Every finding on record at Arboretum Nursing and Rehabilitation Center of Win

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation: 1. The facility failed to ensure opened food items stored in the walk-in dry pantry area were properly sealed in plastic bags to prevent exposure to the air. 2. The facility failed to ensure food items in the facility walk-in dry storage were dated or labeled.3. The facility failed to ensure that spoiled food items were discarded.4. The facility failed to ensure the outside of food containers were free of food particles.5. The facility failed to ensure dishes were sanitized properly prior to being stored in clean area. These failure could place residents at risk of food-borne illnesses.Findings Included: Observation and initial tour of the kitchen on 09/29/2025 at 8:30 a.m. indicated inside the dry food pantry were 1 gallon bottle of apple cider vinegar with an expiration date of 06/30/2025. Inside the bottle of vinegar there was dark brown and grey colored clumpy sediment inside. An opened 16-ounce bag of Fresh gourmet wonton strip inside an opened plastic bag with a best buy date of August 20,2024. An opened 35-ounce bag of Crisp [NAME] Cereal with a best buy date of November 17, 2024. An opened 2.2-pound bag of Cacao powder had a use before date of 03/16/2024. A 6-quart container with multi-colored circle cereal was unlabeled and had no date. An opened 16- ounce bag of uncooked noodles was not sealed inside a plastic bag, labeled, or dated. There were 13 unused bowls of cereal on a tray unlabeled. There were 2 of 10 food containers that had hard and sticky clumps of food on the outside of the containers. A 1- quart container labeled Thicker had no date on label. Observation on 09/29/2025 at 9:36 a.m. indicated the dishwasher had an internal temperature of 110 degrees Fahrenheit. Dishwasher A took 6 cups from the dishwasher and placed them on the tray of clean cups. The instructions on the dishwasher read for dishes to be washed and rinsed at 120 degrees or higher to ensure kitchenware were properly disinfected. Observation on 09/29/2025 at 10:00 a.m. indicated 6 large white debris spots located on the mixer counter. An interview on 09/29/2025 at 10:15 a.m., indicated the Dietary Supervisor said there shouldn't be any food items in kitchen past 6 months of the listed date on the product. She said the outside of all food containers should be wiped down after usage to prevent food borne illnesses. The Dietary Supervisor said all food items in the kitchen should be labeled and dated. She said the dishwasher must be at a temperature of 120 degrees Fahrenheit or greater to effectively disinfect kitchenware. The Dietary supervisor said she trained the kitchen staff on labeling items, discarding expired food items, cleaning the mixing station after use, and the dishwasher needing to be at 120 degrees Fahrenheit for the dishes to disinfected. She said her expectation was for all kitchen staff to follow facility policy and the training they have received on labeling and disinfecting kitchenware. An interview on 10/1/2025 at 2:13 p.m., indicated the Administrator said all expired food items or items past a year of the listed date should be thrown away to prevent residents being served expired food items. She said she expected kitchen staff to follow the facility's policy. The Administrator said if dishes were not washed at 120 degrees, the residents could potentially be harmed by cross contamination. An interview on 10/1/2025 at 2:45 p.m., indicated the Regional Nurse said residents could potentially be served expired food items because it's in the dry storage pantry with non-expired food items. She said if the residents were to consume the expired food items, they could potentially experience stomach issues, and diarrhea. The Regional Nurse said all dishes should be washed and rinsed at a temperature of 120 degrees Fahrenheit or higher. She said her expectation was for kitchen staff to follow facility policy. Record Review of the FDA Food and Code dated year of 2022 entitled: Mechanical Ware washing Equipment, Wash Solution Temperature. indicted: :The temperature of the wash solution in spray type ware washers that use hot water to SANITIZE may not be less than: The temperature of the wash solution in spray-type ware washers that use chemicals to SANITIZE may not be less than 49 C (120 F). Record Review of the facility's policy entitled Dietary Services Policy & Procedure Manual 2012 indicated (in part):Food Storage and Supplies- 3. Containers are labeled. Containers are cleaned regularly.4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.6. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf- stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. Record Review of the facility's policy entitled Dishwashing Preparation and Dishwashing dated: year of 2012 indicated (in part): The facility will complete the dishwashing process in a sanitary manner to provide clean and sanitary dishes and utensils. Procedure:2. c. The wash period shall be at least 40 seconds with a temperature of 120 degrees Fahrenheit in the dish machine. The sanitizing rinse period shall be at least 20 seconds with minimum temperature of 120 degrees Fahrenheit.

Based on interview and record review, the facility failed to ensure the physician was consulted regarding a need to alter treatment for 1 of 4 residents reviewed for notification of changes. (Resident #6) The facility failed to consult with Resident #6's physician regarding the pattern of Resident #6's refusal to wear an arm sling related to her fractured right clavicle for 21 out of 30 opportunities on the a.m. shift and 17 out of 30 opportunities on the p.m. shift for September 2025. This failure could place residents at risk for complications due to delayed or failed physician intervention. Findings included: Record review of Resident #6's face sheet dated October 1, 2025, indicated Resident #6 was an 80- year-old female initially admitted on [DATE] and re-admitted on [DATE] with diagnoses of fracture of unspecified part of right clavicle (broken right collarbone), contusion on right hip (deep bruise), and muscle weakness. Record review of Quarterly MDS assessment dated [DATE], for Resident #6 indicated: a Brief interview mental status score of 03 (severe cognitive impairment). An impairment on one side was listed; it does not list which side is impaired.Record review of Resident #6's care plan dated 09/30/2025 indicated: Resident #6 had a history of fractures. The interventions included Monitor/document/report to physician PRN: edema, bruising/discoloration of skin, skin temperature changes, loss of sensation distal to fracture, presence/absence of pulses distal to fracture, if cast is present, skin breakdown or trauma at cast edges.Record review of physician orders dated September 2025 for Resident #6 indicated: Use right arm sling. May wrap and adjust sling for comfort as tolerated. Every day and every night shift for Fractured right clavicle. Record review of Resident #6's Medication administration record dated August 2025 indicated: no right arm sling refusals. Record review of Resident #6's Medication administration record dated September 2025 indicated: Resident #3 refused 21 times out of 30 a.m. administration opportunities and 17 refusals out of 30 p.m. administration opportunities. Record review of Resident #3's Progress notes dated 09/01/2025- 10/1/2025 did not indicate the physician was made aware of Resident #6's arm sling treatment refusals. During an observation on 9/29/2025 at 9:18 a.m., Resident #3's right shoulder was approximately 4 inches lower then her left shoulder. Resident #3 did not have a right arm sling on. During observation on 09/30/2025 at 10:00 a.m., Resident #6 did not have the right arm sling on. During observation on 09/30/2025 at 2:55 p.m., Resident #6 did not have a right arm sling on. During observation on 10/1/2025 at 1:00 p.m., Resident #6 did not have a right arm sling on. During interview on 10/01/2025 at 4:00 p.m., LVN A said she had not notified the physician of Resident #6's pattern of refusing to wear the arm sling for her arm. She said she should have notified the physician of the pattern of refusal so he could have ordered a different treatment. She said Resident #6 not wearing her right arm sling could potentially cause further shoulder misalignment. During an interview and record review on 10/01/2025 at 3:05 p.m., indicated the Regional Nurse said the physician should have been notified of Resident #6's arm sling refusals so an alternative treatment could have been put in place. She said she could not find any documentation showing the physician was notified of resident's refusal. The Regional nurse said her expectation is for all nurses to follow policy and notify the physician of any pattern of refusal to ensure no potential harm came to the residents from not getting ordered treatment or alternative treatment. During an interview on 10/01/2025 at 3:17 p.m., the Administrator said the physician must be notified of any refusals to ensure the residents needs were being met, and no harm came to the residents by not receiving ordered treatment or a potential alternative treatment. Record review of the facility's undated policy Notifying the Physician of Change in Status,indicated: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician.The nurse will notify the physician or their delegated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident 's clinical record.

Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 3 of 22 residents (Residents #8, 42, and 59) reviewed for resident assessments. 1. The facility failed to refer Resident #8 for a PASRR review following a new mental illness diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) on 03/28/25. 2. The facility failed to refer Resident #42 for PASRR review following a new mental illness diagnosis of psychosis (a mental disorder characterized by a disconnection from reality) on 11/04/24. 3. The facility failed to refer Resident #59 for PASRR review following a new mental illness diagnosis of bipolar disorder on 07/22/25. These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.Findings included: 1. Record review of a face sheet dated 10/01/25 indicated Resident #8 was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses included bipolar disorder, cognitive communication deficit (a difficulty in communication caused by impaired thing processes, such as memory, attention, problem-solving, and organization), and dementia (a group of thinking and social symptoms that interfere with daily functioning). Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #8 had clear speech and was able to express her needs and comprehend others. She had a BIMS score of 7 indicating she had severe cognitive impairment, required substantial/maximal assistance with most ADLs, and had an active diagnosis of bipolar disorder. Record review of a care plan dated 04/07/25 indicated Resident #8 had a diagnoses of psychosis, bipolar disorder, and attention deficit hyperactivity disorder (a chronic condition including attention difficulty, hyperactivity, and impulsiveness). Interventions included administering medications as ordered by the physician and psych services as indicated. During record review of the physician orders dated September 2025 indicated Resident #8 received Risperdal oral solution at bedtime for attention deficit disorder with start date of 04/09/25. During an interview on 10/01/25 at 9:06 a.m., the MDS Nurse said that Resident #8's diagnosis of bipolar disorder was unknown to the facility until her physician ordered a gradual dose reduction and the discontinuation of her Risperdal (an antipsychotic medication used to treat bipolar disorder). She said Resident #8's family questioned why her Risperdal had been discontinued because the resident had been taking the medication for more than 10 years to manage her bipolar disorder and attention deficit hyperactivity disorder and they did not want the medication discontinued. The MDS Nurse said Resident #8's physician reordered the Risperdal per the family's request. She said the facility failed to complete a 1012 form (a form that assists the NF in determining whether a resident with a negative PASRR level 1 screening needs further evaluation for mental illness). She said the Social Worker was responsible for PASRR evaluations at the facility. During an interview on 10/01/25 at 9:45 a.m., the Social Worker said that she was responsible for coordinating PASRR for the facility. She said she had been doing PASRR for a year and had received PASRR training through webinar classes given by HHSC. She said she was not aware that if a resident was diagnosed with a new mental illness or the facility learned of a history of mental illness that a 1012 form should be submitted to the physician to determine if a resident should be screened for PASRR services. She said the 1012 form for a new mental illness was probably included in the training she attended, but she missed it. She said she should have submitted a 1012 form to Resident #8's doctor when the facility learned of her bipolar diagnosis, but she didn't. She said she would fill out a 1012 form and send it to Resident #8's physician. She said the possible negative outcome of not completing a 1012 form and sending it to the doctor could be that Resident #8 would not receive needed services that she could qualify for through PASRR. During an interview on 10/01/25 at 3:35 p.m., the MDS Nurse said that a 1012 Mental Illness/Dementia Resident Review form had been completed (after surveyor intervention) for Resident #8. Record review of a 1012 form dated 10/01/25 and signed by Physician A indicated that Resident #8 had a primary diagnosis of dementia and a new PL1 was not needed at that time. 2. Record review of a face sheet dated 10/01/25 indicated Resident #42 was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses included cerebral infarction (a condition where blood flow to the brain is interrupted, leading to brain cell damage), psychosis, and dementia. Record review of the most recent MDS assessment dated [DATE] indicated Resident #42 had clear speech and was able to express her needs and comprehend others. She had a BIMS score of 4, indicating she had severe cognitive impairment, required substantial/maximal assistance with most ADLs, and had an active diagnosis psychotic disorder. Record review of a care plan last revised 04/17/25, indicated Resident #42 required anti-psychotic medications related to her dementia with psychosis. Interventions included administering medications as ordered by the physician and psych services. During an interview on 10/01/25 at 1:51 p.m., the Social Worker said that she did not complete the required 1012 form for Resident #42 when she received the new mental illness diagnosis of psychosis. She said the negative outcome of not completing the required 1012 form was that the physician had not reviewed Resident #42 to determine if she should be evaluated for receiving specialized services through PASRR. During an interview on 10/01/25 at 3:35 p.m., the MDS Nurse said that a 1012 Mental Illness/Dementia Resident Review had been completed (after surveyor intervention) for Resident #42. Record review of a 1012 form dated 10/01/25 and signed by Physician A indicated that Resident #42 did not have a primary diagnosis of dementia and a new PL1 was needed so the resident could be evaluated for PASRR services. 3. Record review of a face sheet dated 10/01/25 indicated Resident #59 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of bipolar disorder [chronic mental health condition characterized by extreme mood swings between mania high (energy, euphoria, and impulsivity) and depression (low mood, fatigue, and hopelessness)] with onset date of 07/22/25. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #59 had clear speech with a BIMS score of 00 indicating she had severe cognitive impairment and an active diagnosis bipolar disorder. Record review of a care plan dated 07/22/25 indicated Resident #59 requires anti-psychotic medications for diagnosis of bipolar disorder. Interventions included administering medications as ordered by the physician. Record review of a PASRR level 1 screening for Resident #59 dated 01/31/25 indicated Resident #59 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record. During an interview on 10/01/25 at 2:15 p.m., the Social Worker said that she did not complete the required 1012 form for Resident #59 when she received a new mental illness diagnosis of bipolar disorder. While looking at Resident #59's medical record face sheet, the Social Worker stated Resident #59 had a diagnosis of Bi-polar that had an onset date of 07/22/2025. The Social Worker acknowledged Resident #59's PASRR was inaccurate and another PASRR screen or form 1012 would be completed for Resident #59 and uploaded to the portal. She said the negative outcome of not completing the required 1012 form or updating the PASRR could put the resident at risk of not receiving specialized services offered through the PASRR program. In an interview on 10/01/25 at 2:45 p.m. with the Administrator, she said her expectations were for the Social Worker to complete PASRR screenings according to regulatory guidelines and that Residents #8, #42 and #59's PASRR Level 1 screenings needed to be updated to include the new diagnosis. The Administrator stated that not having an accurate Level 1 put the resident at risk of not getting psych services and/or not getting the treatment they needed that was offered through the PASRR program. During an interview on 10/01/25 at 3:35 p.m., the Social Worker said that a 1012 Mental Illness/Dementia Resident Review had been completed (after surveyor intervention) for Residents #8, #42 and #59. Record review of the facility's undated policy titled Form 1012 Policy & Procedure with Instructions read in part: Purpose: Form 1012 assists nursing facilities (NF) in determining whether a resident with a negative Preadmission Screening and Resident Review (PASRR) Level I(PL1) Screening form submitted into the Long-Term Care (LTC) Portal, needs further evaluation for Mental Illness (MI).Section C. Mental Illness (MI) Indication. Examples of MI are: .mood disorder(bipolar disorder.).

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 1 (Hall B) of 4 hallways reviewed for environment. The facility failed to ensure the janitor closet, that contained potentially unsafe chemicals, on Hall B was secured on 09/29/25. This failure could result in residents coming into contact with potentially unsafe items.The findings were: During an observation on 09/29/25 at 9:35 a.m., during the initial tour on hall B, a janitor's closet's door knob was locked , however the door just opened when pushed on. The closet contained a 1/2 full bottle of multipurpose cleaner on the floor. The container had a label which indicated to keep out of the reach of children and animals. There was no staff in sight. During an interview on 09/29/25 at 9:45 am, the Maintenance Supervisor walked down the hall and met the surveyor at the unlocked room. He said someone must have forgotten to pull the door hard so the lock would latch. He said all chemicals should be in the sight of the staff or locked up to prevent residents from having accidents. The Maintenance Supervisor said all the staff was responsible for securing chemicals. During an interview with the Administrator on 09/30/25 at 1:30 p.m., the Administrator said the maintenance supervisor tightened the self-shutting mechanism to shut the door so it would lock and adjusted the lock. Record review of the Daily Common Area Cleaning policy dated 2021 indicated . Housekeeping carts/chemical must be locked when not within eyesight of a staff member.

