Resident #4 further stated, she usually puts on her jacket and hat, and it would be ok, since it got cold outside it will get cold in the dining room. <BR/>Interview on 01/17/2024 at 01:59 p.m., Resident #5 stated that she chooses to eat in her room because she noticed temperatures are warmer down in her hallway compared to the dining room, Resident #5 stated the dining room can be cold, especially during the winter and at night.<BR/>Interview on 01/17/2024 at 02:39 p.m., the ADON stated that the dining hall and nursing station uses the same HVAC system. The ADON stated that to her knowledge, the system is working for that area, and at this time we are not able to provide temperature logs for the building, the ADON added if residents express concerns on the facility temperatures being cold, we, turn up the heat, offer and give blankets to our residents. The ADON commented on the temperatures in the dining hall and stated, I think it is the window or the door used to our courtyard, is where the cold air comes in, the door leads to the designated area where residents smoke during the designated smoking times, and that door is also used by staff to access the outside area. The ADON added that the dining room is emptied after the dinner service for cleaning. <BR/>Interview on 01/17/2024 at 03:37 p.m., the ADM stated that at this time she is not able to provide the temperature logs for the facility, and that no residents have informed her of the temperatures of the dining hall. The ADM added that to her knowledge the HVAC system for that area is working. The ADM commented on the temperatures in the dining hall and stated, we have residents that smoke during the designated times, some residents use wheelchairs so it may take some time to get them ready and safely escort the residents to the area, the door is left open to escort the residents out to the area and also back in. <BR/>Review of the facility's Quality of Life-Homelike Environment policy, no date, reflected a policy statement that Resident are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy reflected, <BR/>2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: <BR/>G. Comfortable temperatures

**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 neglect were reported immediately to the state survey agency, for 1 of 1 resident (Resident# 25) reviewed for elopement.<BR/>The facility did not report to the state survey agency when Resident #25 eloped from the facility on 05/14/2024 without facility knowledge and was found at the convenience store 0.4 miles away.<BR/>This failure places residents at risk for elopement, accidents, and heat exhaustion due to lake of supervision.<BR/>Findings included: <BR/>Review of Resident #25's Face sheet dated 05/28/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Vertigo (A sense of spinning experienced even when someone is perfectly still.), anxiety disorder, (Fear characterized by behavioral disturbances.) and lack of coordination. <BR/>Review of Resident #25 Annual MDS dated [DATE] reflected he was assessed to have a BIMS score of 7 indicating moderate cognitive impairment. Resident #25 was assessed to not have wandering behavior during the assessment period. Resident #25 was assessed to require moderate assist with ADLs.<BR/>Review of Resident #25's Comprehensive care plan reflected a focus area dated 09/23/22 Resident #25 has impaired cognitive function/dementia or impaired thought processes related to dementia, impaired decision making. Further review reflected a focus area dated 01/10/0223 Resident #25 has vertigo related to dizziness. And a focus area dated 07/26/2022 Resident #25 is a wanderer r/t Disoriented to place. He has ideations of wanting to go home and believes he has a vehicle at the community that he can get in and drive. Goals included: The resident's safety will be maintained through the review date and the resident will not leave facility unattended through the review date. Interventions included: Assess for fall risk. Date Initiated: 07/26/2022; Disguise exits; cover door knobs and handles, tape floor. Date Initiated: 07/26/2022, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 07/26/2022 , Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 07/26/2022; Monitor for fatigue and weight loss. Date Initiated: 07/26/2022.<BR/>Review of Resident #25's nursing progress notes reflected an entry dated 05/13/2024 At approx. 6:25 PM, Resident #25 asked to walk to store, stating they let me do it all the time, I just sign out. This charge nurse verified request with Administrator. This charge nurse was informed that resident cannot leave residence unattended due to being observed breaking the smoking policy and smoking unattended while walking to store on a previous occasion. Resident was mildly argumentative but agreed and verbalized understanding. Further review reflected an entry dated 05/14/2024 at 8:30 PM This resident was observed walking from the facility toward the neighborhood store. Resident stated he went to store to buy candies This charge nurse informed CNA to pick up resident from store due to the fatigue from the walk. The CNA brought resident back to facility. This charge nurse did head to toe assessment. No skin issues noted. Resident denies pain or discomfort at this time. This charge nurse asked resident if he would cooperate with a physical search to make, he doesn't have any unpopular items. Resident refused physical search of himself. Assessed vitals: B/P 124/71, P78, R18, T 98.0. Q 15 min checks initiated. <BR/>In an interview on 05/28/2024 at 3:02 PM the Administrator stated the incident with Resident #25 was not reported to the state. She stated he did leave the facility and he did not sign out and the facility did not know where he was. She stated it was not an elopement he just went to the store unattended he likes to get cigarettes. She stated again it was not an elopement, but a behavior and we discourage him from going. Administrator stated she did not know if he was his own responsible party.<BR/>In an interview on 05/29/2024 at 10:32 AM the DON stated Resident #25 did not elope she stated he was alert. When asked if anyone knew he was gone, she stated no. She further stated he has had an increase in narcotic use due to a fall and complaints of hip pain. She stated she has heard of his behaviors of confusion and wandering but has not seen any. She did not know what the facility's policy was regarding elopement. The DON stated the incident was not reported to the stated because she did not think it was an elopement. <BR/>Review of the facility policy abuse/ neglect (not dated) reflected It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation . Neglect is the failure to provide necessary and adequate (medical, personal or psychological) care. Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional . All allegations of abuse will be reported to the appropriate State Agencies immediately after the initial allegation is received. A final investigation report will be submitted to the appropriate State Agencies within 5 working days . The Administrator is the Abuse Coordinator. Preliminary Investigation Report: The abuse coordinator must submit a preliminary investigation report to the appropriate State Agencies immediately once assurances for the resident's or other resident's safety have been established. However, if the event that caused the allegation of abuse results in serious bodily harm, the allegation of abuse must be reported to appropriate state agencies immediately and not later than 2 hours after receiving the allegation of abuse. Final Investigation Report: The abuse coordinator must submit a final investigation report to the appropriate State Agencies within five (5) working days of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents had orders and followed physician's orders for the resident's immediate care for 1 of 15 Residents (Resident #80) reviewed for admission orders.<BR/>The facility failed to provide physician's orders for fingerstick blood sugar checks for Resident #80 who was admitted to the facility on [DATE].<BR/>The facility failed to check Resident #80's blood pressure per Physician's orders. <BR/>This failure could place the resident at risk of not receiving necessary care and services upon admission that could result in a deterioration of her condition. <BR/>Findings included:<BR/>Record review of the undated Face Sheet for Resident #80 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Type 2 Diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy) and Morbid Obesity (severely overweight). <BR/>Record review of the Discharge Medications list dated 04/23/2024 from a hospital and provided by Resident #80. The medication list was transcribed by LVN C, the receiving nurse for Resident #80 and reflected Insulin glargine 60 Units subcutaneously (underneath all of the layers of the skin) twice a day for Type 2 Diabetes and Lisinopril Oral tablet Give 1 tablet by mouth one time a day for hypertension [high blood pressure] hold for SBP &lt;110, DBP&lt; 80 or HR &lt; 60.<BR/>In an interview on 05/29/2024 at 4:05 PM Resident #80's Physician stated he no idea who wrote the orders for Resident #80. He stated normally the on-call Dr. would write the orders but he did not know who that Dr. was or if they were called. He stated the facility knew he would visit the resident the week after admission. He stated Resident #80 was a low risk for problems with her blood sugar as she was aware when it was low, but doing a blood sugar check would be appropriate before administering insulin. He stated it would be a standard of care to have blood pressure checks prior to blood pressure medications and blood sugar checks prior to giving insulin. He stated he would set parameters for giving the medications. <BR/>In an interview on 05/30/2024 12:10 PM LVN C stated she was the receiving nurse and had worked the evening shift when Resident #80 was admitted . She stated she had called the facility Medical Director to confirm orders and stated she got the Resident's medications from paperwork she had provided from her recent discharge from a hospital. She stated she had put in blood pressure parameters and told the Medical Director the resident had been checking her blood sugars at home. <BR/>In an interview on 05/30/2024 01:00 PM LVN A stated there were no orders in the chart for FSBS and she did not see orders for FSBS from admission. She stated she had not seen any orders for blood pressure checks. She stated she was still learning how to use the facility electronic health care charting. <BR/>Record review of the Blood Pressure Summary for Resident #80 reflected she had blood pressure checks on 5/25/2024 at 31 minutes past midnight, at 10:04 AM on 05/27/2024, at 3:24 PM on 05/28/2024 and at 10:03 AM on 5/29/2024. No other blood pressure checks were recorded. <BR/>Record review of the Blood Sugar Summary for Resident #80 reflected she had her blood sugar checked on 05/24/2024 at 10:30 PM with a reading of 129 and on 05/30/2024 at 9:41 AM with a reading of 168. No other blood sugars were recorded. <BR/>In an interview on 05/30/2024 at 3:25 PM the DON stated the standard of care for a resident with diagnoses of insulin-dependent diabetes would be blood sugar accuchecks (blood sugar monitoring). She stated an abnormally high or low blood sugar could be a risk to the resident. She stated the standard of care for a resident receiving blood pressure medication would be blood pressure checks. She stated she had started in her position three months ago, and it was a process training the nurses. <BR/>Record review of a facility Therapeutic Interchange Program for medications signed by the DON on 03/22/2024 reflected for a resident receiving insulin, blood glucose monitoring was recommended. <BR/>In an interview on 05/30/2024 at 4:21 PM the ADM stated her expectation was that nursing staff follow physician's order. She stated she did not understand the risk of not taking a blood pressure or blood glucose check as that was a clinical question.<BR/>Review of an article titled Blood Glucose Monitoring dated 05/23/2023 from the National Institute of Health/National Library of Medicine reflected Blood glucose monitoring helps to identify patterns in the fluctuation of blood glucose (sugar) that occur in response to diet, exercise, medications, and pathological processes associated with blood glucose fluctuations, such as diabetes mellitus. Unusually high or low blood glucose levels can potentially lead to life threatening conditions, both acute and chronic. The human body attempts to maintain blood glucose levels at about 72 to 108 mg/dl. Regular daily blood glucose monitoring is recommended for those with diabetes mellitus using insulin therapy.<BR/>Review of an article titled Open Resources for Nursing Blood Pressure Introduction dated 2021 from the National Institute of Health/National Library of Medicine reflected The accurate measurement of blood pressure is important for ensuring patient safety and optimizing body system function. Blood pressure measurements are used by health care providers to make important decisions about a patient's care. Blood pressure measurements help providers make decisions about whether a patient needs fluids or prescription medications. It is crucial to follow the proper steps to obtain a patient's blood pressure to ensure the care team has accurate data to help make health care decisions and determine a plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remains free of accidents and hazards for one (1) (Resident #1) of four (4) residents reviewed for accidents and hazards.<BR/>The facility failed to properly supervise Resident #1 and as a result she had a cigarette lighter stored in her room.<BR/>This deficient practice placed residents at risk for accidents resulting in injuries or hospitalization related to burns or fire.<BR/>Findings include:<BR/>Review of Resident #1's face sheet dated 1/3/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Personal History of Lung Cancer, Muscle Wasting and Atrophy, Dementia (age related memory loss) and Paraplegia (partial paralysis).<BR/>Review of Resident #1's MDS dated [DATE] reflected a BIMS of 11, indicating moderate cognitive impairment. Review of Section G, Functional status revealed resident was limited assistance with eating; extensive assistance with transfers, mobility, dressing and personal hygiene; extensive assistance with toilet use and bathing. Resident # 1 required one person assistance with all activities except transfers where she was a two person assist.<BR/>Review of Resident #1's Care Plan dated 11/5/2023 revealed Resident #1 was a smoker with interventions: Instruct resident about smoking risks and hazards and about smoking cessation aids that are available; Instruct resident about the facility policy on smoking: locations, times, safety concerns; Notify charge nurse immediately if it was suspected resident has violated facility smoking policy; Observe clothing and skin for signs of cigarette burns.<BR/>Record review of Resident #1's smoking safety screens dated 11/18/2023 and 1/3/2024 revealed Resident #1 was safe to smoke with supervision.<BR/>During an observation on 1/3/2024 at 12:55 pm of the outside smoking area, Resident #4 was observed smoking a cigarette. There was no staff in the area and Resident #4 did not have a smoking apron on his person.<BR/>During an observation on 1/3/2024 at 1:00 pm in the facility common room, the ADON approached Resident #4 and asked him if he had a lighter on him. Resident #4 replied that he did and produced the lighter out of his pocket. The ADON asked him for the lighter and the resident handed it to her. <BR/>During an observation on 1/3/2024 at 1:35 pm of the outside smoking area, 3 residents were observed to be smoking with one staff in attendance. Two residents were observed wearing smoking aprons.<BR/>During an interview on 1/3/2024 at 11:35 am, RN-A stated she had been working at the facility for 3 to 4 months and she had not witnessed any issues with residents being unsafe or not following the smoking policy. RN - A stated smoking materials were locked up in the medication room and the smoking aprons were also kept in the medication room. She stated when it was time for the residents' smoke break, the designated staff would hand out cigarettes to the residents and take them outside of the dining room to smoke. She stated staff would hand out the Aprons to the supervised smokers and light their cigarettes for them.<BR/>During an interview on 1/3/2024 at 12:55 pm, Resident #4 he stated he had gotten cigarettes from then nurse and went outside and lit his own cigarettes. He produced a lighter from out of his coat pocket and showed this investigator.<BR/>During an interview on 1/3/2024 at 1:10 pm AD stated Resident #4 had completed a smoking safety screen and was determined to be an unsupervised smoker; Resident #4 could smoke outside unsupervised in the designated smoking area, could go without an apron and could have a cigarette lighter on his person.