Every finding on record at Avir at Itasca

Based on observation, record review, and interview the facility failed to ensure 3 of 7 residents, Resident 1, Resident #2, and Resident #3 reviewed for admission to the secured unit were free from involuntary seclusion.The facility failed to ensure Resident #1, Resident #2, and Resident #3, had no physician's order for admission to the secured unit. The failures placed all residents on the secured unit at risk of not being assessed properly, not meeting the criteria to be placed on the unit, diminished quality of life and involuntary seclusion.Findings included:Record review of Resident #1's face sheet, 07/30/2026, revealed a sixty-eight year old male who was admitted to the facility on [DATE] with a diagnosis that included drug induced subacute dyskinesia (a movement disorder causing involuntary muscle motions-such as twisting,) jerking, or repetitive facial movements), schizoaffective disorder, bipolar type (a chronic mental health condition defined by a combination of schizophrenia symptoms (like hallucinations or delusions) and mood disorder episodes, specifically alternating bouts of mania and depression), post-traumatic stress disorder, chronic (a long-lasting mental health condition defined by persistent re-experiencing, avoidance, and hyperarousal lasting more than one month and often persisting for years).Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 05/27/2026 Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 0 indicating severe cognitive issues and Section and E - Behavior revealed no wandering behavior.Record review of Resident #1's care plan, undated, revealed no focus or interventions for residing in the facility secured unit. Record review of Resident #2's face sheet, 07/30/2026, revealed a seventy-one-year-old male who was admitted to the facility on [DATE] with a diagnosis that included cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery (ischemic stroke (cerebral infarction) caused by the narrowing (stenosis) or blocking (occlusion) of the left posterior cerebral artery (PCA), where the exact underlying mechanism or specific type of blockage is not explicitly detailed), generalized anxiety disorder (a mental health condition defined by excessive, uncontrollable worry and physical tension occurring most days for at least six months), and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain).Record review of Resident #2's MDS (clinical assessment to determine resident's strength and needs) dated 06/23/2026 Nursing Home Comprehensive Section C - Cognitive Patterns revealed no BIMS score recorded and Section and E - Behavior revealed no wandering behavior.Record review of Resident #2's care plan, undated, revealed no focus or interventions for residing in the facility secured unit. Record review of Resident #3's face sheet, 07/30/2026, revealed a seventy-one-year-old male who was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (a long-term lung disease that blocks airflow and makes it hard to breathe, primarily caused by smoking or air pollution, and includes conditions like emphysema and chronic bronchitis), and bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, and activity levels, specifically swinging between high phases (mania or hypomania) and low phases (depression). Record review of Resident #3's MDS (clinical assessment to determine resident's strength and needs) dated 07/04/2026 Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 8 reflecting moderate cognitive impairment and Section and E - Behavior revealed no wandering behavior. Record review of Resident #3's care plan, undated, revealed a focus of Resident #3 was at risk for wandering/elopement identified dated 07/28/2026 with intervention dated 07/28/2026 may be housed on secure unit.Record review of Resident #1, Resident #2, and Resident #3's facility physical orders reflected no physician's order for the residents to reside in the facility secured unit. During an interview by phone on 07/30/2026 at 4:11 PM with the MD, he said there should an MD order for a resident to be admitted to the secure unit. The MD said the facility was a new building for him and he began working as the MD for the facility on 07/01/2026. The MD agreed that there should be proper documentation. During an interview on 07/30/2026 at 4:39 PM DON said she began working at the facility on 06/15/2026. She said she had seen Resident #1 walk to the door of the secured unit, and it was interpreted as exit seeking. The DON said it was important to document why someone was admitted to the secured unit. The DON said the facility's policy should have been followed. The DON said the previous MD left and a new MD started. She said no orders had been placed for Residents #1, #2, and #3 to be in the secured unit but that was no excuse for the facility not to have the orders for residents to be placed in the secured unit. The DON said residents should have the opportunity to live in the least restrictive environment. The DON said that even if a resident was transferred from a previous facility and resided in a locked unit there should be an assessment, an order, and documentation for residents to be in the secured unit.During an interview on 07/30/2026 at 5:42 PM the Administrator said she began working at the at the facility at the end of May 2026. The Administrator said there were no orders for Resident #1, Resident #2, or Resident #3 to be in the facility secure unit. The Administrator said she believed that residents should have the least restrictive environment. The Administrator said a possible negative effect of residents living in the secured unit without an order would be inappropriate placement for the residents and the possibility of depression. During an interview on 07/30/2026 at 6:12 PM Resident #1 said he knew he was in a secure unit and the door was locked and he could not get out. He said it made him feel safe. During an interview on 07/30/2026 at 6:14 PM Resident #3 said he said he knew he was in a locked unit and it did not really bother him. Resident #3 said he spent 23 years in prison, and he has accepted the condition of the locked unit because he received a bed, people who helped him, he was feed, and he had a room to live in. Resident #3 said it would be nice to go outside the unit, but he had accepted that he was on a secure unit.During an interview on 07/30/2026 with at 7:11 pm Resident #2 he said he was doing fine and he said he liked it at the facility. He said he had been at the facility for 25 or 30 years. Record review of facility Secured Unit Policy dated July 2025 reflected that the secure unit is designed to provide a safe and structured environment for residents who are at risk of elopement or harm due to cognitive impairment (e.g., dementia, Alzheimer's disease, or other behavioral health concerns). This policy ensures that all residents' rights, safety, and dignity are protected while maintaining compliance with federal and state regulations. The following will be reviewed for all new admissions being considered for the Secure Unit. a. A cognitive assessment (BIMS) will be completed on admission, quarterly and as needed, to validate that the resident has a cognitive deficit.b. Appropriate payor sourcec. History and physical and medication reviewd. Wandering, past elopement or potential for elopemente. Cognitive deficient f. Inter disciplinary team to review for appropriateness of admissiong. Consent will be obtained for the non-cognitively impaired residentsh. A physician's orderI. RP and or Guardian consentadmission Criteria:Residents must meet medical and cognitive criteria for placement.A physician's order to admit to the secure unit is required.Informed consent must be obtained from the resident or legal representative

Based on observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely for 1 of 1 facility observed.A)The facility failed to ensure the walls in the secure unit were free of gouges, scuffs, holes, peeling paint, and shredded sheetrock.The facility failed to ensure the handrails in the secure unit were free from peeling paint.The facility failed to ensure the blinds in the secure unit dining room were not broken.The facility failed to ensure the community shower room toilet was clean from feces and urine.The facility failed to ensure the floor tile was not broken and missing in the hallway in front of the kitchen entrance.B)The facility failed to empty Resident #20's 3 bedside urinals observed full on 01/06/26 and 01/07/26 at different times of the day resulting in a urine odor, gnats/flies, and unsanitary environment.This failure could place residents at risk of feeling uncomfortable and uncared for in their home.Findings Included: A)In an observation on 01/06/2026 at 12:30 p.m., of the secure unit the following was noted:- broken blinds on 2 of 5 windows in the dining room,-the community shower bathroom had a brown foul-smelling substance on the toilet seat and urine in the toilet,-the floor had a sewage drainage hole exposed and uncovered with gnats flying out of it,-the hallway rails was covered with chipped and peeling paint,-the paint around the room doors and on walls was scuffed, peeling, with gouged sheetrock in the hall,-the floor tile at entrance of the secure unit was missing and broken with a large black mat laying over it, the kitchen door is just to the right of the entrance and a hallway to the smoking area was to the left of the secure unit entrance.During an observation on 01/7/2026 at 3:08 p.m., urine and brown substance remained on toilet in secure unit shower. The exposed pipe remained without a cover, and gnats were flying in the shower room.In an interview with 01/08/2026 at 11:15 a.m., the Dietary Aide stated the floor in front of the kitchen and secure unit had been broken for several months. She stated there have been no falls that she is aware of. She stated they have to roll their meal carts to the right of the mat to ensure it doesn't tip over. The dietary aide said residents who smoke all know the mat and broken tile is there because they come by this area multiple times a day. She stated it could be a trip hazard for residents. In an interview on 01/08/2026 at 11:20 a.m., CNA B stated the housekeeper's clean the secure unit 3-4 times a day. The housekeepers were responsible for cleaning the shower room. She stated she was not aware of the brown substance on the toilet seat or the urine in the commode. CNA B stated any staff who sees a mess should take initiative to clean it up or notify housekeeping to come and clean. That included the broken blinds and generalized dirtiness of the secure unit she stated having a dirty toilet could spread germs and cause infection. She stated having broken blinds and dented drywall, and scratched paint was not a very homelike environment. She stated the gnats have been a problem in the shower room for several months, the drainage pipe has been uncovered for some time. In an interview on 01/08/2026 at 11:27 a.m. Housekeeper stated he did not normally work on the secure unit. He stated the person who did work back there quit yesterday, The Houskeeper stated that all surfaces should be cleaned every day, and some may require to be cleaned more frequently. He stated he was not aware of the urine in the shower room or the brown substance on the seat. He stated it definitely could spread germs. The Houskeeper stated the drainage pipe in the shower room had been uncovered there was a top that went on that, but he had no idea where it went. He stated he had poured household cleaner down the pipe to help fight them, but they just returned, he stated he was not sure the gnats had been reported to the administrator or not. He stated that all the problems in the secure unit did not make for a homelike environment.In an interview on 01/08/2026 at 11:48 a.m., The Maintenance Director stated the facility had ordered new blinds for the windows, but they were the wrong size. He stated he was responsible for painting on the secure unit, he said he had not painted it in about 2 weeks. He stated the building was old and he prioritized the work orders as they came in. He stated anything reported regarding life safety was fixed first. He stated the facility does have new flooring coming and a contract crew coming to install it. He stated the floor for the entire south wing, including in front of the kitchen would be replaced. He stated the contract did include drywall and painting repairs. The shower room drainpipe did have a cover on it he was not sure what happened to it, but he did have a replacement to fix it. The Maintenance Director stated, housekeeping was responsible for the cleaning of the secure unit, he stated department heads do rounds every day to monitor problems within the building. He stated staff do notify him in his app for needed repairs he stated the building had so much, he said we do our best to keep up. He stated it's not a very homelike environment.Attempted to call the housekeeping supervisor on 01/08/2026 at 12:07 p.m., no answer.Interview on 01/08/2026 at 12:42 p.m., the ADM stated the facility had a housekeeping supervisor and he was responsible for monitoring and assisting housekeeping services. She stated she expects the bathrooms to be clean, and maintenance to be notified of any issues such as gnats, broken blinds, and paint issues. She stated there had been no fall due to the broken floor tiles and the rug had adhesive on it so it would not move from the floor. She stated it was not a homelike environment the residents deserved better and expected the secure unit to be clean and orderly. B)Review of Resident #20's face sheet dated 01/08/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included paraplegia (paralysis of the lower body), edema (swelling caused by fluid in the body trapped in the body tissues), immobility syndrome, and anxiety disorder (group of mental health conditions characterized by excessive fear, worry, and apprehension.Review of Resident #20's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 indicating cognition intact. Section GG for functional abilities reflected resident was independent of bed to wheelchair transfers and toilet transfers. Section I for active diagnosis reflected paraplegia was checked.An observation on 01/06/26 at 11:41 AM, in Resident #20's room observed gnats in the room and hanging from bedside drawer 3 full bedside urinals. Urine odor noted in the room. Resident #20 was in his room in bed with miltipodus boots on both legs.An observation on 01/07/26 at 11:14 AM, in Resident #20's room observed gnats in the room appeared around Resident #20 and appeared to be attracted to 3 full bedside urinals that had not been emptied. A fly was also noted flying around the room. Urine odor noted in the room. Resident #20 was in his room in bed with miltipodus boots on both legsAn observation on 01/07/26 at 02:20 PM, in Resident 20's room observed gnats still surrounding Resident #20 along with urinals (3) still not emptied. Urine odor noted in the room. Resident #20 was in his room in bed with miltipodus boots on both legsIn an interview on 01/07/26 at 11:14 AM, with Resident #20 he stated that he observed gnats and flies in the room, does not know what could be attracting them. He stated he usually empties the bedside urinals but hasn't been able to. Resident #20 was observed in bed with multipodus boots to both legs, a staff member was observed entering and leaving room without emptying the bedside urinals.In an interview on 01/08/26 at 10:00 AM, with CNA E stated a negative outcome of not emptying the bedside urinals in Resident #20's room had the potential to attract pests such as the gnats and flies and contribute to the foul smell in the room. She stated these were emptied upon request by the resident.In an interview on 01/08/26 at 10:13 AM, with the ADM she stated that most of the residents that were cognitive and able to move would dump the bedside urinals on their own. She stated that if residents required assistance that they could push their call light and ask a staff member to dump the urinal out as well. She stated it was her expectation that staff assisted the residents to dump the urinals out if the residents requested or they saw that they were full. She stated if they are full and not dumped the residents could not use the restroom if they needed, they could overflow and create a fall risk and be unsanitary. She stated that residents used to only get one bedside urinal which promoted more frequent emptying but that they began asking for more urinals.In an interview on 01/08/26 at 11:48 AM, with Maintenance Director, he stated that urinals that were full and not emptied could attract pests. He stated he believed they should be emptied, and staff could assist. He stated full urinals created a smell or attracted pests did not create a homelike environment.In an interview on 01/08/26 at 12:13 PM, the DON stated it was her expectation that bedside urinals were checked and emptied between every 2-4 hours. She stated that any staff member can assist a resident to empty the bedside urinal out if they see it is full but that it was ultimately the responsibility of the CNAs to assist. She stated when she learned they were not being emptied she went around to ask CNAs how often they should be emptied and that each CNA she questioned provided a different response; she stated she would be providing retraining on the expectation of checking them and emptying every 2-4 hours.Record review of facility policy titled Homelike Environment dated February 2021 reflected the following: The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary and orderly environment;