Based on observations, interviews, and record review, the facility failed to ensure residents who enter the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable for 1 of 4 (Resident #10) reviewed for range of motion. 1.The facility failed to implement interventions to prevent the decline of Resident #10's range of motion to her left hand on 10/1/2 025. 2. The facility failed to document Resident #10's change of condition to her left hand from within functional limit to a decreased range of motion. These failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Record revied of Resident #10's face sheet dated 10/01/2025 indicated she was a [AGE] year-old female that was admitted to the facility on [DATE], with diagnoses of muscle weakness (generalized), Dementia (a decline in cognitive abilities, such as memory, thinking, problem-solving, and language), Alzheimer's disease (loss of cognition), Osteoporosis (weakens bones, making them more prone to fractures). Record review of Resident #10's Quarterly minimum data set assessment dated [DATE] indicated she had no upper extremity impairment (shoulder, elbow, wrist, hand). In Section O of the MDS entitled- Special Treatments, Procedures, and Programs indicated Resident #10 started Occupational therapy 08/14/2025. Record review of Resident #10's therapy screen dated 08/13/2025 at 5:12 p.m., indicated Resident #10 exhibited a decrease in her upper extremities range of motion and strength. In section C- (Immobilizing Device) indicated Resident #10 did not have a splint, brace, nor a placed cast on any extremity. The Occupational therapist registered #1 made a recommendation for Resident #10 to have an Occupational therapist registered and Physical therapist evaluation. Record review of Occupational therapy evaluation & plan of treatment dated 08/18/2025 at 12:55 p.m., indicated the reason for referral to occupational therapy was due to her decline in ability to perform functional activities without physical assistance, activities of daily living participation and strength. The Musculoskeletal System Assessment section indicated Resident #10's upper extremity range of motion and strength was within functional limits on both her left and right side. She also had no contractures present. In the Assessment Summary it listed risk factors such as further decline in her function and compromised general health to Resident #10 if she does not receive Occupational therapy. Record review of Resident #10's treatment administration record for the month of September 2025 did not reflect that any resting hand splint had been used on Resident #10's left hand. Record review of Resident #10's current physician orders did not indicate an order for a soft resting hand splint or hand roll for her left hand. Record review of Resident #10's Occupational therapy treatment encounter notes dated 08/14/2025- 09/27/2025 did not mention any updates on Resident #10's left hand to reflect her current decrease in range of motion. An observation on 09/29/2025 at 9:20 a.m., indicated Resident #10 did not have a hand roll or splint in her left hand. Resident #10's left hand was balled in a tight fist while sitting in her wheelchair during activities. An observation on 09/29/2025 at 3:45 p.m., indicated Resident #10 did not have a hand roll or splint in her left hand. Resident #10's left hand was balled in a tight fist resting on her lap while sitting in her wheelchair at the dining table. An observation on 09/30/2025 at 8:45 a.m., indicated Resident #10 did not have a hand roll or splint in her left hand. Resident #10's left hand was balled in a tight fist resting on her lap while sitting in her wheelchair. An observation on 09/30/2025 at 3:00 p.m., indicated Resident #10 did not have a hand roll or splint in her left hand. Resident #10's left hand was balled in a tight fist resting on her lap. An observation on 10/01/2025 at 12:00 p.m., with Registered Occupational therapist and the Director of Rehabilitation indicated Resident 10's left hand was balled up in a tight fist resting on top of her lap. Resident #10 was unable to open her left hand on her own. The Registered Occupational therapist attempted to open Resident #10's left hand but was met with resistance. She massaged Resident #10's left arm to relax the arm muscle to open her hand. The Registered Occupational therapist was unable to completely open her hand. An observation on 10/01/2025 at 1:45 p.m., indicated Resident #10 had a soft resting hand splint on her left hand. An interview on 10/1/2025 at 12:20 p.m., indicated the Registered Occupational therapist said she had not documented any decreased range of motion to Resident #10's left hand in her notes. She said she should have documented the change and reported it to the Director of Rehabilitation to ensure Resident #10 received a resting hand splint to prevent further limited range of motion. An interview on 10/1/2025 at 12:45 p.m., indicated the Director of Rehabilitation was not aware that Resident #10 had a decreased range of motion in her left hand that required a resting hand splint. She said she had expected the Registered Occupational therapist to report any change of conditions on any resident to her and document it in her notes. The Director of Rehabilitation said by Resident #10 not receiving a resting arm splint could potentially worsen her range of motion and overall health. An interview on 10/1/2025 at 2:15 p.m., indicated the Administrator said she expected therapy staff to follow facility policy by documenting resident's' changes, communicating resident needs to nursing staff/ management, and ordering needed resting arm splints. She said not following the policy could potentially cause limited range of motion that residents did not previously have. Record review of the facility's policy Immobilization Devices, Splints/ Slings/ Collars/Straps. dated year 2003 indicated: Splints are rigid devices that can be used to treat a bone fracture, dislocation, or to prevent further damage of bones, joints, and muscles following injury or during acute phases of chronic diseases such as arthritis.15. Document all care and the residents response to treatment in the clinical record.

Based on observations, interviews, and record reviews, 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 infections for one (Resident #76) of 22 residents reviewed for infection control. The facility failed to ensure CNA C performed hand hygiene before she applied clean gloves during incontinent care for Resident #76. This failure placed residents at risk for healthcare associated cross contamination and infections.Findings included: Record review of face sheet, dated 10/01/25, indicated Resident #76 was a [AGE] year-old male admitted on [DATE] with diagnoses which included Parkinson's disease (a disorder of the central nervous system that affects movement) and dementia (disease of the brain with impairment of memory and abstract thinking). Record review of quarterly MDS assessment dated [DATE] indicated Resident #76 was severely impaired with cognition and was frequently incontinent for bladder and bowel. Resident #76 required partial/moderate assistance with toileting hygiene. Record review of comprehensive care plan dated 08/08/25 indicated Resident #76 required extensive assistance of 1 person for occasionally incontinent of bladder and bowel. Resident #76 had an ADL self-care performance deficit and required staff to provide incontinent care after each episode. During an observation on 09/30/25 at 10:30 a.m., CNA C and CNA D washed their hands, donned gowns and gloves. CNA C cleaned the pubis area (below the abdomen) and the genital area of Resident #76. CNA C did not push back the foreskin and did not clean under the foreskin. CNA C changed her gloves and did not perform hand hygiene. CNA D turned Resident #76 on his left side. CNA C cleaned Resident #76's buttocks and placed a clean brief on the resident. During an interview on 09/30/25 at 10:45 a.m., CNA C said she had been trained on incontinent care for males. She said she should have used hand sanitizer with a glove change. She said not cleaning her hands could spread germs. During an interview on 4/7/25 at 11:15 a.m., the ADON B said her expectation was for all the staff to perform hand hygiene when gloves were removed to prevent infections. She said all of the nursing staff had been trained on hand hygiene when they removed gloves on hire and at least annually. Record review of The Perineal Care Male policy dated 12/08/09 indicated . if gloved , remove and discard gloves. Wash hands. Provide for resident's comfort .

Based on observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #76) of 22 resident reviewed for incontinent care. The facility failed to ensure that CNA C cleaned under the foreskin (the retractable roll of skin covering the tip of the penis) for Resident #76 while incontinent care was provided on 09/29/2025. This failure could place the residents at risk of cross-contamination and development of urinary tract infections.Findings included: Record review of face sheet, dated 10/01/25, indicated Resident #76 was a [AGE] year-old male admitted on [DATE] with diagnoses which included Parkinson's disease (a disorder of the central nervous system that affects movement) and dementia (disease of the brain with impairment of memory and abstract thinking). Record review of quarterly MDS assessment dated [DATE] indicated Resident #76 was severely impaired with cognition and was frequently incontinent for bladder and bowel. Resident #76 required partial/moderate assistance with toileting hygiene. Record review of comprehensive care plan dated 08/08/25 indicated Resident #76 required extensive assistance of 1 person for occasionally incontinent of bladder and bowel. Resident #76 had an ADL self-care performance deficit and required staff to provide incontinent care after each episode. During an observation on 09/30/25 at 10:30 a.m., CNA C and CNA D washed their hands, donned gowns and gloves. CNA C cleaned the pubis area (below the abdomen) and the genital area. CNA C did not push back the foreskin and did not clean under the foreskin. CNA C changed her gloves and CNA D turned Resident #76 on his left side. CNA C cleaned Resident #76's buttocks and placed a clean brief on the resident. During an interview on 09/30/25 at 10:45 a.m., CNA C said she had been trained on incontinent care for males. She said she should have pushed the foreskin back,cleaned, and then replaced the foreskin. She said normally she did push back the foreskin, but said she was nervous. She said cleaning under the foreskin could prevent infections. During an interview on 09/30/25 at 11:15 a.m., the ADON B said her expectation was for the CNAs to pull back the foreskin and clean and dry for the uncircumcised male residents to prevent infections. Then put the foreskin back in place. She said all CNAs are trained on incontinent on hire and annually. Record review of the Perineal Care Male dated 12/08/09 indicated . I.Wipe across the pubis area. Retract foreskin of uncircumcised male. Wash the urethal area in a circular motion. Continue to wash down the penis and the rest of the perineal area .