<BR/>During an interview on 1/3/2024 at 1:15 pm, Resident #1 stated RN -A had just come in the room and asked her if she had a lighter in her possession and if so, could she give it to her. Resident # 1 stated she handed her lighter to RN-A. Resident #1 stated she had kept the lighter in her dresser drawer when she was not using it and had kept it there for several weeks. Resident #1 stated she was familiar with the facility's smoking policy. She stated she could only smoke at the designated times out back, and she had to be supervised and she had to wear an apron. She stated she would get her cigarettes from the staff and the cigarettes were kept in a lock box in the medication room. She stated she knew she was not supposed to have a lighter in her room, but she likes having her own lighter.<BR/>During an interview on 1/3/2023 at 1:40 pm, RN- A stated the ADON had asked her to go around and ask all the smokers if they had lighters. She stated she went to Resident #1 and Resident #1 initially denied it but then told RN-A the lighter was in her top drawer. RN-A retrieved the lighter and held on to it until Resident #1 went out to smoke a short while later. RN -A stated when the residents came back in from their smoke break, the lighter was put in the lock box in the medication room. <BR/>During an interview on 1/3/2024 at 2:45 pm, the AD stated she had been working at this facility since 11/27/2023. She stated they have no residents that wander and no intrusive residents currently at this facility. She stated there have been no incidents involving close calls with lighters since she had been here. She stated the facility currently had no residents on continuous oxygen and that none of the residents that smoke had roommates. She stated if a resident passed their smoking safety screen, they could smoke independently in the designated smoking area and were allowed per the facility policy to keep smoking material on their person. She stated they had one resident who was an independent smoker, and that resident was allowed to keep a lighter on his person, but the cigarettes were still locked up in the medication room.<BR/>During an interview on 1/3/2024 at 3:17 pm, the Activity Director stated the facility held a resident council meeting on 11/2/2023 and the local Ombudsman came to the meeting to talk to the residents about their rights and review the facility smoking policy. She stated the Ombudsman discussed smoking break times, smoking safety and went over the entire smoking policy. She stated Resident #1 attended this council meeting. She stated she frequently takes the smokers out for their smoke breaks and the supervised smokers were very good about wearing their smoking aprons and abiding by the policy. She stated she had not witnessed any unsafe encounters while supervising the residents on their smoke breaks.<BR/>During an interview with the AD and RDCO (Regional Director of Clinical Operations) on 1/3/2024 at 5:30 pm, the AD stated they were not able to find the smoking behavior contract for Resident #1 but was sure she signed one when she was admitted . The DON stated there had been no safety incidents with any of the smokers since she had been here. Corporate Staff stated the definition of smoking materials in the facility's smoking policy includes all tobacco products and lighters.<BR/>During an interview with the AD on 1/3/2024 at 6:45 pm, she stated her expectations of staff, when they take residents out for smoke breaks, was that the residents that required supervision, the staff would be the one to light their cigarettes and then hold onto the lighter until they came back inside and then the lighter went in the lock box in the medication room. She stated Resident #1 having a lighter in her room did not meet her expectations and that a resident could potentially burn themselves or burn someone else, or even start a fire.<BR/>Review of Resident #4's Smoking - Safety Screen dated 11/11/2023 revealed Resident #4 is Safe to smoke without supervision. Resident is able to demonstrate task without difficulty.<BR/>Review of facility smoke break sign, undated, posted at the nurses station revealed Designated Smoking times 8:30 am, 11:00 am, 1:30 pm, 3:30 pm, 7:00 pm, 9:00 pm Further the sign stated No one is to smoke in the front of the building. A member of the staff is to accompany Residents to monitor safety. Please be sure cigarette butts are out when discarded, empty ashtray before lighting cigarettes. Thank you<BR/>Review of the facility Incident/Accident Report date 1//3/2024 revealed no incidents involving smoking, burns or lighters for the period of 7/4/2023 to 1/3/2024.<BR/>Review of facility staff in-service record dated 5/15/2023 revealed residents requiring supervision should not light their own cigarettes. Staff should light cigarettes and keep the lighter. Further it stated, supervised resident: Resident #1.<BR/>Review of facility Resident Council Minutes dated 11//2/23 at 10:15 am in the dining room revealed Resident #1 was in attendance at the meeting and topics were Resident Rights, Meals, Care Plans, Family Council and Smoking Policy.<BR/>Review of undated facility policy Nursing Policies and Procedures Stated under Smoking Safety - Resident Assessment #9 Smoking materials for residents who are determined by the interdisciplinary team as needing assistance with smoking, and for residents who use or reside in a room with oxygen use, will be stored by the nursing staff beginning at the time of admission, when purchased by the residents and/or received from family or other visitors; #10 Smoking materials for residents who are determined by the interdisciplinary team as safe for independent smoking may be managed by the resident, but must be stored on their person or in a locked box inaccessible to other residents.

**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 such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for 4 of 4 residents (Residents #88, #22, #19 and #24) reviewed for respiratory care. <BR/>A. <BR/>The facility failed to ensure Resident #80's CPAP mask was covered with a dated plastic bag on 05/28/2024 at 9:52 AM <BR/>B. <BR/>The facility failed to ensure Resident #22's nebulizer mask was covered with a dated plastic bag on 05/29/2024 at 2:33 PM. <BR/>C. <BR/>The facility failed to ensure Resident #19's oxygen tubing was dated on 05/28/2024 at 11:02 AM and failed to ensure her nasal cannula was covered with a dated plastic bag when not in use.<BR/>D. <BR/>The facility failed to ensure Resident #24's nebulizer mask was covered with a dated plastic bag on 05/29/2024 at 2:33 PM when not in use. <BR/>These failures could place residents at risk for respiratory infections.<BR/>Findings included:<BR/>A.<BR/>Record review of the undated Face Sheet for Resident #80 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Type 2 Diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy), Morbid Obesity (severely overweight), insomnia (sleep disorder in which a person has trouble falling or staying asleep), shortness of breath and sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). <BR/>Record review of a Care Plan dated 05/28/2024 for Resident #80 reflected she used a CPAP machine while sleeping. Interventions: Change filter out weekly on the C-pap machine, clean tubing and mask weekly as directed. <BR/>Record review of Physician's Orders dated 05/29/2024 for Resident #80 reflected CPAP apply at bedtime.<BR/>Observation on 05/28/2024 at 9:52 AM in Resident #80's room, a CPAP mask was on top of her mattress and not bagged. <BR/>Observation on 05/29/2024 at 2:16 PM in Resident #80's room a CPAP mask was uncovered and hanging off the side of her bedrail.<BR/>B.<BR/>Record review of the undated Face Sheet for Resident #22 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease with acute exacerbation (group of lung diseases that block airflow and make it difficult to breathe), and Unspecified Dementia (a person loses the ability to think, remember, learn, make decisions, and solve problems). <BR/>Record review of an MDS OSA Item Set dated 05/19/2024 for Resident #22 reflected she had a BIMS score of 15 indicating intact cognitive status. Her active diagnoses included Chronic Obstructive Pulmonary Disease.<BR/>Record review of Physician Orders for Resident #22 dated 02/08/2024 reflected she had an order for Albuterol Solution (medication that relaxes the muscles in the lungs to open up the airways and make breathing easier) 0.5-2.5 (3) mg/3 ml 1 vial two times a day. <BR/>Observation on 05/28/2024 at 10:25 AM revealed Resident #22's nebulizer mask was uncovered and on top of her bedspread. <BR/>C.<BR/>Record review of the undated Face Sheet for Resident #19 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Paroxysmal Atrial Fibrillation ((hearts upper chamber beat chaotically, irregularly, and out of sync with the lower heart chambers that reverts to a regular rhythm within 7 days), Sepsis (life-threatening complication of an infection) and Allergy, unspecified.<BR/>Record review of the MDS OSA Item Set dated 05/13/2024 for Resident #19 reflected she had a BIMS score of 11 indicating moderate cognitive impairment. <BR/>Observation on 05/28/2024 at 11:02 AM in Resident #19's room revealed she had oxygen tubing connected to a concentrator. A plastic bag attached to the concentrator was dated 5/20/2024. The nasal cannula was uncovered and was on top of her bedspread.<BR/>D.<BR/>Record review of the undated Face Sheet for Resident #24 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Unspecified Dementia (a person loses the ability to think, remember, learn, make decisions, and solve problems), Cognitive Communication Deficit (person struggles with memory, organization, and problem solving making it difficult to properly speak, listen, read, write or interact in social situations), and seasonal allergy Rhinitis (allergic response causing itchy, watery eyes, sneezing).<BR/>Record review of Quarterly MDS dated [DATE] for Resident #24 reflected she had a BIMS score of 9 indicating moderate cognitive impairment. <BR/>Observation on 05/29/2024 at 2:33 PM of Resident #24's nebulizer mask, which was sitting in a box uncovered on a dresser.<BR/>In an observation and interview on 05/29/2024 at 2:44 PM in Resident #80's room, LVN A, stated her CPAP mask should have been in a zip lock bag with the date on it. She stated the last time she was on duty; the resident did not have the CPAP machine. LVN A observed the CPAP mask hanging off of the bed rail and stated it was not sanitary, could have germs on it and she could get a respiratory infection. <BR/>In an observation and interview on 05/29/2024 at 2:47 PM in Resident #24's room LVN A stated her nebulizer mask should have been bagged. She stated it was not in the right place and there was no date on it. She further stated all other places she had worked; the night nurses changed the respiratory equipment on Sunday nights. <BR/>In an interview on 05/30/2024 at 3:35 PM the DON stated respiratory equipment should have a bag over it and the policy in the facility was for the Sunday night nurse to change the tubing, bag, and date the equipment. She said the nurses had not been trained on that policy since she had been there. She stated the potential risk to the resident was an infection as all kinds of bacteria could be on the equipment. <BR/>In an interview on 05/30/2024 at 4:24 PM the ADM stated nursing staff should be changing oxygen tubing and dating it. She stated she did not know if the masks or cannulas should be covered.<BR/>Record review of an undated facility policy and procedure titled Departmental (Respiratory Therapy) Prevention of Infection. The purpose of this procedure is to guide prevention of infection associated with therapy tasks and equipment, including ventilators, among residents and staff. Infection control considerations related to oxygen administration: 8. Keep the oxygen cannula and tubing used prn in a plastic bag when not in use. Infection control considerations related to medication nebulizers/continuous aerosol: 8. Store the circuit in plastic bag, marked with date and resident's name between uses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow guidelines for mandatory electronic submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 4 quarters reviewed for payroll data information (Quarter 1 2024).<BR/>The facility failed to submit PBJ staffing information to CMS for the 1st quarter ([DATE] to March 30) of fiscal year 2024.<BR/>This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.<BR/>Findings included:<BR/>Review of the facility's Civil Rights Survey Report dated 05/28/2024 (Form 3761) indicated the following:<BR/>3 RNs <BR/>7 LVNs <BR/>9 Direct Care Staff<BR/>6 Dietary<BR/>4 Housekeeping & Laundry <BR/>7 All Others<BR/>Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report) 1705 D FY Quarter 1 2024 (October 1-December 31), dated 05/22/2024, indicated the following entry: Metric Failed to Submit Data for the Quarter, Result Triggered Definition Triggered = No Data Submitted for Quarter.<BR/>In an interview on 05/30/2023 at 1:20 PM the Administrator stated the corporate office was in charge of reporting the CMS PBJ staffing data. She stated the pervious company was responsible for reporting the 1st quarter staffing information and it was not done. She stated the new corporate office did report the 2nd order. <BR/>Review of the facility's policy (undated) reflected Policy Statement: Direct care staffing information is reported electronically to CMS through the Payroll-Based Journal system. Policy Interpretation and Implementation:<BR/>1. Complete and accurate direct care staffing information is reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS. 8. Technical specifications for uploading data directly from a payroll or time and attendance system will be accessed through: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html.9. Direct care staffing information is submitted on the schedule specified by CMS, but no less frequently than quarterly. 10. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows:<BR/>Fiscal Quarter <BR/>Date Range <BR/>Submission Deadline<BR/>1 <BR/>October 1 - December 31 <BR/>February 14<BR/>2 <BR/>January 1 - March 31 <BR/>May 15<BR/>3 <BR/>April 1 - June 30 <BR/>August 14 <BR/>4 <BR/>July 1 - September 30 <BR/>November 14

Based on observations, interviews, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 dining rooms and 1 of 1 shower room reviewed for environment.<BR/>The facility failed to ensure the dining room was free of flies during the resident meal service on 05/28/2024 at 12:15 PM.<BR/>The facility failed to ensure the shower room was free of roaches and water bugs on 05/29/2024 at 1:15 PM.<BR/>These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live. <BR/>Findings included:<BR/>Observation on 05/28/2024 at 12:15 PM revealed one resident swatting a fly off of her food. The fly landed in her dessert cup and was stuck on the inside. Another resident had a fly land on her drink cup several times. <BR/>Observation on 05/29/2024 at 1:15 PM in the shower room of a small brown roach crawling toward the commode and a water bug (a large insect that can bite and prefers very wet environments) approximately one-inch-long crawling on the wall above the linen cart. <BR/>In an interview on 05/30/2024 at 4:35 PM the ADM stated she and the MS did the pest control for the facility. She stated they used over the counter products, and she was not aware of any live roaches, but she had seen dead roaches. She stated they sprayed around the outside of the building one time a month. She stated a commercial pest control company had quit coming to the facility and she did not know why. <BR/>In an anonymous staff interview on 05/30/2024 at 12:34 PM they stated there were water bugs in the facility and the infestation was worse in the summer. They stated there were a lot of flies everywhere in the building and especially in the dining room. <BR/>In an interview on 05/30/2024 at 12:39 PM MA I stated she had been at the facility since the end of January. Stated there are a lot of flies in the dining room and at the nurse's station. She stated she had not observed crawling insects, but she did not go into the shower room. <BR/>In an interview on 05/30/2024 at 3:50 PM the DON stated her expectation was that the facility would be pest free. She stated insects could contaminate food. She stated she had not seen any roaches, but she had seen flies in the dining room.<BR/>In an interview on 05/30/2024 at 4:30 PM the ADM stated her expectation was that the facility would be pest free which she stated was not realistic. She stated food that insects landed on could be contaminated. She stated she obtained the pest control chemicals from the local big chain store, or the hardware store and the chemicals were stored outside in the storage room. She stated she and her MS sprayed the pest control products monthly and as needed. She stated she did not know why the pest control company quit coming and stated the company she worked for had taken over the facility November 1st, 2023.<BR/>Record review of an undated facility policy and procedure titled Pest Control reflected Purpose: to provide an environment free of pests. Policy: 1. The facility will have pest control that provides frequent treatment of the environment for pests. It will allow for periodic treatment when a problem is detected. There will be emphasis on the pest control in the kitchens, cafeterias, laundries, loading docks, construction activities and other areas prone to infestation. Monitoring of the environment will be done by the facility's staff. Pest control problems will be reported promptly. Screens will be maintained in all windows that open to the outside.