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored food in 1 of 2 reach in refrigerators were labeled and dated. The facility failed to ensure expired items were removed from dry storage and discarded. The facility failed to ensure Dietary Aide A properly sanitized a food thermometer when taking food temperatures for lunch services on 01/07/26. These failures could place residents who received prepared meals from the kitchen at risk for foodborne illness and cross-contamination.The findings included: During an initial tour on 01/06/26 beginning at 10:00 AM of the one and only kitchen revealed: 1 of the 2 reach-in refrigerators in the dry storage room of the kitchen contained a large zip sealed bag holding smaller prepackaged bags of sliced sandwich meat. Neither the large zip seal bag or the smaller bags inside contained the open date or the use by date.The dry storage room contained a box of bananas that were dark brown/black in color and mushy in texture and a 50-pound sack of onions which had multiple onions that were observed dark black and spoiled and others that had approximately 6-inch sprouts. Upon closer inspection of the onions and bananas were observed to have a large swarm of gnats that flew around when the items were disturbed. In an interview 01/06/26 at 11:10 AM, with the DM who was in the dry storage room at the time she stated it was her expectation that items in the refrigerator were labeled and dated to indicate what the item is, when it was received, when it was opened and the use by or expiration date. She stated it was also her expectation that there were no expired items in the kitchen and that any expired items should be discarded. She stated the unmarked sandwich meat and the spoiled bananas and onions did not meet her expectations. She stated it was both her and her staff responsibility to ensure items were labeled properly and that spoiled items were discarded. She stated that not having items labeled with a use by date could result in food reaching the residents that could not be good for them. She stated that having spoiled items in the dry storage room could result in food reaching residents that could potentially make them sick and could attract pests like those we observed. She stated a negative outcome of those pests being around the food were that it could contaminate food going to the residents and cause illness. In a follow up observation and interview in the kitchen on 01/07/26 at 11:44 AM, an observation was made of Dietary Aide A taking the temperature of the lunch foods. Dietary Aide A was observed using the same alcohol swab when cleaning the food thermometer probe for 3 of 4 food items checked. Dietary Aide A stated that when she used the same alcohol swab to clean the probe in between foods it could have caused cross contamination of foods which had the potential to make residents sick. She stated she believed it was ok previously to use the same one each time because she was told she could use the same alcohol wipe for each temperature check if she flipped it to the other side but would not specify who advised that. In an interview on 01/08/26 at 08:40 AM. with the DM she stated it was her expectation that when food temperatures are completed that staff are to use an alcohol swab to clean the food thermometer probe in between each food item and that a new clean swab is used each time. She stated failure to do so and using the same swab each time could result in cross contamination of the food. The DM stated that Dietary Aide A should be using a new alcohol swab after each temperature check moving forward and revealed that she had spoken to Dietary Aide A and provided retraining on this matter. In an interview on 01/08/26 at 10:28 AM, with the ADM she stated it was her expectation that food items stored in the refrigerator are labeled to include what the item is and a use by or expiration date. She stated it was also her expectation that the kitchen is not to have expired or spoiled items stored, that they should be regularly inspected and discarded if they go bad. She stated failing to label items properly or remove them if they go bad has the potential to make residents sick and cause foodborne illness which she stated, is not right because they trust us to have safe food in the kitchen. The ADM stated, if bananas or onions go bad get rid of them she stated, nothing should be in there allowing pests to grow. The ADM stated it was the DM's responsibility to ensure all items in the kitchen were being properly labeled and dated and that spoiled items were discarded. Review of the facility Food Receiving and Storage policy revised November 2022 reflected: Food shall be received and stored in a manner that complies with safe food handling practices Non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen, or discarded. Review of the 2022 U.S. Food and Drug Administration Food Code revealed:3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: P if(1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Of and(2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition.(A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it:(2) Is in a container or PACKAGE that does not bear a date or day; or3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation.FOOD shall be protected from cross contamination by:(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings.

Based on observation, interview and record review, the facility failed to ensure the residents' right to be treated with respect and dignity during personal care for 1 of 6 residents (Resident #39) reviewed for respect and dignity in that:The facility failed to ensure RN A provided resident care with the door shut during an observation on 1/7/2026 at 9:13 am of wound care.The failure could place residents at risk for a lack of privacy. Findings included:Review of Resident #39's undated face sheet reflected Resident #39 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of paraplegia (paralysis affecting the lower half of the body), non-pressure ulcer of the right foot, non-pressure ulcer of the left foot, and unspecified open wound to the left ankle.Record review of Resident #39's quarterly MDS assessment, datd 10/10/2025, reflected Resident #39 had a BIMS score of 7 indicating she was cognitively impaired. Resident #39 required partial to moderate assistance with bathing and was independent with dressing. The MDS indicated Resident #39 has a pressure ulcer injury over a bony prominence requiring the application of a nonsurgical dressing.Record review of Resident #39's care plan reflected a focus area, dated 12/04/2025, reflected Rights Heel, Left Hallux abrasion, and Ankle Goal included, . Wound will show signs of improvement. Interventions included to Provide wound care per treatment order.Observation on 01/07/2026 at 9:13 a.m., revealed RN A performed wound care to the right heel, left hallux abrasion, and ankle with the door open. She proceeded to clean all 3 wounds in the same manner as described. In an interview on 01/07/2026 at 9:40 a.m., RN A stated she just messed everything up, she stated she did wound care with the door open because the residents room light was out, she stated she could have closed the door, that performing wound care with the door open violated residents' rights to privacy.In an interview on 01/7/26 at 12:30 p.m., Resident #39 stated the light works in her room. She stated it was out a couple of weeks ago, but the maintenance man had since fixed it. She stated the nurses always leave my door open when they doctor my feet. She stated it's probably not a very nice sight if they can see her feet. In an interview on 01/08/2026 at 12:13 p.m, the DON stated it was her expectation the door to be closed when providing resident care. She stated the door must be closed for privacy and dignity. She stated she was responsible for monitoring and making sure nursing staff follow rules related to privacy and she does that by making rounds frequently throughout the day. She stated that not closing the door could make the residents uncomfortable. Record review of facility's policy titled Resident Rights revised in February 2021, reflected: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: privacy and confidentiality

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #39) of 6 residents reviewed for infection control practices.The facility failed to ensure RN A used a clean technique on Resident #39's right and left foot ulcers during an observation of wound care on 1/7/2026 at 9:13 am.The failure could place residents at risk for healthcare associated cross contamination leading to worsening pressure ulcers, discomfort, pain, and potential infections.Findings included:Review of Resident #39's undated face sheet reflected Resident #39 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of paraplegia (paralysis affecting the lower half of the body), non-pressure ulcer of the right foot, non-pressure ulcer of the left foot, and unspecified open wound to the left ankle.Record review of Resident #39's quarterly MDS assessment, dated 10/10/2025, reflected Resident #39 had a BIMS score of 7 indicating she was cognitively impaired. Resident #39 required partial to moderate assistance with bathing and was independent with dressing. The MDS indicated Resident #39 has a pressure ulcer injury over a bony prominence requiring the application of a nonsurgical dressing.Record review of Resident #39's care plan reflected a focus area, dated 12/04/2025, reflected Rights Heel, Left Hallux abrasion, and Ankle Goal included, . Wound will show signs of improvement. Interventions included to Provide wound care per treatment order.Observation on 01/07/2026 at 9:13 a.m., revealed RN A opened gauze, calcium alginate (a type of wound dressing that goes inside of open wound to promote healing and fight bacteria) and wound covering on top of her cart prior to entering the room. RN A did not clean or disinfect area or place a barrier down on the surface prior to setting up supplies. She proceeded into Resident #39's room and placed her gloves on. RN A removed the old dressings and laid open right heel wound on the bedsheets, she cleansed her hands with wound cleanser, applied gloves, and proceeded to clean wound and apply clean dressing. RN A performed wound care with the door open. She proceeded to clean all 3 wounds in the same manner as described. In an interview on 01/07/2026 at 9:40 a.m., RN A stated she should not have used wound cleanser to clean her hands, but she did not have any alcohol-based hand sanitizer on the treatment cart. She stated she just forgot to clean her work surface prior to the start of her wound care, and laying wounds directly on the sheet after it had been cleaned just made the wound contaminated again. She stated she had been checked off and educated by the DON on wound care, but she could not remember when. RN A stated all of this could spread infection making the wound worse and delay healing. In an interview on 01/08/2026 12:13 p.m., the DON stated she was responsible for monitoring and ensuring nurses perform wound care properly. She stated she had seen RN A perform wound care. She stated it was her expectation that nurses follow the wound care policy for proper wound care. The nurses were expected to not contaminate clean wounds when doing wound care, have 2 pads down for clean surfaces, remove dirty/contaminated pads, and wash their hands with either soap and water or alcohol-based hand sanitizer. The DON stated once a week the wound care nurse Practitioner evaluated Resident #39's wounds to ensure healing. The DON stated not following policy for wound care opens the residents up to infection.Record review of facility's policy titled Wound Care dated October 2010 and updated July 2024 reflected:1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly.3. Position resident. If necessary, place disposable cloth next to residents (under the wound) to serve as a barrier to protect the bed linen and other body sites.4. Put on exam gloves. Loosen tape and remove dressing.5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly (handsanitizer can be used).6. Put on gloves. Gown as indicated based on EBP definition. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely.7. Use no-touch technique. Use tongue blades and applicators to remove ointments and creams from their containers.8. Pour liquid solutions directly on gauze sponges on their papers.9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 10. Wear gloves when physically touching the wound or holding a moist surface over the wound.l l. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or normal saline solution.12. Apply treatments as indicated.