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 26 residents (Resident #1) reviewed for accident hazards and supervision. The facility failed to ensure Resident #1 was provided two persons assist with transfer from sitting in wheelchair to standing position to provide toilet hygiene on 04/22/2025 which resulted in Resident #1 being lowered to floor by CNAT C and causing discoloration with abrasion to the left buttock, small avulsion fracture (a ligament or tendon pulls away a small piece of a bone) off the right distal fibula (calf bone), and a right ankle sprain. The non-compliance was identified as past non-compliance. The PNC began on 04/22/2025 and ended on 04/23/2025. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk of severe injury, hospitalization, and decline in quality of life.Record review of Resident # 1's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE], readmitted [DATE] with the diagnoses included: Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), displaced fracture of right tibia (two or more broken bones in the shinbone that is displaced from their original position), pathological fracture right fibula (broken calf bone, break happens due to underlying disease leaving bones weak and brittle), vitamin D deficiency, cognitive communication deficit (impairment in the ability to receive, send, process, and comprehend concepts of verbal, nonverbal communication), and dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Record review of Resident #1's quarterly MDS assessment dated [DATE], indicated other musculoskeletal fractures, a BIMS score of 7, which indicated severe cognitive impairment. She required moderate assistance (helper does less than have the effort) with toileting hygiene (ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement) and sit to stand (ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and toilet transfer (ability to get on and off a toilet or commode) was not attempted due to medical condition or safety concerns. Record review of Resident #1's Optional State Assessment (OSA) dated 04/19/2025, indicated she required two+ persons physical assist/support for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and toilet use (how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes.) Record review of Resident #1's care plan revised 08/16/2022 and Kardex dated as of 04/22/2025 indicated she needed assistance with ADLs and mobility needs with interventions of extensive assistance x 1 staff member for toileting task and extensive assistance x 2 staff members for transfer task. Record review of Resident #1's event note dated 04/22/2025 at 3:30 p.m. indicated she was being assisted with a brief change in her bathroom. Her legs gave out and she was lowered to the floor. Resident #1 sustained a 2-inch abrasion with redness discoloration to left buttocks during the fall. Resident #1 denied pain or discomfort. RP and PA notified of the incident. Record review of Resident #1's physician's order dated 04/23/2025 for x-ray to right lower extremity due to pain post fall with start date of 04/23/2025 and end date of 04/25/2025. Cleanse abrasion to left buttock with normal saline, pat dry and apply TAO LOTA daily on day shift for 5 days with start date of 04/23/2025 and end date of 04/29/2025. May wear walking boot to right foot x 1 week on day and night shift for 7 days with start date of 04/28/2025 and end date of 05/06/2025. Weight bearing as tolerated and bed rest as needed for 1 week with start date of 04/28/2025 and end date of 05/05/2025. Apply ice to right ankle/leg as needed; every 2 hours as needed for edema; pain for 1 week start date of 04/28/2025 and end date of 05/05/2025. Tramadol 50 mg give 2 tablets by mouth every 6 hours as needed for moderate pain with start date of 11/16/2024. Acetaminophen Extra Strength Tablet 500 mg give 500 mg by mouth every 6 hours as needed for mild pain with start date of 05/23/2017. Record review of Resident #1's medication administration record indicated she received Tramadol 50 mg 2 tablets by mouth every 6 hours as needed for moderate pain on 04/22/2025 at 9:31 p.m., 04/23/2025 at 5:41 p.m., 04/23/2025 at 2:30 p.m., and 04/24/2025 at 8:00 a.m. with effectiveness. She received Acetaminophen Extra Strength 500 mg 1 tablet every 6 hours as needed for mild pain on 04/23/2025 at 2:03 a.m. with effectiveness. Record review of Resident #1's nursing follow-up injury note dated 04/22/2025 at 9:30 p.m. she complained of a dull pain to her right upper and lower leg, and ankle relieved with PRN pain medication of tramadol. PA was notified of the pain and x-ray to the right upper and lower extremity was ordered. Record review of Resident #1's social service progress note dated 04/23/2025 at 8:14 a.m. indicated SW spoke with resident regarding the incident which occurred on 04/22/2025. Resident stated a CNA was changing her, and her legs went out on her and she was lowered to the ground. She said her right side was hurting and she was supposed to get an x-ray that day. Resident #1 was lying in her bed at the time and said she did not feel the CNA was intentionally trying to harm her. Resident #1 denied abuse and neglect. Record review of Resident #1's right ankle and right tibia/fibula x-ray results dated 04/23/2025 at 11:40 a.m. indicated right ankle 2 view findings: intramedullary rod with nail (internal fixation technique originally mainly used for the surgical management of long bone fractures) seen traversing a healing fracture deformity along the distal tibia (shinbone). A suspected hairline (fracture without separation of the fragments) cortical (outer layer) fracture lucency (areas that appear darker due to lower density) faintly and partially visualized along the distal fibula (lower end of the calf bone). No dislocation, or bony destructive lesions are noted. Talar dome (ankle bone) and ankle mortise (ankle joint) appear normal. The bony mineralization is unremarkable. Right ankle impressions: stable postprocedural status, internally fixed healing distal diaphyseal fracture (break of the shaft of the bone) of the right tibia (shinbone) noted. A suspected hairline (fracture without separation of the fragments) cortical (outer layer) fracture lucency (areas that appear darker due to lower density) faintly and partially visualized along the distal fibula (lower end of the calf bone), no acute osseous findings. Right tibia/fibula (lower leg bones) 2 view findings: there is an intramedullary rod transfixing (internal fixation technique originally mainly used for the surgical management of long bone fractures) distal 3rd tibial (Shinbone) fracture. No evidence of hardware failure or new fracture seen. There is a healed fracture of the distal fibula (calf one). Soft tissues are unremarkable. Right tibia/fibula impression: slightly osteopenia bone but intact normally aligned distal tibial and fibular fractures with hardware in good alignment. Record review of Resident #1's weekly skin assessment dated [DATE] at 10:17 a.m. indicated abrasion present: red abrasion noted to left upper buttocks approximately 3 inches. Record review of Resident #1's nursing progress note dated 04/23/2025 at 4:02 p.m. indicated x-ray images obtained, PA, DON and RP aware of finding. PA instructed to call orthopedic clinic and schedule a follow up appointment with Resident #1's established orthopedic to determine if findings on x-rays are new or old injuries. Orthopedic appointment scheduled regarding right leg discomfort and clarification of x-ray results for 04/28/2025 at 3:20 p.m. Record review of Resident #1's nursing note dated 04/23/2025 at 4:46 p.m. indicated an abrasion present on left buttocks cheeks and complaining of pain/discomfort in right leg and pain was being addressed. Record review of Resident #1's nursing progress note dated 04/23/2025 at 9:45 p.m. indicated a 7cm x 1cm abrasion/bruise present on left buttocks cheeks and no pain present during assessment. She was being monitored Q shift with follow up assessments. Record review of Resident #1's nursing progress note dated 04/24/2025 at 1:23 p.m. indicated a 7cm x 1cm abrasion/bruise present on left buttock. Record review of Resident #1's nursing progress note dated 04/24/2025 at 10:50 p.m. indicated a 7cm x 1cm blue/purple bruise present on left buttocks cheeks and no pain present during assessment. Record review of Resident #1's nursing progress note dated 04/25/2025 at 12:55 p.m. indicated a 7cm x 1cm blue/purple bruise present with a 2cm x 2cm abrasion in bruised area on left buttock and no dressing, s/s of infection or pain present during assessment. Record review of Resident #1's nursing note dated 04/25/2025 at 11:19 p.m. indicated a 7cm x 1cm blue/purple bruise present with a 2cm x 2cm abrasion in bruised area on left buttock and no dressing, s/s of infection or pain present during assessment. Record review of Resident #1's nursing progress note dated 04/28/2025 at 6:13 p.m. indicated resident had an appointment at orthopedic clinic and returned to the facility with no concerns or discomforts. The report stated there was a possible small avulsion fracture (a ligament or tendon pulls away a small piece of a bone) off the distal fibula and right ankle sprain and the resident may have to wear a boot for a week or two for support. Record review of Resident #1's orthopedic visit note dated 04/28/2025 at 3:20 p.m. present illness indicated [Resident #1] was an established patient with orthopedic clinic and well known to physician and underwent intramedullary nail fixation of right tibia fracture on 11/20/2024 and was doing well until a few days ago when she had an incident at facility. They got a portable x-ray there are some concerns for fracture so referred her for further evaluation with pain primarily about the right lateral ankle. The assessment/plan indicated plain films of the right tibia (shinbone)/fibula (calf bone) obtained and indicated orthopedic implants with subacute fractures (a bone break that has occurred recently, usually several weeks or months ago, and is in the healing process) of the tibia and fibula and a possible small avulsion fracture (a ligament or tendon pulls away a small piece of a bone) off the distal fibula. Status post intramedullary fixation of right tibia/fibula fracture, now with likely right ankle sprain will treat this conservatively. She can go into her boot for a week or so. She will elevate, ice and rest. Then advance her activity as tolerated, if unable to do that will need to contact clinic, otherwise follow-up as needed. Record review of Resident #1's treatment administration record dated April 2025 indicated cleanse abrasion to left buttock with normal saline, pat dry and apply TAO LOTA daily. She may wear walking boot to right foot x 1 week every day and night shift for 7 days and apply ice to right ankle/leg as needed every 2 hours for edema and pain for 1 week starting 04/29/2025. During an interview on 08/18/2025 at 11:10 a.m., Resident #1 said the day of the incident she was needing to be changed and was in her bathroom in preparation to have her brief changed. She stated CNAT C entered her bathroom, and she requested to be changed. She said CNAT C assisted her to stand up, she held onto the grab bars, when she was reapplying the new brief, her knees became weak and gave way. She said with the assistance of CNAT C, she was lowered to the floor. She said she did not have any pain at the time of the incident, but later that evening, her right lower leg started hurting and an x-ray was obtained. She said she went to the orthopedic doctor for treatment. She said she had weakness in her lower extremities and that was why she was receiving therapy. She said only one staff member was assisting her at the time of the incident, but now two staff members assist her with all transfers and toileting hygiene. She said her right lower leg and ankle hurt for 2 or 3 days after incident, and she wore a boot to help keep stable, but it was better now. During an interview on 08/18/2025 at 1:10 p.m., Resident #4 (roommate) said the day of the incident, she was in the room and heard Resident #1 say her knees were getting weak. She said the bathroom door was closed so she did not see the incident. She said only one staff was assisting Resident #1 that day and usually there was two staff. She said several staff entered the room after the incident to assist Resident #1. During an interview on 08/19/2025 at 11:43 a.m., CNAT C said she was completing her clinical rotation for her CNA certification at the facility, and on 04/22/2025 she was instructed by her trainer to answer call lights on the hall. She said Resident #1 call light alarmed, so she went to answer and found Resident #1 in her bathroom damaging to be changed immediately. She said she stood the Resident #1 up, had her hold the grab bars on the wall, and while completing the hygiene task and applying her new brief, Resident #1's knees gave away and she began to lower toward the floor. She said she attempted to but the wheelchair under her, but she slid down grazing wheelchair with her buttocks/hip, and she then assisted her by lowering her to the floor and called for assistance. She said Resident #1 said she was not injured and started cussing at her to get her off the fucking floor. She said two nurses and a CNA entered Resident #1's bathroom so she left. She said the clinical educator had informed the trainees not to perform hands on care until approval by trainer or clinical educator, but she had received training on transfers and been checked off, so thought she could assist with the requested transfer. She said she was not aware Resident #1 was a 2 person assist with transfers and had she been aware, she would not have attempted to transfer her by herself. She said as a CNA trainee she was not provided access to the Kardex, so would have to ask her trainer if the resident required 2-person transfer. She said she had provided care to other residents under the supervision or guidance of the trainer or clinical educator. CNA trainee C said she received one on one training from clinical educator, DON and administrator regarding the incident on abuse, neglect, incontinent care, safe transfers, Kardex use, and expectations and proved task a clinical trainee and trainer can/should perform. CNA C trainee said she should not have transferred Resident #1 by herself. During an interview on 08/19/2025 at 11:43 a.m., CNA D said she was the trainer for CNAT C at the time of the incident with Resident #1. She said she had told CNAT C to answer the call light and do minor task like give ice, water, or report complaints to the CN. She said she had told CNAT C several times during her clinical rotation not to provide hands on care without her as the trainer or clinical educator present. CNA D said Resident #1 could be demanding and manipulative to get her way. CNA D said she assisted the LVN to get Resident #1 back to her wheelchair after the LVN assessed her after the incident and she denied pain when facility staff ask about pain. During an interview on 08/19/2025 at 2:15 p.m., LVN E said she was one of the LVNs that assessed Resident #1 after the incident and she, another LVN and CNA D assisted her to her wheelchair after the incident. LVN E said she walked in the resident's room observed resident #1 on the bathroom floor sitting on her butt, with her right leg under her left leg and CNAT C was holding her in the upright sitting position. She said CNAT C said her knees gave out and she lowered her to the floor. She said it appeared Resident #1 was holding onto the grab bars and had to be lowered to the floor. She said Resident #1 denied hitting her head, pain, and refused any pain medications during the assessment. She said Resident #1 did have a discoloration with an abrased area to her left buttocks which was in proximate of hitting the wheelchair arm. During an interview on 08/19/2025 at 4:00 p.m., LVN G said she provided care for Resident #1 on 6 p.m. to 6 a.m. shift after the incident 04/22/2025. She said around 9:30 p.m., Resident #1 complained of pain/discomfort to right upper and lower leg, and dull pain to right ankle. She said she administered PRN pain medication of Tramadol with effectiveness. She said she notified the PA of the complaint of pain to right upper and lower leg and ankle and he ordered an x-ray. She said she send an x-ray requested to the mobile x-ray unit. She said Resident #1 had pain the evening and night of the incident and maybe the next day but after that did not recall her complaining of pain or giving her any PRN pain medications related to her right lower leg or ankle. During an interview on 08/20/2025 at 11:15 a.m., RN F said she was the clinical educator, and she does the training and oversees the CNA trainees while they are in the facility for their clinical rotation. She said the CNA trainee contacts her to be placed on the clinical rotation schedule; she verifies they have completed their 60 hours of on-line education and received a certificate. She says they are in the facility for 40 hours to be trained on different task a CNA may be responsible for completing. She said the rotation is usually five 8-hour days totaling 40 hours. She said the first 1/2 of the day usually consist of classroom training, demonstrating with mannequin certain task and then the trainee would shadow a trainer completing the task assignment. She said trainee was provided transfer training and competency check off by facility physical therapy staff. She said the trainees are told not to provide any hands-on task/care unless the trainer or herself was present. She said the trainees are not provided logins to the electronic medical records to access task or ADL care because facility staff trainer should be accessing and instructing the trainee. Unsuccessful attempts to interview orthopedic physician on 08/19/2025 at 3:11 pm and 08/20/2025 at 8:00 a.m. During an interview on 08/20/2025 at 1:25 p.m., the DON stated the CNA trainee should not have been performing task without trainer or clinical educator present. She said the facility staff have been in-serviced CNA trainer were not allowed to allow student nurses aide or CNA trainees to perform direct resident task without supervision. The DON said all facility staff should follow policy regarding transferring a resident and if the resident requires two persons assist that two staff members were to transfer the resident, no exceptions. The DON said if the transfer assist task needs to be updated then the staff should notify the CN or DON for review. The DON said facility therapist provided transfer training and competency check offs. The DON said the residents may be injured if proper assistants not provided during transfer. During an interview on 08/20/2025 at 1:45 p.m., the Administrator said she expected facility staff, CNA students and trainees to follow facility policies and CNA trainees and students were not to be allowed to provide ADL care or task until approved by clinical educator or trainer. The Administrator said not utilizing 2 staff members for a resident requires a 2-person transfer could result in a fall or injury. During an interview on 08/20/2025 at 4:15 p.m., the Orthopedic physician nurse said she clarified with the orthopedic physician and Resident #1 did have a small avulsion fracture (a ligament or tendon pulls away a small piece of a bone) of the distal fibula and right ankle sprain possibility from the incident, but he would prescribe the same treatment for both injuries, which included an immobilizer boot and elevate, ice and rest. Record review of the facility's nursing policy and procedure titled, Moving a resident, bed to chair/chair to bed. Purpose: The purposes of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the Procedure. Note: This procedure may require two (2) persons. f. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her on the edge of the bed/chair. Record review of the facility's policy titled, Preventive Strategies to reduce fall risk undated 10/05/2016, indicated Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: After risk is assessed, individualize nursing care plans will be implemented to prevent falls. The resident and/or family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family's, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. The facility implemented the following interventions before the survey entrance on 08/18/2025. During an interview on 08/20/2025 at 1:00 p.m., RN F, Clinical educator, said she now stressed to all CNA trainees they were not to provide any hands-on skills unless approval from her as the clinical educator. Record review of in-service training titled, Incontinent care dated 04/22/2025 for nursing staff indicated 39 staff in attendance. Summary: Provide incontinent care on all residents with lower extremity weakness, requires two-person assistance with transfers and/or utilize mechanical lift for transfers in the bed only. Record review of in-service training titled, CNA trainers dated 04/22/2025 for CNA's indicated 36 staff in attendance. CNA trainers do not allow student nurses' aides or trainees to perform direct resident task without supervision. Record review of in-service training titled, How to use Kardex to communicate resident information and needs to the CNAs. Ensure you follow all care planned interventions including how much staff is required to perform an ADL. If unable to have the proper number of staff to assist a resident, do not perform the task until the proper amount is present. Do not rush. If for any reason the amount of staff assistance needed is not listed for bathing, bed mobility, transferring, walking, incontinent care, then you should contact the charge nurse, ADON and/or DON. If more assistance is required than what is on the Kardex, report to the DON, ADON or MDS case manager immediately so Kardex can be adjusted. Charge nurse- through assessment of affected residents for injury or pain and report findings to the NP/MD dated 04/22/2025 with 38 staff in attendance. Record review of in-service training titled, Transfer training dated 04/23/2025 for all nursing staff indicated 40 staff in attendance. Summary safe, effective transfer training with demonstrations. Interviews with 36 staff members from all shifts from 08/18/2025 at 8:50 a.m. to 08/20/2025 at 2:30 p.m. the following staff LVN A, CNA B, CNAT C, CNA D, LVN E, RN F, LVN G, RN H, RN J, LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, CNA R, CNA S, CNA T, CNA U, CNA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, CNA CC, COTA LL, ST MM, OT NN, SNA OO, CNAT PP, CNAT QQ, CNAT RR, CNA SS, and CNA/MA TT confirmed completion of in services/training of incontinent care, always follow the plan of care, care plan and Kardex when providing resident care, look at the Kardex for resident required assistance, transfer training, and if a trainer with the CNA trainees or student do not allow student nurses' aides or trainees to perform direct resident task without supervision. The staff, CNA trainees and students were able to verbalize understanding and information provided in the in-service/training. During an observation on 08/19/2025 at 1:30 p.m. SNA OO was observed providing one person transfer with Resident #5 using correct procedure. During an observation on 08/20/2025 at 9:35 a.m. CNA/MA TT and CNA AA were observed providing a two person transfer with Resident #6 using correct procedure. The non-compliance was identified as past non-compliance. The PNC began on 04/22/2025 and ended on 04/23/2025. The facility had corrected the non-compliance before the survey began.