Based on observation, interview and record review, the facility failed to ensure that all expired drugs and biologicals were removed and destroyed for 1 of 1 medication storage rooms reviewed for medications and failed to ensure 1 of 1 medication storage room refrigerators was free of contaminants. <BR/>The facility failed to remove 7 bottles of expired medication from the medication storage room and 1 container of expired protective skin applicators when it was observed on 05/28/2024 at 3:45 PM. <BR/>The facility failed to ensure the medication room refrigerator was free of contaminants including staff food and drinks when it was observed on on 05/28/2024 at 3:45 PM. <BR/>This failure could place all residents at an increased risk of receiving expired and/or contaminated medications/supplements resulting in adverse health consequences. <BR/>Findings included:<BR/>Observation on 05/28/2024 at 3:45 PM in the medication storage room revealed one bottle of Aspirin 81 mg expiration date 08/2023, four bottles of Docusate Sodium expiration date 04/2024, one bottle of natural tear eye drops expiration date of 09/24/2023, Skincote protective dressing applicator expiration date 08/2023. The medication room refrigerator had one open container of lemon-flavored thickened liquid, and two magic cups (nutritional supplement) for residents. Staff food items included an open container of yogurt, an open strawberry-flavored drink, two bottles 33 oz. water, one of which was open, cheese sticks, one large 32 oz soft drink with a straw in it, crispy onion salad topper and a jar of opened mayonnaise. <BR/>In an interview on 05/28/2024 at 3:55 PM MA H stated she had been working in the facility since May 1, 2024, and stated the staff used the refrigerator in the medication room because the staff did not have one in their break room. She stated the medications that were expired would not be as potent if given to a resident. <BR/>In an interview on 05/28/2024 at 4:12 PM LVN B stated the expired medications would not be as effective if given to a resident. She stated the staff remove expired medications as a team and no one person was responsible. She further stated the staff should not be using the refrigerator in the medication room for their personal food as there could be cross contamination.<BR/>In an interview on 5/28/2024 at 4:20 PM the DON stated she had been working at the facility since February 2024. She stated regarding the expired medications, the staffing coordinator had quit a month ago and they had not gotten around to removing the expired medications. She stated the potential risk of expired medications could be GI upset and they would be less effective. Regarding staff food in the resident's refrigerator, she stated there could be cross-contamination. She stated the staff did not have a refrigerator in their break room. <BR/>In an interview on 05/30/2024 at 3:45 PM the DON stated she and other staff had pulled expired medications off of the storage room shelves at the beginning of April 2024. She stated the central supply person was no longer at the facility and it was one of her duties to remove expired medications. She stated having staff food in the refrigerator could be an issue due to cross contamination and expired medications would not be as potent or the resident could have an adverse reaction. <BR/>In an interview on 05/30/2024 at 4:26 PM the ADM stated her expectation was that the medication aides would clean expired medications off of the storage room shelves. She said the task depended on who the DON assigned it to. She stated expired medications could potentially be ineffective. She stated food and drinks should not be in the storage room refrigerator as it was an infection control issue.<BR/>Review of a facility policy and procedure dated 01/01/2024 titled Storage of Medications reflected The facility will store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 8. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan after each assessment, including comprehensive and quarterly review assessments, for 2 of 4 residents (Resident #1 and #2) reviewed for care plan timing, in that:<BR/>1. Resident #1's quarterly MDS assessment was completed on 08/08/23 and her most recent comprehensive person-centered care plan was revised and completed on 01/06/2023. <BR/>2. Resident #2's quarterly MDS assessment was completed on 07/20/23 and his most recent comprehensive person-centered care plan was revised and completed on 02/03/2023. <BR/>This deficient practice could place residents at risk of not having their current preferences, goals, and needs met. <BR/>Findings included: <BR/>Review of Resident #1's face sheet, dated 09/29/2023, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, personal history of COVID-19, unspecified muscle wasting and atrophy (a decrease in size and wasting of muscle tissue), other abnormalities of gait and mobility, other speech and language deficits following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), essential (primary) hypertension (high blood pressure), generalized muscle weakness, unspecified acute kidney failure, dysuria (discomfort when urinating), unspecified altered mental status, history of falling, other lack of coordination, unspecified protein-calorie malnutrition, presence of cardiac pacemaker, unspecified anxiety disorder, unspecified feeding difficulties, personal history of urinary tract infections, and post traumatic stress disorder. <BR/>Review of Resident #1's quarterly MDS assessment, dated 08/08/2023, reflected a BIMS score of 5, indicating severe cognitive impairment. Resident #1 was frequently incontinent with urinary and bowel continence. Resident #1 had one fall since admission and sustained a minor injury. Resident #1 required extensive assistance of one person with bed mobility, transfers, dressing, toilet use, and personal hygiene, supervision with eating, and physical help with bathing. <BR/>Review of Resident #1's care plans reflected her last comprehensive person-centered care plan was revised and completed on 01/06/2023. Resident #1 also had a comprehensive person-centered care plan started on 07/15/2023 with no completion date. <BR/>Review of Resident #2's face sheet, dated 09/29/2023, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified macular degeneration (an eye disease that can blur central vision), blindness of one eye, recurrent, severe major depressive disorder, unspecified insomnia, essential (primary) hypertension (high blood pressure), unspecified bipolar disorder, unspecified feeding difficulties, overactive bladder, unsteadiness of feet, personal history of COVID-19, other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy (a decrease in size and wasting of muscle tissue), generalized muscle weakness, unspecified constipation, repeated falls, high risk of heterosexual behavior, abnormal weight loss, cognitive communication deficit, dysphasia (swallowing difficulties), and unspecified lack of coordination. <BR/>Review of Resident #2's quarterly MDS assessment, dated 07/20/2023, reflected a BIMS score of 2, indicating severe cognitive impairment. Resident #2 was always incontinent with urinary continence and frequently incontinent with bowel continence. Resident #2 required extensive assistance of one person with bed mobility, transfers, dressing, eating, toilet use and personal hygiene and physical help with bathing. <BR/>Review of Resident #2's care plans reflected his last comprehensive person-centered care plan was revised and completed on 02/03/2023. Resident #2 also had a comprehensive person-centered care plan started on 07/15/2023 with no completion date. <BR/>During an interview on 09/29/2023 at 12:48 PM, CNA A stated she was not sure who was responsible for reviewing and revising residents' care plans. CNA A stated she thought she could access and view residents' care plans to determine their needs. CNA A stated she was not sure if residents could be negatively affected by staff not reviewing and revising their care plans to meet their current needs. <BR/>During an interview on 09/29/2023 at 1:07 PM, CNA B stated he was not sure who was responsible for reviewing and revising residents' care plans. CNA B stated he could access and view residents' care plans to determine their needs. CNA B stated residents could be negatively affected by staff not reviewing and revising their care plans to meet their current needs. <BR/>During an interview on 09/29/2023 at 1:13 PM, LVN A stated the ADON was responsible for reviewing and revising residents' care plans. LVN A stated she could access and view residents' care plans to determine their needs. LVN A stated residents could be negatively affected by staff not reviewing and revising their care plans to meet their current needs. <BR/>During an interview on 09/29/2023 at 1:25 PM, ADON stated the Regional MDS Coordinator was responsible for reviewing and revising residents' care plans. The ADON stated she was aware some residents' care plans were not reviewed and revised. The ADON stated residents' care plans that were not reviewed and revised were because of the staff turnover rate. The ADON explained the facility did not have an MDS coordinator when she began her employment at the facility six months ago. The ADON stated residents could be negatively affected by staff not reviewing and revising their care plans to meet their current needs if staff did not know the residents. <BR/>During an interview on 09/29/2023 at 1:34 PM, the ADM stated the Regional MDS Coordinator was responsible for reviewing and revising residents' MDS assessments and care plans. The ADM stated he was aware some residents' care plans were not reviewed and revised. The ADM stated he thought residents' care plans were being addressed and revised. The ADM stated residents' care plans that were not reviewed and revised were because of the staff turnover rate and the facility not having its own MDS coordinator. The ADM stated residents' needs could not be met by staff not reviewing and revising their care plans to meet their current needs and if residents' had a change of condition. <BR/>During an interview on 09/29/2023 at 1:55 PM, the Regional MDS Coordinator stated she was responsible for reviewing and revising residents' care plans. The Regional MDS Coordinator stated she had been reviewing and revising residents' care plans for a few months because of the facility's staffing shortage to ensure the facility remained in compliance with residents' MDS assessment and care plan reviewing and revision timeframe requirements. The Regional MDS Coordinator stated she tried to revise residents' care plans when revising their MDS assessments. The Regional MDS Coordinator stated she fell behind on reviewing and revising residents' care plans in the last few weeks because of regulation changes and trainings given for October 2023. The Regional MDS Coordinator stated she thought all residents whose care plans were last reviewed up to September 2023 should have revised care plans. The Regional MDS Coordinator stated residents might be negatively affected by staff not reviewing and revising their care plans to meet their current needs depending on their issues. The Regional MDS Coordinator stated she was currently the only person reviewing and revising residents' care plans. The Regional MDS Coordinator stated the former DON was helping her with reviewing and revising residents' care plans before leaving her employment with the facility. <BR/>During an interview on 09/29/2023 at 2:09 PM, the BOM stated the ADON, DON, and Regional MDS Coordinator were responsible for reviewing and revising residents' care plans. The BOM stated residents would not receive the care they need by staff not reviewing and revising their care plans to meet their current needs. BOM stated he was not sure if CNAs could access and view residents' care plans to determine their needs. <BR/>Review of the facility's comprehensive person-centered care plan policy and procedure, revised March 2022, reflected the following: <BR/>Policy Statement: <BR/>A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.<BR/>Policy Interpretation and Implementation: <BR/>11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.<BR/>12. The interdisciplinary team reviews and updates the care plan:<BR/>a. when there has been a significant change in the resident's condition;<BR/>b. when the desired outcome is not met;<BR/>c. when the resident has been readmitted to the facility from a hospital stay; and<BR/>d. at least quarterly, in conjunction with the required quarterly MDS assessment.<BR/>Review of the facility's interdisciplinary team care planning policy and procedure, revised March 2022, reflected the following: <BR/>Policy Statement:<BR/>The interdisciplinary team is responsible for the development of resident care plans.<BR/>Policy Interpretation and Implementation:<BR/>1. Resident care plans are developed according to the timeframes and criteria established by &sect;483.21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical and psychosocial status for one (Resident #4) of seven residents reviewed for changes in condition.<BR/>1. The facility failed to notify Resident #4's RP of Resident #4 being hit by a peer on 2/3/25.<BR/>2. The facility failed to notify Resident #4's RP of a visit to the ER after Resident #4 had a fall on 2/7/25 with an onset of increased confusion. <BR/>These failures could put residents at risk of not having their care needs and health changes communicated and addressed with their responsible party.<BR/>Findings included:<BR/>Review of Resident #4's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset (a progressive disease that destroys memory, thinking and behavior, interfering with daily functioning), cognitive communication deficit (reduced ability to communicate needs), and dementia (brain impairment of at least two brain functions). Responsible Parties are listed as Resident #4 and RP E. <BR/>Review of Resident #4's payment MDS assessment, dated 1/25/25, reflected a BIMS score of 9, indicating moderate cognitive impairment. <BR/>Review of Resident #4's quarterly care plan, initiated 1/28/25, reflected focus areas of diet and falls. <BR/>Review of Resident #4's Progress Notes from 1/13/25 through 2/8/25, revealed there were no entry on the notes for 2/3/25. Continued review revealed on 2/7/25 RN D documented at 11:20 pm that a weekly skin assessment was completed. At 11:32 pm Pt sent to hospital for evaluation post unwitnessed fall, skin tear and new onset of confusion. On 2/8/25 at 10:09am Resident #4 was noted to have returned from the ED with orders for an antibiotic for seven days. No diagnoses or other orders were noted. <BR/>Review of an IR dated 2/7/25 included Pt found laying down on the floor in room next to wheelchair with blood from the right wrist due to skin tear. The predisposing physiological factors included check marks indicating confusion and impaired memory. People notified were listed as the physician, DON, and Resident #4 herself. <BR/>During an interview on 2/9/25 at 9:54 am, Resident #4's RP E revealed they did not know that Resident #4 had been hit by another resident or that she had been sent to the ER after a fall. RP E stated although they had not been able to be as involved in Resident #4's care, they still would like to be notified of those types of events. RP E stated the frequency of events like this would indicate whether Resident #4 was in a safe place and that would be something they are interested. RP E stated they had been notified of Resident #4's admission into the facility but had not been notified since that time. RP E stated Resident #4 was not able to make decisions on her own which was why she was on a secure unit, she no longer had safety awareness. <BR/>During an interview on 2/8/25 at 12:48 pm, CNA F stated he normally worked alone on the secure unit. He stated he can usually handle it but will request help occasionally. CNA F stated on 2/3/25 there was an incident in which Resident #4 was hit by Resident #7. He stated he asked a physical therapist who was in the unit working with another resident to notify the nurse and administration. CNA F stated he separated the two residents into different areas and LVN C came to assess the residents. CNA F stated he assumed someone in administration had also been notified. CNA F stated Resident #4 had redness to