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for 1 of 1 facility reviewed for pest control. The facility failed to keep an effective pest control program to ensure areas including residents' rooms and kitchen (dry storage) were free of flies and gnats. This failure could place residents at risk for reduced quality of life and poor sanitary environment.An observation on 01/06/26 at 10:00 AM, in the kitchen revealed a swarm of gnats surrounding a box of spoiled bananas and 50-pound bag of spoiled onions in the dry storage room. An observation on 01/06/26 at 11:41 AM, in Resident #20's room observed gnats in the room and near 3 full bedside urinals. Urine odor noted in the room. An observation on 01/07/26 at 11:14 AM, in Resident #20's room observed gnats in the room appeared around Resident #20 and appeared to be attracted to 3 full bedside urinals that appeared to have not been emptied. A fly was also noted at this time flying around the room. Urine odor noted in the room. An observation on 01/07/26 at 02:20 PM, in Resident 20's room observed gnats still surrounding Resident #20 along with urinals (3) still not emptied. Urine odor noted in the room. In an interview 01/06/26 at 11:10 AM, with the DM stated it was her expectation that spoiled foods were not stored which attracted pests and had the potential to contaminate food which could make residents sick. She stated pest control was at the facility on a monthly basis and that it was her responsibility to notify maintenance or ADM if she needed services sooner for pests. She stated she was not aware of the pests on the spoiled food items. In an interview on 01/07/26 at 11:14 AM, with Resident #20 stated he had observed the gnats and flies in the room, does not know what could be attracting them. He stated he usually empties the bedside urinals but hasn't been able to and stated he felt staff would help if he asked. Resident #20 was observed in bed with multipodus boots to both legs, a staff member was observed entering and leaving room without emptying the bedside urinals. In an interview on 01/08/26 at 10:00 AM, with CNA E she stated a negative outcome of not emptying the bedside urinals in Resident #20's room had the potential to attract pests such as the gnats and flies and contribute to the foul smell in the room. She stated pests are reported to maintenance; she stated she did not recall reporting pests in Resident #20s room. In an interview on 01/08/26 at 10:28 AM, the ADM stated it was her expectation that the facility pest control was effective. She stated if food was spoiled in the kitchen it needs to be discarded and it would be the responsibility of the DM to monitor that and to report to her or the Maintenance Director if pest control services are needed. The ADM stated the pest issues in the kitchen were not reported by the DM on 01/06/26 when addressed by surveyor and that she was only learning of the pest issues today 01/08/26. The ADM stated staff can report pest issues to Maintenance Director and they can get emergency pest control services out here if they know there is an issue, she stated their contract allows for emergency pest control services. The ADM stated the last time pest control was in the building was December 2025 and that they are in the building on a monthly basis. In an interview on 01/08/26 at 11:48 AM, the Maintenance Director stated it was his responsibility along with the ADM to manage the pest control services of the facility. He stated it was the responsibility of the DM to let him know if there were gnats or other pests in the kitchen and that staff could advise him if there were pest issues in the residents rooms or other common areas. He stated that rotting food in the kitchen has the potential to attract pests as well as bedside urinals that are full and not being dumped could also attract them. Maintenance Director stated pest control comes to the facility monthly but they could also call them sooner as needed for emergency services. Review of the facility Pest Control policy revised May 2008 reflected: Our facility shall maintain an effective pest control program. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Maintenance services assists, when appropriate and necessary, in providing pest control services.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 7 of 12 residents reviewed for environment. 1. The facility failed to ensure the secure unit was a comfortable temperature on 11/26/24, and Residents #1, 2, 3, 4, 5, and 6 felt uncomfortably cold. 2. The facility failed to ensure Resident #7's room was free of holes, paint scuffs, and had a well-fitting screen for the window. These failures placed residents at risk of discomfort and diminished quality of life. Findings included: Review of the undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included hypertension, anemia, underweight, osteoarthritis of hip, pain in right lower leg, and dementia. Review of the quarterly MDS assessment for Resident #1 dated 08/23/24 reflected a BIMS score of 03, indicating severe cognitive impairment. It also reflected she required supervision/touching assistance in the activity of dressing. Review of the undated face sheet for Resident #2 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included hypertension, muscle wasting and atrophy, lack of coordination, dementia, and major depressive disorder. Review of the admission MDS assessment for Resident #2 dated 11/17/24 reflected a BIMS score of 03, indicating severe cognitive impairment. It also reflected she required supervision and touching assistance in the activity of dressing. Review of the undated face sheet for Resident #3 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, vascular dementia, urinary incontinence, facial pain, difficulty in walking, weakness, adjustment disorder with depressed mood, unspecified head injury, muscle wasting and atrophy, chronic obstructive pulmonary disease, and depressive episodes. Review of the quarterly MDS assessment for Resident #3 dated 11/07/24 reflected a BIMS score of 06, indicating severe cognitive impairment. It also reflected he required supervision or touching assistance in the activity of dressing. Review of the undated face sheet for Resident #4 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included mild malnutrition, vascular dementia, peripheral vascular disease, muscle wasting and atrophy, hypothyroidism, and vitamin D deficiency. Review of the quarterly MDS assessment for Resident #4 dated 11/06/24 reflected a BIMS score of 01, indicating severe cognitive impairment. It also reflected he was independent in the activity of dressing. Review of the undated face sheet for Resident #5 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included muscle wasting and atrophy, abnormal weight loss, atherosclerotic heart disease, malnutrition, anxiety disorder, and Alzheimer's disease. Review of the quarterly MDS assessment for Resident #5 dated 10/22/24 reflected a BIMS score of 01, indicating severe cognitive impairment. It also reflected he required substantial/maximal in the activity of dressing. Review of the undated face sheet for Resident #6 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, muscle wasting and atrophy, difficulty in walking, vitamin D deficiency, and unspecified pain. Review of the annual MDS assessment for Resident #6 dated 11/05/24 reflected a BIMS score of 01, indicating severe cognitive impairment. It also reflected he required substantial/maximal in the activity of dressing. Review on 11/29/24 of a web page found at the address www.timeanddate.com/weather/@4700235/historic reflected the outside temperature in the facility town was 46 degrees Fahrenheit at 09:30 AM on 11/26/24. Observation and interview on 11/26/24 at 09:39 AM revealed the thermostat in the secure unit of the facility was reading 67 degrees Fahrenheit. Residents #1 and #2 were sitting in a television room on chairs, both in their pajamas with shoes and socks on. The room was dark, due to a large entertainment center blocking the window. It felt cold in the room. Resident #1 stated it was very cold in there, and she would love some hot coffee. Resident #2 did not use words, but when asked if she was cold, nodded her head vigorously. The ADM adjusted the desired heat from 76 to 79 degrees Fahrenheit. Within five minutes, the thermostat read 70 degrees Fahrenheit. Observation and interview on 11/26/24 at 11:26 AM revealed the thermostat in the hall for the secure unit read 68 degrees Fahrenheit. Residents #1 and #2 were walking around the common areas talking about how cold it was. Resident #1 was wearing a robe over her pajamas, and Resident #2 had on a sweater. Resident #1 said to Resident #2 Even the chairs feel too cold to sit in. Resident #1 held out her hands, and they were very cold to touch. Resident #6 was walking up and down the halls in a t-shirt, pajama pants, and non-skid socks, and his hands were also cold to touch. He did not respond verbally when asked if he was cold. A call light came on in Resident #598's room, and he stated he needed another blanket. When asked if he was cold, he stated, Hell yeah! Resident #3 was lying in his bed and stated he was trying to take a nap but was cold. Resident #4 was lying in his bed with a coat on and several blankets over him. He did not respond verbally to any questions. The MAINT used a laser thermometer to take the temperatures in the resident rooms. Resident #3 and #4's room was 66 degrees Fahrenheit by the door and 63 degrees Fahrenheit by the window. Resident #5's room was 66 degrees by the door and 64 degrees by the window. The MAINT stated he was going to take apart the heater and figure out what was going on. The ADM was passing out warm hats, and a medication aide brought warm coffee in to serve the residents. Observation and interview on 11/26/24 at 01:13 PM revealed the temperature in the secure unit was no longer cold. The thermostat read 74 degrees. Resident #1 stated she was comfortable now, and she was warm enough. 2. Review of the undated face sheet for Resident #7 reflected a [AGE] year-old female admitted to the facility on [DATE]. Review of the quarterly MDS assessment for Resident #7 dated 08/13/24 reflected a BIMS score of 12, indicating intact cognition. Observation and interview on 11/26/24 at 10:41 AM revealed two holes in the drywall in Resident #7's room, scratches in the wall paint behind her bed, and many scratches in the paint on her dresser. Observation also revealed the window screen was bent and no longer fit in the window. Resident #7 stated the holes in the drywall scared her, because she was worried rats and bugs would come into her room. She stated she did not know if any bugs or rats had come inside. She stated the scratches in the paint were ugly, but the facility had said they were going to fix it. She stated she would really like to open her window sometimes and get fresh air. She stated she could not open her window, because the screen was broken. During an interview on 11/26/24 at 03:00 PM, the MAINT stated the company had just been in the building to fix the heater a couple of weeks prior. He stated the problem was the sensor that went from the thermostat to trigger the fan to start blowing out warm air became disconnected. He stated that was what had happened that morning, and he was able to go into the machine and adjust it, and it was now working. He stated the HVAC company would still be coming out, because they thought they had fixed it permanently but obviously had not. The MAINT stated the holes in drywall and paint scratches in the rooms were on the back burner, as there were so many other things that needed fixing in the building. He stated it was an old building, and he had worked there a little over a year, but problems came up every day. He stated he wanted to take all the doors and handrails off, sand them, and repaint them, but the facility owner had told him to wait until they do a complete renovation. He stated he did not know exactly when that would happen, but it was supposed to be coming up soon. He stated Resident #7 had not complained to him about the holes and scratched paint in her room or the window screen. He stated he did not know what the potential negative impact on a resident might be if they had no working window screen or damaged areas of their rooms. During an interview on 11/26/24 at 03:43 PM, the ADM stated the MAINT was the responsible person for ensuring the temperatures in the facility were compliant. She stated she looked at the thermostats each day. She stated she had already turned up the thermostat early that morning, but then when she walked back through, it was still cold, so she had turned it up again. The ADM stated she always did a morning round of the whole facility when she arrived for the day, and she made rounds throughout the day but could not say at what interval she did so. She stated she perceived it was cold in the secure unit that morning, turned the thermostat up to 76 degrees F, and then when she walked through with the surveyor, and it was still cold, so she turned the thermostat up to 79 degrees F. She stated she had put a call out to their HVAC company to come look at it, but the HVAC company had only just been there to ensure everything was working well, and they fixed the exact thing that was not working well that morning. She stated she was not sure of the exact date but would produce the invoice. The ADM stated they generally made all repairs as they came up. She stated the Owner recently visited the building, and they made a list of things that needed to be done. She stated a potential negative outcome of the secure unit being colder than required was it could make the residents sick. She stated a potential negative impact of the holes and scratched paint in resident rooms was it might mess with their minds a little bit. Review of an invoice provided by the ADM on 11/26/24 reflected the service performed by the HVAC company on 11/19/24 was the following: Checked unit operation: flame sensor was unplugged, removed and cleaned the flame sensor, and checked heating operations. No other mechanical issues at this time. Review of the maintenance log from September 2024-November 2024 reflected no mention of any issues with the heater in the facility and no issues related to damage to Resident #7's room. Review of facility policy dated February 2021 and titled, Homelike Environment reflected the following: Residents are provided with a safe, clean, comfortable, and homelike environment, and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, home setting. These characteristics include: A. clean, sanitary, and orderly environment; H. Comfortable and safe temperatures (71 F to 81 F).

Based on observation, interview, and record review the facility failed to maintain the resident's privacy during wound treatments for 2 of 2 resident (Residents #8 and #13) reviewed for privacy. The facility failed to ensure Dr-B and the ADON protected the resident's privacy by closing the curtain and/or the resident's door when performing wound care on Resident #8 and Resident #13. This failure could place residents at risk for embarrassment, shame, and loss of dignity. Findings include: Record review of Resident #8's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Pressure ulcer Stage 3 (skin damage extending into muscle) depression, Hyponatremia (low sodium), Dementia, and Fracture of the lower leg. Record review of Resident #8's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 9, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident #8's Care Plan dated 8/6/24 reflected a Focus area was initiated for Dementia on 5/24/2018 with a goal to maintain current level of cognitive function. Resident #8's interventions included to promote dignity, converse with resident, and maintain privacy while providing care. Record review of Resident #13's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (lung disease), Muscle Wasting, and Abnormality of Gait and Mobility. Record review of Resident #13's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 01, which indicated the resident's cognitive ability was severely impaired. Record review of Resident #13's Care Plan dated 6/25/2024 reflected a Focus area was initiated for Dementia on 1/7/2020 with a goal to maintain current level of cognitive function. Resident #13's interventions included to promote dignity, converse with resident, and ensure privacy while providing care. Record review of Resident #18's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Diabetes Mellitus Type II, Anxiety disorder, depression, and Pressure Ulcer Stage 1 (skin damage is superficial). Record review of Resident #18's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, which indicated the resident's cognitive ability was not impaired. Observation on 10/09/2024 at 8:54 a.m. revealed Dr-B and the making wound care rounds and performing wound care on Resident 8. Wound care was in process with the privacy curtain pulled to the right which left a large gap between the wall and the curtain. Roommate Resident 18 was sitting a few feet from the curtain gap and had a view of care and Resident #8's uncovered body. Surveyor observation from the hallway included a full view of Resident #8's uncovered buttock area when she was turned. Staff corrected the curtain several minutes later. Observation on 10/09/2024 at 9:05 a.m. revealed Dr-B and the ADON making wound care rounds and performing wound care on Resident 13. Wound care was performed with the door open completely and people walking up and down the hallway. Resident was visible from the hall as the wound dressing on her foot was done. Progress of the wound was discussed during the treatment. In an interview on 10/10/24 at 12:47 PM CNA-A stated privacy should be protected during all resident's treatments by pulling resident's curtain, closing shades/blinds, covering resident, and closing the door. She stated that would include all wound care treatments. CNA-A stated it was not acceptable at all for roommates to be able to see the other resident's private body areas during treatments. She stated that could cause the resident to feel exposed, embarrassed, and not to feel good. In an interview on 10/10/24 at 1:42 PM LVN -A stated privacy should be protected during all resident treatments by closing the resident's door and curtain, pulling blinds closed, and limiting exposed body areas to only the part that had to be exposed at that time. She stated that would include wound treatments and that it was not acceptable for a roommate to be able to see the other resident's private body areas. LVN-A stated the negative outcome to the resident if privacy was not maintained would be loss of self-esteem and embarrassment. In an interview on 10/10/24 at 1:45 PM the ADMIN stated privacy should be protected during all resident treatments by closing blinds, closing resident's door and curtain. She stated that would include all wound treatments and that it is not acceptable for a roommate to be able to see the other resident's private body areas. The ADMIN stated the negative outcome to the resident if privacy was not maintained would be shame at personal exposure. In an interview on 10/10/24 at 2:13 pm the DON stated that privacy should absolutely be protected during all resident treatments by pulling the curtain, closing the door, and only allowing the nursing personnel needed in the room. She stated that would include wound care treatments and that it was not acceptable for the roommate to be able to see the other resident's private body areas. The DON stated the negative outcome to the resident if privacy was not maintained would be embarrassment and loss of dignity. A record review of the facility policy titled, Dignity dated 2001 Med-Pass, Inc. with a last revision date of February 2021, reflected the following: Residents are treated with dignity and respect at all times. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on interviews and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 4 residents (Residents #36) reviewed for resident assessments. The facility failed to ensure Resident #36's Quarterly MDS reflected that Resident #36 primary diagnosis of orthostatic hypotension. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. Findings include: A record review of Resident #36's face sheet dated 10/09/24 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36's diagnoses included orthostatic hypotension (a type of low blood pressure that occurs when you stand up after sitting or lying down), age related nuclear cataract bilateral (a common cause of blindness in older adults and the elderly), and ocular pain left eye (sharp and throbbing pain in the eye), muscle weakness (loss of muscle strength of the inability to move a muscle normally), and vascular dementia (occurs when the blood vessels in the brain are damaged, causing problems with thinking, memory, and behavior). A record review of Resident #36's Quarterly MDS assessment, dated 08/07/24, reflected the resident had a BIMS score of 06, which indicated severe cognitive impairment. Resident #36's Quarterly MDS did not reflect Resident 36's current primary diagnosis of orthostatic hypotension. A record review of Resident #36's care plan, dated 08/06/2024, did not reflect or address Resident #36's primary diagnosis of orthostatic hypotension. A record review of Resident #36's physician's orders, dated 10/09/2024, reflected Resident #36 had an order dated 06/19/24 for midodrine tablet with special instructions: give at 0700 and at noon. Keep patient sitting or standing for several hours after giving it each time. During an interview with the MDS Coordinator on 10/10/24 at 12:30pm, the MDS Coordinator stated that she was responsible for completing MDS and care plan assessments. The MDS Coordinator stated a Resident #36's MDS assessment should reflected her primary diagnoses of orthostatic hypotension. The MDS Coordinator stated it was mistake she forgot to list Resident #36 primary diagnoses of orthostatic hypotension. The MDS Coordinator stated that if a resident's MDS assessment was inaccurate then the resident may not receive the appropriate care. During an interview with the DON on 10/10/24 at 1:20pm, the DON stated that Resident #36's primary diagnosis of orthostatic hypotension should have been reflected on the MDS assessment dated [DATE]. The DON stated there would be no negative outcome if Resident #36's MDS assessment did not reflect the resident's primary diagnosis because the resident's physician's orders had special instruction when giving her medication for her diagnosis of orthostatic hypotension. During an interview with the ADM on 10/10/24 at 1:45pm, the ADM stated that Resident #36's primary diagnosis of orthostatic hypotension should have been reflected on the MDS assessment. The ADM stated that diagnosis of orthostatic hypotension would cause a person to be dizzy or lightheaded due to blood pressure dropping when standing after lying down. The ADM stated that Resident #36's primary diagnose of orthostatic hypotension should be reflected on her most MDS due to the MDS triggering care plan care areas. The ADM stated if Resident #36's MDS was inaccurate that could cause the care plan to be inaccurate as well. The ADM stated it was the MDS nurses' responsibility for completing the MDS assessments and care plans. The ADM stated she expected staff to thoroughly review residents' records to ensure MDS assessments and care plans are completed accurately. A record review of the facility's Resident Assessment policy, dated 2001 revised October 2023, reflected A comprehensive assessment of each resident is completed at intervals designated by OBRA regulations and PPS requirements. Data from the Minimum Data Set (MDS) is submitted to the internet Quality Improvement Evaluation Systems (iQIES) as required. Policy Interpretation and Implementation 1. OBRA Required Assessment are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessment include: a. Admission Assessment. b. Quarterly Assessment. c. Annual Assessment. d. Significant Change in Status Assessment (SCSA). e. Significant Correction to Prior Comprehensive Assessment (SCPA). f. Significant Correction to Prior Quarterly Assessment (SCQA); and g. Discharge Assessment (return anticipated and return not anticipated). 10. Assessment are completed by staff members who have the skills and qualifications to assess relevant care area and who are knowledgeable about the resident's strengths and areas of decline. 11. All persons who have completed any portions of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 12. Information in the MDS assessment will consistently reflect information in the progress notes, plans of care and resident observations/interviews.