Based on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for 4 of 6 residents (Residents #33, #40, #290, and #1) and prevent coffee burns for 1 of 2 residents (Resident #2) reviewed for accident hazards and supervision. 1. The facility failed to prevent Resident #33 from eloping from the facility on 04/14/2024, 06/20/2024 and 06/21/2024. 2. The facility failed to prevent Resident #40 from eloping from the facility on 08/09/2024. 3. The facility failed to prevent Resident #290 from eloping from the facility on 06/13/2024. 4. The facility failed to prevent Resident #1 from eloping from the facility on 07/13/2024. 5. The facility failed to ensure Resident #2's coffee lid was placed properly which resulted in her spilling it on herself on 04/04/2024. 6. The facility failed to ensure Resident #2 was served coffee in a cup with a lid on it, which resulted in her spilling it on herself on 06/09/2024. An Immediate Jeopardy (IJ) situation was identified on 08/20/2024 at 4:15 p.m. While the IJ was removed on 08/21/2024, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of serious injury or harm. The findings included: 1. Record review of Resident #33's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with a diagnosis which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of the quarterly MDS assessment, dated 08/12/2024, indicated Resident #33 made herself understood and understood others. Resident #33's BIMS score was 7, which indicated her cognition was severely impaired. Resident #33 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 12/26/2023, indicated Resident #33 was at risk for wandering and elopement. The interventions included: distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, redirect away from entrances and exits, monitor the location frequently and document the wandering behavior and attempted diversional interventions. Record review of Resident # 33's Elopement assessment, dated 04/14/2024, 06/20/2024, and 06/21/2024, reflected Resident #33 was at risk for elopement. Record review of the event nurse's note dated 04/14/2024 at 11:00 a.m., reflected Resident #33 followed another resident outside through the front door. Resident #33 was observed by a staff propelling in the front parking lot of the facility. Record review of the event nurse's note dated 06/20/2024 at 2:10 p.m., reflected Resident #33 was found outside in the front parking lot. Resident #33 stated she really did not know where she was. Record review of the event nurse's note dated 06/21/2024 at 9:00 p.m., reflected Resident #33 was found by a family member outside by vehicles approximately 50 feet from the entrance door. 2. Record review of Resident #40's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with a diagnosis which included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the quarterly MDS assessment, dated 08/06/2024, indicated Resident #40 made herself understood and usually understood others. Resident #40's BIMS score was 0, which indicated her cognition was severely impaired. Resident #40 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 08/09/2024, indicated Resident #40 attempted to elope and was found in the parking lot to the back of building. The interventions included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, supervise closely and make regular compliance rounds whenever residents in the room. Record review of Resident # 40's Elopement assessment, dated 08/09/2024, reflected Resident #40 was at risk for elopement. Record review of the event nurse's note dated 08/09/2024 at 8:41 a.m., reflected Resident #40 was observed rolling in her wheelchair outside in the parking lot around the building. Resident #40 stated she was going to see a friend at the hospital. 3. Record review of the face sheet, dated 08/20/2024, revealed Resident #290 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of Traumatic brain injury (head injury causing damage to the brain by external force or mechanism), unspecified dementia with agitation (group of symptoms affecting memory, thinking, and social abilities with excessive verbal or physical aggression that causes emotional distress and excess disability), schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and bipolar disorder with psychotic features (serious mental illness characterized by extreme mood swings). Record review of the quarterly MDS assessment, dated 07/23/2024, revealed Resident #290 had clear speech and was usually understood by others. The MDS revealed Resident #290 was able to understand others. The MDS revealed Resident #290 had a BIMS score of 5, which indicated severely impaired cognition. The MDS revealed Resident #290 had disorganized thinking, which fluctuated. The MDS revealed Resident #290 had delusions, but no behaviors, wandering, or refusal of care. The MDS revealed Resident #290 used a manual wheelchair. Record review of the comprehensive care plan, revised on 04/18/2023, revealed Resident #290 was at risk for elopement and wandering because of impaired safety awareness. The goals included: The resident will not leave facility unattended through . and The resident's safety will be maintained . The interventions included: Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes; Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; 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; and Monitor location frequently. Document wandering behaviors and attempted diversional interventions. Record review of the elopement risk assessment dated [DATE], 06/12/2024, and 06/13/2024, revealed Resident #290 was at risk for elopement. Record review of the event nurses' note, dated 06/13/2024, revealed Resident #290 exited out the front door of the building and was witnessed in the parking lot by vehicles. Resident #290 told staff she was going to work. 4. Record review of the face sheet, dated 08/20/2024, revealed Resident #1 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of intracranial injury (head injury causing damage to the brain by external force or mechanism). Record review of the quarterly MDS assessment, dated 07/29/2024, revealed Resident #1 had unclear speech and was usually understood by others. The MDS revealed Resident #1 was usually able to understand others. The MDS revealed Resident #1 had a BIMS score of 0, which indicated severe cognitive impairment. The MDS revealed Resident #1 had disorganized thinking, that fluctuated. The MDS revealed Resident #1 had no behaviors, wandering, or refusal of care. The MDS revealed Resident #1 used a wheelchair. Record review of the comprehensive care plan, revised 07/15/2024, revealed Resident #1 was at risk for elopement and wandering. The goals included: The resident will not leave facility unattended . and The resident's safety will be maintained . The interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; 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.; If the resident is exit-seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc.; Provide structed activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes.; . Resident redirected back into facility, educated on the dangers of being in parking lot and ongoing monitoring in place. Record review of the elopement risk assessments dated 12/28/2023, 03/29/2024, 06/29/2024, and 07/13/2024 revealed Resident #1 was at risk for elopement. Record review of the event nurses' note, dated 07/13/2024, revealed Resident #1 exited out the front door and was found, by a family member, sitting in his wheelchair behind an employee vehicle. Resident #1 stated he was enjoying the sunshine. Record review of the facility's policy titled, Elopement Prevention, revised 10/27/2010 indicated, .every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement .2. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team . Physical Plant .1. All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts .2. All others exit not considered fire exits will be locked when not occupied by staff members .3. All exit devices will be maintained by the manufacture's recommendations and function of each door device will be verified weekly and a log maintained . During an observation on 08/19/2024 at 8:15 a.m., the front door had an automatic sliding door and no alarm had sounded upon entrance to the building. The facility was located on a busy highway. During an interview on 08/19/2024 at 4:12 PM, LVN K said if a resident was a high risk for elopement, they redirected them. LVN K said interventions for residents at risk for elopement were redirecting them, and they had the two double doors before the door to exit that acted as an intervention to stop them. The double doors were not locked. LVN K said the door to the exit had a button you had to push for it to open, but it was not locked either. LVN K said it would be hard for a resident to reach the button in a wheelchair. LVN K said the door to the exit did not have an alarm. LVN K said they did not have a wander guard system or anything like it to put on the residents that wandered. LVN K said elopement risk assessments were completed on admission, every three months, and if a resident had an elopement attempt. LVN K said if a resident attempted to elope 1-2 times they would be moved to the secure unit. During an observation on 08/20/2024 at 7:15 a.m., the front door had an automatic sliding door and no alarm had sounded upon entrance to the building. No staff members were observed in the lobby. During an observation on 08/20/2024 beginning at 7:21 a.m., Resident #33 was wheeling herself down the B-Hall during breakfast time. The only staff member on the hallway was a housekeeper, who was in another resident's room cleaning. Resident #33 started from the nurses' station and slowly wheeled herself down to the therapy gym. Resident #33 wheeled herself around the therapy gym, then sat in the doorway wheeling herself back and forth. During an interview on 08/20/2024 beginning at 9:38 a.m., the DON stated residents at risk for elopement, not on the secured unit, had no special monitoring. The DON stated the direct care staff were made aware of the residents at risk for elopement and were instructed to keep a close eye on them. The DON stated there were no set timeframes for monitoring the residents, they should have been monitored according to their judgment. The DON stated the facility did not use a wander guard system or alarms. The DON stated the facility tried to keep the double doors leading into the lobby closed and a staff member in lobby to slow residents who were at risk for eloping down. The DON stated if residents actually eloped, then the residents were redirected into the building. The DON stated if residents were not easily redirected, they were placed on the secured unit. The DON stated labs were ordered on a case-by-case basis to determine if an acute illness was causing wandering behaviors or if placement on the secured unit was necessary. The DON stated residents were placed on the secured unit pending labs. The DON stated after an elopement, residents were placed on 72-hour monitoring. The DON stated the IDT usually met after an elopement to discuss and update the care plan. The DON stated Resident #40 started wandering during the evening times. The DON stated Resident #40 was able to go outside without staff supervision as long as a staff member was sitting in the lobby. The DON stated Resident #40 was easily redirected into the building and 72-hour monitoring was performed. The DON stated she did not believe Resident #40 had been evaluated for the secured unit. The DON stated Resident #290 and Resident #33 had been on the secured unit previously but had to be taken out of the secured unit because they were having combative behaviors with other residents. The DON said there was no special monitoring in place for Resident #290 or Resident #33. The DON stated Resident #33 wandered constantly around the building and have instructed staff to ensure she was watched. The DON stated after Resident #290 and Resident #33 eloped they were placed on 72-hour monitoring. The DON was unsure if labs had been completed. The DON stated Resident #1 was able to wheel himself around the facility. The DON stated Resident #1 was probably at risk for elopement related to past attempts. The DON stated Resident #1 was placed on 72-hour monitoring and reeducated on the dangers of wandering outside. The DON stated the risk for residents eloping would depend on the time of the day, but they were at an increased risk for injury or elopement. During an interview on 08/20/2024 beginning at 2:03 p.m., The Administrator stated the preventative measures put in place currently for residents at risk for elopement who do not reside on the secured unit included: staff monitoring and closing the double doors in the front lobby to slow the residents down. The Administrator stated she had been asking corporate to get the facility a locked keypad for the front door and it was supposed to have been a work in progress. The Administrator stated the facility did not have a wander guard system or alarms for the front door. The Administrator stated if a resident eloped the facility implemented 72-hour monitoring. The Administrator stated incident and accidents were reviewed regularly but she was unsure if any trends had been identified. The Administrator stated she asked for the door keypad around the time the resident elopements had started. Record review of a printed screen shot, provided on 08/20/2024 with a time of 2:31 p.m., revealed the Administrator had asked the corporate office for a keypad entry and exit for the front door on 05/07/2024. Record review of a printed copy, provided on 08/20/2024, revealed a submitted proposal on 05/23/2024 for a keypad entry and exit for the front door. The owner had not signed. 5. Record review of a face sheet dated 08/20/2024 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety (deterioration of memory, language, and other thinking abilities without behaviors), cerebral infarction (stroke), and glaucoma (eye disease that can cause vision loss or blindness). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 usually understood others and was usually able to make herself understood. Record review of the MDS assessment indicated Resident #2 had a BIMS score of 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #2 required supervision or touching assistance with eating, substantial/maximal assistance with toileting hygiene, and was dependent for showering/bathing and personal hygiene. Record review of Resident #2's care plan last reviewed 07/25/2024 indicated Resident #2 was at risk of burns due to hot liquids with interventions which included coffee and other hot liquids should not be served if over 140 degrees, educational in-service was given to staff about making sure cup lid was on properly to prevent spillage, if hot liquid was spilled on self, staff should pour room temperature or lower temp liquid on the affected area of the resident, resident to use spill proof cup with lid for coffee, should be seated in upright position with table or overbed table when hot liquids were being consumed, and staff to provide observation and verbal assistance when resident had hot liquids. Record review of the Order Summary Report dated 08/21/2024, indicated Resident #2 had an order for a fortified/enhanced diet, mechanical ground texture, regular consistency, and liquids by straw. Record review of an Event Nurses' Note - Burn dated 04/04/2024 indicated Resident #2 was in the dining room and had a burn caused by coffee, tea, or other hot liquid to the left abdomen and left lower breast. Details of injury indicated she had an 8x9 cm red area, no blistering, slight pain to touch. Nursing Description of the event indicated, CNA stated she was bringing another resident to the dining room and resident was saying help me, when CNA went to her, she noted that her shirt was wet and the resident stated she spilled her coffee. Resident had her personal cup with lid. Unknown who fixed coffee for resident as she is not able. Resident Statement indicated, Resident stated that she did not know who got her coffee but the lid was not on it like it was supposed to be and she spilled it. Initial treatment/new orders indicated, No treatment at this time, will monitor and offered pain med and was refused. Interventions initiated by nurse indicated, Lid on cup/mug/glass. Signed by Treatment Nurse H. Record review of an Injury Nurses' Note 12 hr dated 04/05/2024 12:09 AM, indicated Resident #2 had no injury. Record review of an Event Nurses' Note - Burn dated 06/09/2024 indicated Resident #2 was in the dining room and had a burn caused by coffee, tea, or other hot liquid to the left breast and under left breast. Details of injury indicated she had a burn injury slightly red, approximately 4 cmx2 cm to under left breast and 6 cmx5 cm to left breast. Nursing Description of the event indicated, CNA observed residents blouse being wet, and when she checked she seen the redness underneath. Resident Statement indicated, Resident stated leave me alone. Initial treatment/new orders indicated Zinc oxide (ointment used for skin) BID x 3 days. Interventions initiated by nurse indicated, Lid on cup/mug/glass. Signed by LVN P. Record review of an Injury Nurses' Note 12 hr dated 06/10/2024 12:43 PM, indicated Resident #2's redness related to the burn was gone. During an observation on 08/20/2024 at 7:20 AM, Resident #2 was observed sitting in the dining room drinking coffee from a covered cup with a straw. During an interview on 08/20/2024 at 7:44 AM, the Food Service Supervisor said Resident #2 was the only one who had spilled coffee on herself that she could think of, and she believed it was only once. The Food Service Supervisor said there had not been any further incidents after June 2024. The Food Service Supervisor said if the residents needed therapy ordered a spill proof cup, and Resident #2 required a spill proof cup for her coffee. The Food Service Supervisor said Resident #2 had to be served her coffee, but the residents that were able to, served themselves coffee. The Food Service Supervisor said they checked the coffee temperature daily and ensured it was at 140 degrees to prevent burns. The Food Service Supervisor said she monitored coffee was available during the day while kitchen staff were present. During an interview on 08/20/2024 at 9:32 AM, LVN L said residents had access to coffee in the dining room all day. LVN L said residents were allowed to get coffee on their own. LVN L said Resident #2 required a special cup because she had spilled coffee on herself a couple of times, and the cup was needed to prevent future burns. LVN L said if she noticed a resident was having issues holding a cup, she would let the nurse manager know and they would get with therapy to get the devices the residents needed. During an interview on 08/20/2024 at 9:56 AM, CNA O said the residents usually had coffee available to them all day. CNA O said the residents were able to get it themselves. CNA O said Resident #2 had a special cup for coffee that had a lid on it, and she was the only one that she knew of. CNA O said Resident #2 required the cup because her grip was not good, and to prevent her from spilling the coffee on herself and getting burned. During an interview on 08/20/2024 at 10:01 AM, the DON said on 04/04/2024 when Resident #2 spilled coffee on herself Resident #2 said the lid was not on tight enough. The DON said Resident #2 was supposed to be using the cup with the lid on it at that point. The DON said she educated the staff to make sure the lid was properly secured to prevent spillage. The DON said she provided an in-service. The DON said they were unable to determine what degree burn she had gotten from the spilled coffee but there was redness, no blister, and had resolved by the next day. The DON said on 06/09/2024 when Resident #2 spilled coffee on herself Resident #2 did not have the coffee cup with the lid on it. The DON said Resident #2 was unable to get coffee herself that somebody had given it to her. The DON said the staff was reeducated again on ensuring Resident #2 had her special cup. The DON said the education was provided verbally and she did not have documentation of it. The DON said they were doing the coffee logs to ensure the coffee was at safe temperatures. The DON said there was not anything implemented to see if any of the other residents were at risk for burning themselves with hot liquids. The DON said they did not complete hot liquid assessments. During an attempted phone interview on 08/20/2024 at 10:31 AM, LVN P did not answer the phone. During an interview on 08/20/2024 at 2:04 PM, the Director of Rehab said they did not have a particular screen to assess residents for their abilities to handle hot liquids. The Director of Rehab said if they noticed or were told by the staff a resident was having issues feeding themselves or required adaptive equipment therapy would evaluate and address the need. The Director of Rehab said she believed when Resident #2 was burned she was already receiving occupational therapy and they ordered a cup with a lid for her. During an interview on 08/20/2024 at 2:14 PM, the DON said the nurses should be assessing the residents needs for their abilities to feed themselves and on admission therapy screened the residents for any special needs. During an interview on 08/22/2024 at 6:48 PM, the Administrator said Resident #2 did not want to sit still with her coffee, and they discussed getting her a cup that would assist with spills. The Administrator said residents were assessed by the nurses on a resident-by-resident case for their abilities to handle hot liquids. The Administrator said anytime there was a change of status the residents were supposed to be assessed. The Administrator said there was always a risk for an accident to happen. Record review of the Coffee Temperature log for February 2024, March 2024, April 2024, June 2024, indicated the coffee temperature was 140 daily. Record review of a Record of Inservice Education dated 04/04/2024 with a subject of Coffee cup for Resident #2 indicated, Resident #2 has a cup for coffee with a lid to help prevent spills. It is very important that you make sure lid is on correctly why you make her coffee. Record review of the undated Guidelines on Serving Coffee in the Nursing Facility indicated, .3. Any residents who have risk factors for coffee burns, such as significant cognitive impairment or extreme shaking may be evaluated for additional safety precautions using a hot beverage risk assessment. Safety precautions may include but are not limited to additional supervision when consuming coffee, insulated or non-insulated coffee mugs with sippy lids, coffee service at lower temperatures, or restricted coffee availability . This was determined to be an Immediate Jeopardy (IJ) on 08/20/2024 at 4:15 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 08/20/2024 at 4:19 p.m. During an observation on 08/20/2024 at 5:00 p.m., the speed limit sign in front of the facility changes from 45 to 55 miles per hour. During an observation on 08/21/2024 at 7:15 a.m., the front door had an automatic sliding door and no alarm had sounded upon entrance to the building. During an interview and observation on 08/21/2024 beginning at 9:18 a.m., the Administrator was standing at the front door with a technician. The Administrator stated she had not realized the alarm system had not been functioning. The Administrator stated the technician had disabled the alarm system the last time he worked on it. The Administrator stated the technician was working on the system and adding another contact alarm that would alarm when the front door was opened. The doors had automatically slid open and the alarm had sounded. Beeping was heard at the nurse's station. The following plan of removal submitted by the facility was accepted on 08/21/2024 at 4:27 p.m. and included the following: Interventions: 1. On 8/20/24, Residents #33, Resident #1 and Resident #290 will be transferred to a sister facility for appropriate supervision. All 3 residents will be placed on 1:1 supervision until transferred. Both residents have been screened and do not meet the criteria to be placed on the secure unit. Other interventions such as alarms, increased staff, wander guards have been reviewed. All doors and alarms have been tested and are functioning properly. All doors with existing alarms were tested and in operation 8/20/24. Front door had an alarm installed the morning of 8/21/24 and will be monitored every shift. 2. On 8/20/24, Resident #40 will be transferred to the secure unit inside the facility. 3. Elopement risk assessments for all residents in the facility were completed and reviewed by the DON/ADON/Designee on 8/20/24. No additional concerns were identified. 4. All elopement risk care plan interventions were reviewed on 8/20/24 by the Regional Compliance Nurse, DON, and ADON. All interventions are in place and care planned. 5. The Administrator, DON, and ADON were in-serviced 1:1 by the ADO and Regional Compliance Nurse on 8/20/24 on the following: A. Elopement Prevention Policy- This in-service includes implementing interventions for residents at risk for elopement. - Completing the elopement risk assessment to determine at risk residents. This in-service also includes reporting to the Charge Nurse, Administrator, or DON any resident who is attempting to elope. The policy includes interventions to assist in preventing elopements, environmental modifications, and staff training. B. Elopement Response Policy- Nursing personnel must report and investigate all residents who attempt to elope. This includes when a resident is observed leaving the premises. A response plan will be implemented immediately. The resident's care plan will be modified to include interventions to prevent further elopement attempts. C. Abuse and Neglect- Neglect includes the failure to prevent, supervise, monitor, and/or intervene when a resident has eloped from the facility. Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. o The Elopement Risk Assessment will be completed upon admission by the charge nurse. The assessment will be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behavior, and upon change of condition. The Elopement Risk Assessment will be completed by the charge nurse or designee. The DON will be responsible for ensuring the completion and review of the assessment. This will begin 8/20/24. o All residents who are at risk for elopement will be assessed by the interdisciplinary team. This will begin 8/20/24. o The resident's care plan will be modified by the DON, MDS Coordinator, or designee to indicate the resident is at risk for elopement with appropriate interventions to prevent elopement attempts. This will begin 8/20/24. 6. Medical Director notified of the immediate jeopardy on 8/20/24. 7. An ADHOC QAPI meeting was conducted on 8/20/24 to discuss the immediate jeopardy citation and subsequent plan of correction. In-services: The Regional Compliance Nurse, Administrator, DON, and ADON will in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. A. All staff were in-serviced on the Elopement Response Policy by the Compliance Nurse, Administrator and DON on 8/20/24. Nursing personnel must report and investigate all residents who attempt to elope. This includes when a resident is observed leaving the premises. A response plan will be implemented immediately. The resident's care plan will be modified to include interventions to prevent further elopement attempts. B. All staff were in-serviced on Elopement Prevention by Compliance Nurse, Administrator and DON on 8/20/24. This in-service includes implementing interventions for residents at risk for elopement. - Completing the elopement risk assessment to determine at risk residents. This in-service also includes reporting to the Charge Nurse, Administrator, or DON any resident who is attempting to elope. The policy includes interventions to assist in preventing elopements, environmental modifications, and staff training. C. All staff were in-serviced on Abuse and Neglect by the Compliance Nurse, Administrator, and DON on 8/20/24. Neglect includes the failure to prevent, supervise, monitor, and/or intervene when a resident has eloped from the facility. On 08/21/2024 the survey team confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. During an observation and interview on 08/21/2024 beginning at 4:49 p.m., Resident #33, Resident #1, and Resident #290 were no longer in the facility. The Administrator stated the residents were transferred to a sister facility for appropriate supervision. The Administrator stated the residents were unable to have been placed on the secu [TRUNCATED]