the side of her face but no other injuries. <BR/>During an interview on 2/8/25 at 4:21pm, LVN C stated she had been aware of the incident during which Resident #4 was hit but had not documented or notified the RP as she had been told the DON was involved and she assumed everything needed would be done by the DON. <BR/>During an interview on 2/8/25 at 11:05 pm with RN D revealed he was not aware that a peer had hit Resident #4. He was working on 2/7/25 when Resident #4 fell. RN D stated she had been sent to the ED due to a possible change in the level of confusion. RN D explained Resident #4 had a history of confusion, but seemed at the time more so than usual and they were not able to determine the cause of the fall. He did not notify the RP; the resident was her own RP. <BR/>During an interview on 2/10/25 at 8:45 am, the facility DOR stated on 2/3/25 one of the PT staff had come to her while she was in a meeting with the administration, and reported she needed to tell the Administrator about an incident involving two residents on the secure unit. The DOR stated the Administrator was in the meeting so she directed her staff to him. <BR/>During an interview on 2/10/25 at 9:50 am, the Adm stated he was notified by a PT staff on 2/3/25 that the staff on the secure unit wanted to see him. The Adm stated he assumed the staff wanted to see him regarding an issue they had been discussing previously he had not realized there was an incident of aggression between two residents. He stated had he known about the incident he would have sent a nurse to assess the resident, notify the physician if needed, write an IR, and notify the RP. <BR/>During an interview on 2/10/25 at 9:30 am, the DON stated she was not notified of Resident #4 being hit by another resident. The DON stated she had been notified of Resident #4's fall and was aware that Resident #4 was being sent to the ED. The DON stated she had instructed RN D to notify Resident #4's RP. She stated that the RP should have been notified of both events. <BR/>Review of the facility's Charting and Documentation policy, revised April 2008, reflected the policy included the following:<BR/>All incidents, accidents, or changes in the resident's condition must be recorded. Documentation of procedures and treatments shall include care-specific details and include at a minimum: <BR/>f. <BR/>Notification of family, physician, or other staff, if indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident was free from abuse or neglect for one Resident, Resident #1. <BR/>LVN A made derogatory statements and yelled at Resident #1. <BR/>This failure put residents at risk of experiencing humiliation, degradation, and a decreased quality of life.<BR/>Findings included:<BR/>Review of Resident #1's 05/22/2023 face sheet reflected a [AGE] year-old woman admitted to the facility on [DATE] with diagnoses including partial traumatic amputation at level between knee and ankle left lower leg, bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs and lows, and schizophrenia (mental disorder characterized by continuous or relapsing episodes of hallucinations (typically hearing voices), delusions, and disorganized thinking). <BR/>Resident #2 admitted to the facility on [DATE] and did not have an MDS or care plan in place. <BR/>In an interview on 05/22/2023 at 1:14 PM Resident #1 revealed that on 05/21/2023 LVN A insulted her, ridiculed her, and told her to die. Resident #1 revealed that when Resident #1 told LVN A that she needed assistance LVN A told her, I don't care. Resident #1 revealed LVN A used profanity when she spoke to her, and she has overheard LVN A use profanity when LVN A spoke to the other employees. Resident #1 revealed that LVN A told Resident #1 to, leave her alone. Resident #1 revealed LVN A talked to Resident #1 as if Resident #1 was not a human. Resident #1 fell, was bleeding, and needed bandages. Resident #1 revealed LVN A told her you should not have touched it and picked at it (referring to Resident #1's bleeding residual limb). Resident #1 revealed that LVN A, when she was bandaging Resident #1's limb said, do you want to do this? Resident #1 said that LVN A's face was, distorted and mean looking. Resident #1 said she was shocked that a caregiver spoke to her and treated her with such little care. She said she was very angry about the treatment from LVN A and did not want to ever see LVN A again. She reported she had never been treated so poorly . Her feelings were hurt and she was stunned and shocked by LVN A's treatment of her and LVN A made her feel like a dog. Resident #1 revealed she reported LVN A's behavior to the ADM and the Activity Director.<BR/>In an observatin on 05/22/2023 at 1:14 PM Resident #1 appeared angery, hurt, and shocked when she reported her 05/21/2023 interations with LVN B. <BR/>In an interview on 05/22/2023 at 2:18 PM the former DON revealed LVN A was not very friendly, and a lot of staff have complained that LVN A was mean and rude, but she had not heard of any resident complaints and there was no direct evidence of LVN doing anything against the residents. The former DON revealed LVN A was, really good at selling her story when it is not the truth. <BR/>In an interview on 05/22/2023 at 3:37 PM CNA C revealed that on 05/21/2023 Resident #1, who has an amputated right leg, fell in her bathroom. CNA C said she ran and got LVN A who was outside smoking. CNA C said Resident #1 was bleeding pretty badly. CNA C said that LVN A yelled at Resident #1 and told Resident #1 she was, crazy. CNA C revealed that Resident #1 wanted to use the facility telephone and CNA A told her no, you have your own cell phone in your room, you can use that. CNA C revealed that LVN A told Resident #1 to stop bothering her and Resident #1 needed to go to bed. CNA C revealed she has heard her yell at residents but can't remember the specifics. CNA C said she was trained in resident abuse, neglect and exploitation and resident abuse is make resident people feel unheard, neglected, and yelling at residents. CNA C revealed that she feels LVN A was abusive to Resident #1. When asked if CNA C told the ADM about LVN A's behavior towards residents she said no. CNA C revealed she does not think the ADM would listen and when you told people things at the facility you didn't get heard and people liked to play favorites. <BR/>A review of LVN A's Elder Abuse Posttest dated 12/27/2022 reflected she revealed the following: LVN A felt comfortable with her current knowledge of how to provide advocacy within the criminal justice system to address ageist tendencies that may dismiss older victims as unreliable witnesses, she felt confident that she could give a comprehensive definition of elder abuse if she needed to define it for a colleague or client, she identified the types of elder abuse as financial exploitation, neglect, sexual, physical, and emotional, she listed that older adults may not report abuse because of shame/embarrassment, fear, retaliation, and pride.<BR/>A review of Facility Policy, undated, revealed the facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Resident abuse may include staff to resident abuse. Verbal abuse is defined as the use of oral . or gestured language that willfully included disparaging and derogatory terms to residents or within their hearing distance or sight, regardless of their age, ability to comprehend or disability. Examples are name calling, cursing, or yelling at a patient in anger. Threats of harm, saying things to frighten a resident, evidence of psychological harm, verbal abuse may be considered a type of mental abuse. Mental abuse is the use of verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, harassment, threats of punishment or deprivation.

Based on observation, interview, and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for facility service safety and preparation for one of one kitchen. <BR/>The facility failed to ensure Dietary [NAME] A properly sanitized hands between tasks.<BR/>This failure could place the residents, who received food from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life.<BR/>Findings included: <BR/>Observation of the kitchen on 03/09/2023 at 9:25 AM revealed the Dietary [NAME] A was using oven mitts and checked on food cooking in the oven. When she heard the knock at the door, she turned around and the surveyor asked if she had a hair net. Dietary [NAME] A stated yes and picked up a dirty wet rag and washed her hands with the rag. She walked toward the hair nets at the other locked entrance door and placed the hair net in the surveyor's hand. She walked with the surveyor to the sink and the surveyor washed both hands. She stood by the surveyor until hand washing was completed. She returned to the stove and looked at the vegetables she was preparing for lunch. Dietary [NAME] A touched her clothes and side of her hair in the small open area of the hair net with all her fingers on her right hand. She walked to a shelf and opened a large container with different types of ladles. She reached for a ladle and touched the section of the ladle used to place inside the cooking pot. She returned to the stove and put the same ladle into the cooking pot with California vegetable medley being prepared and began to stir the food. The dietary cook A did not properly sanitize or wash hands between these tasks.<BR/>In an interview on 03/09/2023 at 9:35 AM the Dietary [NAME] A stated she did use the wet rag to wash her hands. She stated she did touch her clothes and her hair. She stated her hair felt lose underneath the hair net. She stated it was required for her to wash hands at the sink in between tasks or anytime her hands may be dirty. She stated she did not follow how she was trained to wash her hands. She stated anytime her hands touched anything dirty or if it was a possibility her hands were dirty, she was expected to use the sink in the kitchen with soap and water to sanitize her hands. She also stated she had been in serviced on hand hygiene and she was aware of proper hand hygiene. She stated she was not thinking when she washed her hands with the disinfectant rag. She stated the rag was dirty and had disinfectant on it to clean the prep tables and sink. She stated she did not wash, sanitize, or wear gloves after she washed her hands when she first entered the kitchen around 6:00 AM today. <BR/>In an interview on 03/09/2023 at 9:50 AM the Dietary Manager stated it was her responsibility to monitor hand hygiene in the kitchen. She stated she had stepped out of the kitchen for several minutes during this incident. She stated all staff was expected to follow proper hand hygiene protocol. She stated dietary cook was expected to wash her hands in the sink in between tasks and whenever her hands were contaminated by touching objects or anything may not be clean. She stated if she touched her clothing and hair, she was expected to wash her hands immediately. She stated touching inside of the ladle had potential of cross contamination of bacteria on her hands onto the ladle. She stated if the ladle in the vegetables on the stove was the ladle, she touched the ladle would be considered contaminated. She stated she had in-serviced staff on hand hygiene in the kitchen. She also stated if the food was contaminated a resident may become sick with a virus, could have diarrhea or vomiting and become dehydrated. She stated there was a possibility a resident may need hospital care. <BR/>In an interview on 03/09/2023 at 2:45 PM the Director of Nurses stated all staff was expected to use proper hand hygiene protocol including dietary staff. She stated anytime the staff's hands were contaminated they were expected to immediately wash their hands at the designated sink using soap and water. She also stated the dietary staff was expected to follow their hand hygiene protocol/policy. She stated if a dietary staff's hands were potentially contaminated and touched any type of utensils and used the utensils in the pan while cooking there was a possibility bacteria would transfer from the utensil to the food. She stated residents had potential of becoming ill with some type of gastrointestinal virus. She stated there was a potential a resident be admitted to the hospital with certain type of viral infections. She also stated it was her responsibility to monitor all sanitation including hand hygiene in the kitchen. <BR/>Record Review of Dietary [NAME] A's time sheet for 03/09/2023 reflected dietary cook clocked in for the day at 5:46 AM. <BR/>Record review of the Safety Data Sheet of Sink and Surface Cleaner Sanitizer (not dated) reflected wash hands thoroughly after handling. In case of hand contact rinse with plenty of water. If swallowed rinse mouth and get medical attention if symptoms occur. Keep out of reach of children. <BR/>Record review of Facility Policy titled Employee Sanitation dated 2018 reflected the nutrition and food service employees of the facility will practice good sanitation practices in accordance with state and US Food Codes to minimize the risk of infection and food borne illness. Employees must wash their hands and exposed portions of their arms at designated hand washing facilities at the following times:<BR/>1. Immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles.<BR/>2. During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks. <BR/>3. After engaging in other activities that contaminate hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (Resident #25 and Resident #2) of 12 residents reviewed for quality of care.<BR/>1. The DON failed to ensure Resident #25's GI consult was scheduled in a timely manner.<BR/>2. Resident #2 was not wearing compression bandages as ordered on 3/29/2023 and 03/30/23 and did not receive monitoring for edema as ordered.<BR/>These failures placed residents at risk of delayed care and services in accordance with professional standards of practice. <BR/>Findings included:<BR/>1.<BR/>A record review of Resident #25's face sheet dated 3/30/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of metabolic encephalopathy (brain disorder), type 2 diabetes (uncontrolled blood sugar), Alzheimer's disease (memory loss), hypertension (high blood pressure), unspecified convulsions (irregular muscle movements), epileptic seizures (neurological disorder), major depressive disorder (depression), schizophrenia (mental disorder), acute myocardial infarction (heart attack), hyperlipidemia (high cholesterol), and post-traumatic stress disorder (recurrent distress). <BR/>A record review of Resident #25's MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. A review of Section G (Functional Status) reflected Resident #25 required extensive assistance and a two person physical assist with transferring. <BR/>A record review of Resident #25's care plan last revised on 2/21/2023 reflected she had a history of constipation and staff were to monitor for signs and symptoms of complications related to constipation such as abdominal distension, vomiting, and small loose stools. <BR/>An observation on 3/28/2023 at 2:12 p.m., revealed Resident #25 was lying in bed and appeared free of distress. Resident #25 was non-interviewable. <BR/>During an interview on 3/28/2023 at 2:58 p.m., Resident #25's family member stated Resident #25 had been hospitalized twice on Friday, 3/24/2023. Resident #25's family member stated she received a call from a nurse at the facility around 6:00 a.m. on 3/24/2023. Resident #25's family did not know which nurse she spoke with but said the nurse reported Resident #25 had abdominal pain and coffee ground vomit. Resident #25's family member stated she did not understand what this meant until later, when a different nurse explained what that meant. Resident #25's family member stated she was concerned about Resident #25's condition and requested Resident #25 be sent out to the hospital for the second time on 3/24/2023. Resident #25's family member stated she felt the facility was non-communicative when she wanted updates about Resident #25's condition. Resident 25's family member stated she felt the facility should have called her to provide an update on 3/24/2023 but since they did not, she had to call the facility herself at 4:45 p.m. on 3/24/2023. <BR/>A record review of Resident #25's progress notes dated 3/24/2023 reflected the following: <BR/>At 6:02 a.m., LVN C documented Resident throwing up coffee ground emesis. Bowel sounds active all four quadrants. BS 267,t 97.7, oxygen 90% on room air, BP 146/92, P 100, R 22. Alert X 1. Notified [Physician] and she gave order to send to ER. Notified 911 and they are en route.