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents (Residents #36) reviewed for comprehensive care plans. Resident #36's comprehensive care plan did not reflect Resident #36's primary diagnosis of orthostatic hypotension. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings include: A record review of Resident #36's face sheet dated 10/09/24 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36's diagnoses included orthostatic hypotension (a type of low blood pressure that occurs when you stand up after sitting or lying down), age related nuclear cataract bilateral (a common cause of blindness in older adults and the elderly), and ocular pain left eye (sharp and throbbing pain in the eye), muscle weakness (loss of muscle strength of the inability to move a muscle normally), and vascular dementia (occurs when the blood vessels in the brain are damaged, causing problems with thinking, memory, and behavior). A record review of Resident #36's Quarterly MDS assessment, dated 08/07/24, reflected the resident had a BIMS score of 06, which indicated severe cognitive impairment. Resident #36's Quarterly MDS did not reflect Resident 36's current primary diagnosis of orthostatic hypotension. A record review of Resident #36's care plan, dated 08/06/2024, did not reflect or address Resident #36's primary diagnosis of orthostatic hypotension. A record review of Resident #36's physician's orders, dated 10/09/2024, reflected Resident #36 had an order dated 06/19/24 for midodrine tablet with special instructions: give at 0700 and at noon. Keep patient sitting or standing for several hours after giving it each time. During an interview with the MDS Coordinator on 10/10/24 at 12:30pm, the MDS Coordinator stated that she was responsible for completing MDS and care plan assessments. The MDS Coordinator stated a Resident #36's care plan should have reflected the residents' primary diagnosis of orthostatic hypotension. The MDS Coordinator stated that if a resident's care plan was inaccurate then the resident may not receive the appropriate care. During an interview with the DON on 10/10/24 at 1:20pm, the DON stated that Resident #36's primary diagnosis of orthostatic hypotension should have been reflected on the resident care plan. The DON stated there would be no negative outcome if Resident #36's care plan did not reflect the resident primary diagnosis because the resident's physician's orders had special instruction when giving her medication for her diagnosis of orthostatic hypotension. During an interview with the ADM on 10/10/24 at 1:45pm, the ADM stated that Resident #36's primary diagnosis of orthostatic hypotension should have been reflected on the resident care plan. The ADM stated it was the MDS nurses' responsibility for completing the MDS assessments and care plans. The ADM stated she expected staff to thoroughly review residents' records to ensure MDS assessments and care plans are completed accurately. The ADM stated if a resident care plan was inaccurate that could cause the resident not to receive the proper care. A record review of the facility's Care Plans, Comprehensive Person-Centered policy, dated 2001, reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 7. The Comprehensive, person-centered care plan will: a. Include measurable objective and time frames. b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including: . c. includes the resident's stated goals upon admission and desire outcomes. d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions.

Based on observations, interviews and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 12 residents' (Resident #34) refrigerators reviewed. Resident #34's personal in-room refrigerator was not monitored for safe temperatures. This deficient practice could place residents who had personal in-room refrigerators at risk of food borne illnesses. The findings were: A record review of Resident #34's face sheet dated 10/10/24 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #34's diagnoses included essential hypertension (a type of blood pressure that develops gradually over time and has to clear cause), major depression disorder (a mental health condition that involves a persistent feeling of sadness, loss of interest, or low mood that last for a long time), Gastro-esophageal reflux disease with esophagitis without bleeding (occurs when stomach contents leak back into the esophagus, causing inflammation and damage), paranoid schizophrenia (type of schizophrenia that involves paranoia and delusions) A record review of Resident #34's Quarterly MDS assessment, dated 08/0824, reflected the resident had a BIMS score of 12, which indicated moderate cognitive impairment. During an observation on 10/08/24 at 9:35am, revealed Resident #34 had a personal room refrigerator with no refrigerator temperature log attached. During an observation on 10/08/24 at 11:50am, revealed Resident #34 had a personal room refrigerator with no refrigerator temperature log attached. During an interview with Resident #34 on 10/08/24 at 9:45am, Resident #34 stated that she had not seen a refrigerator temperature log on her refrigerator in months. During an interview with the NA on 10/10/24 at 2:20pm, the NA stated it was the housekeeper's responsibility to document on the resident's personal refrigerator temperature log daily. The NA stated that if a resident's temperature log was not completed daily the resident's refrigerator may not be cooling correctly. The NA stated if the resident's refrigerator was not working properly then the items in the resident's refrigerator would spoil. During an interview with the HK on 10/10/24 at 2:30pm, the HK said that it was the HKs responsibility to document the resident's personal refrigerator temperature daily. The HK stated he was responsible for completing Resident #34's personal refrigerator's temperatures log. The HK stated that he didn't remember if he completed the temperature log or not. The HK stated each resident that had a personal refrigerator should have a temperature log on it for the housekeeping staff to document the temperature daily. The HK stated if temperatures weren't documented daily the refrigerator may not be working properly. During an interview with the DON on 10/10/24 at 2:50pm, the DON stated that it was the housekeeper's responsibility to document the resident's personal refrigerator's temperature. The DON stated that if a resident's temperature log was not completed daily the refrigerator might not be working properly. During an interview with the ADM on 10/10/24 at 2:55pm, the ADM stated that it was the housekeeper's responsibility to document the resident's personal refrigerator's temperature. The ADM stated that if a resident's temperature log was not completed daily the refrigerator might not be working properly. The ADM stated if a resident's refrigerator was not working properly then that could cause the resident refrigerated items to be spoil or be thrown out. The ADM stated she expect for the housekeepers to document temperatures on the resident's refrigerators daily. A record review of the facility's Refrigerators and Freezers policy, dated 2001 revised November 2022, reflected This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation 1. Refrigerators and/pr freezers are maintained in good working condition. Refrigerators keep foods at or below 41 [degrees] F and freezers keep frozen foods frozen solid. 2. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures.

Based on interview and record review, the facility failed to notify the Resident representative when the Resident experienced a significant change in condition for 1 (Resident #1) of 7 Residents reviewed for Resident rights. The facility failed to notify Resident #1's Family Member or Hospice Agency of his x-ray results that showed he had a left hip fracture on 05/15/24 due to Resident #1 falling on 05/14/24. The facility failed to notify Resident #1's Family Member or Hospice Agency that he was transferred to the hospital on 05/15/24 due to the left hip fracture which was revealed from an x-ray taken on 05/15/24 due to Resident #1 falling on 05/14/24. This failure could result in the Resident representative not being aware of conditions that may require them to make medical decisions. Findings included: Record review of Resident #'1s face sheet dated 07/18/24 reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included: dementia (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities), diabetes (a group of diseases that result in too much sugar in the blood), left femur fracture (a serious injury that requires immediate medical attention), and repeated falls (frequent falling). Resident #1's face sheet revealed FM was 1st in line to be called. Record review of Resident #1's initial MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 06 indicating Resident #1 had severe cognitive impairment. Section GG-Functional Abilities and Goals revealed Resident #1 required partial/moderate assistance with bathing and personal hygiene and required set-up or touching assistance with toileting hygiene. Record review of Resident #1's progress notes dated 05/16/24 at 11:16 AM and signed by LVN A reflected [Recorded as Late Entry on 05/17/2024 11:22] Daughter called and said that they did not know that her father was sent to the hospital. She said, I wouldn't have sent him to the hospital. He wouldn't be able to go thru surgery anyway. I apologized for not calling her myself thinking the nurse on duty was going to call. Record review of Resident #1's SBAR/Change in Condition form dated 05/17/2024 at 1:53 PM reflected when asked for Name of Responsible Party/Health Care Agent Notified the answer was none. Form was created due to Resident #1 previously falling and x-ray reports revealed resident had a fractured left hip. In an interview on 07/18/2024 at 12:58 PM, LVN A stated Resident #1 had the x-ray done due to the change in condition after the fall he had on 05/14/24. She stated she had gotten the results from the x-ray and called and informed the doctor that resident had a left hip fracture. She stated the doctor gave orders to transfer Resident #1 to the emergency room for evaluation and treatment. She stated she sent Resident #1 to the hospital and was going to call the RP the next morning because it was late in the evening when Resident #1 went out to the hospital. She stated she did not notify the family or hospice when resident was transferred to the hospital. She stated she sent the Resident #1's face sheet to the hospital when he transferred there via care flight. She stated residents family and hospice was in the facility when the x-ray was ordered but not when the results came back in. She stated she would normally call and inform the family and hospice, if a resident had been receiving hospice services, if a resident was transferred to the hospital, but because the family member and HRN already knew Resident #1 had a possible fracture and the family member worked in a hospital, family member knew they would possibly have to send resident out. She stated she had been trained on notifying RP's, families, and hospice agencies for any change with the residents, including x-ray results and sending resident to the hospital. She stated if she did not notify the family or hospice agency of a resident transferring out of the facility, the family or hospice agency would not have known where the resident was and a wreck with the ambulance or anything could have happened. In an interview on 07/18/2024 at 1:10 PM, the ADM stated it was her expectation that staff would notify family, responsible parties, or hospice when there was any change in condition, new orders received, or transfer to hospital. She stated staff had been trained on notifying families of residents and hospice, if a resident was receiving hospice services, of any emergency transfers. She stated there could have been a delay in treatment if a residents family member or hospice was not notified of a resident transferring to the hospital. She stated she had not been aware that Resident #1's family or hospice agency had not been notified of his transfer to the hospital. In an interview on 07/18/2024 at 2:09 PM with FM, she stated she had initially been informed by the facility that Resident #1 had fallen and had been assessed with no injuries found. She stated the following day she went to the facility and when she tried to get Resident #1 up out of bed, she could tell something was wrong with him. She stated she had brought something to eat for Resident #1, and after they ate, she asked the nurse on duty to help her get Resident #1 back into bed. She stated the HRN came to the facility about 30 minutes later and ordered an x-ray due to Resident #1's foot being turned outward. She stated the facility nurse told HRN she would notify her and the family of the x-ray results when they came in. She stated she or the HRN was not notified of the x-ray results or Resident #1's transfer to hospital. In an interview on 07/18/2024 at 3:49 PM, the HRN stated she was informed by the facility that Resident #1 had a fall, and she went out to the facility to assess Resident #1. She stated upon her assessment she found that Resident #1's left ankle was turned outward which was a sign of a possible fracture, so she ordered an x-ray. She stated Resident #1 only complained of pain when he was moved but when asked if he was in pain, he said no. She stated Resident #1 had a diagnoses of dementia. She stated the staff at the facility had medicated resident with his PRN pain medication as ordered and the medication appeared to be effective. She stated the x-ray was done but she was not notified of the results. She stated when Resident#1's FM called her the following morning to ask for results, she could not reach the facility. She stated she went back to the facility and found that Resident #1 had a fractured left hip and had been transferred to the hospital. She stated she informed the Resident #1's FM and they called the hospital where Resident #1 had been sent. She stated Resident #1 had not received any treatment besides his regularly ordered medication and the hospital had been waiting on the doctor to see Resident #1 for any possible treatment. She stated it was usually up to the family if they want to send a resident out to the hospital for treatment or not, but because this family had not been made aware, they could not make that decision. Record review of facility's policy dated 2001 and revised September 2012 titled Transfer or Discharge, Emergency reflected Policy Statement: Our facility shall make an emergency transfer or discharge when it is in the best interest of the resident. Policy Interpretation and Implementation: 1. Should it become necessary to make and emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: e. Notify the representative (sponsor) or other family member.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and kitchen safety. The facility failed to label and date food products io the refrigerator and thaw foods appropriately. There failures could place residents at risk for food-born illness. Findings included: Observations on 8-22-2023 at 8:30 AM of the facility's refrigerator revealed parmesan cheese and sliced American cheese loosely wrapped, exposed to the air, without labels to signify the date in which the product was opened and when it was supposed to expire. Observations on 8-22-2023 at 8:30 AM of the facility's freezer revealed two large containers of ice cream that were not labeled or dated. The outside of the ice cream tubs were covered in a 1/2 inch layer of frost. Interview on 8-22-2023 at 8:35 AM with the KM revealed she knew that food was supposed to be labeled and dated but was unsure how long the facility policy allowed food to be stored in the refrigerator. She stated that she would check the items that were undated for freshness and either throw them out or affix a label and date. KM stated that they were responsible for ensuring that food subject to spoilage were properly packaged, labeled, and dated. Observations and on 8-22-2023 at 11:15 AM in the facility's kitchen revealed one medium sized package of frozen turkey thawing in a large metal sink basin in 120-degree Fahrenheit water. The turkey in the 120 Degree Fahrenheit was not thawed out; a second medium sized frozen turkey, still frozen solid, was left out at room temperature to thaw on a cart just outside of the freezer door. Interview on 8-22-2023 at 11:15 AM with the KM revealed that soaking the frozen turkey in120-degree Fahrenheit water was not the correct way to thaw food. The KM stated that the correct way to thaw out a frozen turkey was to place it refrigerator in a sheet pan and thawed over the course of 2-3 days. The KM removed the turkey from the 120 degree Fahrenheit water, opened it, and began to cut it with a large serrated knife. The turkey was still visably frozen. The KM put the other frozen turkey, the one that was left out at room temperature to thaw on a cart, back in the freezer Record review of the KM food handlers card revealed a valid date from 7-21-2021 to 7-7-2024 and a Hospitality Manager Diploma dated July 2021. Interview on 8-24-2023 at 8:39 AM with the ADM revealed that she wanted more training about the kitchen requirements so they could provide better supervision. She stated that she did not want anyone to get sick. She stated that food borne pathogens could cause residents to get sick, which could lead to dehydration unintended weight loss, and result in the resident having to be isolated. Record review of the facility's Food and Preparation Service policy, which was dated July 2014, reflected the proper procedure for thawing foods. The policy reflected that food could not be thawed at room temperature. The policy reflected to thaw in the refrigerator in a drip proof container; submerge the item in cold running water (70 degrees Fahrenheit or below); thaw in a microwave oven and then cook and serve immediately; or thaw as a continued cooking process. Record review of the facility's Food Receiving and Storage policy, which was dated July 2014, reflected that all stored in the refrigerator and freezer were to be covered, labeled, and dated.