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 24 residents (Resident #24 and Resident #82) and 1 of 5 medication carts (D-hall medication cart) reviewed for drugs and biologicals. 1. The facility failed to ensure LVN L secured the D-hall medication cart and keys during medication administration and while the D-hall medication cart was not in use. 2. The facility failed to ensure LVN N secured the D-hall medication cart during medication administration. 3. The facility failed to ensure the controlled medications awaiting disposal were under a double lock. 4. The facility failed to ensure Resident #82's Carbidopa-Levodopa (medication used to treat Parkinson's Disease) medication label matched her physician order. 5. The facility did not ensure Resident #12's Preparation H (medication used to temporarily relieve swelling, burning pain and itching caused by hemorrhoids) was properly safe and secured. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: 1. During an observation of medication administration on 08/20/2024 starting at 8:46 AM, LVN L gathered supplies to administer medications and went into the resident's bathroom. The D-hall medication cart was left in the hallway across from where the room was located. LVN L did not lock her medication cart and left the keys on top of the medication cart. During an interview on 08/20/2024 at 9:27 AM, LVN L said she was supposed to lock the medication cart every time she walked away from it. LVN L said she did not realize she had left the medication cart unlocked and the keys on top of the medication cart. LVN L said leaving the medication cart unlocked and the keys to the medication cart on top of the medication cart could result in a resident or any staff getting into the medication cart. During an observation and interview on 08/20/2024 at 4:22 PM, the D-hall medication cart was at the nurses' station unlocked. LVN L was observed down the hall on the opposite side. LVN L noticed the State Surveyor standing at the medication cart and approached it. LVN L said she forgot to lock the medication cart. 2. During an observation and interview of medication administration on 08/21/2024 starting at 8:19 AM, LVN N went into a resident's room to check a blood sugar. LVN N left the D-hall medication cart unlocked and out of her view. LVN N said she thought she had locked the medication cart. LVN N said the medication cart should be locked every time she stepped away from the medication cart. LVN N said it was important to lock the medication cart so the residents and no one could get into the medication cart. LVN N said if the medication cart was unlocked the residents could get a hold of the medications. 3. During an observation on 8/21/2024 at 3:00 p.m., the regional nurse was sitting in the DON's office alone. The DON's office door was not locked. During an observation and interview on 08/22/2024 starting at 2:58 PM, an observation was made of where the DON kept controlled medications awaiting disposal. The DON's door to her office was open and unlocked upon entering. The DON opened the single locked file cabinet located in her office. There were approximately 10 different controlled medications awaiting disposal. The medications were not stored under two locks. The DON said she was responsible for keeping the controlled medications awaiting disposal. The DON said the controlled medications should be stored under two locks. The DON said the lock on her door was one lock and the lock on the cabinet was the second lock. The DON said she was normally in her office. The DON said it was important to store the controlled medications under a double lock to ensure nobody could go in and get them. During an interview on 08/22/2024 at 6:47 PM, the Administrator said the controlled medications awaiting disposal should be under two locks. The Administrator said the DON was responsible for keeping the controlled medications awaiting disposal. The Administrator said it was important for them to be stored under two locks to ensure nobody could take the medications. 4. Record review of a face sheet dated 08/21/2024 indicated Resident #82 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease without dyskinesia, without mention of fluctuations (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves causes unintended or uncontrollable movements). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #82 was able to make herself understood and understood others. The MDS assessment indicated Resident #82 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #82 required substantial/maximal assistance with toileting hygiene, set-up or clean up assistance for eating, oral hygiene, and upper body dressing, and partial to moderate assistance with showering/bathing and lower body dressing. Record review of Resident #82's care plan dated 07/22/2024 indicated she had Parkinson's to administer medications as ordered by the physician and to monitor/document side effects and effectiveness. Record review of the Order Summary Report dated 08/21/2024 indicated Resident #82 had an order for Carbidopa-Levodopa 25-250 MG (Carbidopa-Levodopa) Give 1 tablet by mouth three times a day with a start date of 07/19/2024. During an observation of medication administration and interview on 08/21/2024 starting at 8:19 AM, LVN N administered medications to Resident #82. Resident #82's medication label instructions indicated Carbidopa-Levodopa 25 mg/250 mg take 1.5 tablets by mouth four times a day. LVN N said she was administering 1 tablet because that was what the order indicated. LVN N said the medication labels on the resident's medication should match their orders. LVN N said she did not regularly administer medications to Resident #82. LVN N said the nurse that noticed the discrepancy was responsible for notifying the pharmacy of the discrepancy. LVN N said a sticker should be placed on the label to alert staff the directions had changed. LVN N said it was important for the orders to match the medication label because the dosage could be wrong, and this could lead to a medication error. During an interview on 08/22/2024 starting at 6:07 PM, the DON said the charge nurses were responsible to ensuring the resident's medication label matched the order. The DON said the hall managers were supposed to monitor the medication carts monthly to ensure the residents' medication labels matched their orders. The DON said a change of direction label should have been placed on the medication. The DON said the medication label not matching the resident's order placed the resident at risk of not getting the correct dose. The DON said this also placed the resident at risk of what they were getting treated for not getting managed properly. The DON said it was the nurses' responsibility to ensure the medication carts were locked and they kept the keys on themselves at all times. The DON said the medication carts should be locked anytime the nurses walked away from the cart. The DON said she made rounds twice a day and looked at the medication carts to make sure they were locked. The DON said in the past she had noticed medication carts not locked and she would tell the nurses to lock them. During an interview on 08/22/2024 at 6:22 PM, ADON Q said the nurses were responsible for checking the medication labels when they were received from the pharmacy to ensure they matched the residents' orders. ADON Q said she had looked at Resident #82's Carbidopa-Levodopa during medication administration before, and she had not noticed the discrepancy between Resident #82's order and the medication label. ADON Q said she guessed she missed it. ADON Q said it was important for the residents' medication labels to match their orders to ensure they received the correct dosage. ADON Q said the medication labels not matching the residents' orders placed them at risk for being under or over medicated. During an interview on 08/22/2024 starting at 6:43 PM, the Administrator said she expected for the nurses or whoever received the medication order to follow through and ensure the medication label matched the order. The Administrator said the ADON/hall nurse should be reviewing the medications to ensure they matched. The Administrator said it was important for the medication label to match the order to ensure the residents received the correct dose. The Administrator said she expected for the nurses to lock the medication carts when thy walked away from them. The Administrator said the DON and the hall managers were responsible for monitoring the nurses. The Administrator said if the medication carts were not locked the residents could access stuff that they should not have access to. 43047 5. Record review of Resident #12's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with diagnoses which included hypertensive heart disease (high blood pressure that affect the heart) without heart failure and unspecified protein-calorie malnutrition. Record review of the quarterly MDS assessment, dated 07/23/2024, indicated Resident #12 usually made herself understood and usually understood others. Resident #12 BIMS score was 8, which indicated her cognition was moderately impaired. Resident #12 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 07/26/2022, indicated Resident #12 required staff assist with ADL and mobility tasks. The interventions included: limited staff assist x1 for personal hygiene, oral care task, and continent of bowel with occasional incontinent episodes of bladder. Record review of the order summary report dated 08/21/2024 did not address the use of Preparation H. During an observation on 08/19/2024 at 2:56 p.m., Resident #12 was sitting in her recliner. There were 2 tubes of Preparation H cream located in a 4-drawer clear storage container in Resident #12's bathroom. During an observation and interview on 08/20/2024 at 11:08 a.m., Resident #12 was sitting in her recliner visiting family members. When asked if the state surveyor could look in her clear storage container, she stated yes. The State Surveyor asked Resident #12 what the 2 tubes that were in the storage container were used for, she stated, I use it for my bottom. Resident #12 stated a family member brought the medication to her. Resident #12 stated I don't use it often. During an interview and observation on 08/21/2024 at 1:58 p.m., RN G stated Resident #12 had not been checked off for self-administration. RN G stated if a resident was able to self-administer an assessment must be completed and an order obtained prior to administration. RN G observed the 2 tubes of Preparation H in Resident #12's clear storage container. RN G stated it was important that medications were not left in the room because others could ingest the medication or cause toxicity. During an interview on 08/22/2024 at beginning at 5:41 p.m., the DON stated nurses were responsible for ensuring medications were stored appropriately. The DON stated before a resident could keep medications at bedside a self-administer assessment must be completed. The DON stated the MD must be notified and orders would be obtained. The DON stated she monitored by routine checks to ensure compliance. The DON stated she has had issues in the past with medications being stored at bedside. The DON stated if there was an issue it was corrected immediately by removing the medication and educating the resident and the family. The DON stated champion rounds were done every morning by the Admission Coordinator. The DON stated it was important to ensure medications were not left at bedside for resident safety and to prevent harm. During an interview on 08/22/2024 at 6:02 p.m., the Admission Coordinator stated she was responsible for champion rounds for Resident #12. The Admission Coordinator stated during rounds she checked to see if the residents have any concerns, questions, or issues. The Admission Coordinator stated she also looked around the room and bathroom to see if there was anything that needed to be addressed. The Admission Coordinator stated, I would assume those tubes were toothpaste or polydent (denture cream). The Admission Coordinator stated it was important that medications were not left in room to prevent an adverse reaction to another medication. During an interview on 08/22/2024 at 6:26 p.m., the Administrator stated that if the resident did not have an order to self-administer, she expected medications to be stored on the medication cart. The Administrator stated the DON, the ADONs, and the charge nurses were responsible for monitoring and overseeing that medications were not left out. The Administrator stated it was important to ensure medications were not let at bedside to prevent an adverse reaction. Record review of the facility's policy titled, Self-Administration of Drugs, revised 01/09/2006 indicated, . 1. Only medication permitted (ordered) for self-administration shall be left in residents' room . Record review of the facility's policy from the Pharmacy Policy & Procedure Manual 2003 titled, Medication Administration Procedures, indicated, .After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured . Record review of the facility's policy from the Pharmacy Policy & Procedure Manual 2003 titled, Order Changes, indicated, .Medication orders for which changes have been made are to be completely re-written in the medication administration record as a new order. The previous order is to be discontinued. The nurse may apply a Label Change, Check Med-Sheet@, or a similar accessory label to the medication package for continued use of the medication. This will alert subsequent staff that the directions have been changed . Record review of the Texas Administrative Code Texas Administrative Code (state.tx.us) accessed on 08/28/2024 indicated, .Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container. For example, a double lock can include a lock on the cabinet or filing cabinet and the door to the closet where medications are stored .