<BR/>At 9:33 a.m., LVN C documented [local hospital] called and said they are discharging resident with the diagnosis of constipation. Notified B&M transport and they are going to transport resident by ambulance. Notified RP.<BR/>At 11:32 a.m., LVN C documented Resident arrived via ambulance per stretcher. Alert and Oriented X 2. Clean and dry. V/S WNL. RP aware of her return.<BR/>At 3:49 p.m., LVN C documented Resident trembling and skin clammy and cold to touch. V/S 179/111, 176, 22, 98.8, Oxygen Saturation 92% room air. Daughter called and wanted an update on previous ER Visit. This nurse informed daughter what she was diagnosed at the ER. Daughter was not satisfied with resident's care and wanted her sent to a big Hospital Like [name removed]. Notified 911 and they are on their way.<BR/>At 4:01 p.m., LVN C documented EMT came back in to the facility to say they were taking her back to [local hospital] because their was nothing wrong with her. Spoke with the ER MD and informed her the family wanted a cardiac workup done based on previous Ml and current V/S. The MD stated she would do what she could.<BR/>At 10:47 p.m., LVN D documented Returned from [local hospital] ER per EMS at 21 :15 (9:15pm). Taken to room per stretcher and transferred by total lift by 2 EMS personnel and this nurse. Resident alert and answering simple questions. Does appear to be tired and falls asleep easily if not stimulated. VS taken. Respirations even and non-labored, breath sounds CTA bilaterally, sats 94% on room air. Bed placed in lowest position and blue mat on floor next to bed. 21 :25 (9:25pm) phoned [Physician] and reviewed new orders and radiology reports. New orders include to increase Keppra to 1000mg daily, and to start Macrobid 100mg BID for 7 days for UTI. Follow up with private physician in 2-3 days, follow up with PCM and neurology in the next 5-7 days<BR/>A record review of Resident #25's progress note dated 3/27/2023 at 4:57 p.m., authored by LVN D reflected Spoke with [Physician] regarding ER recommendation to consult with neurologist. [Physician] has referred Resident to Neurology [consultant]. Sent referral to fax number she provided requesting appt and alert to what forms/info we need to fax to them. Resident family member aware the doctor would be contacted for referral.<BR/>A record review of Resident #25's hospital discharge instructions dated 3/24/2023 reflected she was to be seen by the Physician within 4-5 days and patient/nursing instructed to follow up with PCP for GI consult for reevaluation causes of upper GI bleed and need for upper endoscopy.<BR/>A record review of Resident #25's lab work dated 3/24/2023 reflected her hemoglobin and hematocrit were within normal range.<BR/>A record review of Resident #25's hospital discharge paperwork dated 3/24/2023 reflected she received a GI consult with her first hospital admission on [DATE], and she received a neurology consult for her second hospital admission on [DATE]. <BR/>A record review of Resident #25's chart on 3/29/2023 reflected LVN D sent Resident #25's medical information to a neurology clinic on 3/27/2023 at 3:00 p.m. Resident #25's chart reflected no documentation indicating her medical information was sent to a GI specialist. <BR/>A record review of Resident #25's progress notes on 3/29/2023 reflected no mention of Resident #25 needing a GI consult. Resident #25's progress notes did not reflect she had been experiencing any vomiting or GI symptoms since 3/24/2023. <BR/>A record review of Resident #25's physician orders on 3/29/2023 reflected no mention of Resident #25 needing a GI consult.<BR/>A record review of Resident 25's ADL flow sheet for bowel elimination reflected that since her hospital discharge on [DATE], she had bowel movements on 3/26/2023, 3/27/2023, and 3/28/2023.<BR/>During an interview on 3/29/2023 at 2:21 p.m., the DON stated LVN C faxed all of Resident #25's hospital paperwork to the Physician. <BR/>During an interview on 3/29/2023 at 2:38 p.m., the Physician stated she had not visited with Resident #25 since she was discharged from the hospital on 3/24/2023. The Physician stated a GI consult did not require a referral from herself and that the facility could send in referrals to specialists. The Physician stated she was aware of the recommendation that Resident #25 see a GI specialist and stated it was the facility's responsibility to act on that. When asked if the GI consult had been set up, the Physician stated the facility was working on it. The Physician stated there should be no delay in a resident seeing a GI doctor if they had a GI bleed. The Physician stated if the hospital thought Resident #25 had a GI bleed, they should have admitted her. The Physician stated if there were anything acute, Resident #25 should have stayed in the hospital.<BR/>During an interview on 3/29/2023 at 2:54 p.m., the DON stated Resident #25's appointment with a GI specialist had not yet been scheduled. The DON stated it was not in the nurses' 24-hour report that a GI appointment needed to be set up. When asked why the appointment had not yet been scheduled, the DON stated LVN C would set it up then. The DON stated LVN B, who was the previous ADON, used to set up appointments like that but her daughter got sick recently. The DON stated that from that point forward, she would be responsible for making those appointments. When asked how soon she expected those appointments to be made, the DON stated, I would have to check our policy. <BR/>During an interview on 3/29/2023 at 3:10 p.m., the DON stated there was no policy for scheduling consults but the procedure was to follow the MD's orders. <BR/>During an interview on 3/29/2023 at 3:18 p.m., LVN C stated she had just scheduled Resident #25's appointment with the GI doctor. LVN C stated usually they would give referrals to the ADON and the ADON would schedule appointments when there was a consult. LVN C stated LVN B used to be the ADON but they were switching over right now and were transitioning to a different ADON. When asked how soon consults should be scheduled after they are received, LVN C stated, right away, I would think. LVN C stated the ADON was responsible for scheduling those consults. When asked why the GI consult had not been scheduled prior to that day, LVN C stated, I really don't know. It was so busy that day. We overlooked it I guess. LVN C stated, I really thought someone had made it and stated, they don't usually tell us to make appointments. LVN C stated LVN B had bad been working the role of ADON and CNA lately. When asked what a potential negative outcome might be if Resident #25 had a GI bleed and her GI consult was not scheduled in a timely manner, LVN C stated, probably not real good and stated she might need a blood transfusion or possibly worse. <BR/>A record review of the facility's undated 24-hour nursing report titled Communications from 3/24/2023 through 3/30/2023 reflected there was no mentions of Resident #25 needing a GI consult until 3/29/2023 when LVN C documented that Resident #25 had a GI consult on May 8th @ 845am Lakeside Professional Building.<BR/>During an interview on 3/29/2023 at 3:20 p.m., the DON stated LVN B's daughter was sick and that was why she stepped down as ADON. <BR/>During an interview on 3/29/2023 at 4:00 p.m., the DON stated she did not think there was a policy on following written orders, just that nursing staff needed to follow orders.<BR/>During an interview on 3/30/2023 at 8:45 a.m., LVN B stated she stepped down from ADON the week prior so she had just been working as an LVN. LVN B stated the ADON started her role last week. LVN B stated she had not worked from 3/24/2023-3/27/2023 but was aware of Resident #25's hospitalization. LVN B stated she did not see Resident #25's consult to see a GI doctor and stated she never saw the paperwork. LVN B stated she had been training the ADON the past two weeks but there had not been a consult that came through for LVN B to show the ADON the steps of how to schedule appointments. LVN B stated if the consult did not mention a specific doctor, the DON, the ADON or herself-or whoever saw the order-should have called Resident #25's insurance to find a doctor who was covered through her insurance. LVN B stated appointments should be scheduled within three days of receiving a consult. LVN B stated if Resident #25 had had any vomiting or GI symptoms, those would be documented. LVN B stated staff had not reported to her any GI symptoms since 3/24/2023. LVN B stated when she worked on 3/28/2023-3/30/2023, she had not observed Resident #25 to have any vomiting or GI issues and Resident #25 had not reported any GI concerns. When asked how failing to schedule a GI consult in a timely manner might impact Resident #25, LVN B stated, She could have something going on with her bowels. If she had coffee grounds, that's old blood. LVN B stated probably when asked if this had fallen through the cracks with the transition of ADONs.<BR/>During an interview on 3/30/2023 at 9:00 a.m., the ADON stated she was the ADON in training. The ADON stated she worked Monday through Friday but did not work Friday 3/24/2023. When asked if LVN B had trained her on scheduling consults, the ADON stated ,LVN B hasn't had time and had not been in the facility. The ADON stated the DON had trained her on some things but had not specifically trained her on scheduling consults. The ADON stated she was told Resident #25 wen to the hospital but she was not sure what all transpired. The ADON stated prior to 3/29/2023, she was not aware Resident #25 needed a GI consult. The ADON stated that was her first time in that role but stated oftentimes the charge nurse passed that information on and it went to management from there. The ADON stated typically the charge nurse would put an order in for the consult or document in the 24-hour report so there was some way it could be tracked and someone could find it. The ADON stated prior to 3/29/2023, she was not sure any action had been done on the GI order for Resident #25. The ADON stated staff had not reported Resident #25 had any GI symptoms and the ADON stated she saw Resident #25 the night of 3/29/2023 and she was fine. When asked what a potential negative resident outcome could be if a resident ad a GI bleed and did not have a GI consult scheduled in a timely manner, the ADON stated, so many things, it could go so many different ways, and it could be a bad situation if we didn't follow up on it. The ADON stated Resident #25 was stable enough for the hospital to send her back to the facility. <BR/>During an interview on 3/30/2023 at 9:18 a.m., the DON stated, this whole thing has been bothering me. The DON stated the facility did follow up with the Physician within 4-5 days, but when she had looked at the discharge orders which were sent to the Physician, there was no mention to the Physician about Resident #25's GI bleed. The DON stated the Physician was notified that day and the whole process is going to change anyway. When asked how she ensured the facility was following recommendations from the hospital when the Physician was busy, the DON stated, we would send an ASAP text to the Physician and she usually responds. The DON stated, I think we need to put in an emergency thing. The DON stated if Resident #25 had possible perforation of the gut, that scared her. When asked how nursing staff monitored Resident #25 for symptoms, the DON stated she would think they would be watching her stool and seen if she had thrown up. When asked if she had talked to staff to see if they had been keeping an eye on Resident #25, the DON stated, I will now and obviously I need to do some education with them. The DON stated, I always thought they needed a referral to see a specialist. The DON stated she reviewed Resident #25's labs and the labs did not show low hematocrit or hemoglobin levels (blood levels that can become low with bleeding). When asked how she thought a delay in scheduling the GI consult could potentially affect Resident #25, the DON stated she did not think the delay would do anything because Resident #25 did not have symptoms. <BR/>During an interview on 3/30/2023 at 10:14 a.m., LVN C stated Resident #24 had not had any nausea or vomiting since Friday 3/24/2023. LVN C stated Resident #25's last bowel movement was on 3/28/2023. LVN C stated if Resident #25 had any GI symptoms, nursing staff would document it in Resident #25's chart. LVN C stated no staff had reported any GI symptoms to her. <BR/>During an interview on 3/30/2023 at 2:22 p.m., when asked if it was his expectation that staff followed hospital discharge orders, the Administrator stated, it would be the DON that would need to answer that<BR/>During an interview on 3/30/2023 at 2:40 p.m., the DON stated she had read Resident #25's discharge instructions on 3/24/2023. <BR/>A record review of the facility's undated policy titled Quality of Care reflected the following: <BR/>Purpose: Ensure identification and provision of needed care and services that are resident-centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental and psychosocial needs.<BR/>Procedure: Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and resident choices. <BR/>Each resident's care plan must reflect person-centered care and include resident choices, preferences, goals, concerns/needs and describe the services and care that is to be furnished to attain or maintain, or improve the resident's highest practicable physical, mental and psychosocial well-being.<BR/>2.<BR/>A record review of the undated face sheet for Resident #2 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heart rate), dementia without behavioral disturbance, hypertension (high blood pressure), hyperlipidemia (high cholesterol), congestive heart failure (impairment of the heart's blood pumping function that causes fluid retention), weakness, peripheral vascular disease (a slow and progressive circulation disorder).<BR/>A record review of the quarterly MDS for Resident #2 dated 12/2/2022 reflected she required the extensive assistance of one person for dressing, personal hygiene, and bathing. It reflected a diagnosis of heart failure. It did not reflect a diagnosis of peripheral vascular disease. <BR/>A record review of the care plan for Resident #2 dated 9/28/2022 reflected the following: <BR/>Focus (Resident #2) has Peripheral Vascular Disease (PVD) r/t AFib, CHF. Goal The resident will be free of s/sx of PVD through the review date. <BR/>Interventions<BR/>Ace wrap per MD order<BR/>Educate resident to use caution with heating pads, hot water bottles etc.<BR/>Educate the resident on the importance of proper foot care including: proper fitting<BR/>shoes, wash and dry feet thoroughly, Keep toenails cut, inspect feet daily, daily<BR/>change of hosiery and socks.<BR/>Elevate legs when sitting or sleeping.<BR/>Encourage good nutrition and hydration.<BR/>Encourage resident to change position frequently, not sitting in one position for long<BR/>periods of time.<BR/>Give medications for improved blood flow or anticoagulants as ordered<BR/>If resident has thick nails, corns, calluses, refer to podiatrist.<BR/>Keep skin on extremities well hydrated with lotion in order to prevent dry skin and<BR/>cracking of the skin.<BR/>Monitor the extremities for s/sx of injury, infection or ulcers.<BR/>Monitor/document for excessive edema and encourage resident to elevate legs.<BR/>Monitor/document/report PRN any s/sx of complications of extremities: coldness of<BR/>extremity, pallor, rubor, cyanosis and pain.<BR/>Monitor/document/report PRN any s/sx of skin problems related to PVD: Redness,<BR/>Edema, Blistering, Itching, Burning, Bruises, Cuts, other skin lesions.<BR/>A record review of physician orders for Resident #2 on 3/30/2023 reflected the following: <BR/>Wrap both legs with ace wrap below the knees daily, rest periods during the day and leave off at night while in bed every day shift related to PERIPHERAL VASCULAR DISEASE, UNSPECIFIED with a start date of 1/19/2023.<BR/>Remove ACE wrap from BLE at night before bed. Every night shift for removal with a start date of 1/26/2023.<BR/>Review of the TAR for Resident #2 reflected the order to wrap Resident #2's legs with a compression bandage was not marked off for 3/30/2023.