47772 Based on observation, interview, and record review, the facility failed to maintain an effective ongoing pest control program to ensure the facility was free of pests and rodents for 4 of 8 resident rooms (rooms 1, 3, 5, and 7) reviewed for issues with pest control. The facility failed to follow their pest control company's recommendations to prevent pests' and rodents' entry into the building. This failure could place residents at risk for exposure to diseases carried by rodents. Findings included: Interview on [DATE] at 10:03 AM with the RN on the SU revealed that the SU had recent rodent activity on the SU about 1 month ago. She explained that there was a rodent problem, which stemmed from the closet in one of the resident's rooms. She stated that the previous resident, who had since expired, kept food in their closet. The RN stated that the room number was 3A. Record review on [DATE] of the facility's pest control company, [DATE] inspection, dated [DATE], revealed two pages of their recommendations for the facility to prevent pests from entering the building. On [DATE], the inspector annotated a comment which reflected that a screen was broken on a vent; recommended to repair it to prevent pest entry. Observation on [DATE] at 11:00 AM of the facility's perimeter brick walls revealed a rectangular hole, a vent, which was uncovered. The screen was partially removed, which could allow rodents and pests to enter the building. The vent was on the outer portion of the building which housed the secure unit. Observations and interview on [DATE] at 11:30 AM with the MW resulted in a brief tour outside of the facility. The tour revealed the uncovered vent on the outer perimeter of the building. The MW stated that he was working on a plumbing issue in [DATE] near where the vent was located. He stated he had to remove the screen from the vent but did not secure the screen when he was finished. He stated that the screen was off the vent since [DATE]. The MW stated that the wall on the other side of the vent was the SU's dining room and rooms ,d+[DATE]. The MW stated that he did not get instructions from the ED for pest management or building modifications. Observations on [DATE] at 11:49 AM in Res # 29 and Res # 11's room, 1A and 1B, of the SU revealed multiple small black cylinder-shaped (size of a grain of rice) mouse droppings on the windowsill. Observations on [DATE] at 11:50 AM in Res # 29's room, 3A, revealed dozens of small black cylinder-shaped (size of a grain of rice) mouse droppings in the closet. Interview on [DATE] at 1:15 PM with Res # 29 revealed that he had seen mice in his room recently. He was unable to recall specific dates or times. Observations on [DATE] at 11:53 AM in Res # 41 and Res # 20's room, 5A and 5B, revealed several small black cylinder-shaped (size of a grain of rice) mouse droppings in the closet. Observations on [DATE] at 11:55 AM in Res # 197's room, 7B, revealed dozens of small black cylinder-shaped (size of a grain of rice) mouse droppings on the windowsill. Interview on [DATE] at 10:42 AM with the ADM revealed she did not review the pest control reports. She did not think that there was anything to do in conjunction with the pest control company's reports. The ADM stated that the facility was in a rural area and that critters are always trying to get in the building. The ADM stated that she would start to review the recommendations from the pest control company and assign them to the MW. Record review of the facility's undated pest control policy revealed the facility was to maintain an on-going pest control program to ensure that the building is kept free of insects and rodents; windows are screened at all times; maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 8 of 82 (Rooms #'s 16, 17,18, 19, 20, 21, 22 and 23) resident rooms reviewed for square footage. Rooms 16, 17,18, 19, 20, 21, 22 and 23 which were double occupancy were not 80 square feet per resident. This practice could result in overcrowding in resident rooms. Findings include: During an interview on 08/22/2023 at 10:35 AM with the ADM, she stated she requested a room waiver for semiprivate rooms 16, 17,18, 19, 20, 21, 22 and 23 that were less than 80 sq. ft. per resident. She stated there had been no changes in the rooms. During an observational tour of the resident rooms on 08/22/2023 at 11:11 AM revealed 8 semi-private resident rooms did not provide 80 square feet per resident. The rooms with less than 80 square feet were rooms #16,17, 18, 19, 20, 21, 22 and 23. Review of the HHSC/DADS Form 3740 Bed Classification dated 08/22/2023 revealed rooms 16, 17,18, 19, 20, 21, 22 and 23 were licensed for two residents.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure kitchen staff used proper hand washing and sanitation procedures when handling food. B. Ensure stored food was properly labeled and dated. These failures placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings include: An observation of the kitchen freezer on 6/7/22 at 9:05 a.m. revealed the following: 1. 4 bags of French fries, no label or date, and not in the original box. 2. 1 package of meat, no label or date, and not in the original box. 3. 1 package of fish, no label or date, and not in the original box. 4. 4 packages of diced chicken, no label or date, and not in the original box. In an observation on 06/07/2022 at 11:40 AM revealed Cook A was observed touching various surfaces in the kitchen with gloved hands. Cook A got the lunch serving utensils out of a drawer, placed the utensils in the food items on the steam table, adjusted the rolling rack for the lunch trays and then picked up a clean plate. Cook A then began plating food. Cook A then picked up a piece of chicken with her gloved hand and placed the chicken on the plate. Cook A put a cover on the plate and placed the plate of food in the rolling rack. Cook A picked up another plate and began plating food. Cook A then picked up a piece of chicken with her gloved hand and placed it on the plate without washing her hands or changing her gloves. Cook A was asked about touching food with gloved hands and Cook A stated she should be using tongs to plate the chicken and she should have washed her hands and changed her gloves before plating the food. She stated she just forgot. Cook A stated she could cause residents to get sick from cross contamination by using her dirty gloves to pick up the meat. Cook A stated the DM was in charge of education and she had told dietary staff to wash their hands, change gloves and use tongs. In an observation of the kitchen freezer on 6/8/22 at 9:00 a.m. revealed the following: 1. 1 bag of French fries, no label or date, and not in the original box 2. 2 packages of diced chicken, no label or date, and not in original box In an interview on 06/08/2022 at 10:00 AM, the DM stated she expected the food employees to use tongs when serving food and to wash their hands and change gloves between tasks. The DM stated she will in-service Cook A and all the kitchen staff on proper handwashing. The DM further stated she thought she had labeled and dated all food items. The DM stated she would make sure the foods are labeled and dated from now on. The DM stated the consequences of improper glove changes and not labeling and dating foods would be food borne illness for the residents. Record Review of the facility's undated policy titled Glove Use Policy reflected hand hygiene should be performed before and after the use of gloves Record Review of the facility's undated policy titled Safe Food Handling in the Changing Long Term Care Environment reflected foods should be stored, prepared and distributed under sanitary conditions .Facility must follow proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses. Change gloves if moving to another food activity .Use tongs while handling food Record Review of the facility's policy titled Food Receiving and Storage from the Dietary Services Policy and Procedure Manual 2008 reflected all foods stored in the freezer would be covered, labeled and dated. Record Review of the facility's policy titled Food Service Distribution from the Dietary Services Policy and Procedure Manual 2010 reflected food service staff would wash their hands before serving food to residents and prior to handling food trays .gloves were single use items and must be discarded after each use. Record review of the FDA Food Code, dated 2017, revealed in part: 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD .3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . Record review of the USDA Food Code dated 2017, revealed in part: Preventing Contamination by Employees 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. P (C) FOOD EMPLOYEES shall minimize bare hand and arm contact with exposed FOOD that is not in a READY-TO-EAT form.

Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment; housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; and comfortable and safe temperature levels withing a range of 71 to 81 F for 4 of 40 rooms on 3 of 3 Zones (Zone 3, 5, & 6) and 3 of 3 shower rooms (Shower Room A, B and C) reviewed for environment. A. In Resident #20's shower/bathroom on Zone 3, the temperature was 68.0 F. B. In Residents #8 & # 43's room on Zone 6, the temperature was 64.5 F. C. In Resident #48 & # 24's room on Zone 6, the temperature was 65.0 F. D. In Resident #30's room on Zone 5, the temperature was 70.7 F. E. In Shower Room A on Zone 5, there was scratched paint on the door and door trim, multiple missing tiles on the floor, lightbulbs were out, and a brown splattered substance on the wall behind the toilet. F. In Shower Room B on Zone5, the air vent was covered in dust, the door to the vanity cupboard was missing exposing a soiled urine measuring container, the faucet on the sink had a small stream coming from it, there was grime on the floor behind the toilet and the door and door frame was also scratched up. G. In Shower Room B on Zone 6, there were flies, multiple missing tiles on the floor, trash on the floor behind the toilet and the temperature was 68.8 F. H. On Zone 5, there were multiple scratches on the handrails exposing the bare wood under the paint, all air vents were covered with dust, paint scratched off the walls, approximately 3-5 flies in the dining room, dead bugs inside the light fixtures in the dining room over the tables, cobwebs on the ceiling from the water sprinklers to the light fixtures, missing coverings on the light fixtures exposing the bulbs, dirty air return vents, and debris on the floor These failures could place residents at risk for a diminished quality of life and a diminished clean, safe, and homelike environment. Findings included: During an observation on 06/09/22 at 9:37 AM of room [ROOM NUMBER] on Zone 6 revealed there two residents in the room sleeping, Resident #8 and Resident #43. Both were covered from head to toe with a thick blanket and a heavy comforter. The room temperature was 64.5 F. The air vent in the ceiling was fully open. During the observation Resident #43 sat up and started sneezing. He sat on the side of the bed and was wearing a long-sleeved sweatshirt and sweatpants. An interview was attempted but he didn't answer any questions. During an observation and interview on 06/09/22 at 9:41 AM of room [ROOM NUMBER] on Zone 6 revealed there were two residents in the room. Resident #48 was sitting in his wheelchair wearing a heavy red cardigan sweater. He said he was uncomfortably cold. The temperature in his room was 65.0 degrees. Resident #24 said the housekeepers didn't clean very well, especially in the bathroom/shower room. Resident #24 said sometimes there was water standing in the shower room an inch deep. During an observation on 06/09/22 at 9:47 AM in the secured unit on Zone 5 revealed Resident #30 was in her room lying in her bed asleep. She had a heavy sweater on with a blanket and a comforter covering her body up to her shoulders. The temperature in the room was 70.7 F. During an observation on 06/09/22 at 9:50 AM of Shower Room A on the secured unit on Zone 5 revealed the door was scratched up and showing the wood surface all along the inside edge of the door. Inside of the room, the floor between the shower and the rest of the room had two different types of tile. The edge of the boundary had large grout patches that had no tiles, causing an uneven surface of the floor. The tile wall behind the toilet had a dark brown splattered substance that had dried to the tiles. The black plastic trim along the bottom of the wall had pealed back and onto the floor behind the toilet revealing dirt and grime. The light fixture above the sink did not illuminate and the light in the shower stall also did not illuminate. The overhead light of the room had 2 lights burnt out and the fixture had no cover, exposing the bulbs. The tile floor between the toilet and the vanity had a dark brown stain leading from the toilet to the vanity. The air vent above the toilet was covered in a thick layer of dust. The mirror above the sink had spots on it. There was a square cut out of the wall behind the shower that exposed the pipes. The outlet beside the mirror had no cover on it. The countertop sink on the vanity was not connected on one of the corners, exposing the wood frame. The front of the vanity had scratches in the paint and unknown yellow substances dried onto the cupboard doors. During an observation on 06/09/22 at 9:54 AM of room [ROOM NUMBER] on Zone 3 revealed the temperature in the room was 71 F. The air vent on the ceiling had dust on it and the ceiling surrounding the vent also had dust all around the vent spreading out approximately 12 inches. The temperature of the adjoining shower/bathroom was 68.8 F. During a previous interview on 06/07/22 at 2:04 PM, Resident #20 said she resided in room [ROOM NUMBER]. She said her room was cold and her adjoining shower room was even colder. She said she was always cold, and the air ducts were full of dust. During an observation on 06/09/22 at 10:01 AM of Shower Room C on Zone 6 revealed the door was scratched up along the bottom edge of the door The door trim leading into the room was also scratched along the lower portion of the trim. Inside of the room there were several flies flying around, multiple missing tiles on the floor, and trash on the floor near the toilet. There was an unknown brown substance on the wall behind the toilet. The air vent above the toilet had a thick layer of dust on it. The temperature inside the shower/bathroom was 68.8 F. During an observation on 06/09/22 at 10:07 AM of the secured unit on Zone 5 revealed there were multiple scratches on the hand rails exposing the bare wood under the paint, all air vents were covered with dust, paint scratched off the walls, approximately 3-5 flies in the dining room, dead bugs inside the light fixtures in the dining room over the tables, cobwebs on the ceiling from the water sprinklers to the light fixtures, missing coverings on the light fixtures exposing the bulbs, dirty air return vents, and debris on the floor. In Shower Room B the air vent was covered in dust, the door to the vanity cupboard was missing exposing a soiled urine measuring container, the faucet on the sink had a small stream coming from it, there was grime on the floor behind the toilet and the door and door frame was also scratched up. During an observation on 06/09/22 at 10:18 AM of the hallway in Zone 6 revealed there was a hole in the middle of the ceiling where an air vent would go but the air vent was missing. On the wall near the conference room, above the baseboard, there was a rectangle cut out of the sheetrock that had been patched but not painted over. The doorway separating the hallway of Zone 6 was scratched exposing bare wood. During a follow-up observation on 06/09/22 at 10:50 AM of Shower Room A on the secured unit on Zone 5, there was now a sign sitting on the floor that reflected, Caution Wet Floor. The floor was wet. The room appeared to be in the same condition as it had when observed at 9:50 AM on 06/09/22. During an interview on 06/09/22 at 10:53 AM with Housekeeper B and Housekeeper C, they said Housekeeper B had just cleaned Shower Room A. Housekeeper C said she had worked at the facility for 8 years and no renovations had been done in that time. When asked about the spots still on the mirror, Housekeeper C said those spots wouldn't come off. When asked about the plastic trim along the bottom of the wall that had pealed back and onto the floor behind the toilet revealing dirt and grime, she said the Maintenance Supervisor was supposed to fix that. Housekeeper C said Housekeeping was responsible for maintaining a clean environment. During an interview and observation on 06/09/22 at 10:56 AM with the Housekeeping Supervisor, when shown the shower room/restroom on the secured unit on Zone 5, he said the air vent and the tile behind the toilet should have been cleaned by the housekeepers. He said the Maintenance Supervisor needed to replace the plastic trim behind the toilet and replace the lightbulbs that were burnt out. During an interview, record review and observation on 06/09/22 at 11:01 AM with the Maintenance Supervisor, he said he tried to keep the temperature in the building between 72 F and 75 F. He said the residents tampered with the thermostats and turn the setting cooler sometimes. He said even though the thermostats have a plastic covering on them that are locked with a key, they stick something inside the box to push the buttons to adjust the air temperature. He said everyday he randomly checked the air temperature in the rooms of the facility but did not have a log of these temperatures. He said he did have a daily checklist of duties he did each day. While reviewing the checklist titled, Morning Walk-Through Log it was noted that checking the air temperature throughout the building was not listed. When shown the hole in the ceiling that didn't have an air vent in it and asked what that was, he said, I don't have a clue. I think it should have a cover on it. When shown the large grout patches that had no tiles on the floor in Shower Room A on Zone 5, he said he was replacing tiles throughout the facility and was working his way to this room. The Maintenance Supervisor said he had no assistants to help him and that he was responsible for maintaining the environment. During an interview on 06/09/22 at 11:19 AM with the ADM, she said the room temperatures should be not higher than 77 F and no lower than 70 F. She said they had been working on replacing the missing tiles on the floors. She said they have tried to paint the patches on the walls but couldn't find any matching paint color. Record review of the facility's Maintenance Service policy & procedure revised December 2009 reflected the following: 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Record review of the facility's Quality of Life - Homelike Environment policy & procedure revised April 2014 reflected the following: Policy Interpretation and Implementation 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order. g. Comfortable temperatures.

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 1 of 2 medication aides (MA E) observed for skills competency. The facility failed to ensure MA E had the appropriate competencies and skills to administer medications unsupervised. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills competencies to provide care that is safe and capable of minimizing exposure accidents, hazards, and communicable diseases and infections. Findings include: During an observation on 06/07/22 at 10:20 AM revealed LVN F and MA E conducted a medication pass. LVN F prepared the medications and handed them to MA E to give to the resident. MA E walked in with the medication in the medication cup and was attempting to give them to the resident, however, she could not get the resident to sit up. LVN F then proceeded to walk in the room to assist MA E. When the med aide was asked by this Surveyor if she was going to give the medications, even though she did not prepare them, she stated, I trust her (meaning LVN F). When asked if that was a common practice to not verify the medications before giving them, she said she was new and was not sure of the facility's policy. LVN F said they had done this same process earlier in the day. When asked if this was a common practice to have someone else prepare the medications and then give them to residents without verifying what medications were in the cup, both LVN F and MA E said they were not sure. During an interview on 06/07/22 at 10:54 AM the DON said her expectations regarding one nurse preparing the medications and another MA attempting to give them were that the meds should be given by the person that prepared them. During an observation of a med pass on 06/07/22 at 12:13 PM revealed MA E was passing meds to a resident. MA E said this was her second day working at the facility and she was employed by an agency. MA E completed the med pass on her own with no supervision. During an interview on 06/07/22 at 2:19 PM the DON said MA's should be observed for a minimum of three days by a nurse before passing medications on their own. When asked if the MA E should be passing meds on her own, the DON stated, No. During an interview on 06/08/22 at 9:44 AM the DON said for three consecutive days, the MA in training should be watched with every single medication pass by another nurse or another MA that had been trained. The DON said something could happen to the resident if given medications by a MA that was not fully trained. She said checking off and assessing competency was important. Record review of the facility's Administering Medications policy and procedure revised December 2012 revealed the following: Policy Interpretation and Implementation 1. Only person licensed or permitted by this state to prepare, administer and document the administration of mediations may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 26. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. 27. The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored in locked compartments for 1 of 2 med carts observed. LVN D left insulin pens unattended on top of a med cart. This failure could place residents at risk for drug diversion, drug overdose, and accidental or intentional administration of medications to the wrong resident. Findings include: During an observation and interview of a medication administration on 06/07/22 at 11:51 AM revealed LVN D had a basket with insulin pens inside the basket. LVN D then proceeded into the room to administer the medication to a resident and left the basket with insulin pens on top of the cart unattended. When asked if it was policy to leave medications unattended, she stated, No. It's not like it had a needle so it wouldn't matter. During an interview on 06/07/22 at 11:56 AM, the DON stated no medications should be left unattended. The DON was asked what could happen if a resident was walking by when meds were left on top of the med cart and she said the resident could have taken the medication. Record review of the facility's Administering Medications policy and procedure revised December 2012 revealed the following: Policy Interpretation and Implementation 16. During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to resident or others passing by.

Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 8 of 82 (Rooms #'s 16, 17,18, 19, 20, 21, 22 and 23) resident rooms reviewed for square footage. Rooms 16, 17,18, 19, 20, 21, 22 and 23 which were double occupancy were not 80 square feet per resident. This practice could result in overcrowding in resident rooms. Findings include: In an interview on 06/07/2022 at 09:34 AM, the Administrator stated she requested a room waiver for semiprivate rooms 16, 17,18, 19, 20, 21, 22 and 23 that were less than 80 sq. ft. per resident. The Administrator stated there had been no changes in the rooms. During an observational tour of the resident rooms on 06/7/2022 at 1:35 PM revealed 8 semi-private resident rooms did not provide 80 square feet per resident. The rooms with less than 80 square feet were rooms #16,17, 18, 19, 20, 21, 22 and 23. The square footage for these rooms ranged from 137.17 to 154.9 square feet for rooms certified for two residents. Review of the HHSC/DADS Form 3740 Bed Classification dated 06/07/2022 revealed rooms 16, 17,18, 19, 20, 21, 22 and 23 were licensed for two residents.

Based on observation, interviews and record reviews the facility failed to ensure that each resident received adequate supervision to prevent accidents and hazards for one (Resident #1) of 11 residents reviewed for accidents and hazards. The facility failed to provide adequate supervision and routine resident checks for Resident #1 on the secure unit. The facility failed to have sufficient staffing in secure unit to meet residents' needs. The facility failed to provide adequate supervision or monitoring of residents in secure unit to prevent elopement risk. On 09/09/2021 on or around 3:00 a.m., Resident #1 climbed out of a window of the secure unit dining area. Resident #1 got a ride from a male stranger and was located 30 miles away on or around 9:00 am on 09/09/2021. Midlothian PD was called to complete a welfare check. Within same timeframe Itasca PD was contacted by facility to report missing resident. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 09/10/2021 at 8:12 p.m. While the IJ was removed on 9/15/2021 at 6:02 p.m. the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could affect residents on the secure unit placing them in dangerous situation that could result in injury, harm or death. Findings include: Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Type II Diabetes with unspecified complications, unspecified abnormalities of gait and mobility, unsteadiness on feet, paranoid [CONDITION(S)], [CONDITION(S)], long term drug therapy, [CONDITION(S)], lack of coordination, muscle wasting and atrophy, infection of skin, constipation, [CONDITION(S)] and unspecified mood affective disorder. Review of Resident #1's quarterly MDS dated [DATE], revealed Resident #1 was assessed to have a BIMS score 12 out of 15 indicating moderately impaired. Review of Resident #1's Comprehensive Care Plan dated 8/17/2021 did not address an elopement risk. Review of a care plan dated 09/09/2021 reflected Resident #1 had a high risk for injury, elopement risk factor and or exit seeking behavior. In an interview on 09/10/2021 on or around 12:04 p.m., LVN #1 stated that she worked on the morning of 09/09/2021 the 6:00 am - 2:00 pm shift. LVN #1 stated that she was the charge nurse for the whole building. LVN #1 stated that as a charge nurse she does insulin, blood sugar, skin treatment, chart, call MD, check on residents, answer the door and screen staff and visitors at entry. LVN #1 stated that usually in the morning she will make rounds when boarding shift. LVN #1 stated that rounds are done at 7:00 am. LVN #1 stated that yesterday when she did her rounds, she thought that Resident #1 was in the bathroom. LVN #1 stated that she did not see nor go back to check on Resident #1 because she began her insulin rounds and just got busy. LVN #1 stated that NA#1 informed her that Resident #1 was not present at on or around 8:30 am. LVN #1 stated that NA #1 reported to her she noticed Resident #1 didn't eat breakfast. LVN #1 stated that they then began to search the building. LVN #1 stated the administrator, DON, a medication aide and herself all searched the building. LVN #1 stated that a couple of staff were outside looking as well. LVN #1 stated that when Resident #1 wasn't found in or around the building and that the Administrator and other staff began driving further out from the parking area. LVN #1 stated that when Resident #1 returned later that day, she told staff she went through a window in the dining room of the secure unit. LVN #1 stated that what happened to Resident #1 was neglect, because she was not monitored as frequently as she should have been. In an interview on 09/10/2021 on or around 12:21 p.m., NA #1 stated that she worked 09/09/2021 6am- 2pm shift. NA #1 stated that she began her rounds at 6:20 a.m. NA #1 stated that she didn't see Resident #1 while providing incontinent care for Resident #1's roommate around 7:00 a.m. NA #1 stated that she didn't look in the bathroom, just assumed that Resident #1 was in the bathroom. NA #1 stated that it was around 7:30 a.m. she began passing out breakfast trays. NA #1 stated that while passing out trays she assumed again that Resident #1 was in the bathroom because she does go frequently. NA #1 stated that after breakfast around 8:00 a.m. she realized that Resident #1 had not touched her food. NA #1 stated that she then looked in bathroom, closet room and checked all the other rooms on secure unit. NA #1 stated that she didn't see anything out of place. NA #1 stated that she called LVN #1, the charge nurse. NA #1 stated that she was working alone in secure unit and that there should be two staff working in secure unit at all time. NA #1 stated that they normally have one person working. Interview on 09/10/2021 on or around at 1:11 p.m., Resident #1 showed surveyor the window in dining area of the secure wing and stated that this was how she left the building. Resident #1 stated that she thought the time was around 2 or 3 am in the morning. Resident #1 stated that she didn't see anyone working and just decided she wanted to go to Ft Worth. Resident #1 stated that she walked to either the gas station or golden chick and got a ride with male stranger. Resident #1 stated that while out she had not been hurt nor harmed by anyone and was upset when the gig was up, and cops found her. Resident didn't state how she was aware of the time. In an interview on 09/10/2021 on or around 1:32 p.m., LVN #2 stated she worked the 10 pm -6am shift on 9/8/2021. LVN #2 stated nursing staff should do rounds every two hours. LVN #2 stated that this is documented on the TARS. LVN #2 stated that she saw Resident #1 at 3:10 a.m. and she was walking around. LVN #2 stated that she didn't do any more rounds before shift ended at 6a.m. In an interview on 9/10/2021 on or around 2:09 p.m. with CNA #1, she stated that rounds were completed 4 or 4:30 a.m. and she did not notice that Resident #1 was gone. CNA #1 then stated maybe her time was wrong when she completed her rounds and saw Resident #1. CNA #1 stated that rounds are to be completed every two hours. CNA #1 stated that she did leave the secure unit around 4 a.m. to provide care to a resident in the non-secure area of the facility. CNA #1 stated that no one relieved her during this time. CNA #1 stated that she then left for the day at 5:40 a.m. before scheduled shift ended and again no one relieved her. CNA #1 stated that nurse and management were aware of her early departures. In an interview on 9/10/2021 at 2:27 p.m. CNA #2 stated that she works 6am- 2pm shift. CNA #2 stated that they do rounds every two hours. CNA #2 stated that she was trained on doing rounds and caring for residents. CNA #2 said she completed her rounds and saw Resident #1. CNA #2 stated she they should have been doing their rounds. In an interview on 9/10/2021 with LVN #3 on or around 2:25 p.m., LVN #3 stated that she wasn't on schedule when this occurred. LVN #3 stated that Resident #1 is very independent and not one that she knows to elope. LVN #3 stated that she feels staff should've been doing their rounds every two hours. LVN #3 stated that nurse on shift should've also been completing rounds every two hours. In an interview on 9/10/2021 with Admin on or around 2:36 p.m. the Admin stated that CNA #1 working and LVN #1 were in the building last night. Admin stated that LVN #1 last completed rounds on or around 3:10 a.m. and saw Resident #1. The Admin stated that her expectations was for rounds to be done every two hours. Admin stated that she arrived around 7:50 a.m. and she noticed the middle dining room window was cracked and she closed and locked it. Admin stated that NA #1 called out and asked if Resident #1 was in the hospital. Admin stated that they immediately began looking for Resident #1. Admin stated that she called the local county sheriffs dept at 8:23 a.m. Admin stated that she expected staff to see all their residents when they do rounds. Admin stated that CNA #1 stated that she did her rounds at 4 a.m. but didn't tell the truth. In an interview on 9/10/2021 with DON on or around 3:06 p.m., the DON stated that she was very surprised about this happening. DON stated that the administrator was that only person to see the window cracked. DON stated that her expectations of staff was to lay eyes on everyone every two hours. DON stated that she feels they have enough staff working with three aides and one nurse. DON stated that [NAME] should never left her post and the charge nurse didn't know. DON stated that they should've all communicated with each other. DON stated that they do have cameras and she is not sure if they work, she stated that she should've made sure someone was there. DON stated that she hasn't seen any behaviors in the months that she has worked at facility that Resident #1 would try to elope. In an interview on 9/10/2021 with NA #2 on around 4:31 p.m., NA #2 stated that she worked in the secure unit and completed her rounds at 9 p.m. and saw Resident #1 laying down. NA #2 stated that staff need to complete rounds every two hours. NA #2 stated that she didn't see any open windows because she goes around and check. Observation on 9/10/2021 on or around 9:21 pm. Surveyor observed window in secure unit facing the street with no sidewalks. Observation of a dark [NAME] curve apprroxiamtely .8 miles awasy from facility. Record Review of Midlothian Police Department Narrative Date of report: 2021-09-09 Case Number: 21MP 3 Officer: [NAME], [NAME] Approving Supervisor: [NAME], [NAME] Incident number: 21MP 3 On 9/9/2021 at 0602 hours I, Sgt. [NAME] [NAME] #158, along with other Midlothian Police Department officers, assisted in a welfare check at Gerdau Steel Mill, 300 Ward Road, Midlothian, [NAME] County, TX . I met with Officer Vanderkar at the Midlothian Police Department. Officer Vanderkar had driven [NAME] North to the Midlothian Police Department at 1150 N US HWY 67 in Midlothian. Officer Vanderkar reported that he made contact with [NAME] [NAME], who works at Gerdau. [NAME] reported that at around 0300 hours on 9/9/2021 he was at the Exxon/Golden Chick in Itasca, TX, which is located at the exit for FM 934 on I 35W. [NAME] stated that [NAME] was at this gas station and approached him and asked for a ride to [NAME]. [NAME] stated that he took [NAME] to [NAME] but [NAME] then changed her mind and didn't want to stay in [NAME]. [NAME] then took [NAME] with him to Gerdau where he allowed her to wait in his vehicle with the air conditioning running, since [NAME] did not appear to know where she wanted to go or what she wanted to do but seemed to need help of some kind. [NAME] stated that [NAME] exited his vehicle and began walking around the facility at Gerdau so he decided to tell her she needed to leave. [NAME] stated that [NAME] did not appear to have the means to leave and was also reluctant to do so; [NAME] contacted Midlothian Police Department. Midlothian officers felt that [NAME] may be a victim of a crime and they felt she seemed afraid of speaking in front of [NAME]. For these reasons, they offered to bring [NAME] to the police department. Once at the Midlothian Police Department, [NAME] agreed to speak to me. [NAME] stated that she was at the gas station in Itasca because she lives in Itasca but her husband abuses her so she was trying to get to a women's shelter in Fort Worth. [NAME] stated she has been there once before but could not remember the name. [NAME] had no bags with her and seemed slightly unsteady on her feet. [NAME] could not provide us with the name of the street she lives on but was able to give us all other information about herself and knew the year, president, etc. [NAME] seemed to be of sound mind but did appear to be very timid. I asked dispatch to contact Itasca, Hill County, and Euless to check if they were working any type of missing persons case. [NAME] seemed very well cared for and did not appear to be homeless. [NAME] also appeared to be dressed up for a special occasion and was wearing nice jewelry with house shoes, which seemed a strange combination to officers. Eventually, all agencies we contacted confirmed she was not a missing person. In addition, [NAME]'s driver's license did not return with a missing person hit. [NAME] again requested to be taken to a shelter. Eventually, Daniel's Den arranged for [NAME] to be taken to a homeless shelter in Arlington. Shortly after [NAME] left, Itasca PD contacted us at around 0900 hours and reported that [NAME] was a patient at the Homestead Nursing and Rehab Center in Itasca and she had escaped the facility sometime in the night. [NAME] was returned to the Midlothian Police Department where employees from Homestead eventually came to retrieve her around 1130 hours. Homestead Nursing and Rehab advised our dispatch center that [NAME] had a violent episode last night so she was placed in isolation and must have escaped out of the window of this room. Due to the fact that staff at the nursing facility did not know [NAME] was missing for what appears to be almost 5 hours, I filed a complaint with the Department of Health and Human Services (intake number 4). The equipment in interview room #3 was active during this incident. Record Review of TAR for September 2021 revealed that all rounds had been completed every two hours and checked off each shift. Record Review of Progress Notes reflected, an entry dated 8/8/21 at 12:18 p.m. stating, Resident #1 Requires supervision due to behavioral issues and impaired decision-making ability. Record Review of Routine Resident Check policy dated 9/15/2021 Staff shall make routine checks to help maintain resident safety and well-being. Policy Interpretation and Implementation 1.To Ensure the safety and well-being of our residents, nursing staff shall make routine checks on each unit every 2 hours each 8-hour shift. 2. Routine checks involve entering the resident's room and or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the residents' condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting the routine check shall report promptly to the nurse supervisor/charge nurse any changes in the resident's condition and medical needs. 4. The nursing supervisor/charge nurse shall keep documentation related to these routine checks, including the time, identify of the person making checks and outcomes of each check. (Note: CNA's may also record this information and provide to nurse supervisor/charge nurse) Elopement policy revised [DATE] Policy Interpretation and Implementation 1. Staff shall promptly report any residents who tries to leave the premises or is suspected of being missing to the charge nurse or DON. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the charge nurse or DON that the resident has left the premises. 3. When departing individual returns to the facility, the DON or charge nurse shall: a. Examine the resident for injuries b. Notify the Attending Physician c. Notify the resident legal representative (sponsor) of the incident d. Complete and file report of incident/accident and e. Document the event in the resident medical record 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass b. If the resident was not authorized to leave initiate a search of the building (s) and premises. c. If the resident is not located, notify the Administrator and the DON, the resident's legal representative (sponsor), the Attending Physician, law enforcement and necessary volunteer agencies Emergency Management Rescue Squad d. Provide search teams with resident identification and e. Initiate an extensive search of surrounding area. The administrator was notified on 9/10/21 at 8:12 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was provided to the administrator. The facility's Plan of Removal was accepted on 9/15/21 at 06:15 PM and included: Itasca Nursing and Rehabilitation 09/15/2021 Plan of Removal On 9/9/21, Resident #1 received a full body assessment by nursing staff, no concerns emotionally or physically were identified. On 9/9/21 the resident was seen, and her medications assessed by the psychiatric NP. On 9/10/21, the resident was seen and assessed by her physician, no concerns emotionally or physically were identified. On 9/9/21, nursing administrative staff assessed all other residents for emotional or physical harm on the secured unit no concerns were identified. On 9/9/21, nursing administration re-assessed secured unit residents for risk of elopement utilizing a EMR assessment. On 9/12/21, Motion censored alarms placed on the 15 windows in the secure unit. Staff was educated on the use of the motion censored alarms. On 9/9/21, the regional director of operations re-educated the administrator on fully investigating and reporting elopements and or incidents and accidents in the facility. On 9/9/21, the facility administrator disciplined staff who left the secured unit unattended and they received a final warning. On 9/10/21, the regional nurse consultant educated nursing staff on the following. 1. Staff will not leave the facility or the secured unit until their replacement staff has arrived. 2. Secured unit C.N.A. will not leave for breaks until relieved by another nursing staff for any reason. 3. One (1) C.N.A. will have full visual view of the hallway and dining room to identify any residents tampering with any area capable of exit. 4. If a resident requires one-to-one assistance, the C.N.A. will ask the charge nurse to come and/or assign another staff to assist with the task on monitoring the hallway and dining room until the task is completed. 5. The C.N.A. will also inform the charge nurse of any resident requiring the assistance of two (2) CNAs so that the nurse may monitor the hallway and dining room. 6. The charge nurse will make full secured unit rounds at the beginning of every shift with the oncoming C.N.A. to validate that there are no concerns and that all residents are accounted for. 7. The interdisciplinary team will make routine assigned rounds daily during regular business hours and report any concerns immediately to the administrator. 8. The night nurse will make rounds every 2 hours at night. 9. An assigned staff will make rounds on the weekends. Nursing staff not attending. This education will be required to receive it before beginning their next assigned shift. On 9/9/21, all elopement risk assessments reviewed and updated for all secure unit residents. Also, all secure resident care plans were updated. On 9/10/21, the regional nurse consultant initiated an abuse/neglect in-service with facility staff. On 9/11/21, Education on regarding removing screws to windows and placing censor alarms on windows. Also, on fire safety if a window is the only exit not impeded by fire. On 09/11/21, Audit tools were put into place for all mentioned rounds by managers, visual safety checks, window motion sensors and for monitoring that at least one person is always on unit. On 9/12/21, policy was changed to q 2-hour rounds, but q 2-hour rounds were being done prior. On 09/13/21, all physician orders were reviewed and updated to reflect reason for being on secure unit. Updated all consents for residents on secure unit. All residents will be reviewed quarterly and prn by interdisciplinary team for still meeting criteria for secure unit. Trials off unit will be done if criteria are borderline. On 9/13/21 educations were completed for obtaining consents on admission &/or prior to placing resident on the secure unit. Educated on Elopement Risk Assessments to be done on admit, quarterly and as needed. On 9/14/21 educations completed for Interventions that need to be done prior to placing a resident on the secure unit to reside and if resident is placed that re-eval of the need is to be completed at least quarterly and prn. On 9/14/21, Resident C. North was sent to in-patient psychiatric hospital Oceans for medication review and treatment. The administrator will make daily rounds for one (1) week and randomly thereafter to identify any concerns on the secured unit. The interdisciplinary team will make routine assigned rounds daily during regular business hours and 1 time a week and prn at night. Assigned staff will make rounds on the weekends. Night nurses will make rounds q 2 hours at night. Any concerns will be reported immediately to the administrator. The administrator will bring any concerns to the monthly quality assurance performance improvement meeting for tracking, trending, and further interdisciplinary team recommendations. The Plan of Removal was monitored until the Immediate Jeopardy was lowered. Interview on 9/13/2021 on or around 5:27 a.m. with ADON. ADON stated with rounds the nurse and or CNA should make see the face to see the condition of resident when arrive on shift. If you don't see a resident, you will need to look for them. If not located notify charge nurse or DON. This will then send out for code white which means someone missing. ADON stated that they now have to check windows as a part of rounds. ADON stated that the facility has since placed motion sensor alarms on the windows. ADON stated that they have in-serviced on elopement, doing rounds, security checks, fire safety, abuse and neglect and fifteen minutes checks. Observation om 9/13/2021 on or around 5:31 a.m., sensor on windows chimed when surveyor moved curtain. Observation of nursing staff 10 pm- 6 am and 6 am- 2 pm complete rounds at 5:45 am. They each walked the hallway and visually checked each room for residents. Interview on 9/13/2021 on or around 7:32 a.m., with CNA #3. CNA #3 stated that rounds are to be completed every two. CNA #3 stated that if a resident is incontinent you would change and if they are not you will make visual contact with resident supply hydration and see if they have needs to be met. CNA #3 stated that both the aide and charge nurse should've been completing rounds and are lucky resident #1 is alive. CNA #3 stated that they did in-service elopement, routine checks, abuse and neglect, supervision and secure unit. CNA #3 stated that she learned to make sure staff doesn't leave the secure unit without another aide or charge nurse on it. CNA #3 stated that you also have to keep constant visual on hall when not assisting a resident. Interview on 9/13/2021 on or around 8:11 a.m., CNA #4 stated that a round consist of checking on a resident for incontinent care and if not, incontinent care she checks for any needs to be met. CNA #4 stated that if she doesn't see a resident, she will go look for them. CNA #4 stated that if she can't find them, she will go and ask another aide. CN #4 stated that they have been in-serviced on 15 minutes interval check, checking the windows and doing a walk around with previous aide before they leave shift. On 09/15/2021 at 06:15 PM, the administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to continue to monitor the effectiveness of their plan of correction.

Based on interview and record review, the facility failed to ensure residents were free from neglect for one of seven residents (Resident #1) reviewed for neglect, in that; Resident #1 was not positioned in her wheelchair as per her assessment and care plan. On 8/20/2020, Resident #1 fell out of her wheelchair and sustained a [MEDICAL CONDITION]. This failure could place residents at risk of not receiving care and services to meet their needs, resulting in injury, illness, and death. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed no BIMS score. Further review revealed the resident required total assistance of one to two persons for mobility, transfer, and locomotion. Record review of Resident #1's Care Plan dated 08/20/2020, revealed Resident #1 had history of falls: has experienced a fall due to confusion and stated resident rocks legs back and forth causing her to slide down in chair, wheelchair has to be in tilt back position. The goal states Resident#1 will have no falls and be free from significant injury through next review date. The approaches include: attempt to discover cause and resolve reasons for falls, conduct fall assessment per policy, monitor for pain during task, notify physician/responsible party as needed of issues, provide assistance as needed, document ADL performance of resident and assistance provided by staff per policy, provide assistance as needed to perform transferring as needed, provide needed equipment, refer to therapy prn. Continued review revealed Resident#1 is at risk for falls due to confusion and requires total assistance. The goal stated Resident#1 will have one or fewer falls and be free from significant injury through next quarter. The approaches stated call bell in reach, fall risk assessment per policy, notify charge nurse, Responsible Party and/or physician as appropriate of changes, Physical therapy to evaluate for safe wheelchair positioning and caregiver training. Record review of Resident #1's Progress note dated 08/13/2020, at 6:22 pm, revealed the resident was seen sliding out of wheelchair and nurse guided her down to the floor. Progress note dated 8/20/2020, at 4:30 pm, revealed resident found lying on floor in room in front of wheelchair. Resident's wheelchair wasn't in tilt back position. Progress note dated 8/27/2020, at 3:15 pm, as late entry on 8/28/2020, at 11:17 am, revealed resident to have 2+ [MEDICAL CONDITION] to lower leg and foot. Progress note dated 8/28/2020, at 9:45 am, as late entry on 9/2/2020, at 9:45 am, revealed noted bruising to inside of left thigh. Progress note dated 8/28/2020, at 10:00 am, revealed [MEDICAL CONDITION], redness and swelling. Progress note dated 8/29/2020, at 4:53 pm, revealed that physician was notified of left [MEDICAL CONDITION] and an order for [REDACTED]. Record review of facility Incident report dated 9/2/2020, revealed incident occurred 8/20/2020, Resident #1 was found lying on floor next to her wheelchair. Resident #1 is non-verbal and has contracted legs and arms. Post assessment, nurse and nurse aide positioned resident back in w/c with slight recline to w/c back as this is the usual position of the chair. Resident #1 was no longer in the facility. In an interview on 9/14/2020, at 12:03 pm, LVN-A stated she had received in-service and training on resident rights, abuse and neglect. She stated an example of abuse would be yelling at a resident and example of neglect would be refusing to feed them. She stated she had not witnessed abuse or neglect but would report it to the Administrator. In an interview on 9/15/2020, at 2:48 pm DON stated there was no documentation that Resident #1's wheelchair should have been reclined. She stated the seat had not been dropped, but intermittently the back would be reclined. At the time the resident was found on the floor, the back was not reclined. She stated the staff felt, the resident may not have scooted out of her chair, if the back had been reclined. She stated during the assessment at the time of the fall, there were no visible signs or symptoms of pain or injury. The resident was assisted back to bed. She stated eight days later the swelling and bruising appeared, so an X-ray was ordered which revealed a fracture and the resident was transported to ER for medical treatment. She stated when the resident was discharged from the hospital her family requested she be sent to another nursing facility to be closer to the family. In an interview on 9/15/2020, at 3:11 pm, CNA-B, stated she had been off for several days and returned to work on 8/26/20. She stated she noticed Resident #1's left leg was swollen, she stated she reported it and was told it was normal disease issues. On 8/27/20, she was providing incontinent care for the resident and noticed a bruise around the left groin area and notified the nurse. She stated on 8/27/2020, the Administrator had done ROM with the resident prior to her going in to provide incontinent care. She stated on 8/28/20, she asked CNA-C to assist her when she was changing Resident #1 and she noticed the bruise was lighter in color, but it was farther down the leg. In an interview on 9/15/2020, at 3:15 pm CNA-C stated she was working on 8/27/2020, and was asked by CNA-B to assist with changing Resident #1. She stated she noticed bruising around the groin area of the left leg. She stated CNA-B told her it was bigger than the day before and had moved farther down her leg. She and CNA-B reported it to the Administrator and an X-ray was ordered that day. On 9/14/2020 and 9/15/2020, an interview with the administrator who was the facility Abuse and Neglect reporting coordinator was not possible, as she was out for personal reasons. Record review of the complaint report submitted by SW-E, for the hospital, revealed Resident #1 had a [MEDICAL CONDITION] hip. The hospital doctor was concerned, and nursing staff at the facility had noticed left hip swelling and that the resident was in pain. The report stated this had to be a bad fall to be consistent with the swelling and pain. Resident #1 was not a candidate for surgery with extensive knee and hip flexion contractures and is non-weight bearing for the lower extremities. The facility policy and procedures titled Abuse and Neglect - Clinical Protocol dated 2005, (Revised April 2013) revealed in part: . Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness . The facility management and staff will institute measure to address the needs of residents and minimize the possibility of abuse and neglect. In-service Logs dated 8/29/2020, revealed training was provided for Falls and Post Fall assessments and Proper Positioning.

Based on interviews and record reviews, the facility failed to ensure that residents environment remained as free of accident hazards as possible for one of seven residents reviewed for accidents (Resident #1) . Resident #1 was not postioned appropriately in her wheelchair, fell out and sustained a [MEDICAL CONDITION] hip on 8/20/2020. This failure could place residents at risk of not receiving care and services to meet their needs, resulting in injury, illness, and death. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS dated [DATE] revealed no BIMS. Further review revealed the resident required total assistance of one to two persons for mobility, transfer, and locomotion. Record review of Resident #1's Care Plan dated 08/20/2020, revealed Resident #1 had history of falls: has experienced a fall due to confusion and stated resident rocks legs back and forth causing her to slide down in chair, wheelchair has to be in tilt back position. The goal states Resident#1 will have no falls and be free from significant injury through next review date. The approaches include: attempt to discover cause and resolve reasons for falls, conduct fall assessment per policy, monitor for pain during task, notify physician/responsible party as needed of issues, provide assistance as needed, document ADL performance of resident and assistance provided by staff per policy, provide assistance as needed to perform transferring as needed, provide needed equipment, refer to therapy prn. Continued review revealed Resident#1 is at risk for falls due to confusion and requires total assistance. The goal stated Resident#1 will have one or fewer falls and be free from significant injury through next quarter. The approaches stated call bell in reach, fall risk assessment per policy, notify charge nurse, Responsible Party and/or physician as appropriate of changes, Physical therapy to evaluate for safe wheelchair positioning and caregiver training. Record review of Resident #1's Progress note dated 08/13/2020, at 6:22 pm, revealed the resident was seen sliding out of wheelchair and nurse guided her down to the floor. Progress note dated 8/20/2020, at 4:30 pm, revealed resident found lying on floor in room in front of wheelchair. Resident's wheelchair wasn't in tilt back position. Progress note dated 8/27/2020, at 3:15 pm, as late entry on 8/28/2020, at 11:17 am, revealed resident to have 2+ [MEDICAL CONDITION] to lower leg and foot. Progress note dated 8/28/2020, at 9:45 am, as late entry on 9/2/2020, at 9:45 am, revealed noted bruising to inside of left thigh. Progress note dated 8/28/2020, at 10:00 am, revealed [MEDICAL CONDITION], redness and swelling. Progress note dated 8/29/2020, at 4:53 pm, revealed that physician was notified of left [MEDICAL CONDITION] and an order for [REDACTED]. Record review of facility Incident report dated 9/2/2020, revealed incident occurred 8/20/2020, Resident #1 was found lying on floor next to her wheelchair. Resident #1 is non-verbal and has contracted legs and arms. Post assessment, nurse and nurse aide positioned resident back in w/c with slight recline to w/c back as this is the usual position of the chair. Resident #1 was no longer in the facility. In an interview on 9/14/2020, at 12:03 pm, LVN-A stated she had received in-service and training on resident rights, abuse and neglect. She stated an example of abuse would be yelling at a resident and example of neglect would be refusing to feed them. She stated she had not witnessed abuse or neglect but would report it to the Administrator. In an interview on 9/15/2020, at 2:48 pm DON stated there was no documentation that Resident #1's wheelchair should have been reclined. She stated the seat had not been dropped, but intermittently the back would be reclined. At the time the resident was found on the floor, the back was not reclined. She stated the staff felt, the resident may not have scooted out of her chair, if the back had been reclined. She stated during the assessment at the time of the fall, there were no visible signs or symptoms of pain or injury. The resident was assisted back to bed. She stated eight days later the swelling and bruising appeared, so an X-ray was ordered which revealed a fracture and the resident was transported to ER for medical treatment. She stated when the resident was discharged from the hospital her family requested she be sent to another nursing facility to be closer to the family. In an interview on 9/15/2020, at 3:11 pm CNA-B she stated she had been off for several days and returned to work on 8/26/20. She stated she noticed Resident #1's left leg was swollen, she stated she reported it and was told it was normal disease issues. On 8/27/20, she was providing incontinent care for the resident and noticed a bruise around the left groin area and notified the nurse. She stated on 8/27/2020, the Administrator had done ROM with the resident prior to her going in to provide incontinent care. She stated on 8/28/20, she asked CNA-C to assist her when she was changing Resident #1 and she noticed the bruise was lighter in color, but it was farther down the leg. In an interview on 9/15/2020, at 3:15 pm CNA-C stated she was working on 8/27/2020, and was asked by CNA-B to assist with changing Resident #1. She stated she noticed bruising around the groin area of the left leg. She stated CNA-B told her it was bigger than the day before and had moved farther down her leg. She and CNA-B reported it to the Administrator and an X-ray was ordered that day. On 9/14/2020 and 9/15/2020, an interview with the administrator who was the facility Abuse and Neglect reporting coordinator was not possible, as she was out for personal reasons. Record review of the complaint report submitted by SW-E, for the hospital, revealed Resident #1 had a [MEDICAL CONDITION] hip. The hospital doctor was concerned, and nursing staff at the facility had noticed left hip swelling and that the resident was in pain. The report stated this had to be a bad fall to be consistent with the swelling and pain. Resident #1 was not a candidate for surgery with extensive knee and hip flexion contractures and is non-weight bearing for the lower extremities. In-service Logs dated 8/29/2020, revealed training was provided for Falls and Post Fall assessments and Proper Positioning.