Based on observation, interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 3 residents (Resident #11, Resident #15, and Resident #35) reviewed for hospice services. The facility did not ensure Resident #11 and Resident #35 had the most current hospice plan of care. The facility failed to obtain Resident #15's most current hospice certification and plan of care, nurse visit notes, and aide visit notes. These deficient practices could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: 1. Record review of Resident #11's face sheet dated 08/21/2024 indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system). Record review of Resident #11's Quarterly MDS assessment dated [DATE] indicated she sometimes was able to make herself understood and sometimes understood others. The MDS assessment indicated Resident #11 had a BIMS score of 7, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #11 received hospice care while a resident at the facility. Record review of Resident #11's care plan last reviewed 07/25/2024 indicated she had a terminal prognosis and was receiving hospice services, and if receiving hospice services, to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met. Record review of the Order Summary Report dated 08/21/2024 indicated Resident #11 had an order to admit to hospice for diagnosis of chronic obstructive pulmonary disease with a start date of 01/23/2024. Record review of Resident #11's hospice Facility Document delivery indicated hospice documents were delivered 06/25/2024, and the last hospice Plan of Care in the documents was dated 06/18/2024. There were no plans of care for the month of July 2024 and August 2024. 2. Record review of a face sheet dated 08/21/2024 indicated Resident #35 was an 87- year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #35 was understood by others and was able to understand others. The MDS assessment indicated Resident #35 had a BIMS score of 08, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #35 received hospice care while a resident at the facility. Record review of Resident #35's care plan last reviewed 07/10/2024 indicated he had a terminal prognosis and was receiving hospice services, and if receiving hospice services, to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Record review of the Order Summary Report dated 08/21/2024 indicated Resident #35 had an order to admit to hospice for diagnosis of Alzheimer's disease with a start date of 06/17/2024. Record review of Resident #35's hospice Facility Document delivery indicated hospice documents were delivered 07/25/2024, and the last hospice Plan of Care in the documents was dated 07/23/2024. There were no plans of care for the month of August 2024. During an interview on 08/21/2024 at 4:26 PM, the hospice nurse said the facility had requested for the hospice documents to be sent to them electronically. The hospice nurse said the hospice office was responsible for sending the residents hospice documents to the facility, and they were sent monthly. The hospice nurse said it was important for the facility to have the hospice documents for the facility to be up to date on the hospice plan of care. During an interview on 08/22/2024 at 3:53 PM, LVN K said Resident #11 and Resident #35 received hospice services from the same company. LVN K said she was not able to view any of the hospice records. LVN K said she was able to communicate with the hospice nurse almost daily regarding the residents' care. LVN K said it was important for the facility to have access to the hospice records so they could give the correct medications and for continuation of care. 33249 3. Record review of a face sheet dated 8/22/2024 indicated Resident #15 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of hypertensive heart disease (heart damage from high blood pressure over time) and dementia (memory loss disease). Record review of the Annual MDS dated [DATE] indicated Resident #15 was understood and understands others. The MDS indicated Resident #15's BIMS score was a 6 indicating severe cognitive impairment. Section O- Special Treatment, Procedures, and Programs indicted Resident #15 received hospice services while a resident of the facility. Record review of the comprehensive care plan revised on 12/29/2022 indicated Resident #15 had a terminal prognosis of hypertensive heart disease. The goal of the care plan was Resident #15 would be comfortable. The care plan interventions included to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Record review of the consolidated physician's orders dated August 22, 2024, indicated Resident #15 was ordered on 12/29/2022 to admit to hospice care with the diagnosis of hypertensive heart disease. Record review of the comprehensive care plan revised on 12/29/2022 indicated Resident #15 had a terminal prognosis of hypertensive heart disease. The goal of the care plan was Resident #15 would be comfortable. The care plan interventions included to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Record review of the Annual MDS dated [DATE] indicated Resident #15 was understood and understands others. The MDS indicated Resident #15's BIMS score was a 6 indicating severe cognitive impairment. Section O- Special Treatment, Procedures, and Programs indicted Resident #15 received hospice services while a resident of the facility. During an observation on 8/19/2024 at 8:52 a.m., Resident #15 was lying on her bed, awake, and oriented to herself only. During an observation and interview on 8/19/2024 at 1:40 p.m., RN A said Resident #15 had hospice services. RN A said Resident #15's nurse visited twice weekly, and the hospice aide 3 times weekly, and was unsure of the social worker or chaplain. RN A reviewed in the miscellaneous section of the EMR and indicated the last upload hospice records was delivered on 6/25/2024 and included the signed recertification of Terminal Illness for the benefit period of 5/24/2024 - 6/23/2024. The contents of this delivery included a demographics page, a medication regimen, nurse notes dated 5/24/2024, 5/28/2024, 5/29/2024, 6/04/2024, 6/06/2024, 6/11/2024, 6/13/2024, 6/17/2024, 6/20/2024, a medical social worker hospice visit note dated 5/29/2024 and 6/11/2024, a chaplain note dated 6/04/2024 and 6/18/2024, nurse aide care plan reports dated 5/24/2024, and a missed visit note dated 5/31/2024, 6/03/2024, 6/06/2024, 6/10/2024, 6/13/2024, 6/17/2024. The hospice packet also included a Hospice Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report indicated the benefit period was 4/05/2024 - 6/03/2024 (the hospice certification was not current) and another Interdisciplinary Group Comprehensive Assessment and Plan of Care with the benefit period on 6/04/2024 - 8/02/2024. The Hospice Interdisciplinary Group Comprehensive Assessment indicated the nurse would have weekly assessments. Record review of a Facility Document Delivery form indicated on 7/25/2024 the hospice delivered Resident #15's signed recertification of Terminal illness for benefit period 6/24/2024 to 7/23/2024. The contents of this delivered package were a patient information sheet, medication record, and nurse visit notes dated 6/25/2024, 6/27/2024, 7/02/2024, 7/10/2024, 7/11/2024, 7/18/2024, 7/19/2024, and 7/22/2024. The packet included a Medical Social Worker Hospice Visit note dated 6/26/2024 and 7/15/2024. The packet included two chaplain visits dated for 7/01/2024 and 7/18/2024. The packet included nurse aide visit reports for 6/28/2024, 7/01/2024, 7/05/2024, 7/12/2024, 7/15/2024, and 7/18/2024. The packet had a missed visit notification for the nurse on 7/05/2024 and an aide missed visit on 7/08/2024. The packet included the Hospice IDG (Interdisciplinary Group) comprehensive Assessment and Plan of Care update Report with the benefit dates of 6/04/2024 - 8/02/2024. The IDG report indicated the skilled nurse would visit 1 time weekly and prn, the chaplain would visit 2 times monthly, the aide visit plan was not documented. During an interview on 8/20/2024 at 11:30 a.m., Medical Records said she had not requested the medical records from Resident #15's hospice provider. The Medical Records staff member said she had found in the medical records department a packet delivered on 7/25/2024 and had uploaded this in the EMR. The Medical Records said the hospice provider delivers a month at a time of hospice records. The Medical Records staff member said she would have to call the hospice and request records after 7/25/2024. During an interview on 8/21/2024 at 3:55 p.m., the Hospice Nurse said the hospice office staff send the residents medical records over electronically per the facility's request. The Hospice Nurses said sending the hospice visit notes and certifications timely would ensure the staff would be knowledgeable of any changes and updates. The Hospice Nurse said she visits all the hospice residents 2 times weekly, the nurse aide was scheduled two times weekly, and the chaplain and social worker were once monthly. The hospice nurse said the risk to the resident was the facility staff would not be updated on the current hospice plan of care. During an interview on 8/21/2024 at 4:14 p.m., the Hospice Administrator said the hospice sent the resident medical records to the facility monthly unless the facility requests something different. The Hospice Administrator said with the hospice plan of care not being current she could see how the facility nursing staff would not be aware of the current plan of care. During an interview on 08/22/2024 at 5:53 PM, the DON said medical records wereas responsible for uploading the hospice records into the residents' electronic health record. The DON said she was not aware the residents' hospice records were not up to date. The DON said it was important for the hospice records to be up to date to ensure they had the most recent plan of care, and they were doing what they needed to do. During an interview on 08/22/2024 at 6:18 PM, the Administrator said she expected for the hospice records to be current in the residents' electronic health record. The Administrator said the hospice usually scanned them to the facility towards the end of the month. The Administrator said they received the hospice records monthly. The Administrator said she expected for the nurses to know they had the hospice records available to them, and LVN K probably did not know because she was new. The Administrator said the DON and the ADONs checked the hospice records to ensure they were kept up to date. Record review of the Hospice Services policy dated 2/13/2007 indicated as an end-of-life measure, the resident or responsible family member may choose to use hospice services within the facility. Goals: 1. The resident and/or responsible party will verbalize wishes for end-of-life measures. 2. The resident and/or responsible party will receive comfort care. 3. The family will verbalize feelings about end-of-life measures Procedures .11. The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record Hospice Plan of Care. 12. The nursing facility and hospice provider must ensure that a coordinated plan of care reflects the participation of the hospice, nursing facility, the recipient, and legal representative to the extent possible. 13. The plan of care must include directives for managing pain and other uncomfortable symptoms. The plan must be revised and updated as necessary to reflect the resident's current status. Record review of the Amendment to Nursing Facility Hospice Services Agreement effective July 26, 2019, indicated, .Review and Revision of Plan of Care. The IDT, in consultation with Nursing Facility representatives and the Nursing Facility Attending Physician, shall review and revise the individualized Plan of Care as frequently as the Resident Patient's condition requires, but no less frequently than every fifteen (15) calendar days .2.7 Patient Care Information Provided. Hospice shall provide the Nursing Facility Designee with the following: (a) A copy of the most recent Plan of Care specific to each Resident Patient; (b) A copy of the Hospice election form and any advance directives specific to each Resident Patient; (c) A copy of the physician certification and recertification of the terminal illness specific to each Resident Patient; (d) Names and contact information for Hospice personnel involved in the hospice care of each Resident Patient; (e) Instructions on how to access the Hospice's twenty-four (24) hour on-call system; (f) A copy of Hospice medication information specific to each Resident Patient; and (g) A copy of Hospice physician and Attending Physician (if any) orders specific to each Resident .