<BR/>Observation on 3/29/2023 at 11:08 a.m., revealed Resident #2 seated in her wheelchair at the nurse's station in a knee length skirt. Her legs were not wrapped with compression bandages and were dark purple, very shiny, and exhibited signs of lymphedema (swelling in the arms or legs).<BR/>Observation and interview on 3/29/2023 at 2:11 p.m., revealed Resident #2 seated in her recliner with her legs elevated and no compression wraps. Her legs were much less purple and had a red hue, but there were signs of mild weeping (lymphatic fluid seeps from skin) and pitting (swelling in which pressure to the skin results in an indentation that lasts for a few moments) in her legs. Resident #2 stated she had been in the shower, so her bandages had come off, and no one had come to reapply them. She stated she wanted them on and would wrap them herself if she could reach the bandages. <BR/>During an interview on 3/29/2023 at 2:17 p.m., CNA E stated she had worked at the facility for 40 years, and she knew Resident #2 very well. She stated Resident #2 could not put her own compression wraps on her legs and was completely dependent on the nurse to do so. She stated she had given Resident #2 a shower earlier that morning and Resident #2 was waiting for the nurse to rewrap her legs.<BR/>Observation on 3/29/2023 at 4:12 p.m., revealed Resident #2 was in her recliner with her feet elevated and her legs bare. <BR/>Observation on 3/30/2023 at 8:15 a.m., revealed Resident #2 in the dining room having breakfast in her wheelchair at lunch with no wraps on her legs.<BR/>Observation on 3/30/2023 at 9:59 a.m., revealed Resident #2 seated in her recliner with legs not elevated and no wraps on her legs. <BR/>Observation on 3/30/2023 at 11:05 a.m., revealed Resident #2 seated in her recliner with legs not elevated and no wraps on her legs. <BR/>Observation and interview on 3/30/2023 at 1:18 p.m., revealed Resident #2 seated in her recliner with her legs not elevated and not wrapped. She was awake and visiting with family members. Her family members stated they visited Resident #2 every couple of weeks and did not know her legs were supposed to be wrapped during the day. They stated they saw the wraps on her legs about half the time when they visited and did not see them on her legs the other half of the time. <BR/>During an interview on 3/30/2023 at 1:22 p.m., LVN C stated Resident #2's legs were wrapped and that she had wrapped them at 6:00 a.m. that morning. When informed that Resident #2's legs had been observed unwrapped for several hours, LVN C stated Resident #2 must have taken the wraps off. When asked if she had noticed the wraps were not on, LVN C stated she had not. LVN C stated she had not marked the wraps on Resident #2's TAR because she had not done her documentation yet, but she did wrap the legs that morning. <BR/>During an interview on 3/30/2023 at 1:32 p.m., the DON stated the order to wrap Resident #2's legs was lacking in detail and did not include times they should be wrapped or times she should have rest from the wraps. The DON stated the staff should have been monitoring for edema, especially because she was on spironolactone and furosemide and they needed to ensure the medications were effective. The DON stated Resident #2 was ordered to have her legs elevated. The DON stated she felt the legs should have been wrapped first thing in the morning and that the intention of the order was for Resident #2 to have her legs wrapped for most of her waking hours. The DON stated there was no way to ensure Resident #2 was being monitored for edema if it was not ordered. The DON stated she had only been at the facility for one month and was still discovering problems that needed to be addressed, and she would be addressing this one.<BR/>During an interview on 3/30/2023 at 1:50 p.m., CNA E stated she did not believe Resident #2 could take her compression wraps off herself. <BR/>During an interview on 03/30/23 at 3:02 p.m., the ADM stated the facility did not have a written policy for following physician orders, but the policy and procedure was to follow physician orders.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for four of 30 days reviewed for RN coverage.<BR/>The facility failed to ensure they had an RN on duty on 03/05/23, 03/12/23, 03/19/23, and 03/25/23.<BR/>This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.<BR/>Findings included:<BR/>Review of RN staffing hours for March 2023 reflected zero hours worked by an RN on 03/05/23, 03/12/23, 03/19/23, and 03/25/23.<BR/>During an interview on 03/30/23 at 12:27 PM, the DON stated the facility census has been between 32 and 35 for over a year, and she has worked as the facility RN either Sunday or Saturday since she started. She stated she thought the rules about RN coverage were that if the census was low enough, they did not need an RN on duty every day. She stated she lived only a few minutes away from the facility and was on call 24/7 if there was an issue or a need for RN assessment or presence. The DON stated there was not an RN on duty the previous Sunday or other Sundays in March 2023, and she understood it was an issue because of supervision. When asked to elaborate on possible negative outcomes to residents if no RN was on duty, she stated she did not think there would be one since she was on call and available all the time and could be at the building so quickly. <BR/>During an interview on 03/30/23 at 12:33 PM, RN A stated she worked PRN at the facility and had not been called to pick up any shifts in March 2023. She stated she had not worked any Sundays in March, but she would be available to work Sundays when they needed her. <BR/>During an interview on 03/20/23 at 12:47 PM, the administrator provided facility policy on departmental supervision and stated the policy required an LVN or RN to be on duty at all times. He acknowledged the facility policy did not meet the regulatory requirement. He stated they had an RN who was willing to work weekends for them, and he thought she had been scheduled during weekends. He stated he was not aware that RN A had not been on the schedule in March 2023. He stated he monitored for compliance with regulations on RN staffing by delegating that task to his DON.<BR/>Record review of facility policy dated August 2006 reflected the following, Policy Statement: <BR/>The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times. <BR/>Policy Interpretation and Implementation: <BR/>1. A registered or licensed practical/vocational nurse (RN/LPN/LVN) is on duty 24 hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. <BR/>2. A registered nurse (RN) is employed as the Director of Nursing Services. The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, a nurse supervisor/charge nurse is responsible for the supervision of all nursing department activities, including the supervision of direct care staff. <BR/>3. The nurse supervisor/charge nurses are registered nurses (RN) or licensed practical vocational nurses (LPN/LVN), and are duly licensed by the state. <BR/>4. The Director of Nursing Services and/or the nurse supervisor/charge nurse, as a minimum, is responsible for: <BR/>a. making daily resident visits to observe and evaluate the residence, physical and emotional status; <BR/>b. reviewing medication, cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies;<BR/>c. reviewing individual, resident care, plans for appropriate goals, problems, approaches, and revisions, based on nursing needs; <BR/>d. Assuring that the residence plan of care is being followed; <BR/>e. arranging schedule to allow time for supervision and evaluation of performance of nursing personnel, and paid feeding assistants; <BR/>f. informing attending physicians and resident families of changes in the residence, medical condition; <BR/>g. charting and documenting medical records as necessary; <BR/>h. keeping Nursing Service Personnel, informed of status of residence, and other related matters through written reports and verbal communication; <BR/>i. Assigning work schedules and staffing to meet the needs of residence; providing direct resident care as necessary or appropriate; <BR/>j. and other tasks and functions, that may become necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 5 residents (Residents #1 and #2) reviewed for infection control.<BR/>The facility failed to ensure Resident #1 was placed on Isolation after she tested COVID-19 (Coronavirus 2019) positive in the hospital on [DATE]. <BR/>The facility failed to have signage on Resident #1's door that reflected PPE was required for infection control.<BR/>The facility failed to removed Resident #2 from a COVID-19 positive room even though she tested negative for COVID.<BR/>These failures could place residents at risk for infection, or hospitalization.<BR/>Findings included:<BR/>According to the intakes received by HHSC, The facility is not practicing infection control. They are not quarantining the covid positive Residents. [Resident #3] is next door to [Resident #1], and she is Covid Positive. The staff are not wearing PPEs, gloves or gowns. The staff are saying the Resident's covid test results are negative. This is false. The Complainant is concerned Covid will spread to other Residents due to the facility lack of infection Control, and on [DATE], [Resident #1] was sent to the local hospital due to loss of appetite, body aches and cough .The Resident came back from the hospital a couple of hours later. The Complainant assisted EMS with getting the Resident back into the facility and overheard an EMT tell [LVN A] that [Resident #1] had COVID. [Resident #1] is not receiving treatment, and there is not even isolation sign on her door. The complainant fears the illness will spread to other Residents. There Complainant is not aware of other active COVID-19 cases in the facility, but there are several Residents with similar symptom.[sic] <BR/>Review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Systemic Lupus Erythematosus unspecified (a chronic autoimmune disease in which the body's immune system mistakenly attacks healthy tissues in many parts of the body), nontraumatic intracranial hemorrhage (bleeding within the intracranial vault including the brain), Cognitive communication deficit, Acute respiratory failure with hypoxia (Hypoxia is low level of oxygen in the body tissue).<BR/>Review of Resident #1's Quarterly MDS Assessment, dated [DATE], reflected Resident #1 had a BIMS score of 10, which indicated she had moderate cognitive impairment. <BR/>Review of Resident #1's Comprehensive Care Plan dated [DATE] reflected Resident #1 had an ADL self-care.<BR/>performance deficit, had impaired cognitive function/dementia or impaired thought processes, had altered respiratory status/difficulty breathing.<BR/>Review of Resident #1's progress noted dated [DATE] at 9:51 am written by LVN A reflected, minimally responding to verbal and tactile stimulation, very clammy and diaphoretic. New order received: IV 1L 100ml/hr. CBC,<BR/>CMP, UA, chest Xray.<BR/>Review of Resident #1's progress noted dated [DATE] at 1:36 pm written by LVN A reflected, doc notified of COC, resident appears to be lethargic, clammy, and diaphoretic. to receive from doc: CBC, CMP, UA, chest Xray, IV NS 1000mL at 100mL/h.<BR/>Review of Resident #1's progress notes dated [DATE] at 9:00am written by the DON reflected, LATE ENTRY<BR/>Note Text: Spoke with nurse at hospital notified at this time that resident was given test for Covid which was NEGATIVE. Also notified that MD seen no need for IV placement. Resident is not dehydrated. Resident sent back to facility with no medications ordered.<BR/>Review of Resident #1's clinical records from [DATE] through [DATE] did not reflected Resident #1 was COVID positive. It did not reflect Resident #1 was isolated due to COVID and was being monitor. It did not reflect Resident #1 was being treated for COVID 19.<BR/>Review of Resident #2's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] with readmission date of [DATE]. Resident #2 had diagnoses which included Metabolic Encephalopathy (a condition characterized by brain dysfunction caused by systemic metabolic disturbances. Symptoms make include confusion, memory loss, loss of consciousness), Urinary tract infection, Dysphagia (difficulty swallowing) following unspecified cerebrovascular disease (group of conditions that affect blood flow and blood vessels in the brain).<BR/>Review of Resident #2's admission MDS Assessment, dated [DATE], reflected Resident #2 had a BIMS score of 1, which indicated she had severe cognitive impairment. <BR/>Review of Resident #2's Comprehensive Care Plan initiated [DATE] reflected Resident #2 required staff assistance for<BR/>meeting emotional, intellectual, physical, and social needs related to diagnosis of Dementia, Resident is at risk for infection related to risk of COVID-19, and also at risk for social isolation r/t infection control practices implemented by CDC and CMS guidelines to limit visitation, communal dining, and group activities. Community transmission of COVID-19.<BR/>Review of Resident #2's progress notes dated [DATE] written by the DON reflected:<BR/>Late Entry: created [DATE] @1:43 pm<BR/>Note Text: Tested for covid NEGATIVE.<BR/>Review of Resident #2's clinical records did not indicate Resident #2 was moved to another room due to roommate being tested positive for COVID-19<BR/>Review of facility's infection control logs for the months of January, February and March of 2025 did not reflected Resident #1 or any other Resident had COVID-19.<BR/>During an interview on [DATE] at 12:10 pm, LVN A stated she was not in the facility when Resident #1 was transferred to the local Hospital ER on [DATE] and assumed Resident #1 had a changed of condition that is why she was sent to the hospital. LVN A stated she was the assigned nurse when Resident #1 returned from the ER on [DATE] and Resident #1 was not in any Respiratory distress, Resident #1 was at baseline. LVN A stated EMT to her Resident #1 was COVID positive and she told the EMS staff that was not true, Resident #1 was not COVID positive because nurse to nurse report from the hospital and was told Resident #1 was COVID negative. LVN A stated EMS gave her Resident #1's hospital papers and it indicated Resident #1 was COVID negative. LVN A stated she told the DON what the EMS staff had said about Resident #1 being COVID positive and put Resident #1's hospital records in the medical records box. LVN A stated since she had been at the facility from 06/2024 to [DATE], no Resident had tested positive for COVID-19 so there was no need to isolate a Resident.<BR/>During an interview on [DATE] at 12:36 am LVN B stated she was not the nurse on duty who sent Resident #1 to the ER on [DATE]. LVN B stated she had not seen Resident #1 with change of condition, no coughing, no running nose. LVN B stated as far as she can recall, there has been no resident with s/s of covid or tested positive for covid. If someone test positive for covid we have to put them on isolation, let the DON and the Administrator know, they will take it from there and notified whoever.<BR/>During an interview on [DATE] at 12:47pm, Resident #1's family stated, she was told by facility's staff that Resident #1 was sent to the ER to get IV started because they were having trouble starting an IV. Resident #1's family also stated facility staff told her Resident #1 was COVID negative. Family also stated if Resident #1 had COVID, the nurses and the DON did not tell her.<BR/>During an interview on [DATE] at 1:04 pm, CNA C stated he had worked with Resident #1 and was never told she was COVID-19 positive. CNA C stated since he had worked in the facility from 12/2024, no resident had tested positive for COVID-19; No Resident had been put on isolation due to COVID-19. <BR/>During an interview on [DATE] at 1:37 pm, the Medical Record staff stated when a resident comes from the hospital, the nurses give him the resident's hospital records, and it is scanned into PCC. The Medical Record staff stated he did not get hospital records for Resident #1's hospital visit on [DATE]. He stated he was aware that Resident #1 went to the hospital on [DATE] but there were no records. <BR/>During an interview on [DATE] at 1:45 pm, CNA D stated she was usually assigned with Resident #1. CNA stated she could not recall if Resident #1 had signs and symptoms of COVID 19. CNA D stated Resident #1 told her she was COVID positive around the time the resident was sent to the ER. CNA D stated there was a rumor in the facility that Resident #1 was COVID positive but there was nothing done to treat Resident #1. CNA D stated Resident #1 had a roommate, the roommate was never removed from the room and Resident #1 was never isolated.<BR/>During an interview on [DATE] at 2:38 pm, the DON stated she was in the facility when Resident #1 was being sent to the ER on [DATE] due to IV placement. She stated she got nurse-to-nurse report from the hospital on [DATE] regarding Resident #1 was being transfer back to the facility. The DON stated she was also told Resident #1 was COVID negative and Resident #1 did not need IV fluids based on labs done at the hospital. The DON stated she was in the facility when Resident #1 got back, and EMS did not provide hospital papers. The DON said she did not hear EMS say Resident #1 was covid positive. The DON stated, Resident #1's family stated Resident #1 was COVID negative. The DON stated she heard the staff say Resident #1 was positive for COVID, but they did not re-test Resident #1 to confirm because there were no covid test in the facility. The DON stated the COVID test in the facility were all expired. The DON stated, if a Resident was COVID positive, they had to isolate the resident, notify family and the Doctor, test roommate and or remove from the room depending on the test result. <BR/>During an interview with on [DATE] at 2:00 pm, Resident #1 stated she recalled going to the ER for IV meds. Resident #1 stated while in the hospital, they swapped her nose for COVID, and they try to say she had COVID. Resident #1 stated she did not think she had COVID because she did not feel the same as when she had COVID before and was surprised. <BR/>Requested Hospital records for Resident #1's hospital stay on [DATE] from the Administrator and the Hospital.<BR/>Received Resident #1's hospital records on [DATE].<BR/>Reviewed of Resident #1's hospital records dated [DATE] reflected the following:<BR/>COVID-19 confirmed, Cough unspecified-confirmed, fever unspecified-confirmed.<BR/>Chief Complaint-Nausea-Patient is a [AGE] year-old female who comes to the emergency department by EMS from [Nursing Home] complaining of flulike symptoms, of cough, congestions fever, running nose for 2 days. The Nursing home staff was concerned she might be dehydrated and called EMS to have her evaluated. She is speaking in full sentences, alert and oriented without distress.Vital signs stable. Denies any other symptoms.<BR/>Lab results-2019 Coronavirus SARS-CoV-2Ra positive on [DATE] at 11:42 am<BR/>ED Course: Patient is a [AGE] year-old female who comes to the emergency department complaining of generalized flulike symptoms and cough for the past few days. Denies any Nausea or vomiting to me. No clinical evidence of dehydration. Vital signs are stable. Patient is COVID positive, and symptoms have been going on for the past few days. Unable to get a list of her medications and without this I do not feel comfortable prescribing Paxlovid at this time due to possible interactions with her other medications. Patient is asymptomatic and hemodynamically stable at this time. Recommended continued supportive care, fluid hydration orally and close outpatient follow-up with PCP with droplet precaution at the nursing home to avoid spread of the virus to other residents. <BR/>During an interview on [DATE], LVN A stated she and the DON sent Resident #1 out to the hospital on [DATE] for IV placement. LVN A stated Resident #1 had a change of condition, the MD and Resident #1's family were notified. LVN A stated she called EMS and explained why Resident #1 was being sent to the ER. LVN A stated she was still at work on [DATE] when Resident #1 returned from the ER. LVN A stated she did not get report for the hospital regarding Resident #1, the DON got report. LVN A stated the EMS staff told her Resident #1 was COVID positive and she did not take them seriously because the 2 EMS personnels did not want to be there and was just doing the job to get pay. LVN A looked at Resident #1's printed hospital records and stated those were the same records Resident #1 came back from the hospital with on [DATE]. LVN A stated if the hospital records indicated Resident #1 was COVID positive, then she was COVID positive. LVN A stated Resident #1 was sent to the ER for IV placement due to dehydration, not COVID test and was tested by the hospital due to protocol. LVN A stated she came back to the facility at the end of my shift I was ready to go home. I have life outside of work, I come and do my job and leave. I passed report on to the incoming shift that Resident #1 was COVID positive, I don't recall speaking with the DON that Resident #1 was COVID positive, I did not notify the MD, I passed it on in report and went to my Kids. LVN A stated, I am assuming we isolate if a Resident was COVID positive, roommate has to be tested and removed from the room, staff wear full PPEs. LVN A stated she did not test Resident #1's roommate for COVID, she did not know what happened to Resident #1's roommate. LVN A stated she left, went home, not sure if she worked the days following because she had taken some days off. LVN A stated isolation is to prevent them from passing on to somebody else. PPEs included gowns, N95 mask/face shield and gloves.<BR/>During an interview on [DATE] at 09:38 am the DON stated Resident #1 was sent to the ER on [DATE] due to showing signs and symptoms of dehydration such as low blood pressure and dry lips. The DON stated the facility tried to start an IV but was unsuccessful, MD was notified, and Resident was transferred to the hospital. The DON stated LVN A said Resident #1 was sent back without hospital papers. The DON stated Resident #1 should have had hospital records and the admitting nurse is responsible to review the hospital records and give to medical record personnel to enable all staff working with the resident to have access to the records. DON stated she did not see Resident #1's hospital records until [DATE]. The DON stated COVID POSITIVE precautions were isolation, verify the test by retesting, notify families and all parties, test the roommate, if negative they are to be removed from the room, don PPEs such as gowns, gloves, face shield, N95 mask, the sign on the door. The DON stated Resident #1 was not COVID positive, but the roommate was tested negative and moved to another room. <BR/>During an interview on [DATE] at 10:36 am, Resident #1 stated her roommate had been in the room the entire time and had not been moved to another room. Resident #1 stated staff had not been wearing gowns and mask to care for her when she came back from the hospital.<BR/>During an interview on [DATE] from 10:42 am through 1:09 pm CNA D, CNA F, CMA G, CNA H, CNA I, Housekeeper J and Housekeeper K all stated Resident #1 was never isolated when she returned from the hospital. They stated there had not been any communication of COVID positive resident in the facility around the time Resident#1 went to the hospital. They all stated it was never passed in report that Resident #1 had COVID. They all stated Resident #1's roommate was never moved to another room. They stated they were never in-serviced on COVID positive in the last 60 days. <BR/>During an interview on [DATE] at 11:55 am, the Administrator said he first heard Resident #1 went out to the ER on [DATE] during their regular morning meeting due to him being off work. The Administrator stated he was not made aware by the DON that Resident #1 tested positive for COVID 19. The Administrator stated if a resident was COVID positive, the expectation was to isolate the resident and monitor, do not have to put them on another hall, follow infection control precautions. The Administrator stated, if the positive resident had a roommate, the roommate should be tested and quarantine when negative. The Administrator stated the DON have details on the facility's policy on COVID, he did not know. The Administrator stated COVID positive should be communicated with other staff caring for the residents for precautions. The Administrator stated he never saw Resident #1's hospital records until [DATE]. The Administrator stated, when a resident was transferred from the hospital, their hospital records are scanned into the system by the Medical Record staff. The Administrator stated the nurses were supposed to review the records for updates, changes and update the Resident's medical records. The Administrator stated he expected the nurses to take into serious consideration what EMS tells them to familiarize themself with the resident, if not done, they will not know how to properly care for the Residents. The Administrator stated they have not isolated any resident for COVID since he had been at the facility due to not having covid positive resident. The Administrator stated it was the expectation for the staff to call the hospital to get paperwork/records, to follow up from the hospital, for continuity of care. He stated, not following the steps for taking precautions could have caused an outbreak, bigger problems, potential to affect other Residents and staff. He stated the DON was supposed to ensure that there were covid tests in facility.<BR/>During an interview on [DATE] at 2:57 pm, LVN L stated he usually got report from LVN A due to them being on the same rotation. LVN L stated he had never gotten report from LVN A indicating Resident #1 was COVID positive. LVN L stated Resident #1 has never been isolated due to COVID-19 and her roommate had been in the room the entire time. LVN L stated if a Resident tested positive for COVID-19, they are to be isolated in a room by themselves or with another covid positive Resident. Staff would wear full PPE such as N95 mask, gown, gloves, face shield, sign place on the door. LVN L stated if Resident #1 tested positive, it would have been good communicating it to staff that provide care for the resident to prevent the spread of the virus.<BR/>Review of facility's policy titled Infection Prevent and Control Program updated 04/2024 reflected: <BR/>1. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals<BR/>and is an integral part of the quality assurance and performance improvement program.<BR/>2. The elements of the infection prevention and control program consist of coordination/oversight, policies/<BR/>procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of<BR/>infection, and employee health and safety.<BR/>Policies and Procedures<BR/>Policies and procedures are utilized as the standards of the infection prevention and control program.<BR/>The infection prevention and control committee, Medical Director, Director of Nursing Services, and<BR/>other key clinical and administrative staff review the infection control policies at least annually. The<BR/>review will include:<BR/>(1) Updating or supplementing policies and procedures as needed;<BR/>(2) Assessment of staff compliance with existing policies and regulations; and<BR/>(3) Any trends or significant problems since the previous review.<BR/>Prevention of Infection<BR/>a. Important facets of infection prevention include:<BR/>(1) identifying possible infections or potential complications of existing infections;<BR/>(2) instituting measures to avoid complications or dissemination;<BR/>(3) educating staff and ensuring that they adhere to proper techniques and procedures;<BR/>(4) enhancing screening for possible significant pathogens;<BR/>(5) immunizing residents and staff to try to prevent illness;<BR/>(6) implementing appropriate isolation precautions when necessary; and<BR/>(7) following established general and disease-specific guidelines such as those of the Centers for Disease<BR/>Control (CDC).<BR/>Requested facility's COVID policy on [DATE] and [DATE] from the Administrator and policy was never given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical and psychosocial status for one (Resident #4) of seven residents reviewed for changes in condition.<BR/>1. The facility failed to notify Resident #4's RP of Resident #4 being hit by a peer on 2/3/25.<BR/>2. The facility failed to notify Resident #4's RP of a visit to the ER after Resident #4 had a fall on 2/7/25 with an onset of increased confusion. <BR/>These failures could put residents at risk of not having their care needs and health changes communicated and addressed with their responsible party.<BR/>Findings included:<BR/>Review of Resident #4's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset (a progressive disease that destroys memory, thinking and behavior, interfering with daily functioning), cognitive communication deficit (reduced ability to communicate needs), and dementia (brain impairment of at least two brain functions). Responsible Parties are listed as Resident #4 and RP E. <BR/>Review of Resident #4's payment MDS assessment, dated 1/25/25, reflected a BIMS score of 9, indicating moderate cognitive impairment. <BR/>Review of Resident #4's quarterly care plan, initiated 1/28/25, reflected focus areas of diet and falls. <BR/>Review of Resident #4's Progress Notes from 1/13/25 through 2/8/25, revealed there were no entry on the notes for 2/3/25. Continued review revealed on 2/7/25 RN D documented at 11:20 pm that a weekly skin assessment was completed. At 11:32 pm Pt sent to hospital for evaluation post unwitnessed fall, skin tear and new onset of confusion. On 2/8/25 at 10:09am Resident #4 was noted to have returned from the ED with orders for an antibiotic for seven days. No diagnoses or other orders were noted. <BR/>Review of an IR dated 2/7/25 included Pt found laying down on the floor in room next to wheelchair with blood from the right wrist due to skin tear. The predisposing physiological factors included check marks indicating confusion and impaired memory. People notified were listed as the physician, DON, and Resident #4 herself. <BR/>During an interview on 2/9/25 at 9:54 am, Resident #4's RP E revealed they did not know that Resident #4 had been hit by another resident or that she had been sent to the ER after a fall. RP E stated although they had not been able to be as involved in Resident #4's care, they still would like to be notified of those types of events. RP E stated the frequency of events like this would indicate whether Resident #4 was in a safe place and that would be something they are interested. RP E stated they had been notified of Resident #4's admission into the facility but had not been notified since that time. RP E stated Resident #4 was not able to make decisions on her own which was why she was on a secure unit, she no longer had safety awareness. <BR/>During an interview on 2/8/25 at 12:48 pm, CNA F stated he normally worked alone on the secure unit. He stated he can usually handle it but will request help occasionally. CNA F stated on 2/3/25 there was an incident in which Resident #4 was hit by Resident #7. He stated he asked a physical therapist who was in the unit working with another resident to notify the nurse and administration. CNA F stated he separated the two residents into different areas and LVN C came to assess the residents. CNA F stated he assumed someone in administration had also been notified. CNA F stated Resident #4 had redness to the side of her face but no other injuries. <BR/>During an interview on 2/8/25 at 4:21pm, LVN C stated she had been aware of the incident during which Resident #4 was hit but had not documented or notified the RP as she had been told the DON was involved and she assumed everything needed would be done by the DON. <BR/>During an interview on 2/8/25 at 11:05 pm with RN D revealed he was not aware that a peer had hit Resident #4. He was working on 2/7/25 when Resident #4 fell. RN D stated she had been sent to the ED due to a possible change in the level of confusion. RN D explained Resident #4 had a history of confusion, but seemed at the time more so than usual and they were not able to determine the cause of the fall. He did not notify the RP; the resident was her own RP. <BR/>During an interview on 2/10/25 at 8:45 am, the facility DOR stated on 2/3/25 one of the PT staff had come to her while she was in a meeting with the administration, and reported she needed to tell the Administrator about an incident involving two residents on the secure unit. The DOR stated the Administrator was in the meeting so she directed her staff to him. <BR/>During an interview on 2/10/25 at 9:50 am, the Adm stated he was notified by a PT staff on 2/3/25 that the staff on the secure unit wanted to see him. The Adm stated he assumed the staff wanted to see him regarding an issue they had been discussing previously he had not realized there was an incident of aggression between two residents. He stated had he known about the incident he would have sent a nurse to assess the resident, notify the physician if needed, write an IR, and notify the RP. <BR/>During an interview on 2/10/25 at 9:30 am, the DON stated she was not notified of Resident #4 being hit by another resident. The DON stated she had been notified of Resident #4's fall and was aware that Resident #4 was being sent to the ED. The DON stated she had instructed RN D to notify Resident #4's RP. She stated that the RP should have been notified of both events. <BR/>Review of the facility's Charting and Documentation policy, revised April 2008, reflected the policy included the following:<BR/>All incidents, accidents, or changes in the resident's condition must be recorded. Documentation of procedures and treatments shall include care-specific details and include at a minimum: <BR/>f. <BR/>Notification of family, physician, or other staff, if indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to, in response to allegations of abuse, neglect or mistreatment, have evidence that all alleged violations were thoroughly investigated for two (Residents #4 and #7) of seven residents reviewed for abuse and neglect.<BR/>The facility failed to investigate an allegation of abuse when Resident #7 hit Resident #4 on her face on 2/3/25. <BR/>This failure placed residents at risk of further abuse, trauma, and psychosocial harm.<BR/>Findings included:<BR/>Review of Resident #4's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset (a progressive disease that destroys memory, thinking and behavior, interfering with daily functioning), cognitive communication deficit (reduced ability to communicate needs), and dementia (brain impairment of at least two brain functions). Responsible Parties are listed as Resident #4 and RP E. <BR/>Review of Resident #4's MDS assessment, dated 1/25/25, reflected a BIMS score of 9, indicating moderate cognitive impairment. <BR/>Review of Resident #4's quarterly care plan, initiated 1/28/25, reflected focused areas of diet and falls. <BR/>Review of Resident #4's Progress Notes from 1/13/25 through 2/8/25, revealed there were no entry on the notes for 2/3/25. <BR/>Review of Resident #7's face sheet, dated 2/9/25, reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of dementia severe with agitation (brain impairment of at least two brain functions with worry and anxiety) and schizoaffective disorder (a combination of schizophrenia, a mental health condition with symptoms of hallucinations or delusions mixed with mood disorder such as mania and depression)<BR/>Review of Resident #7's MDS Assessment, dated 1/31/25, reflected Resident #7 had a BIMS score of a 3, which indicated severe cognitive impairment. <BR/>Record review of Resident #7's Comprehensive Care Plan, initiated, 1/28/25 reflected a focus area of a regular/mechanical soft diet. No other focused areas were included.<BR/>Review of Resident #7's Progress Notes from 1/15/25 through 2/8/25, revealed there were no entry on the notes for 2/3/25. <BR/>During an interview on 2/8/25 at 12:48pm, CNA F stated on 2/3/25 there was an incident in which Resident #4 was hit by Resident #7. He stated he asked a physical therapist who was in the unit working with another resident to notify the nurse and administration. CNA F stated he separated the two residents into different areas and LVN C came to assess the residents. CNA F stated he assumed someone in administration had also been notified. CNA F stated Resident #4 had redness to the side of her face but no other injuries. <BR/>During an interview on 2/8/25 at 4:21pm, LVN C stated she had been aware of the incident during which Resident #4 was hit but she had not documented or notified the RP as she had been told the DON was involved, and she assumed everything needed would be done by the DON. <BR/>During an interview on 2/10/25 at 8:45 am, the DOR stated, on 2/3/25, one of the PT staff had come to her while she was in a meeting with the administration, and reported she needed to tell the Administrator about an incident involving two residents on the secure unit. The DOR stated the Administrator was in the meeting so she directed her staff to him.<BR/>During an interview on 2/10/25 at 9:30 am, the DON stated she was not notified of Resident #4 being hit by another resident. She stated had she been notified, she would have reported the incident as abuse.<BR/>During an interview on 2/10/25 at 9:50 am, the Adm stated he was notified by a PT staff on 2/3/25 that the staff on the secure unit wanted to see him. The Adm stated he assumed the staff wanted to see him regarding an issue they had been discussing previously he had not realized there was an incident of aggression between two residents. He stated had he known about the incident he would have sent a nurse to assess the resident, notify the physician if needed, write an IR, and notify the RP. The Adm stated if he had been told, he would have investigated the incident to make sure the residents were safe and determine whether or not the incident was reportable. <BR/>Review of the facility policy abuse/ neglect, undated, reflected the policy included the following: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation .The Administrator is the Abuse Coordinator in this facility and is responsible for developing and implementing the abuse prevention training curriculum and conducting the investigation in situations of alleged abuse/neglect.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one (secure hall) of three halls reviewed for physical environment.<BR/>The facility failed to ensure an exit door on the secured unit contained an alarm to alert staff if a resident exited the door. <BR/> This deficient practice could place residents at risk of injury or harm.<BR/>Findings included:<BR/>Review of the facility Midnight Census report dated 2/9/25 revealed there were 7 residents listed as residing on the secure unit.<BR/>Review of the facility IRs from 10/1/2025 through 2/9/25 revealed there were none related to unauthorized departure. <BR/>During an observation and interview on 2/8/25 at 12:48 pm with CNA F revealed he believed that the exit door contained an alarm that went off when it was opened. CNA F was not certain how to turn the alarm off. He stated he would normally ask the Administrator, who was not at the facility on that day. CNA F stated he had not observed any residents trying to go out the door. Observation of the exit door revealed there was a small box to the right of the door on the wall. There was no indication of the box being connected to the door. <BR/>During an observation and interview on 2/9/25 at 9:30 am with the Adm revealed there was a problem with one of the secure unit exit doors. He stated they were aware and had ordered an alarm for the door. He stated there was no functioning alarm at that time. Observation of the exit door revealed when opened, it opened to an outside fenced area. No alarm was detected or heard. The Adm confirmed the seven residents housed on the secure unit were there for their safety has they had a history of UDs or attempts . He stated he was not aware of any attempts of UD since those residents were admitted to the newly opened secure unit a little over a month ago. The Adm stated there was always a staff member on the unit, making sure the residents were safe. When asked what happened if a resident went out the door while staff was providing personal care to another resident unaware that someone went out, he stated they would be in a fenced in area that contained a tall fence. <BR/>During an interview on 2/9/25 at 4:09 pm with the Maintenance Technician revealed he was notified on 2/3/25 that someone had pulled the wires from the door alarm. He stated he did not know why anyone would do that, but it was not repairable. He stated, on 2/4/25, he ordered a new alarm. He stated, on 2/6/25, he put a temporary alarm up so the staff would know if someone went out. The Maintenance Technician stated he did not know what had happened to make that alarm nonfunctioning, but tomorrow morning, he would make sure there was a functioning alarm. <BR/>During an additional observation and interview on 2/10/25 at 8:15 am with the facility Maintenance Technicia,n he stated the Adm had bought another temporary alarm at a local retail and applied it to the door yesterday. Observation of the door revealed there was a new box to the side of the door. When the door was opened a loud alarm went off.

Based on observation, interview and record review, the facility failed to ensure that all expired drugs and biologicals were removed and destroyed for 1 of 1 medication storage rooms reviewed for medications and failed to ensure 1 of 1 medication storage room refrigerators was free of contaminants. <BR/>The facility failed to remove 7 bottles of expired medication from the medication storage room and 1 container of expired protective skin applicators when it was observed on 05/28/2024 at 3:45 PM. <BR/>The facility failed to ensure the medication room refrigerator was free of contaminants including staff food and drinks when it was observed on on 05/28/2024 at 3:45 PM. <BR/>This failure could place all residents at an increased risk of receiving expired and/or contaminated medications/supplements resulting in adverse health consequences. <BR/>Findings included:<BR/>Observation on 05/28/2024 at 3:45 PM in the medication storage room revealed one bottle of Aspirin 81 mg expiration date 08/2023, four bottles of Docusate Sodium expiration date 04/2024, one bottle of natural tear eye drops expiration date of 09/24/2023, Skincote protective dressing applicator expiration date 08/2023. The medication room refrigerator had one open container of lemon-flavored thickened liquid, and two magic cups (nutritional supplement) for residents. Staff food items included an open container of yogurt, an open strawberry-flavored drink, two bottles 33 oz. water, one of which was open, cheese sticks, one large 32 oz soft drink with a straw in it, crispy onion salad topper and a jar of opened mayonnaise. <BR/>In an interview on 05/28/2024 at 3:55 PM MA H stated she had been working in the facility since May 1, 2024, and stated the staff used the refrigerator in the medication room because the staff did not have one in their break room. She stated the medications that were expired would not be as potent if given to a resident. <BR/>In an interview on 05/28/2024 at 4:12 PM LVN B stated the expired medications would not be as effective if given to a resident. She stated the staff remove expired medications as a team and no one person was responsible. She further stated the staff should not be using the refrigerator in the medication room for their personal food as there could be cross contamination.<BR/>In an interview on 5/28/2024 at 4:20 PM the DON stated she had been working at the facility since February 2024. She stated regarding the expired medications, the staffing coordinator had quit a month ago and they had not gotten around to removing the expired medications. She stated the potential risk of expired medications could be GI upset and they would be less effective. Regarding staff food in the resident's refrigerator, she stated there could be cross-contamination. She stated the staff did not have a refrigerator in their break room. <BR/>In an interview on 05/30/2024 at 3:45 PM the DON stated she and other staff had pulled expired medications off of the storage room shelves at the beginning of April 2024. She stated the central supply person was no longer at the facility and it was one of her duties to remove expired medications. She stated having staff food in the refrigerator could be an issue due to cross contamination and expired medications would not be as potent or the resident could have an adverse reaction. <BR/>In an interview on 05/30/2024 at 4:26 PM the ADM stated her expectation was that the medication aides would clean expired medications off of the storage room shelves. She said the task depended on who the DON assigned it to. She stated expired medications could potentially be ineffective. She stated food and drinks should not be in the storage room refrigerator as it was an infection control issue.<BR/>Review of a facility policy and procedure dated 01/01/2024 titled Storage of Medications reflected The facility will store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 8. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 15 residents (Resident #80) reviewed for baseline care plans.<BR/>The facility failed to ensure Resident #80's baseline care plan dated 05/28/2024 included instructions to address her admission diagnosis, Type 2 Diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy) and physician orders within 48 hours of admission. Resident #80 was admitted to the facility on [DATE].<BR/>This failure could place residents at risk of receiving inadequate care and services.<BR/>Findings included: <BR/>Record review of the undated Face Sheet for Resident #80 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Type 2 Diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy) and Morbid Obesity (severely overweight). <BR/>Record review of the Discharge Medications list dated 04/23/2024 from a hospital and provided by Resident #80 reflected Insulin Glargine 60 Units subcutaneously (underneath all of the layers of the skin) twice a day for Type 2 Diabetes and Lisinopril 20 mg daily for high blood pressure. The list was transcribed by LVN C, the receiving nurse, for Resident #80 on 05/24/2024. <BR/>Record review of the Baseline Care Plan for Resident #80 dated 05/28/2024 (4 days after admission) reflected she had a refrigerator in her room, and she was at risk for falls due to impaired mobility and medications. It stated she used a CPAP machine while sleeping and she was a full code. <BR/>In an interview on 05/30/2024 at 1:00 PM LVN A stated she had not been trained to do a baseline care plan. <BR/>Record review of an undated facility admission Check List stated All starred items must be completed upon admission. All other assessment must be completed by the following nurses every shift until all items are completed within the first 24 hours without exception. Page 2 of the document reflected Baseline Care Plan.<BR/>In an interview on 05/30/2024 at 3:31 PM the DON stated the nurses in the facility had not been trained to do a Baseline Care Plan. She stated she usually started the task of completing Care Plans. She stated Care Plans would be used by the staff to help provide care for the residents.<BR/>Care plan policy review was not provided prior to exit.<BR/>

Based on observation, interview and record review, the facility failed to dispose of garbage properly in 1 of 1 kitchen.On 07/15/2025 at 9:30 AM, 1 of 2 facility garbage containers were observed with no lids attached or on them and they had waste inside. This failure has the potential to affect residents in the facility, staff, and visitors by placing them at risk of infection for exposure to germs and diseases carried by pests and rodents. In an interview with Dietary Supervisor on 07/16/2025 at 3:15 PM, Dietary Supervisor stated that trash cans should always have lids and should remain closed when not in use. Dietary Supervisor stated not keeping the lids closed could lead to cross contamination, placing residents at risk of illness.In an interview 07/17/2025 at 9:51 AM with Dietary Aide D, she stated that she has been employed at the facility for six years and has worked in the kitchen for the past four years. She reported that she has been trained on all kitchen policies. Dietary Aide D stated that trash cans should be kept always closed with a lid. She explained that if a trash can is left open, it can allow germs to accumulate, potentially contaminating the food and causing residents to become ill.Record review of the Dietary Services Policies and Procedures for Waste Control and Disposal, stated that Trash cans must be covered at all times except during use.