Based on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 24 residents (Resident #40) and 2 of 2 staff (CNA NN and CNA YY) reviewed for infection control practices and transmission-based precautions. 1. The facility did not ensure Resident #40 was provided proper incontinent care. 2. The facility did not ensure EBP were put in place for Resident #40 These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life. Findings included: Record review of Resident #40's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the order summary report dated 08/21/2024 indicated Macrobid 100 mg give 1 capsule by mouth two times a day for UTI for 10 days with a start date 08/18/2024. Record review of the quarterly MDS assessment, dated 08/06/2024, indicated Resident #40 made herself understood and usually understood others. Resident #40's BIMS score was 0, which indicated her cognition was severely impaired. Resident #40 was always incontinent of urine and bowel. Resident #40 required substantial/maximal assistance with toileting and partial/moderate assistance with personal hygiene. Record review of the comprehensive care plan, revised on 08/20/2024, indicated Resident #40 had a urinary tract infection. The interventions included: encourage adequate fluid intake, and give antibiotic therapy as ordered. Record review of the urine culture dated 08/12/2024 indicated Resident #40 was positive for a UTI with the organism Klebsiella pneumoniae (urinary tract bacteria). During an observation on 08/19/2024 at 10:16 a.m., revealed Resident #40 had no enhanced barrier precautions in place outside of her room. During an observation on 08/19/2024 at 3:10 p.m., revealed Resident #40 had no enhanced barrier precautions in place outside of her room. During an observation on 08/20/2024 at 07:30 a.m., revealed Resident #40 had no enhanced barrier precautions in place outside of her room. During an observation and interview on 08/19/2024 at 3:15 p.m., CNA NN provided incontinent care to Resident #40 without donning any PPE. CNA NN did not provide hand hygiene or apply hand sanitizer prior to donning (put on) gloves. CNA NN donned gloves and wiped Resident #40 peri area once without separating the inner labia (peri area). CNA NN continued providing incontinent care. CNA NN stated she should have performed hand hygiene before donning her gloves. CNA NN stated she should have wiped Resident #40's peri area once and got another wipe and wiped her again. CNA NN stated, I get nervous when someone watches me. CNA NN stated this failure put Resident #40 at risk for a UTI. When asked if PPE should be worn while providing care, CNA NN stated, no ma'am. During an observation on 08/20/2024 at 9:45 a.m., CNA YY was getting Resident #40 out of the bed to give her a shower without donning any PPE. During an interview on 08/21/2024 at 2:17 p.m. CNA YY stated she had performed incontinent care and given Resident #40 a shower. CNA YY stated she was not aware gown and gloves should be worn while providing care to Resident #40. CNA YY stated she was not informed that PPE should be worn. CNA YY this failure put residents at risk for spread of infection. During an interview on 08/22/2024 at 2:58 p.m., ADON Y stated she was the Infection Control Preventionist for the facility. ADON Y stated she expected CNAs to perform hand hygiene prior to donning gloves. ADON Y stated she expected her to open her peri area and wiped front to back with a clean wipe each time until clear of soilage. ADON Y stated she monitored by monthly in-services, performance of skill check offs, and random checks while performing incontinent care on a resident. ADON Y stated she never had an issue with CNA NN providing incontinent care in the past. ADON Y stated this failure put Resident #40 at risk for a UTI. ADON Y stated Resident #40 should have had EBP in place when her labs showed positive for MDROs. ADON Y stated she was responsible for ensuring infection control measures were put in place for all residents. ADON Y stated she reviewed the lab results every morning to determine if they need to be on EBP precautions. ADON Y stated, I overlook the page that contained the MDROs positives. ADON Y stated this failure could place the residents at risk for an infection. During an interview on 08/22/2024 at 6:26 p.m., the Administrator stated she expected staff to perform hand hygiene prior to donning gloves to prevent the spread of germs. The Administrator stated she expected staff to clean the peri area correctly. The Administrator stated ADON Y was responsible for monitoring and overseeing infection control practices. Record review of a CNA Proficiency Audit dated 4/11/2024 indicated CNA NN was assessed in the area of hand washing, perineal care; female, and infection control awareness scoring a satisfactory in skill level. Record review of the facility's policy titled, Perineal Care Female, revised 12/08/2009 indicated, .H. Wash hands and put on clean gloves for perineal care .Ib. separate inner labia (peri area) and using a different surface, wash down the center and over the urethral area, wiping downward from front toward back . c. continue to wash the rest of the perineal area Change the wash cloth or pre-moistened cleaning wipe surface or use a new washcloth or pre-moistened cleaning wipe with each wipe . Record review of the facility's policy titled, Enhanced Barrier Precautions, effective 04/01/2024 indicated, .EBP is used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility did not ensure: 1. Food items were labeled and dated. 2. Hair restraints were worn. 3. The prepared green beans were not stored beside dirty dishes. 4. Volunteer XX wore a hair net and performed hand hygiene while assisting with preparing the appetizers prior to the lunch meal on 08/19/2024. These failures could place residents at risk for foodborne illness. Findings included: During the initial tour observation and interview with the Dietary Manager on 08/19/2024 beginning at 8:28 a.m., the following was revealed: 1. The Dietary Manager, [NAME] R, Dietary Aide S hairnets were not covering their entire head. There was loose hair sticking out for all 3 of them. 2. The Dietary Dishwasher was in the kitchen without wearing a hair restraint. 3. Plastic storage bag that was identified by the Dietary Manager as bacon undated and unlabeled. 4. Plastic bag that was identified by the Dietary Manager as cherries unlabeled. 5. Plastic bag that was identified by the Dietary Manager as shrimp undated and unlabeled. 6. A bag of okra undated and unlabeled. 7. A bag of cherry pies unlabeled. 8. A bag of guacamole unlabeled. 9. A bag of Italian breaded zucchini sticks undated. 10. 2 bags of macaroni elbow pasta undated. 11. 1 bag of spaghetti undated. 12. A large pan of frozen green beans were stored on the prepping table by dirty dishes. During an interview on 08/22/2024 at 2:50 p.m., Dietary Aide S stated all kitchen staff were responsible for labeling and dating food products. Dietary Aide S stated hairnets should always be worn while in the kitchen and hairnets were supposed to cover the entire head without loose hair sticking out. Dietary Aide S stated the cook was responsible for ensuring the food was stored correctly. Dietary Aide S stated these failures could put residents at risk for food borne illness and contamination. During an interview on 08/22/2024 at 3:15 p.m., [NAME] U stated all kitchen staff were responsible for labeling and dating food products. [NAME] U stated hairnets should always be worn while in the kitchen and hairnets were supposed to cover the entire head without loose hair sticking out. [NAME] U stated the green beans should have been placed on the stove after prepping them. [NAME] U stated these failures could put residents at risk for food borne illness and contamination. During an interview on 08/22/2024 at 3:40 p.m., the Dietary Manager stated cleanliness was important in the kitchen, so her staff were not spreading germs or contaminating anything. The Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager stated all food should be labeled and dated with the date received and the date it was opened. The Dietary Manager stated hairnets should be worn while in the kitchen and covering the entire head without loose hair sticking out. The Dietary Manager stated the cook should have placed the green beans on the stove after she prepped them. The Dietary Manager stated she was responsible for monitoring and overseeing by daily walk throughs and when there was an issue staff were verbally in serviced immediately. The Dietary Manager stated she had to address these issues in the past. The Dietary Manager stated these failures could potentially put residents at risk for cross contamination and food borne illness. During an interview on 08/22/2024 at 6:26 p.m., the Administrator stated she expected all food to be labeled and dated. The Administrator stated she expected hairnets to always be worn and covering the entire head. The Administrator stated after the cook prepped the green beans, she should have placed them on the stove. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing the kitchen. The Dietary Manager stated these failures could potentially put residents at risk for cross contamination. 47006 4. During an observation on 08/19/24 beginning at 11:39 a.m., Volunteer XX was helping to prepare the appetizer in the main dining room. Volunteer XX was pouring ranch dressing into cups. Volunteer XX had no hair net and applied gloves without washing her hands or using alcohol-based hand sanitizer. Volunteer XX pulled the appetizer out of the oven and then placed more in the oven. Volunteer XX took her gloves off and did not perform hand hygiene. During an observation on 08/19/2024 beginning at 11:46 a.m., Volunteer XX applied gloves without performing hand hygiene. Volunteer XX was holding her cell phone with gloved hands. Volunteer XX put the cell phone on the table with her gloved hands then took food out of the oven. During an interview on 08/22/2024 beginning at 5:00 p.m., Volunteer XX stated she had been volunteering at the facility since 2015. Volunteer XX stated she was instructed by the facility to perform hand hygiene prior to applying gloves and applying a hair net prior to handling food. Volunteer XX stated she knew better she just did not do better. Volunteer XX stated she had taken food handler classes several times per year. Volunteer XX stated when she was asked to help, she just jumped in without thinking. Volunteer XX stated it was important to ensure hand hygiene was performed prior to putting on gloves or taking off gloves and putting on a hair net prior to handling the food to maintain food sanitation. Volunteer XX stated not wearing a hair net or washing hands was unsanitary. During an interview on 08/22/2024 beginning at 5:59 p.m., the DON stated she expected the facility staff and volunteers to ensure a hair net was used when handling food and hand hygiene was performed prior to applying gloves. The DON stated activity and dietary staff were responsible for monitoring to ensure hair nets were used and hand hygiene was performed prior to handling food. The DON stated it was important to ensure a hair net was worn and hand hygiene was performed to prevent food contamination and maintain sanitation of the food. During an interview on 08/22/2024 beginning at 6:51 p.m. the Administrator stated she expected volunteers to ensure hair nets were worn and hand hygiene was performed while preparing food. The Administrator stated the staff member in the dining room was responsible for monitoring to ensure a hair net was used and hand hygiene was performed. The Administrator stated it was important to ensure a hair net was worn and hand hygiene was performed to prevent cross-contamination and maintain food sanitation practices. Record review of the facility's policy titled, Food Safety, dated 2012 indicated, .2. Opened food shall be labeled, dated, and stored properly . Record review of the facility's policy titled, Infection Control, dated 2012 indicated, .1b. Clean hair is required. It is to be covered with an effective hair restraint . Record review of the Texas Food establishment Rules, dated August 2021 indicated .TFER S228.43 states that food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. It does not apply to food employees such as counter staff who only serve TEXAS DEPARTMENT OF STATE HEALTH SERVICES DIVISION FOR REGULATORY SERVICES ENVIRONMENTAL AND CONSUMER SAFETY SECTION POLICY, STANDARDS, AND QUALITY ASSURANCE UNIT PUBLIC SANITATION AND RETAIL FOOD SAFETY GROUP PSRFSGRC - No.19 Hair Restraints April 1, 2016 (Revised February 21, 2017) Page 2 Public Sanitation and Retail Food Safety Group ? PO Box 149347, Mail Code 1987 ? [NAME], Texas 78714-9347 (512) [PHONE NUMBER] ? Facsimile: (512) [PHONE NUMBER] ? http://www.dshs.texas.gov/foodestablishments/ Pub #23 -14843 Rev. 02/21/2017 beverages and wrapped or packaged foods, hostesses, and wait staff if they present a minimal risk of contaminating exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles Record review of the Texas Food establishment Rules, dated August 2021 indicated the container of ready-to-eat food shall be marked to indicate the date by which food shall be consumed on the premises, sold or discarded. The ready-to-eat food if held at 41 F can only be held for a maximum of 7 days, with day of preparation being day 1. Record review of FDA 2-402.11, dated 2022, revealed FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. The FDA further revealed in 5-501.17, Based on a predictive growth curve modeling program for Listeria monocytogenes, ready-to-eat, time/temperature control for safety food may be kept at 5oC (41oF) a total of 7 days. Food which is prepared and held, or prepared, frozen, and thawed must be controlled by date marking to ensure its safety based on the total amount of time it was held at refrigeration temperature, and the opportunity for Listeria monocytogenes to multiply, before freezing and after thawing. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 24 residents (Residents #24) and 1 of 1 facility reviewed for pharmacy services. 1. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. 2. The facility failed to ensure Resident #24 medications were administered during the scheduled time. These failures could place the residents at risk of not having medications available for use, drug diversion, not receiving their medications as ordered, and exacerbation of their disease processes. Findings included: 1. During an observation and interview on 08/22/2024 starting at 2:58 PM, an observation was made of the controlled medications awaiting disposal. The controlled medications awaiting disposal were in a locked file cabinet in the DON's office. There were approximately 10 different controlled medications awaiting disposal in the DON's locked file cabinet in her office. The DON said controlled medications that needed to be disposed of were brought to her. The DON said when a controlled medication that needed to be disposed was brought to her, she made a copy of the narcotic count sheet and gave it to the Administrator. The DON said she was not keeping a log of the controlled medications awaiting disposal as they were brought to her. The DON said it was important to keep accurate reconciliation of the controlled medications awaiting disposal because they could get stolen or something. During an interview on 08/22/2024 at 6:42 PM, the Administrator said the DON was responsible for ensuring the controlled medications awaiting disposal were reconciliated periodically. The Administrator said it was important to reconcile the controlled medications to ensure they were disposed of properly. 43047 2. Record review of Resident #24's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with a diagnosis which included hypothyroidism (thyroid gland does not produce enough thyroid hormone), hypertensive heart disease (high blood pressure that affect the heart) without heart failure, and unspecified protein-calorie malnutrition. Record review of the order summary report dated 08/21/2024 indicated Resident #24 was ordered: Pantoprazole 20 mg 1 tablet by mouth QD at 7:00 a.m. Levothyroxine 100 mcg 1 tablet by mouth QD at 7:00 a.m. Hydrochlorothiazide 12.5 mg 1 tablet by mouth QD at 8:00 a.m. Refresh Tears Ophthalmic Solution Instill 2 drops in both eyes TID at 8:00 a.m. Aspirin EC 81 mg 1 tablet by mouth QD at 8:00 a.m. Multivitamin 1 tablet by mouth QD at 8:00 a.m. Vitamin B12 1000 mcg 1 tablet by mouth QD at 8:00 a.m. Lisinopril 20 mg 1 tablet QD at 8:00 a.m. Metoprolol Succinate ER 24-hour 25 mg 1 tablet by QD at 8:00 a.m. Procardia XL ER 24-hour 30 mg 1 tablet by mouth QD at 8:00 a.m. MiraLAX Powder 3350 17 grams by mouth QD every 3 days at 8:00 a.m. Record review of the Medication Administration Audit Report dated 08/21/2024 indicated Resident #24 received her medications on 08/18/2024 by LVN B as listed: Pantoprazole 20 mg 1 tablet at 9:48 a.m. Levothyroxine 100 mcg 1 tablet at 9:48 a.m. Hydrochlorothiazide 12.5 mg 1 tablet at 9:48 a.m. Refresh Tears Ophthalmic Solution at 9:48 a.m. Aspirin EC 81 mg 1 tablet at 9:48 a.m. Multivitamin 1 tablet at 9:48 a.m. Vitamin B12 1000 mcg 1 tablet at 9:48 a.m. Lisinopril 20 mg 1 tablet at 10:08 a.m. Metoprolol Succinate ER 24-hour 25 mg 1 tablet at 10:08 a.m. Procardia XL ER 24-hour 30 mg 1 tablet at 10:09 a.m. Record review of the Medication Administration Audit Report dated 08/21/2024 indicated Resident #24 received her medications on 08/19/2024 by RN C as listed: Pantoprazole 20 mg 1 tablet at 9:41 a.m. Levothyroxine 100 mcg 1 tablet at 9:41 a.m. Hydrochlorothiazide 12.5 mg 1 tablet at 9:41 a.m. Refresh Tears Ophthalmic Solution at 9:42 a.m. Aspirin EC 81 mg 1 tablet at 9:41 a.m. Multivitamin 1 tablet at 9:42 a.m. Vitamin B12 1000 mcg 1 tablet at 9:42 a.m. Lisinopril 20 mg 1 tablet at 9:41 a.m. Metoprolol Succinate ER 24-hour 25 mg 1 tablet at 9:41 a.m. Procardia XL ER 24-hour 30 mg 1 tablet at 9:42 a.m. MiraLAX Powder 3350 17 grams by mouth at 9:42 a.m. During an interview on 08/20/2024 at 11:08 a.m., Resident #24 stated her medications were not always given on time. Resident #24 stated she preferred her medications to be given before or during breakfast. Resident #24 stated she noticed it only occurred with certain nurses but could not recall the names. During an interview on 08/22/2024 at 10:04 a.m., LVN B stated medications that were scheduled at 7:00 a.m. should have been given between 6:00 a.m.-8:00 a.m. and the medications scheduled at 8:00 a.m. should have been given between 7:00 a.m.-9:00 a.m. LVN B stated, it's impossible to administer medications to 35 residents in a timely manner. LVN B stated this failure could potentially cause an accumulation of medications or adverse effect. During a telephone interview on 08/22/2024 at 11:03 a.m., RN C stated medications that were scheduled at 7:00 a.m. should have been given between 6:00 a.m.-8:00 a.m. and the medications scheduled at 8:00 a.m. should have been given between 7:00 a.m.-9:00 a.m. When asked why the medications were not administered on time, RN C stated, I can't tell you, don't know if I got sidetrack or I charted late. RN C stated this failure could potentially cause an adverse effect. During an interview on 08/22/2024 beginning at 5:41 p.m., the DON stated she expected medications to be administered one hour before or one hour after the scheduled time. The DON stated when a medication was given late the MD should have been notified. The DON stated was unaware of the medication administration audit report until the state surveyor intervention. The DON stated her and LVN F reviewed the dashboard on PCC daily to see if there was a green dot which indicated medications were administered or missed. The DON stated the dashboard did not indicate if the medications were administered late. The DON stated the failure of not administering medications on time were not following the physician's order and could cause interactions with other medications. During an interview on 08/22/2024 at 6:26 p.m., the Administrator stated she expected the medications to be administered according to the schedule. The Administrator stated the DON, the ADONs, and the charge nurses were responsible for overseeing and monitoring. The Administrator stated this failure could potentially cause an adverse effect. Record review of the facility's policy titled, Medication Administration Procedures, revised 10/25/2017 indicated, . 9. Defining the schedules for administering medications to maximize the effectiveness of the medication, prevent potential significant medication interactions such as medication-medication 20. The 10 rights of medication should always be adhered to . right time Record review of the facility's policy from the Pharmacy Policy & Procedure Manual 2003 titled, Storage of Controlled Substance, did not address the storage, logging, or reconciliation of controlled substances awaiting disposal.

Based on interviews and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission for 3 of 26 residents (Resident's #29, #37, and #64) reviewed for physician services. The facility failed to ensure Resident's #29, #37, and #64 were seen by a physician within the first 30 days of their skilled admission to the facility. This failure could place the residents at risk for medical conditions not being identified, care needs not being met, and a decline in health status. The findings included: 1. Record review of the face sheet, dated 08/22/2024, revealed Resident #29 was a [AGE] year-old male who admitted to the facility for skilled services on 05/26/2024 with a diagnosis of pneumonitis due to inhalation of food and vomit (aspiration pneumonia or lung infection). The face further revealed the Medical Director was Resident #29's primary physician and his primary payor was Medicare A. Record review of the quarterly MDS assessment, dated 08/04/2024, revealed Resident #29's start date for the most recent Medicare stay was 05/26/2024 with no end date documented. The MDS revealed Resident #29 had clear speech and was understood by others. The MDS revealed Resident #29 was able to understand others. The MDS revealed Resident #29 had a BIMS score of 09, which indicated moderately impaired cognition. Record review of the progress notes, dated between 05/26/2024 and 08/22/2024, revealed no progress note from the Medical Director had been completed for Resident #29. Record review of the PA notes, dated between 05/26/2024 and 08/22/2024, revealed the PA completed visits for Resident #29 on 05/27/2024, 05/29/2024, 06/03/2024, 06/05/2024, 06/10/2024, 06/12/2024, 06/25/2024, 07/01/2024, 07/09/2024, 07/15/2024, 07/22/2024, 07/27/2024, 07/29/2024, 07/31/2024, 08/05/2024, 08/12/2024, and 08/19/2024. During an interview on 08/22/2024 beginning at 10:53 AM, Resident #29 stated he was unsure if he had seen the Medical Director or the physician since he had admitted to the facility. Resident #29 stated he knew he had seen the PA. 2. Record review of the face sheet, dated 08/22/2024, revealed Resident #37 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of peritoneal abscess (infection of peritoneal cavity (inner wall of the abdomen)). The face sheet further revealed the Medical Director was her primary care physician and her primary payor source was Medicare A. Record review of the quarterly MDS assessment, dated 07/09/2024, revealed Resident #37' start date of her most recent Medicare stay was 07/05/2024 with no end date documented. The MDS revealed Resident #37 had clear speech and was understood by others. The MDS revealed Resident #37 was able to understand others. The MDS revealed Resident #37 had a BIMS score of 09, which indicated moderately impaired cognition. Record review of the progress notes, dated between 07/05/2024 and 08/22/2024, revealed no progress note from the Medical Director had been completed for Resident #37. Record review of the PA notes, dated between 07/05/2024 and 08/22/2024, revealed the PA completed visits for Resident #37 on 07/09/2024, 07/11/2024, 07/15/2024, 07/17/2024, 07/22/2024, 07/24/2024, 07/29/2024, 07/31/2024, 08/05/2024, 08/12/2024, and 08/19/2024. During an interview on 08/22/2024 at 2:33 PM, Resident #37 stated she did not remember if the Medical Director had made a visit. 3. Record review of the face sheet, dated 08/22/2024, revealed Resident #64 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of gastrointestinal bleed (bleeding inside the gastrointestinal tract). The face sheet further revealed the Medical Director was her primary care physician and her primary payor source was Medicare A. Record review of the quarterly MDS assessment, dated 07/04/2024, revealed Resident #64's most recent Medicare stay started on 07/02/2024 and no end date was documented. The MDS revealed Resident #64 had clear speech and was understood by others. The MDS revealed Resident #64 was able to understand others. The MDS revealed Resident #64 had a BIMS score of 7, which indicated severely impaired cognition. Record review of the progress notes, dated between 07/04/2024 and 08/22/2024, revealed no progress note from the Medical Director had been completed for Resident #64. Record review of the PA notes, dated between 07/05/2024 and 08/22/2024, revealed the PA completed visits for Resident #64 on 07/09/2024, 07/15/2024, 07/22/2024, 07/29/2024, 08/05/2024, 08/12/2024, and 08/19/2024. During an attempted interview on 08/21/2024 at 5:23 PM, the Medical Director did not answer the telephone. A brief message was left with a call back number. During an interview on 08/22/2024 at 9:27 AM, the PA stated he completed all the visits for patients at the facility. The PA stated the Medical Director only saw patients if she was requested directly. During an attempted interview on 08/22/2024 at 10:31 AM, the Medical Director did not answer the telephone. A brief message was left with a call back number. No return call upon exit of the facility. During an interview on 08/22/2024 at 11:10 AM, LVN F stated the PA primarily handled the direct care of all the residents. LVN F stated the Medical Director only handled residents on hospice or if residents directly requested to see her. LVN F stated the Medical Director did not answer the phone well but if you sent her a text message, she would have responded timely. During an interview on 08/22/2024 at 11:53 AM, the DON stated Medical Records were responsible for monitoring to ensure the Medical Director was performing the initial visits for skilled patients. The DON stated the physician visit notes would have been documented under the progress notes tab in the electronic medical records. The DON stated it was important to ensure the physician completed the initial visits for skilled residents, so the Medical Director knew what was going on with the residents and was involved with their care. During an interview on 08/22/2024 beginning at 6:51 PM, the Administrator stated the Medical Director should have completed the initial assessment for skilled residents and then as requested. The Administrated stated the Medical Director left all other care to her PA. The Administrator stated she was unaware the PA was completing the initial visit and assessment for skilled residents. The Administrator stated Medical Records usually alerted staff if the initial visit was not being completed by the Medical Director. The Administrator stated the Medical Records were responsible for monitoring to ensure the Medical Director completed the initial visit for skilled patients. The Administrator stated it was important to ensure the physician was completing the initial visit on skilled patients to ensure she was kept in the loop and included in the care of her patients. Record review of the Physician Services Guidelines, undated, revealed Frequency: A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required .

Based on observations, interviews, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident (Resident #40) reviewed for incontinent care. The facility failed to ensure Resident #40 was provided proper incontinent care. These failures could place residents at risk for urinary tract infections and a decreased quality of life. Findings included: Record review of Resident #40's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life. Record review of the quarterly MDS assessment, dated 08/06/2024, indicated Resident #40 made herself understood and usually understood others. Resident #40's BIMS score was 0, which indicated her cognition was severely impaired. Resident #40 was always incontinent of urine and bowel. Resident #40 required substantial/maximal assistance with toileting and partial/moderate assistance with personal hygiene. Record review of the comprehensive care plan, revised on 08/20/2024, indicated Resident #40 had a urinary tract infection. The interventions included: encourage adequate fluid intake, and give antibiotic therapy as ordered. Record review of the order summary report dated 08/21/2024 indicated Macrobid 100 mg give 1 capsule by mouth two times a day for UTI for 10 days with a start date 08/18/2024. During an observation and interview on 08/19/2024 at 3:15 p.m., CNA NN provided incontinent care to Resident #40. CNA NN did not provide hand hygiene or apply hand sanitizer prior to donning (put on) gloves. CNA NN donned gloves and wiped Resident #40 peri area once without separating the inner labia (peri area). CNA NN continued providing incontinent care. CNA NN stated she should have performed hand hygiene before donning her gloves. CNA NN stated she should have wiped Resident #40's peri area once and got another wipe and wipe her again. CNA NN stated, I get nervous when someone watches me. CNA NN stated this failure put Resident #40 at risk for a UTI. During an interview on 08/22/2024 at 2:58 p.m., ADON Y stated she was the Infection Control Preventionist for the facility. ADON Y stated she expected CNAs to perform hand hygiene prior to donning gloves. ADON Y stated she expected her to open her peri area and wipe front to back with a clean wipe each time until clear of soilage. ADON Y stated she monitored by monthly in-services, performance of skill check offs, and random checks while performing incontinent care on a resident. ADON Y stated she never had an issue with CNA NN providing incontinent care in the past. ADON Y stated this failure put Resident #40 at risk for a UTI. During an interview on 08/22/2024 at 6:26 p.m., the Administrator stated she expected staff to perform hand hygiene prior to donning gloves to prevent the spread of germs. The Administrator stated she expected staff to clean the peri area correctly. The Administrator stated ADON Y was responsible for monitoring and overseeing appropriate peri care. Record review of a CNA Proficiency Audit dated 4/11/2024 indicated CNA NN was assessed in the area of hand washing, perineal care; female, and infection control awareness scoring a satisfactory in skill level. Record review of the facility's policy titled, Perineal Care Female, revised 12/08/2009 indicated, .H. Wash hands and put on clean gloves for perineal care .Ib. separate inner labia (peri area) and using a different surface, wash down the center and over the urethral area, wiping downward from front toward back . c. continue to wash the rest of the perineal area Change the washcloth or pre-moistened cleaning wipe surface or use a new washcloth or pre-moistened cleaning wipe with each wipe .

Based on interviews and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 24 residents (Resident #64) reviewed for grievances. The facility did not ensure a grievance was filed for Resident #64's black bra and 1 pair of pants when they were not returned from the laundry. This failure could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of a face sheet dated 08/22/24 indicated Resident #64 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety (deterioration of memory, language, and other thinking abilities without behaviors) and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #64 was able to understand others and was able to make herself understood. The MDS assessment indicated Resident #64 had a BIMS score of 7, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #64 required partial/moderate assistance with dressing and personal hygiene. Record review of the grievances for the months of February 2024 through August 2024 did not indicate a grievance for Resident #64's black bra and pants. During an interview on 08/19/2024 at 10:22 AM, Resident #64 said she had lost a pair of aqua green pants and a black sports bra. Resident #64 said they had been sent to the laundry a couple months ago and were not returned. Resident #64 said she had told the laundry lady (was not able to provide a name) when she went by to leave her clothes. Resident #64 said the laundry lady told her she was still looking for it when Resident #64 asked her about the pants and bra. During an interview on 08/22/2024 at 8:41 AM, Laundry Staff D said Resident #64 told her a couple months ago that she was missing a black bra, and she had looked for it and could not find it. Laundry Staff D said she was not aware of the missing pants. Laundry Staff D said when a resident reported a missing item, they first looked in the resident's closet, the clothing items with no name, and in the laundry. Laundry Staff D said if she was not able to locate the missing clothing, she would tell the residents I am so sorry, but I could not find it. Laundry Staff D said she was not aware she could file a grievance for missing clothes. Laundry Staff D said it was important for the residents clothing to be returned because it was something valuable to them. During an interview on 08/22/2024 at 2:17 PM, Laundry Staff E said Resident #64 told her she was missing a bra and pants about three weeks ago. Laundry Staff E said she had looked for them but had not found them. Laundry Staff E said when a resident reported missing clothes, they looked for it on the laundry carts and on the carts with clothing that had no names, and other residents' closets. Laundry Staff E said if the clothing was not found she notified the Laundry Supervisor. Laundry Staff E said she had notified the Laundry Supervisor that Resident #64's clothes were missing. Laundry Staff E said it was important for the residents clothing to be returned to them because it was their belongings. During an interview on 08/22/2024 at 2:24 PM, the Laundry Supervisor said when residents reported clothing missing, they searched the laundry, the lost and found, and the residents' rooms. The Laundry Supervisor said when clothing went missing a grievance was filed, and if the clothing was not found it was replaced. The Laundry Supervisor said the laundry staff were supposed to notify her if a resident reported missing clothes to them. The Laundry Supervisor said she was not notified of Resident #64's missing bra and pants. The Laundry Supervisor said it was important for a grievance to be filed so they knew what was missing, and so they could look for the clothes and be aware of if it happened again. The Laundry Supervisor said it was important for the residents clothing to be returned to them because it was their personal stuff and their clothing. During an interview on 08/22/2024 at 6:37 PM, the Administrator said if the residents reported missing clothes to the laundry staff, they were supposed to notify the laundry/housekeeping supervisor, and she notified the Administrator. The Administrator said she would text the CNAs and the laundry staff would check the lost and found and conduct a room to room sweep. The Administrator said if the clothing item was not found and they had proof of the item they would repurchase the missing clothes. The Administrator said she was not aware Resident #64 was missing a bra and pants. The Administrator said a grievance was filed to track the steps and progress. The Administrator said it was important for the residents clothing to be returned to them because it was their stuff, and they had a right to have it. Record review of an undated policy titled, Grievance Forms, indicated, Grievance Policy All residents have the right to voice grievances with respect to treatment or care without fear of discrimination or reprisal. In accordance with state and federal laws, community residents, their family members or any other interested parties have the right to file oral and/or written grievances regarding the community, staff members and other residents . EVERY complainant shall be notified of the actions taken in a timely manner .

Based on interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed by the interdisciplinary team and that the resident was invited to participate in developing the care plan and making decisions about his or her care for 1 of 24 residents (Resident #64) reviewed for care plan timing and revision. The facility failed to ensure Resident #64 was invited to participate in the development and review of her care plan. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of a face sheet dated 08/22/24 indicated Resident #64 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety (deterioration of memory, language, and other thinking abilities without behaviors) and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #64 was able to understand others and was able to make herself understood. The MDS assessment indicated Resident #64 had a BIMS score of 7, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #64 required partial/moderate assistance with dressing and personal hygiene. Record review of Resident #64's care plan last reviewed 08/14/2024, did not address inviting Resident #64 to participate in the development and review of her care plan. During an interview on 08/19/2024 at 10:24 AM, Resident #64 said she had not been invited or attended any care plan meetings. Record review of Resident #64's electronic health record on 08/22/2024 did not indicate any care plan meetings had been completed. During an interview on 08/22/2024 at 10:55 AM, the Social Worker said the care plan meetings were documented in the electronic health record under the assessments as a Care Plan Conference. The Social Worker said the care plan meetings should be completed every three months. The Social Worker said Resident #64 had not had a care plan meeting yet. The Social Worker said Resident #64 should have had one already, but she was trying to catch up from COVID. The Social Worker said it was important for the care plan meetings to be completed with the IDT (IDT team consisted of the RN or hall nurse the dietary manager, MDS nurse, therapy if on therapy, and the activities director) to be able to touch base with the residents and families, to address any issues the residents were having, and to ensure they were all on the same page. During an interview on 08/22/24 at 6:39 PM, the Administrator said the care plan meetings were offered to the resident and family, and they were completed quarterly. The Administrator said social services was responsible for the care plan meetings. The Administrator said it was important for the care plan meetings to be completed to keep everybody up to date on the plan of care. Record review of an undated policy titled, Comprehensive Care Planning, indicated, .Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life . The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions . The facility will provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation .

Based on observations, interviews, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good hygiene for 1 of 3 residents (Resident #32) reviewed for ADLs. The facility did not ensure Resident #32's fingernails were cleaned. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. The findings included: Record review of the face sheet, dated 08/22/2024, revealed Resident #32 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and dementia (group of symptoms affecting memory, thinking and social abilities that interfere with their daily lives). Record review of the quarterly MDS assessment, dated 07/23/2024, revealed Resident #32 had clear speech and was usually understood by others. The MDS revealed Resident #32 was usually able to understand others. The MDS revealed Resident #32 had a BIMS score of 7, which indicated severe cognitive impairment. The MDS revealed Resident #32 had no behaviors or refusal of care. The MDS revealed Resident #32 required substantial/maximal assistance (helper does more than half the effort) with personal hygiene and shower/bathing. Record review of the comprehensive care plan, revised 04/25/2024, revealed Resident #32 required assistance with ADLs and mobility needs. The interventions included: extensive assistance x 1 staff member for bathing and personal hygiene tasks. Record review of the task documentation schedule for August 2024, revealed Resident #32 received bathing assistance on 08/20/2024. During an interview and observation on 08/19/2024 beginning at 3:36 PM, Resident #32 had a thick black gooey substance under his fingernails. Resident #32 said he received a shower regularly by the facility staff. Resident #32 stated the staff would have completed his nail care tomorrow (08/20/2024) with his shower. During an interview and observation on 08/20/2024 beginning at 9:02 AM, Resident #32 had a thick black gooey substance under his fingernails. Resident #32 said the facility staff had not performed nail care yet. During an interview and observation on 08/21/2024 beginning at 8:04 AM, Resident #32 had a thick black gooey substance under his fingernails. Resident #32 said he received his bed bath yesterday (08/20/2024), but the staff could have forgotten to clean his nails. During an interview on 08/22/2024 beginning at 2:45 PM, CNA RR stated she assisted Resident #32 with his bed bath on 08/20/2024. CNA RR stated she was helping out on the floor because the facility was short-staffed. CNA RR stated normally nailcare was completed with a bed bath or showers, but she forgot to go back and clean Resident #32's nails because she got busy. CNA RR stated it was important to make sure nail care was performed so the residents did not put their hands in their mouth which could spread or cause infection. CNA RR stated dirty fingernails were unsanitary. During an interview on 08/22/2024 beginning at 5:59 AM, the DON stated CNAs were responsible for cleaning fingernails. The DON stated some residents go to pretty nails (an activity where nails were clean, painted, and trimmed) but most of the time nail care was performed during showers. The DON stated all staff were responsible for monitoring to ensure nail care was completed. The DON said unit managers perform daily champion rounds in which the staff looked for things like that specifically. The DON stated she was unsure who was responsible for completing champion rounds on Resident #32. The DON stated it was mostly administrative staff. The DON said it was important to ensure Resident #32's nails were kept clean to prevent infections from spreading and ensure sanitation. During an interview on 08/22/2024 beginning at 6:14 AM, the Admissions Coordinator UU stated she performed champion rounds on Resident #32. The Admissions Coordinator stated Resident #32's hands were under the covers when she went into his room, so she did not notice his dirty fingernails. The Admissions Coordinator stated nail care was something that was looked at during champion rounds, but she did not ask Resident #32 to look at his fingernails. During an interview on 08/22/24 beginning at 6:51 AM, the Administrator stated she expected nail care to have been completed by the facility staff. The Administrator stated nail care was performed during showers and as needed. The Administrator stated all staff were responsible for monitoring to ensure nails were cleaned. The Administrator stated performing nail care was important for infection control. Record review of the Nail Care policy, undated, revealed Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury form scratching by fingernails or pressure of shoes on toenails .It includes cleansing, trimming, smoothing, and cuticle and is usually done during the bath .When performed at bath time, the nail care can be done following the procedure or as a separate procedure when needed at the convenience of the resident .

Based on observations, interviews, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 2 residents (Resident # 5) reviewed for respiratory care. The facility did not ensure Resident #5's oxygen concentrator was set at 2-4 liters per nasal cannula as ordered by the physician. These failures could place residents requiring respiratory care at risk for shortness of breath, respiratory distress, or complications. Findings included: Record review of a face sheet dated 08/20/2024 indicated Resident #5 was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #5 understood others and was able to make herself understood. The MDS assessment indicated Resident #5 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #5 required substantial/maximal assistance with toileting, dressing, and personal hygiene. The MDS assessment indicated Resident #5 received oxygen therapy while a resident at the facility. Record review of Resident #5's care plan last reviewed on 05/26/2024 indicated she had chronic obstructive pulmonary disease with recurrent exacerbation and increase shortness of breath and coughing to give oxygen therapy as ordered by the physician. Record review of the Order Summary Report dated 08/20/2024 indicated Resident #5 had an order for oxygen at 2-4 liters per nasal cannula every day and night shift with a start date of 11/25/2022. During an observation and interview beginning on 08/19/2024 at 3:35 PM, Resident #5 was sitting in the dining room wearing oxygen via nasal cannula with her oxygen concentrator at her side. Resident #5 said she wore the oxygen all the time and it was supposed to be at 2 liters. Resident #5's oxygen concentrator was set at 1 liter. Resident #5 did not appear to be in respiratory distress. Resident #5 said CNA M had put the oxygen on her. The State Surveyor asked LVN K to check Resident #5's oxygen settings. LVN K said Resident #5's oxygen should be set at 2-4 liters. LVN K checked Resident #5's oxygen concentrator and said it was set incorrectly at 1 liter. LVN K adjusted the settings. LVN K said she did not know who had put the oxygen on Resident #5. LVN K said a nurse should put the oxygen on and set it correctly. LVN K said if the oxygen was not set per the physician's order Resident #5's oxygen level could get too low, or she could get short of breath. During an interview on 08/19/2024 at 4:04 PM, CNA M said she had not applied the oxygen on Resident #5. CNA M said she had brought the oxygen concentrator to the dining room and Resident #5 had put it on herself. CNA M said the CNAs were allowed to help them put it on, but they could not adjust the settings. CNA M said she should have gotten the nurse to check the settings to ensure they were set properly. CNA M said it was her mistake, but she was in a rush. CNA M said Resident #5's oxygen being set below what was ordered could make it harder for Resident #5 to breathe. During an interview on 08/22/2024 at 6:05 PM, the DON said the nurses were responsible for ensuring the residents oxygen was set per the physician's order. The DON said the CNA should have let the nurse know that Resident #5 needed oxygen so the nurse could have made sure that the settings were correct. The DON said Resident #5's oxygen being set lower than prescribed placed her at risk for not getting enough oxygen and suffocating. During an interview on 08/22/2024 at 6:41 PM, the Administrator said she expected for the nurses to set the oxygen properly. The Administrator said CNA M had pushed the oxygen concentrator down to Resident #5 and had bumped it and had forgotten to tell the nurse to check the settings. The Administrator said the CNA should have told the nurse. The Administrator said the physician ordered the oxygen to be set at a specific level for a reason, so it needed to be set at the appropriate level. Record review of the policy titled, Oxygen Administration, revised 03/21/2023, indicated, Oxygen therapy includes the administration of oxygen (O2) in liters/minute (I/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse .