Every finding on record at Avir at Madisonville

Based on observation, interview and record review the facility failed to ensure to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for three of three medication carts ( A hall and B hall medication cart and A/D hall nurses' medication cart).1. The facility failed to ensure that the medications and/or biological stored in the A hall medication cart were not expired.2. The facility failed to ensure that the medications and/or biological stored in the B hall medication cart were not expired.3. The facility failed to ensure that the medications and/or biological stored in the A/D hall nurses' medication cart were not expired. This deficient practice could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment.The findings included:An observation on 06/04/2026 at 11:10 AM of the A hall medication cart with MA A revealed a bottle of Artificial Tears eye drops with an expiration date of 05/2026.An observation on 06/04/2026 at 11:17 AM of the B hall medication cart with LVN B revealed a bottle of Vitamin B-Complex tablets with an expiration date of 04/2026.An observation on 06/04/2026 at 11:56 AM of the A/D nurses' medication cart with LVN B revealed a tube of Diclofenac Sodium Topical Gel, 1% with an expiration date of 04/2026.During an interview on 06/04/2026 at 11:12 AM MA A stated the staff who have the keys are responsible for checking the carts for expired medications. MA A stated if expired medications are used for residents, then the medication may not be processed as intended in the resident's body. During an interview on 06/04/2026 at 11:20 AM LVN B stated the person responsible for the cart was responsible for checking for expired medications in the medication carts. LVN B stated medications may not be as effective if administered to residents after the expiration date.During an interview on 06/04/2026 at 11:34 AM the Director of Nurses stated the staff members who are responsible for the medication carts are responsible for checking for expired medications. The Director of Nurses stated if medications are used for the residents, then the expired medication could make the resident sick, or the potency of the medication could be affected. He stated the pharmacist monitored the medication carts monthly to ensure all expired medications and supplies were removed.During an interview on 06/04/2026 at 11:45 AM the Administrator stated the nurses and medication aides were responsible for checking for expired medications on the medication carts. She stated using expired medications for residents could make the residents sick or affect the potency of the medication. She stated the Director of Nurses and the Pharmacist was responsible for monitoring to ensure that the nurses and medication aides removed the expired medications from the medication carts. Review of facility policy titled Medication Labeling and Storage, dated 2001 and last revised February 2023, reflected: ,,,Policy Interpretation and ImplementationMedication Storage.3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.Medication Labeling.6. Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 medications room observed for infection prevention and control.The facility failed to ensure that hypodermic needles stored in the medication storage room were not expired.This failure could place residents at risk for infection, hospitalization, and decreased quality of life.The findings included:An observation on [DATE] at 10:48 AM in the medication storage room with LVN B, the following items were revealed to be expired: 1. Ten 21 gauge x 1 inch hypodermic needles with the expiration date of [DATE], 2. Thirty-nine 22 gauge x 1 inch hypodermic needles with the expiration date of [DATE], 3. Three 25 gauge x 1 inch hypodermic needles with the expiration date of [DATE], 4. Eight 22 gauge x 1 inch hypodermic needles with the expiration date of [DATE], 5. One 22 gauge x 1.5 inch hypodermic needle with the expiration date of [DATE].During an interview on [DATE] at 11:12 AM MA A stated the Director of Nurses was responsible for checking the medication room for expired supplies. She stated if expired supplies are used for resident care, then the resident could be exposed to possible infections.During an interview on [DATE] at 11:20 AM LVN B stated the Director of Nurses was responsible for checking the medication room for expired supplies. She stated that using expired supplies on residents increases the resident's risk of infection.During an interview on [DATE] at 11:34 AM the Director of Nurses stated he was responsible for checking the medication room for expired supplies. The Director of Nurses stated if expired supplies are used for the residents, then the expired supply could make the resident sick. He stated the pharmacist monitored the medication room monthly to ensure all expired supplies were removed.During an interview on [DATE] at 11:45 AM the Administrator stated the nurses and medication aides were responsible for checking for expired supplies in the medication room. She stated using expired supplies for residents could make the residents sick. She stated the Director of Nurses and the Pharmacist were responsible for monitoring to ensure that the nurses and medication aides removed the expired supplies from the medication room.Review of facility policy titled Medication Labeling and Storage, dated 2001 and last revised February 2023, reflected: ,,,Policy Interpretation and ImplementationMedication Storage.3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.Medication Labeling.6. Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident # 14 and Resident # 34) reviewed for ADL care. The facility failed to ensure Resident #14 and Resident #34's nails were cleaned on 06/02/2026. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings include:1. Record review of Resident #14's face sheet, dated 06/03/2026, reflected a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #14 had diagnoses which included muscle weakness (the affected muscle cannot move normally or contract with the required power, even when you try as hard as you can), cerebral infarction, unspecified (brain tissue death due to a lack of blood flow, but the exact artery blocked or the specific cause remains unidentified), and cognitive communication deficit (occurs when a person has difficulty communicating because of disruptions in brain functions such as attention or memory rather than a primary language or speech impairment). Record review of Resident #14's admission MDS Assessment, dated 04/09/2026, reflected Resident #14 had a BIMS score of 2, which indicated his cognition was severely impaired. Resident #14 required substantial/ maximal assistance (helper does more than half the effort) with the following: personal hygiene, lower and upper body dressing, and oral hygiene. He was dependent on staff for showers and toileting hygiene. Resident #14 required partial/moderate assistance (helper does less than half the effort) with eating.Record review of Resident #14's Comprehensive Care Plan, completed on 04/20/2026 and revised on the following dates: 04/23/2026, 04/24/2026, 04/27/2026, and 06/2/2026 reflected Resident #14 had impaired physical mobility. Interventions: assist Resident #14 with movements/tasks. Ensure Resident #14 is in proper position for tasks. Resident #14 was dependent on staff for meeting emotional, intellectual, physical and social needs related to immobility and physical limitations. Interventions: Resident #14 needed assistance with ADLs as required during the activity (referring to activity programs). Resident #14 had a cerebral vascular accident (commonly known as a stroke, occurs when the blood flow to a part of the brain is interrupted or reduced. This deprives brain tissue of oxygen and vital nutrients, causing brain cells to die within minutes), and has contractures to all of his extremities. Interventions: Monitor/ document residents abilities for ADLs and assist Resident #14 as needed. Encourage Resident #14 to do what he is capable of doing for self.Observation and interview on 06/02/2026 at 10:52 a.m. revealed Resident #14 was lying in bed. Resident #14's fingernails on his right hand underneath his forefinger, middle and ring fingernails had a blackish/ brownish substance. He stated I don't know when asked about if staff cleaned his fingernails. Resident #14 did not respond to any further questions about his ADL care of fingernails. 2. Record review of Resident #34's face sheet, dated 06/03/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #34 had diagnoses which included muscle weakness (the affected muscle cannot move normally or contract with the required power, even when you try as hard as you can), and nontraumatic subarachnoid hemorrhage, unspecified (a sudden, spontaneous bleed in the space between the brain and the tissues covering it. The bleeding is confirmed, imaging or medical tests have not identified the exact, specific cause of the bleed).Record review of Resident #34's Quarterly MDS Assessment, dated 04/17/2026, reflected Resident #34 had a BIMS score of 13, which indicated his cognition was intact. Resident #34 required substantial/maximal assistance (helper does more than half the effort with personal hygiene, oral hygiene, and upper body dressing. He was dependent on staff with lower body dressing, toileting hygiene, taking off shoes, and showers. Resident #34 was assessed to require supervision or touching assistance with eating.Record review of Resident #34's Comprehensive Care Plan, dated 04/22/2026, reflected Resident #34 had impaired physical mobility. Interventions: assist Resident #34 with movements/tasks. Ensure Resident #34 was in proper position for tasks. Resident #34 had impaired social interaction. Intervention: Provide assistance with ADLs as needed. He had risk for self-care deficit: bathing, dressing, and feeding. Interventions: Evaluate Resident #34's ability to perform ADLs. Provide assistance with ADLs as needed.Observation and interview on 06/02/2026 at 10:42 a.m. Resident #34 was lying in bed watching a talk show on television. Resident #34's fingernails on his left and right hand underneath his middle and ring fingernails had a blackish/brownish substance. Resident #34 did not want to answer any questions. In an interview on 06/04/2026 at 9:15 a.m., LVN B stated the CNAs were responsible for Residents #14's and #34's nail care. She stated nail care was usually completed on Sundays, as needed and during showers. LVN B stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill, such as an infection in the stomach. She stated there was a possibility a resident may have nausea and vomiting. LVN B stated if a resident refused showers, nail care or any type of care the nurses documented in the nurse's progress notes. LVN B stated she was in-serviced on ADL care, and all staff were to report any nail issues with the resident to the nurse. She stated she was not aware of Resident #34 or Resident #14 refusing nail care.In an interview on 06/04/2026 at 9:40 a.m., CNA C stated if a CNA observed any problems with a resident's nails the CNAs was to report it to the nurse supervisor with any resident. CNA C stated the CNAs completed all nail care for residents without a diabetes diagnosis. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as nausea and diarrhea. CNA C stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. CNA C stated anytime a resident refused any type of care she reported it to the charge nurse and the charge nurse would document it in the resident's medical record. CNA C stated she had given some care to Resident #34 and Resident #14, however, she did not recall if they refused nail care.In an interview on 06/03/2026 at 9:20 a.m., the Director of Nurses stated the CNAs were responsible to clean and trim all residents' nails except for the residents with diabetes. The Director of Nurses stated the residents' nails were usually cleaned during shower days and as needed. He stated if a resident ingested blackish/brownish substance there was a potential the resident may experience vomiting or diarrhea. The Director of Nurses stated it depended on the type of bacteria. The Director of Nurses stated he expected nail care to be completed as needed and on shower days. He stated anytime there was an issue with nails the staff was to report it to the nurse supervisor. The Director of nurses stated any refusal of care would be documented on the resident's care plan.Record review of the facility's policy on Activities of Daily Living (ADLs), dated 2001, reflected Residents will be provided with care, treatment, and services appropriate to maintain or improve their ability to carry out activities of daily living ( ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal, and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care).

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 of 3 residents ( Resident #53). The facility failed to ensure the accuracy of the PASARR Level 1 (PL1) screening for Resident # 53. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis psychotic disorders with hallucinations due to physiological condition ( a person is experiencing loss of contact with reality, specifically seeing, hearing, or feeling things that aren't there, as a direct physical consequence of an underlying medical illness) was present upon Resident #53's admission date on 03/29/2022. Resident #53 major depressive disorder (experience major depressive episode with no history of previous depressive episodes - sadness, loss of interest in daily activities) was present on, 02/19/2024, after Resident #53 admission dateThis failure could place residents at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs.Findings included:Record review of Resident #53's face sheet, dated 06/03/2026, reflected a [AGE] year-old male, admitted [DATE], with the following diagnoses: major depressive disorder, single episode, unspecified (present on 02/19/2026) ( a serious mental health condition characterized by intense feelings of sadness, worthlessness, and loss of interest in activities, lasting at least 2 weeks), hallucinations due to physiological condition ( a person is experiencing loss of contact with reality, specifically seeing, hearing, or feeling things that aren't there, as a direct physical consequence of an underlying medical illness) and, insomnia ( a common sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up too early and struggling to return to sleep, resulting in poor sleep quality and significant daytime impairment). Record review of Resident #53's Quarterly MDS Assessment, dated 03/30/2026, reflected Resident #53 had a BIMS score of 13 indicating his cognition was intact. Resident #53 did not have any behavior or psychosis symptoms. He was assessed to have diagnosis of Psychotic disorder - other than schizophrenia ( a mental health condition that causes a significant disconnection from reality) and depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), and insomnia. Record review of Resident #53's Comprehensive Care Plan, revised on 04/16/2026, reflected Resident # 53 was at risk for altered mood status related to inadequate sleep patterns with difficulty falling or staying asleep. Interventions Administer medications as ordered. Record/monitor sleep patterns as needed. Resident #53 had inappropriate behavior of rummaging in drawers and other things that do not belong to him. He had delusional ideas. Interventions: Approach in a calm and reassuring manner. Reinforce positive behavior. Report significant changes in behavior status to MD. Record review of Resident #53's PASARR Level 1 Screening, dated 03/29/2022, reflected that Section C, Primary Diagnosis of Dementia, was marked no, which indicated she did not have dementia, and Mental Illness was marked as No, which indicated Resident #4 did not have a mental illness.Record review of Resident #53's PASARR Level 1 Screening, dated 12/25/2023, reflected that Section C, Primary Diagnosis of Dementia, was marked no, which indicated she did not have dementia, and Mental Illness was marked as No, which indicated Resident #4 did not have a mental illness.During an interview on 06/03/2026 at 1:30 p.m., Resident #53 stated he was not depressed today and had not been depressed over the past several months. Resident #53 stated he had been talking to a therapist in the facility, and it did help. Resident #53 stated he thought he could benefit from more psychiatry visits when he did not feel like his normal self. He stated sometimes he becomes angry and upset. Resident #53 did not want to discuss any further about his mental status and receiving mental health care.Interview on 06/03/2026 at 9:20 am, The Director of Nurses stated Resident #53's PASARR was not coded correctly. He stated Resident #53 had mental illness and on their PASARR forms it was coded they did not. The Director of Nurses stated it was the MDS Coordinators and Social Workers responsibility to review the PASARR forms when a resident was admitted and if the PASARR forms were not correct they were expected to fill out another one and make the corrections. He stated I do not know why Resident #53's PASARR was not coded correctly or was not checked when Resident # 53 was admitted to the facility. He stated Resident #53 did not have a primary diagnosis of Dementia. The Director of Nurses stated Resident #53 may benefit from PASARR services. Interview on 06/04/2026 at 11:15 am, MDS Coordinator/ LVN C stated Resident # 53 had major depression as his diagnosis. She stated the PASARR did not reflect Resident #53 had a mental illness. She stated the hospital had completed Resident #53's PASARR's prior to the residents being admitted to the facility. She stated it was the Social Workers responsibility to review the PASARRs, when residents were admitted , to ensure they were coded correctly. MDS Coordinator/ LVN C stated Resident #53's was missed. She stated there was a possibility Resident #53 may benefit from services from PASARR. She stated Resident #53 did not have a primary diagnosis of Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory). She stated she had been in-service on PASARR's , however, she did not recall the date or time.Interview on 06/04/2026 at 11:35 am, Social Worker stated she was responsible to review the PASARR's when the residents was admitted to the facility. She stated she was not an employee at the facility when Resident #53 was admitted . Social Worker stated she did complete one of the PASARR and did not code it correctly. She stated Resident #53 PASARR was expected to be coded he had a mental illness. Social Worker stated she did not know how she missed not coding it correctly. She stated Resident #53 did not have a diagnosis of dementia. She stated he had a diagnosis of major depression and hallucinations. Social Worker stated it was a possibility Resident #53 may have benefited from PASARR services. She stated he was being seen by a therapist. Social Worker stated she had been in-service on PASARR's but did not recall the date or time of the in-service.Record review of the facilities Policy on PASRR, dated 01/20/2026, reflected The aim of the PASRR program is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed , whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD. Procedure:The PASRR Level 1 Screen (PL1)The facility Admissions Coordinator or designee will ensure the referring entity provides a copy of the PL1 upon admission.In the event the facility is considering an admission from the community (home, homeless shelter, jail, group home, off the street etc.) and if the facility Interdisciplinary Team (IDT) suspects any MI, ID or DD the community Admissions Coordinator prior to admission will contact the LIDDA and follow the preadmission process. The MDS Coordinator or designee will input all other PL1s into the online portal on admission. This includes negative preadmission PL1s, and PL1s for residents who qualify for exempted or expedited status.When it is determined that a PL1 was filled out incorrectly, the MDS Coordinator, Social Worker or designee will reach out to the hospital/responsible case worker and ask them to correct the form.If the referring case worker is unwilling/unable to correct the PL1 that contains a potential error, the social worker or designee will complete and submit a form 1012 (MI) or new PL1 (ID/DD). A subsequent positive PL1 will be entered according to 1012 findings (MI).

Based on interview 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 timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two of six residents (Resident # 14 and Resident # 34) reviewed for care plans. The facility failed to develop a comprehensive care plan to reflect Resident #14 and Resident #34's ADLs as reflected on the MDS.These failures could place residents at risk of not receiving appropriate interventions to meet their medical needs. Findings include:1. Record review of Resident #14's face sheet, dated 06/03/2026, reflected a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #14 had diagnoses which included muscle weakness (the affected muscle cannot move normally or contract with the required power, even when you try as hard as you can), cerebral infarction, unspecified (brain tissue death due to a lack of blood flow, but the exact artery blocked or the specific cause remains unidentified), and cognitive communication deficit (occurs when a person has difficulty communicating because of disruptions in brain functions such as attention or memory rather than a primary language or speech impairment). Record review of Resident #14's admission MDS Assessment, dated 04/09/2026, reflected Resident #14 had a BIMS score of 2, which indicated his cognition was severely impaired. Resident #14 required substantial/ maximal assistance (helper does more than half the effort) with the following: personal hygiene, lower and upper body dressing, and oral hygiene. He was dependent on staff for showers and toileting hygiene. Resident #14 required partial/moderate assistance (helper does less than half the effort) with eating.Record review of Resident #14's Comprehensive Care Plan, completed on 04/20/2026 and revised on the following dates: 04/23/2026, 04/24/2026, 04/27/2026, and 06/2/2026 reflected Resident #14's ADLs were not specific as identified on his MDS Assessment. Resident #14 had impaired physical mobility. Interventions: assist Resident #14 with movements/tasks. Ensure Resident #14 is in proper position for tasks. Resident #14 was dependent on staff for meeting emotional, intellectual, physical and social needs related to immobility and physical limitations. Interventions: Resident #14 needed assistance with ADLs as required during the activity (referring to activity programs). Resident #14 had a cerebral vascular accident (commonly known as a stroke, occurs when the blood flow to a part of the brain is interrupted or reduced. This deprives brain tissue of oxygen and vital nutrients, causing brain cells to die within minutes), and has contractures( the permanent tightening or shortening of muscles, skin , or other connective tissues that prevent normal joint movement) to all of his extremities. Interventions: Monitor/ document residents abilities for ADLs and assist Resident #14 as needed. Encourage Resident #14 to do what he is capable of doing for self. 2. Record review of Resident #34's face sheet, dated 06/03/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #34 had diagnoses which included muscle weakness (the affected muscle cannot move normally or contract with the required power, even when you try as hard as you can), and nontraumatic subarachnoid hemorrhage, unspecified (a sudden, spontaneous bleed in the space between the brain and the tissues covering it. The bleeding is confirmed, imaging or medical tests have not identified the exact, specific cause of the bleed).Record review of Resident #34's Quarterly MDS Assessment, dated 04/17/2026, reflected Resident #34 had a BIMS score of 13, which indicated his cognition was intact. Resident #34 required substantial/maximal assistance (helper does more than half the effort with personal hygiene, oral hygiene, and upper body dressing. He was dependent on staff with lower body dressing, toileting hygiene, taking off shoes, and showers. Resident #34 was assessed to require supervision or touching assistance with eating.Record review of Resident #34's Comprehensive Care Plan, dated 04/22/2026, reflected Resident #34's ADLs were not specific as identified on his MDS Assessment. Resident #34 had impaired physical mobility. Interventions: assist Resident #34 with movements/tasks. Ensure Resident #34 was in proper position for tasks. Resident #34 had impaired social interaction. Intervention: Provide assistance with ADLs as needed. He had risk for self-care deficit: bathing, dressing, and feeding. Interventions: Evaluate Resident #34's ability to perform ADLs. Provide assistance with ADLs as needed. In an interview on 06/04/2026 at 11:15 a.m., the MDS Coordinator stated Resident #14 and Resident #34 had ADLs identified on their comprehensive care plan, however, it was not specific to the type of care each resident needed from staff. She stated the comprehensive care plan information was to reflect the residents' MDS. She stated on each Resident's Kardex ( electronic system for the CNAs to refer to when giving ADL care to the residents)the staff follows does list specific information on what type of care Resident #14 and Resident #34 need. The MDS Coordinator stated their care plan needed to be more specific on what type of care each resident needed. She stated the purpose of having a Comprehensive Care Plan was to inform staff how to give the care each resident needed such as physical, behaviors, emotional, activities, type of diet and any other interventions to prevent falls or any injuries. She stated she was responsible to monitor the care plans to ensure they were correct and completed on time. She stated the IDT met once a week and discussed residents' care plans due that week. She stated she had been in-serviced on care plans, however, she did not recall the date or the time.In an interview on 06/04/2026 at 9:50 a.m., the DON stated his expectation was the care plan to be reviewed during care plan meetings to ensure it was correct. He stated the care plan for each resident was a communication tool for all staff to know exactly what type of care each resident needed. He stated ADLs were documented on the comprehensive care plan, however, it was not specific to what type of care Resident # 34 and Resident #14 needed. He stated Resident #14 and Resident #34's ADLs were on their Kardex which matched the MDS.Record Review on 06/04/2026 at 10:00 a.m. reflected Resident #14 and Resident #34's ADLs identified on their MDS were documented on the Kardex the CNAs follows, however, it was not identified on the comprehensive care plan.In an interview on 06/04/2026 at 10:45 a.m. CNA D, stated Resident #14 and Resident #34's ADLs information of how to give care to both residents was on their Kardex. She stated the CNAs follow the Kardex to know how many staff it takes to give care to a resident. CNA D stated all of their ADL information was provided to them on their Kardex and has been on the Kardex since they were admitted to the facility. In an interview on 06/04/2026 at 12:40 p.m., the Administrator stated her expectations of care plans was the IDT discussed care of each resident during the weekly care plan meeting. She stated there were different residents' care plans due each week and all residents' care plans were updated quarterly and as needed. She stated the IDT was expected to ensure the resident's information to give appropriate care to each resident was documented on the care plan whether it was physical, emotional, resident preference, etc. She stated Resident #14 and Resident #34 did have ADLs documented on their care plan, however, it did not reflect what was documented on the MDS. She stated Resident #14 and Resident #34's ADL information documented on their MDS was reflected on the Kardex the CNAs follow when giving care to the resident. Record review of the facility's Care Plan Policy, dated 2001, reflected the following A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for two of seven residents (Resident #4 and Resident #52) reviewed for care plans.The facility failed to update the comprehensive care plan to reflect Resident #4's triggers of PTSD (Post Traumatic Stress Disorder).The facility failed to update the comprehensive care plan to reflect Resident #52 received in room activity programs. These failures could place residents at risk of not receiving appropriate interventions to meet their psychosocial and medical needs. Findings include: 1. Record review of Resident #4's face sheet, dated 06/03/2026, reflected a [AGE] year-old-male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included post-traumatic stress disorder (a psychiatric condition that can develop in individuals who have experienced or witnessed a traumatic, terrifying, or life-threatening event. It lingers long after the danger has passed, causing intense, disturbing thoughts and emotions that disrupt daily functioning), schizoaffective disorder, bipolar type (a chronic mental health condition where a person experiences symptoms such as hallucinations [hearing voices or seeing objects - a sensory experience that feels entirely real but originates within the mind] alongside mood swings such as happiness to intense bursts of sadness), and Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to perform simple daily tasks).Record review of Resident #4's Quarterly MDS Assessment, dated 04/15/2026 reflected Resident #4 had a BIMS score of 10 indicating his cognition was moderately impaired. He was assessed to feeling down, depressed, or hopeless. Resident #4 had an active diagnosis under section I Psychiatric/ Mood Disorder of PTSD and schizophrenia. Record review of Resident #4's Care Plan, dated 04/21/2026, reflected there was not a focus area on the care plan for PTSD with related person-centered goals and interventions or possible triggers for the PTSD.Observation and Interview on 06/02/2026 at 1:05 p.m. Resident #4 was sitting on the side of his bed watching a talk show on television. He stated no one in the facility has asked him about his PTSD and if there was anything that would trigger an episode of PTSD. He stated he preferred to speak with the social worker about his triggers. 2. Record review of Resident # 52's face sheet, dated 06/03/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #52 had diagnoses which included cognitive communication deficit (an impairment in communication skills caused by disrupted thinking and mental processes- such as attention and memory rather than a primary speech issue), cerebral infarction (occurs when a blood vessel in the brain becomes blocked or severely narrowed, cutting off blood flow. The lack of blood deprives brain tissue of essential oxygen and nutrients, causing the affected cells to die), and depression, unspecified (mood disorder that causes persistent feelings of sadness and emptiness. There wasn't enough information yet to meet the strict criteria for a highly specific condition).Record review of Resident #52's admission MDS Assessment, dated 11/04/2025, reflected Resident #52 had a BIMS score of 11, which indicated his cognition was moderately impaired. Resident #52's activity preferences that were very important to him were the following:Listening to music.Be around animals such as pets.Keep up with the newsDo things with group of people.Do favorite activity.Go outside to get fresh air when the weather was good.Participating in religious services and practices.Record review of Resident #52's Quarterly MDS Assessment, dated 04/17/2026, reflected Resident#52 had a BIMS score of 5, which indicated his cognition was severely impaired.Record review of Resident #52's Comprehensive Care Plan, revised on 04/23/2026, reflected Resident #52's activity care plan was not revised to meet his current activity preferences (receive in room activities).Record review of the list of residents on the in-room activity program, dated 02/16/2026, reflected Resident #52 was to receive in-room activities. During an observation and interview on 06/05/2026 at 11:00 a.m., revealed Resident #52 was lying in his bed. He was looking toward a western movie on his television. He was in constant motion with his legs. Resident #52 did not make eye contact and was not interview able.Interview on 06/2/2026 at 9:15 a.m., the Activity Director stated Resident #52 was on the in-room activity program. She stated all residents were expected to have their care plan revised to meet their activity preferences. The Activity Director stated she did not revise Resident #52's care plan to meet their current activity preferences of receiving in-room activities. She stated she did not realize she did not revise Resident #52's care plan. She stated, if a resident was feeling lonely, had behavior issues or was depressed the staff would not have the information of the activities to use to help the resident.In an interview on 06/04/2026 at 11:15 a.m., the MDS Coordinator stated Resident #4 had a diagnosis of PTSD. She stated it was not documented on Resident #4's comprehensive care plan of Resident #4's PTSD triggers. The MDS Coordinator stated she missed documenting it on the care plan. She stated the purpose of having a Comprehensive Care Plan was to inform staff how to give the care each resident needed such as physical, behaviors, emotional, activities, type of diet and any other interventions to prevent falls or any injuries. She stated she was responsible to monitor the care plans to ensure they were correct and completed on time. The MDS Coordinator stated the information the CNAs followed on the Kardex - (electronic system for CNAs use to know what type of care to give the residents)came from the care plan. She stated if a resident needed a certain type of care or had behaviors and it was not care planned, the CNAs or nurses would not have that information to know what type of care to give the residents. The MDS Coordinator stated it was the Activity Director's responsibility to ensure the activity care plans of the residents' activity preferences were documented on the care plan. She stated the IDT met once a week and discussed residents' care plans due that week. She stated the Activity Director attended weekly care plan meetings.In an interview on 06/03/2026 at 9:20 a.m., the DON stated his expectation was the care plan to be reviewed during care plan meetings to ensure it was correct. He stated Resident #4's diagnosis of PTSD with interventions of Resident #4's triggers were expected to be care planned. He stated the care plan for each resident was a communication tool for all staff to know exactly what type of care and needs each resident needed. The DON stated anytime a mental health issue was documented on the MDS it was expected to be care planned. He stated all residents were expected to have their activity preferences documented on the comprehensive care plan. He stated if a resident was sad or had behaviors, the staff would refer to the care plan to know what their activity preferences were to re-direct the resident.In an interview on 06/04/2026 at 12:40 p.m., the Administrator stated her expectations of care plans was the IDT discussed care of each resident and if there was a change with anything which included resident preferences the care plan was expected to be revised. She stated the IDT was expected to ensure the resident's information to give appropriate care to each resident was documented on the care plan whether it was physical, emotional, resident preference, activities, etc.Record review of the facility's Comprehensive Care Plan, dated 2001, reflected The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly MDS assessment and when a resident experiences a status change. Assessments of residents are ongoing, and care plans are revised as information about the resident and the residents' conditions change.

Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two of six residents (Resident # 5, and Resident #52) reviewed for activities.The facility failed to provide Resident #5 and Resident #11 in room activities two- three times per week from May 18, 2026, to June 1,2026. This failure could place residents at risk for boredom, depression, and a diminished quality of life. Findings include:1. Record review of Resident #5's face sheet, dated 06/03/2026, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #5 had a diagnoses which included unspecified dementia, unspecified severity ( when a person exhibits significant decline in memory and thinking skills, but the exact underlying cause cannot be definitively determined), bed confinement status ( a person is permanently or temporarily confined to bed), and unspecified mood disorder ( a diagnosis mental health professionals use when a person experiences significant emotional distress or impaired daily functioning, but their symptoms do not strictly fit the criteria for a specific mental disorder). Record review of Resident #5's Significant Change MDS Assessment, dated 10/16/2025, reflected Resident #5 had a BIMS score of 4, which indicated severely impaired cognition. Resident #5's vision was highly impaired (object identification in question, but eyes appear to follow objects). The following activities were somewhat important to Resident #5:* Keeping up with the news.Record review of Resident #5's Quarterly MDS Assessment, dated 04/18/2026, reflected Resident #5 had a BIMS score of 5, which indicated severely impaired cognition.Record review of Resident #5's Comprehensive Care Plan, revised on 04/22/2026, reflected Resident #5 needed encouragement to attend group activities he had potential for socialization. Interventions: Offer 1:1 ( in room activities) if group attendance falls below 2 times per week. Resident #5 was dependent on staff for meeting emotional, intellectual, physical, and social needs related his immobility. Resident #5 will maintain involvement in cognitive stimulation, and social activities. Interventions: Review Resident #5's activation needs with the family. Resident #5 needs 1:1 beside/in-room visits and activities if unable to attend out-of-room events. Resident # 5 prefers activities which do not involve demanding cognitive tasks. Resident #5's preferred activities were: reminiscing about his past and watching hunting and fishing shows. Resident #5 prefers the following television channels: fishing, westerns, and hunting.Record review of Resident #5's Activity Progress Notes, in the electronic medical record, reflected in-room activities were not being provided for Resident #5 from 05/18/2026 to 06/01/2026. Record review of the list of residents on the in-room activity program, dated 02/16/2026, reflected Resident #5 was to receive in-room activities. During an observation and interview on 06/03/2026 at 12:15 p.m., Resident #5 was in his room in bed. He was watching a western on television. Resident #5 stated he wished someone would come in his room and talk to him. He stated he would enjoy it very much. Resident #5 stated he would prefer someone to visit with him about 3 or 4 times per week. Resident #5 stated he enjoyed television. He stated television gets old sometimes and he would enjoy someone to talk to. He denied being depressed or sad. Resident #5 stated he did not feel like getting out of bed and going to any activities. He stated he wants someone to come to his room to talk to him.Interview on 06/02/2026 at 9:15 a.m., the Activity Director stated Resident #5 was on the in-room activity program. She stated Resident #5 did not enjoy being out of his room. The Activity Director stated Resident #5 needed in room activities for mental stimulation and for emotional support. The Activity Director stated she had not been providing in-room activities with Resident #5 during the majority of the time in May 2026. She stated she did not have an excuse of why she was not providing Resident #5 in room activities. She stated she had been an Activity Director approximately 2 years. The Activity Director stated she documented activity participation of all residents in their progress notes in the electronic medical records. She stated she did not know the term of activation related to activities. 2. Record review of Resident # 52's face sheet, dated 06/03/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #52 had diagnoses which included cognitive communication deficit ( an impairment in communication skills caused by disrupted thinking and mental processes- such as attention and memory rather than a primary speech issue), cerebral infarction ( occurs when a blood vessel in the brain becomes blocked or severely narrowed, cutting off blood flow. The lack of blood deprives brain tissue of essential oxygen and nutrients, causing the affected cells to die), and depression, unspecified (mood disorder that causes persistent feelings of sadness and emptiness. There wasn't enough information yet to meet the strict criteria for a highly specific condition).Record review of Resident #52's admission MDS Assessment, dated 11/04/2025, reflected Resident #52 had a BIMS score of 11, which indicated his cognition was moderately. Resident #52's activity preferences that were very important to him were the following:Listening to music.Be around animals such as pets.Keep up with the newsDo things with group of people.Do favorite activity.Go outside to get fresh air when the weather was good.Participating in religious services and practices.Record review of Resident #52's Quarterly MDS Assessment, dated 04/17/2026, reflected Resident#52 had a BIMS score of 5, which indicated his cognition was severely impaired.Record review of Resident #52's Comprehensive Care Plan, revised on 04/23/2026, reflected Resident #52 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to immobility and physical limitations. Interventions: Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. Record review of Resident #52's Activity Progress Notes, in the electronic medical record, reflected in-room activities were not being provided for Resident #5 from 05/18/2026 to 06/01/2026. Record review of the list of residents on the in-room activity program, dated 02/16/2026, reflected Resident #52 was to receive in-room activities. During an observation and interview on 06/05/2026 at 11:00 a.m., revealed Resident #52 was lying in his bed. He was looking toward a western movie on his television. He was in constant motion with his legs. Resident #52 did not make eye contact and was not interview able.Interview on 06/02/2026 at 9:15 a.m., the Activity Director stated Resident #52 was on the in-room activity program. She stated she did not have an answer of why Resident #52 did not receive in-room activities. The Activity Director stated if a resident was not receiving activities there was a possibility a resident may become bored or lonely. She stated, It is my responsibility to ensure all residents receives activities. The Activity Director did not respond to any further questions about Resident #52 activity care plan or her process to ensure residents received activities.Interview on 06/04/2026 at 12:45 p.m., The Administrator stated it was very important for the residents unable to come out of their room or unable to participate in group activities to receive activities in their room. She stated the Activity Director was over the activity department and he was her supervisor. She stated there was a possibility that a resident may become lonely if they were not receiving activities in their room. The Administrator stated she expected all activities to be documented on every resident on a daily basis to capture who was attending group activities and what the residents were doing during in-room activities. She stated she expected the participation records to be documented in the Activity Director notes in the electronic medical records.Record review of the Activity Director's personnel file reflected how she began working at the facility on 08/08/2024. She had an activity director certificate and does not have an expiration date.Record review of the Facility Activity Programs Policy, dated 2001, reflected Activity programs are designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident. The activities program was provided to support the well-being of residents and to encourage both independence and community interaction. Activities offered are based on the preferences of each resident. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. All activities are documented in the resident's medical record.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of four residents reviewed for catheter care (Resident #4). The facility failed to ensure Resident #4's urinary drainage bag tubing was untangled and bag was kept from being hung on the garbage can. This failure could place residents with indwelling catheters at risk of developing infections. Findings included:Record review of Resident #4's face sheet, dated 06/03/2026, reflected a [AGE] year-old-male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included retention of urine ( when bladder does not empty completely or at all, the cause can be blockages, medications or nerve issues -nerve damage caused by kidney disease ), benign prostatic hyperplasia with lower urinary tract symptoms ( a noncancerous enlargement of the prostate gland), and obstructive and reflux uropathy (Obstructive uropathy is a blockage in the urinary tract that prevents urine from flowing freely out of the body. Reflux uropathy occurs when urine flows backwards from the bladder toward the kidneys. When labeled as unspecified, it is a general medical classification indicating one or both conditions are present, but the exact cause or location of the blockage/reflux hasn't been specifically).Record review of Resident #4's Quarterly MDS Assessment, dated 04/15/2026 reflected Resident #4 had a BIMS score of 10 indicating his cognition was moderately impaired. He required partial/moderate assistance (helper does less than half the effort) with the following: personal hygiene, showers, lower body dressing. Resident #4 was assessed to have an indwelling catheter.Record review of Resident #4's Comprehensive Care Plan, completed on 04/21/2026, reflected Resident #4 was resistive to proper care/ of his foley catheter bag related to not keeping it in a covered/protective. Interventions: Encourage as much participation/ interaction by Resident #4 as possible during care activities. Give clear explanation of all care activities prior to and as they occur during each contact. Observation on 06/02/2026 at 11:02 a.m. Resident #4 catheter bag was hanging on the garbage can and the tubing had a kink in it. There was overflowing garbage around the tubing and catheter bag.Interview on 06/02/2026 at 11:05 a.m. Resident #4 stated someone in nursing came in his room and picked up his clothes and placed the catheter on the garbage can. He stated, I do not remember the staff name and the staff stated she would remove the catheter from garbage can before she left his room. Resident #4 stated I do not like for the cover to be completely on the urine bag. He did not prefer to respond to any further questions about his catheter. Interview on 06/03/2026 at 9:20 am, The Director of Nurses stated Resident #4's catheter was not to be placed on the garbage can. He stated Resident #4's catheter was to be hanging on the bed off the floor and not on the garbage can. The Director of Nurses stated Resident #4 does refuse have a catheter cover over his bag. He stated Resident #4 may obtain an infection with catheter bag not being around garbage. The Director of Nurses stated there was a possibility if bacteria were in the tubing from the garbage, Resident #4 may develop a Urinary Tract Infection (an infection in any part of your urinary system). The Director of Nurses did not respond to any further questions about Resident #4's catheter.Interview on 06/03/2026 at 4:30 pm, The Administrator stated they follow the catheter policy of keeping the catheter off the floor. She did not respond when asked if it was appropriate for the catheter to be hanging on the garbage can.Interview on 06/04/2026 at 9:15 am, LVN B stated she was not aware of Resident #4 placing his catheter on the garbage can. She stated sometimes he would leave it on the floor when he was angry about something. LVN B stated he does not prefer a cover over his catheter bag. She stated if a catheter bag or tubing was next to garbage there was a possibility a resident may develop an infection from the bacteria. She stated a possible Urinary Tract Infection. She stated she had been in-service on proper catheter care and protocol. LVN B did not recall the date or time of the in-service. Interview on 06/04/2026 at 11:15 am, MDS Coordinator LVN C stated anytime a Resident refuses care or be cooperative with staff during care it should be care planned. She stated Resident #4 refusing to use catheter cover bag was care planned, however, there was nothing else about him being uncooperative about his catheter care planned. MDS Coordinator LVN C stated there was a possibility Resident #4 may obtain bacteria through his catheter tubing if it was located anywhere near garbage. She did not respond to any further questions about Resident #4's catheter. Record review of the Facility's Catheter Care, Urinary Policy, dated July 2024, reflected PurposeThe purpose of this procedure is to prevent catheter-associated urinary tract infections.PreparationReview the resident's care plan to assess for any special needs of the resident.Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.Unless specifically ordered, do not apply a clamp to the catheter.The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.Record review of the facility Catheter Care policy, revised on 10/2022, reflected Proper care will be provided for the management of a foley catheter to drain urine from the bladder and to prevent reflux of urine back into the bladder. The catheter may be anchored or stabilized to prevent urethral tension. It is recommended to anchor on the upper thigh in women or the abdomen in men.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Residents #55) of three residents reviewed for respiratory care. The facility failed to ensure Resident #55's mask for CPAP(Continuous Positive Airway Pressure- a machine that delivers a steady stream of pressurized air through a mask while you sleep, to keep a person's breathing passages from collapsing) was properly stored when not in use on 06/02/2026 and 06/03/2026.This failure could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Record review of Resident #55's face sheet, dated 06/03/2026, reflected a [AGE] year-old male, admitted [DATE] and readmitted on [DATE], with the following diagnoses: obstructive sleep apnea ( a common, potentially serious sleep disorder where breathing repeatedly stops and starts during sleep), and seizures ( it temporarily disrupts how brain cells communicate, which can alter a person's behavior, movements, sensations, or state of awareness). Record review of Resident #55's Annual MDS Assessment, dated 03/30/2026, reflected Resident #55 had a BIMS score of 14 indicating his cognition was intact. Resident #55 was assessed to have a non-invasive mechanical ventilator ( a breathing support treatment that delivers air and oxygen into the lungs using a mask rather than an invasive tube inserted down the throat). Record review of Resident #55's Comprehensive Care Plan, revised on 04/17/2026, reflected Resident # 55 had a CPAP (Continuous Positive Airway Pressure- a machine that delivers a steady stream of pressurized air through a mask while you sleep, to keep a person's breathing passages from collapsing) related to obstructive sleep apnea. Interventions: Address/monitor/ document symptoms of snoring and/or daytime sleepiness. Monitor/observe proper use, fitting of face mask to prevent air leaks and discomfort. Record review of Resident #55's Physician Order, dated 04/06/2025, reflected CPAP machine: clean machine and filter every week on Sunday. Observation on 06/02/2026 at 8:55 am, revealed Resident #55 was sitting in his room. It was observed that the resident had a CPAP machine on top of his bedside table with a mask connected to it, the mask was lying on his bed. Did not observe a plastic bag for the mask. Interview on 06/02/2026 at 8:59 am Resident #55 stated there has not been a plastic bag in his room for several days. He stated he asked a staff about getting a bag for the mask , however, no one brought him a plastic bag. Resident #55 stated he did not recall the staff name or their position. He stated he thought the staff was working with nursing.Observation on 06/02/2026 at 10:34 am, revealed Resident #55 was not in his room. It was observed that the resident CPAP mask continued to lay on his bed.Observation on 06/03/2026 at 8:23 am, revealed Resident #55 was not in his room. It was observed that Resident #55's CPAP mask was in the partially opened drawer to his nightstand.Interview on 06/03/2026 at 8:35 am, The Director of Nurses entered Resident #55 room and stated the mask to the CPAP machine was expected to be in a bag with a date and time on the bag when it was placed in the bag. The Director of Nurses stated there was a potential bacteria that could get into the mask and cause respiratory infection. He stated it was the nurses responsibility to ensure the mask was in zip lock bat to prevent any type of bacteria from getting inside the mask.Interview on 06/04/2026 at 9:15 am, LVN B stated any resident with a mask was expected to have a zip lock bag in the room to store the mask. She stated if a CPAP mask was stored on the residents bed and in a drawer there was a potential the resident may develop respiratory infection from the bacteria inside the mask. She stated she had been in-service on storing any type of respiratory masks, however, she did not recall the date or time. In an interview on 06/04/2026 at 10:50 am, the ADON stated the CPAP mask should be inside a plastic bag when not in use and not just lying on the bed or inside a drawer to maintain its cleanliness. She stated bagging the masks was important to prevent the development of infections. She stated the nurses supervisors was responsible for making sure the staff was bagging the masks. She stated the expectation was for the staff to bag the mask after taking it off and to monitor if the masks was bagged. She stated she had been in-service on storing breathing masks. The ADON stated she did not recall the date or time. In an interview on 06/04/2026 at 12:45 pm, the Administrator stated that the masks should be bagged when not in use to prevent cross contamination and respiratory infection. She said the expectation was that the staff would be compliant in bagging the masks of the residents. She said she would coordinate with the DON and the ADONs to make sure that the staff was following the in-service about bagging the masks.Record review of the facility's Policy, dated 2001, on CPAP/ BiPAP Support reflected General Guidelines for CleaningThese are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device.These guidelines are for single-resident use cleaning.Machines must be preprocessed for use between residents by the supplier of the device.

Based on interview and record review the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 3 residents (Resident #4) reviewed for trauma-informed care. The facility failed to ensure Resident #4 had a trauma screening that identified possible triggers when Resident #4 had a history of trauma. This failure could place residents at an increased risk for severe psychological distress due to re-traumatization. The findings include:1. Record review of Resident #4's face sheet, dated 06/03/2026, reflected a [AGE] year-old-male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included post-traumatic stress disorder (a psychiatric condition that can develop in individuals who have experienced or witnessed a traumatic, terrifying, or life-threatening event. It lingers long after the danger has passed, causing intense, disturbing thoughts and emotions that disrupt daily functioning), schizoaffective disorder, bipolar type (a chronic mental health condition where a person experiences symptoms such as hallucinations [hearing voices or seeing objects - a sensory experience that feels entirely real but originates within the mind] alongside mood swings such as happiness to intense bursts of sadness), and Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to perform simple daily tasks).Record review of Resident #4's Quarterly MDS Assessment, dated 04/15/2026 reflected Resident #4 had a BIMS score of 10 indicating his cognition was moderately impaired. He was assessed to feeling down, depressed, or hopeless. Resident #4 had an active diagnosis under section I Psychiatric/ Mood Disorder of PTSD and schizophrenia.Record review of Resident #4's Comprehensive Care Plan, completed on 04/21/2026, reflected ( problem initiated on 11/29/2024 and revised on 05/06/2026) Resident #4 had trauma informed care: PTSD. Resident #4 did not have a focus area in the care plan for PTSD with related person-centered goals and possible triggers for the PTSD. Interview on 06/02/2026 at 1:05 p.m. Resident #4 stated no one in the facility has asked me about his PTSD and if there was anything that would trigger an episode of PTSD. He stated he preferred to speak with the social worker about his triggers.In an interview with the MDS Coordinator on 06/04/2026 at 11:15 a.m., she stated Resident #4 should have PTSD triggers identified and documented in his medical record. She stated the Social Worker was responsible for ensuring the PTSD triggers was identified when she did her assessment. The MDS Coordinator stated a trauma screening should have been completed upon admission.Interview with the DON on 06/03/2026 at 9:20 a.m., the DON stated the Social Worker was responsible to ensure an assessment was completed on any resident with diagnosis of PTSD. He stated a residents triggers was expected to be identified during the assessment. He did not respond to any further questions about PTSD.Interview with the Administrator on 06/04/2026 at 12:40 p.m., she stated the Social Worker, and the IDT team was responsible to ensure the PTSD triggers was identified during the care plan. She stated the Social Worker was responsible to obtain a Residents PTSD triggers when she completed her assessment.Requested via email to the Administrator on 06/03/2026 the facility policy on Quality of Care or Trauma Informed Care. Interview with the Administrator on 06/04/2026 at 8:00 a.m. she stated the facility did not have a policy specific to Quality of Care related to Trauma Informed Care or PTSD.

Based on interview and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for one of five residents (Resident #1) reviewed for dignity. Housekeeper A failed to speak to Resident #1 in a way that promoted her dignity and self-worth. This failure could place residents at risk of a decline in their sense of dignity, level of satisfaction with life, and feeling of self-worth.Findings include: Record review of Resident #1's face sheet, dated 04/15/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of generalized anxiety disorder ( a chronic mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday things), major depressive disorder, recurrent severe without psychotic features ( a chronic mental health condition with the following symptoms: hopelessness, persistent sadness, and extreme fatigue without any psychotic - a mental state characterized by a severe loss of contact with reality- seeing and hearing things not there and false beliefs), and unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, or mood disturbance ( a clinical diagnosis of cognitive decline- memory loss or confusion- where the specific cause is unknown or not yet determined, and the person does not exhibit aggressive, agitated or psychotic symptoms). Record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 14 indicating her cognition was intact. Record review of Resident #1's Comprehensive Care Plan, dated 03/27/2026, reflected Resident #1 had potential to be verbally aggressive, disrespectful to staff related to dementia. Interventions: Analyze key times, places, circumstances, and what de-escalates behavior and document. Assess and anticipate Resident #1's needs for food, thirst, toileting needs, comfort level, and pain. Assess Resident 1's understanding of the situation and allow time for Resident #1 express self and feelings toward the situation. Provide Resident #1 psychiatric consult as indicated. Resident #1 had depression. Interventions: Administer medications as ordered. Arrange psych consult and follow up as indicated. Monitor/ document/ report as needed any risk for harm to self: suicidal plan, past attempnt at suicide, intentionally to try and harm self, refusing to eat or drink, refusing medications, sense of hopelessness or helplessness, and impaired judgement or safety awareness. Monitor / document / report to MD as needed risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Record review of Resident #1's behavior and mood assessment, dated 03/21/2026, she was not in distressed after an hour of the incident with Housekeeper A. Record review of Resident #1's behavior record reflected Resident #1 did not have any behaviors after the incident on 03/21/2026 approximately 6:00 pm and she was not depressed/ upset within an hour after the incident. Record review of Resident #1's activity participation record in March 2026 and April 2026 reflected Resident activity level/ participation in group activities had not declined. Resident #1 was attending at least 3 activities per week. There was no changes in her socialization with other residents outside of her room. Interview on 04/14/2026 at 9:40 am Resident #1 stated she had an incident with Housekeeper A in March. She did not recall the exact date. She stated it occurred over a weekend. Resident #1 stated she was going to the kitchen when she was finishing her meal to ask for milk. She stated Housekeeper A and Dietary Aide B were talking in the dining room. She stated Dietary Aide B was in the kitchen area and Housekeeper A was standing at the door to the dishwashing room. She stated they kept talking and would not listen to her and she propelled herself to another door to the kitchen and began knocking on that door. She stated Housekeeper A asked her what she wanted and began to talk very rude to her in a loud tone. Resident #1 stated Dietary Aide B came to the door and gave her some milk after she requested it several times. She stated Housekeeper A began talking louder and stated, You are ugly and I am going to beat your ass. Resident #1 stated she began to yell back at Housekeeper A because she was not going to allow anyone to talk to her like this and she felt threatened. Resident #1 stated Houskeeper A stated, Why don't you stand up? You can walk; you don't need that wheelchair. iIf you think you can do something, why don't you stand up? Resident #1 stated she stood up and almost fell. She stated she felt humiliated and embarrassed. Resident #1 stated she became angry and was very upset. She stated she propelled herself to her room and later went to the nurses' desk to ask about smoking. Resident #1 stated LVN C was at the nurses' desk, and she would not listen to her. She stated LVN C continued to say, You are mad and upset but you should not be cussing people. Resident #1 stated she tried to explain what happened and LVN C would not listen to her and this made her mad and she began to yell and cuss LVN C. She stated LVN C would not listen to what she had to say about the incident with Housekeeper A and only heard one side of the story from Housekeeper A. She stated she went to her room, and she did calm down approximately an hour after the incident. She stated it did humiliate her and was embarrassing related to other residents heard what happened to her. She stated she did not feel she was treated with respect from Housekeeper A. Interview on 04/14/2026 at 10:30 am Resident #2 stated he was in the dining room when the incident occurred with Resident #1 and Houskeeper A. He stated Resident #1 was trying to get some milk. She went to one of the doors where Housekeeper A and Dietary Aide B were talking. He stated Resident #1 could not get their attention and she propelled herself to the second door of the kitchen and she did get some milk, and this is when Houskeeper A began to argue with Resident #1. Resident #2 stated Houskeeper A began the argument with Resident #1. He stated he felt sorry for Resident #1 related to the way Housekeeper A was speaking to Resident #1. He stated Houskeeper A made her feel embarrassed and Housekeeper A did talk to her in a loud tone and was almost yelling at Resident #1. He stated Houskeeper A told Resident #1 I am going to beat your ugly ass. You need to go on with your funky ass. Resident #2 stated when Houskeeper A made this statement, Resident #1 yelled back at Houskeeper A and was trying to defend herself. He stated he did not want to say exactly what Resident #1 had stated due to not knowing the exact words and did not want to make a false statement. Resident #2 stated he felt sorry for Resident #1 because she was embarrassed and felt disrespected. Resident #2 stated he did see Resident #1 for approximately 2 hours after the incident, and she was calm and was not upset. He stated Resident #1 was very upset and told him she was not respected by Housekeeper A. Record review of Resident #2's Quarterly MDS Assessment, dated 01/31/2026, reflected Resident #2 had a BIMS score of 15 indicating his cognition was intact. Interview on 04/14/2026 at 11:34 am Housekeeper A stated she was in the kitchen cleaning and was standing near the kitchen door while removing the plates. She stated Dietary Aide B was in the dishwasher room and they were talking. She stated Resident #1 rolled up in her wheelchair and began demanding milk. Houskeeper A stated she asked Resident #1 what did she want and Resident #1 stated, Mind your own business you stinking looking man. She stated she asked Resident #1 why she said this to her. Housekeeper A stated she continued to yell. She stated, I may have raised my voice to Resident #1 and may have been in a rude tone, but I did not cuss her. Houskeeper A stated she exited the dining room and reported to LVN C what occurred with Resident #1. Interview on 04/14/2026 at 2:45 pm Dietary Aide B stated she heard Resident #1 in the dining room talking in a loud tone. She stated she was in the dishwasher room, and it was difficult to hear what is being said in the dining room when in the kitchen. Dietary Aide B stated she asked Housekeeper A what did Resident #1 want and she stated she is wanting some milk. Dietary Aide B stated she gave Resident # 1 some milk from another kitchen door. She stated, I heard Housekeeper Aide A and Resident #1 talking loud tone to one another, however, I did not witness the incident. Interview on 04/14/2026 at 3:30 pm Director of Nurses stated he had in-serviced staff on abuse and neglect, interactions with residents with behaviors, and documentation when residents have any type of incident with another resident or staff. He stated Resident #1 does have behaviors and outbursts with staff and other residents. He stated when this does occur staff is to walk away from Resident #1 or any resident if they believe they can not respond appropriately to the resident. The Director of Nurses stated if Resident #1 felt she was embarrassed , humiliated, or became upset with how Housekeeper A spoke to her there was a possibility Resident #1 may not feel she was respected by staff. He stated there was non-consistent interviews during their investigation. He stated Resident #1's physical or emotional status had not changed since 03/21/2026. She has remained at her baseline. Interview on 04/14/2026 at 5:15 pm Social Worker stated she had interviewed Resident #1 on Monday 03/23/2026 after the incident on 03/21/2026. She stated Resident #1 stated she was embarrassed and felt disrespected by Houskeeper A when the incident occurred on 03/21/2026. Social Worker stated Resident #1 was not upset, depressed, or emotional during her conversation with her on 03/23/2026. She stated Resident #1 was already seeing Psych services and was talking to a different therapist. Social Worker stated Resident #1's mood has been at her baseline. She has denied being depressed or sad. She stated Resident #1 was not isolating herself in her room or from others and did not have a decline in appetite. Social Worker stated she has been monitoring Resident #1 several days after the incident on 03/21/2026 and Resident #1 has been at her baseline. She stated when Resident #1 was upset, depressed or anxious she would move her hands above her head and swing her arms/ hands during conversations with her. Social Worker stated she did not have any signs or symptoms of being sad as evidenced by her facial expression which was relaxed and did not have burrowed eyebrow or a frown on her face. She stated she smiled at times during the conversation when they were discussing the incident with Housekeeper A. Interview on 04/14/2026 at 5:30 pm Maintenance Supervisor stated when he came to work the Monday (03/24/2026) after the incident over the weekend, he entered the dining room and Resident #1 called him over to her table. Maintenance Supervisor stated Resident #1 explained to him of Housekeeper A making a statement to Resident #1 I am going to beat your ass. He stated he immediately reported it to the Administrator ( abuse coordinator) and the Director of Nurses. He stated Housekeeper A was not working on the Monday 03/23/2026 and she was contacted and was suspended until further investigation. He stated she turned in her 2 weeks' notice and it was immediately accepted. Maintenance Supervisor stated Housekeeper A was not on schedule to work after the incident on 03/21/2026 and had not been at the facility since she clocked out on 03/21/2026. Interview on 04/14/2026 at 5:55 pm LVN C stated Housekeeper A came to me on a weekend ( she did not recall the exact date) in March 2026. She stated Housekeeper A stated, Resident #1 was at the kitchen door observing staff talking ( Housekeeper A and Dietary Aide B) and Resident #1 began to yell. Housekeeper A stated Resident #1 called Housekeeper A man looking ass bitch. LVN C stated she did not witness the incident between Housekeeper A and Resident #1. She stated her only interaction with Resident #1 was when Resident #1 came to the nurses' desk yelling and wanting to go smoke. LVN C stated Resident was upset at first with the incident with Housekeeper A and was yelling and cussing. LVN C stated she did not document what Resident #1 was saying and she did not recall what she said after the incident. LVN C stated approximately 1 hour after the incident Resident #1 was calm and was at her baseline. She was not upset, anxious or depressed. Interview on 04/14/2026 at 6:20 pm LVN D stated she was late coming into work the date of the incident between Resident #1 and Housekeeper A. She stated when she arrived at the facility approximately 6:30 pm Resident #1 was calm. She stated LVN C gave her a report of what occurred between Resident #1 and Housekeeper A. LVN C stated she observed Resident #1 the rest of her shift. She stated Resident #1 did not have any behaviors and was calm the remaining of her shift. She stated she worked 6 pm to 6am. She stated Resident #1 did not have any signs or symptoms of anxiety or depression. LVN D stated Resident #1 had remained at her baseline since the incident. She stated Resident #1 has not isolated herself from others, has not expressed being sad or depressed, has not shown any signs or symptoms of being sad or depressed. LVN D stated her appetite has remained the same and she has been at her baseline. Interview on 04/14/2026 at 6:30 pm the Administrator stated there was a possibility Resident #1 may have become embarrassed or upset after the incident with Housekeeper A. She stated she did not believe it was verbal abuse but there was a possibility Resident #1 may have been humiliated. The Administrator stated they had called the police, completed safety checks on other residents, in-service staff on abuse/ neglect, intervene with behavior residents, and documentation after an incident between staff and a resident. She stated Housekeeper A was suspended until investigation and she turned in her 2 weeks' notice and it was accepted immediately. The Administrator stated Housekeeper A was not in the facility after the incident occurred on 03/21/2026 approximately 6:00 pm. Interview on 04/15/2026 at 9:00 am LVN E stated she had been assigned to Resident #1 since March 21, 2026. She stated she did not recall how many times. She stated she interacts with Resident #1 when she is working at the facility. LVN E stated she has not observed any changes in Resident #1's mood. She stated Resident #1 has been at her baseline. LVN E stated she has not observed Resident #1 isolating herself and she has not had any changes in her physical condition, cognition, or emotional status. She stated Resident #1 has remained at her baseline. Interview on 04/15/2026 at 9:40 am CNA F stated she had been assigned to Resident # 1 over the past month. She stated she has interacted with Resident #1 every time she is working. She stated Resident #1 has not changed. She has remained at her baseline. CNA F stated Resident #1 has not mentioned any incident with any staff. She stated Resident #1 socializes out of her room and she prefers to do things in her own way and time. CNA F stated Resident #1 has not shown any changes in her mood since March 2026. Interview on 04/15/2026 at 10:15 am CNA E stated she has been assigned to Resident #1 sometimes over the past month. She stated Resident #1 does have behaviors and will yell at staff and can be uncooperative during care. She stated Resident #1 moods/ behaviors are at baseline. CNA E stated there were not any changes in her mood or behaviors over the past month. She stated Resident #1 has remained the same. CNA E stated Resident #1's appetite has remained the same and she had not lost any weight. She has not isolated herself in her room. She stated she has remained her normal routine and has not expressed any incident with another staff. Interview on 04/15/2026 at 11:05 am Psychiatric Mental Health Nurse Practitioner stated she had been treating Resident #1 over a year. She stated Resident # 1 has improved with her mood/ depression over the past month. She stated Resident #1 did not mention any situation between her and a staff. She stated Resident #1 has not shown any signs or symptoms of depression, anxiety or change in her mood over the past month. Psychiatric Mental Health Nurse Practitioner stated she was very optimistic over Resident #1 continue to improve. Interview on 04/15/2026 at 11:40 am Resident #1 stated she felt humiliated, and she was not respected by Housekeeper A on the day of the incident (03/21/2026). She stated she was angry at first and she decided she would not allow Housekeeper A to caused her to be angry, but she felt she was disrespected. Resident #1 stated, I am happy she (Housekeeper A) no longer works at this facility. I don't have anything else to say about this situation. Interview on 04/15/2026 at 11:50 am attempted to call Medical Doctor and left message. He did not return phone call. Requested a copy of Resident Rights via email on 04/14/2026 at 9:15 am on the Entrance Record List provided for all the information needed to conduct investigations. Resident Rights was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure Dietary Aide A wore a beard guard when standing over clean dishes in the kitchen. This failure could place residents who ate food from the kitchen at risk for foodborne illness.Findings included: Observation on 1/27/2026 at 8:45 am revealed Dietary Aide A was not wearing a beard guard. He was standing in the dishwashing room section of the kitchen over the clean plates. He had facial hair approximately 3-4 inches long around his chin. In an interview on 01/27/2026 at 8:50 am, Dietary Aide A stated he was expected to wear a beard guard anytime he was in the kitchen area. He stated if hair fell onto plates and the hair transferred to residents' food there was a possibility a resident may become ill with some type of stomach issues (when asked what type of stomach issues he did not respond to the question). He stated germs were located on hair. Dietary Aide A stated he had been in-serviced on wearing beard guards. He stated he did not recall the exact date. In an interview on 01/27/26 at 9:00 am Dietary Manager stated hair nets or cap and beard guard on facial hair are required for all staff while in the kitchen. Dietary Manager stated it could negatively affect a resident if hair restraints are not worn by a resident receiving food with hair in it. She stated there was a possibility a hair may fall on a clean plate to be used for meals. She stated it was a potential the staff may not see the hair on the plate and may serve food over the hair to a resident. She stated if a resident ingested hair there was a possibility the resident may become physically ill according to what type of bacteria was on the hair such as: nausea, vomiting or diarrhea. Dietary Manager stated it was her responsibility to ensure beard restraints were worn by the male staff in the kitchen. Dietary Manager stated all dietary staff had been in-serviced to wear hair nets and beard guards when in the kitchen. She did not recall the date or time of the in-service. In an interview on 01/27/26 at 12:30 pm the Administrator stated her expectation was that hair restraints were to be worn by all staff in the kitchen. The Administrator stated if hair restraints are not worn there was a possibility a hair may fall onto a clean plate and food can be served over the hair on the plate. She stated there was a possibility that if a resident ingested a hair the resident may become ill with some type of stomach issues or foodborne illness. The Administrator stated all kitchen staff are responsible for wearing hair restraints and that ultimately the Dietary Manager was responsible for ensuring hair restraints are worn by all staff in the kitchen. She stated she was the Dietary Manager's supervisor. Record review of the Facility's Policy on Employee Hygiene for Food Safety, dated 2023, reflected All food and nutrition services employees will practice good personal hygiene and safe food handling procedures. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food.

Based on observation, interview, and record review the facility failed to ensure medications and biologicals were stored in locked compartments for one of two medication carts reviewed for medication storage. The facility failed to ensure Medication Cart A was locked and medications were secure and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the-counter medications.Findings included:Observation on 01/27/2026 at 8:35 am revealed an unlocked medication cart (Medication Cart A) in front of one of the nurse's desks. The back of the medication cart was against the nurse's station. RN B was inside the nurse's station leaning against the desk with her back facing the medication cart. The medication cart's locking mechanism was protruding outward. The drawers of the medication cart were easily opened and the state surveyor captured photos.In an interview on 01/27/2026 at 8:40 am RN B stated she thought she had locked the medication cart before she walked inside the nurse's station. She said she could not believe the cart was unlocked, as she had the only set of keys for that cart. She said if residents had accessed the medication cart they could have overdosed, taken the wrong medication, had an allergic reaction, or could require hospital admission. She said she had previously been in-serviced on locking the medication carts and could not recall the specific date. She said she was aware the medication cart should have been locked. In an interview on 01/27/2026 at 12:30 pm the Administrator stated her expectation was for the medication carts to be locked when the nurses were not administering medications from the carts. She stated there was a possibility a resident may get medications out of the medication cart. The Administrator stated if a resident did take the medications by mouth there was a possibility a resident may have an allergic reaction. She stated it depended on the medication the resident ingested. She stated the nurse assigned to the medication cart was responsible for locking the medication cart after administering medications to a resident. The Administrator stated the Director of Nurses was responsible to monitor the nurse supervisor.In an interview on 01/27/2026 at 1:30 pm the Director of Nurses stated his expectation was for all medication carts to be locked when the nurse was not administering medications. He stated the staff had been in-serviced on securing the medication carts when not in use. The Director of Nurses stated he did not know the exact date of the in-service. He stated residents, other staff, and visitors would have access to the medications in the unlocked medication cart. He stated if a resident ingested medications not prescribed to them, there was a potential the resident may have an allergic reaction or may need to be admitted to the hospital. He stated it was the nurse's responsibility to ensure the medication cart was locked when not dispensing a resident's medication. The Director of Nurses stated he was responsible for monitoring the nurses.Record review of Administering Medications Policy, dated April 2019, reflected Medications are administered in a safe and timely manner, and as prescribed. During administration of medications, the medication cart is 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 residents or others passing by.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for resident rights. The facility failed to ensure Resident #1, Resident #2, and Resident #3's call lights were within reach on 05/20/2025. This failure could place residents at risk of their needs not being met. Findings include: 1. Record review of Resident #1's admission record, dated 05/20/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Rheumatoid arthritis (chronic autoimmune disease that causes inflammation and damage to the joints), muscle weakness (decrease ability of muscles to contract and move), and unspecified dementia mild without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (memory loss and thinking difficulties). Record review of Resident #1's Quarterly MDS assessment, dated 03/19/2025, reflected the resident had a BIMS score of 12, which indicated moderate cognitive impairment. Resident #1 required partial/moderate assistance in the area of shower/bathe self. Resident #1 required setup or cleanup assistance in the areas of eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #1's care plan, dated 05/20/2025, reflected Resident #1 was care planned for high risks for fall and had an intervention of be sure my call lights is within reach and encourage me to use it for assistance as needed. During an observation on 05/20/2025 at 9:54 AM., Resident #1's call light was observed hanging towards the floor on the right side of Resident #1's bed. Resident #1 was asleep in bed at the time of the observation. During an observation on 05/20/2025 at 11:37 AM., Resident #1's call light was observed hanging towards the floor on the right side of Resident #1's bed. Resident #1 was asleep in bed at the time of the observation. During an interview on 05/20/2025 at 12:10 PM., Resident #1 stated that CNA A had picked up her call light and placed it in her reach about five minutes before I entered to talk to her. Resident #1 stated that the call lights were never within reach and residents must yell or go find a staff member when they needed assistance. 2. Record review of Resident #2's admission record, dated 05/20/2025, reflected a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #2 had diagnoses which included: parkinsonism (a brain condition that affects movement and can cause non movement symptoms like fatigue, sleep problems, and depression), muscle weakness (decrease ability of muscles to contract and move), morbid serve obesity due to excess calories (having a high amount of body fat) and chronic obstructive pulmonary disease (lung disease that makes it difficult to breathe). Record review of Resident #2's Quarterly MDS assessment, dated 03/13/2025, reflected the resident had a BIMS score of 11, which indicated moderate cognitive impairment. Resident #2 was dependent in the areas of toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. Resident #2 required substantial/maximal assistances in the area of upper body dressing. Record review of Resident #2's care plan, dated 05/20/2025, reflected Resident #2 was care planned for ADL self-care performance and had an intervention of place call light with reach. During an observation on 05/20/2025 at 9:54 AM., Resident #2's call light was observed hanging approximately two feet behind the resident's bed against the wall. Resident #2's call light was not within reach. Resident #2 was asleep in bed at the time of the observation. 3. Record review of Resident #3's admission record, dated 05/20/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: chronic obstructive pulmonary disease (lung disease that makes it difficult to breathe), muscle weakness (decrease ability of muscles to contract and move), hyperlipidemia (having too much fat in your blood, specifically too much cholesterol and or triglycerides) and essential primary hypertension (high blood pressure). Record review of Resident #3's Quarterly MDS assessment, dated 03/06/2025, reflected the resident had a BIMS score of 13, which indicated cognitive intact. Resident #3 required substantial/maximal assistance in the area of shower/bathe self. Resident #3 required supervision or touching assistance in the areas of putting on/taking off footwear and personal hygiene. Record review of Resident #3's care plan, dated 05/20/2025, reflected Resident #3 was care planned for risks for falls r/t gait/balance problems and had an intervention of be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an interview and observation on 05/20/2025 at 4:00 PM., Resident #3 was yelling for assistance. Resident #3's call light was observed not within her reach near her nightstand. Resident #3 stated that her call light was never within reach and she must yell out for help all the time. During an interview with CNA A on 05/20/2025 at 4:55 PM, CNA A stated she was the CNA for Resident #1 and Resident #2. CNA A stated that she was not aware that the residents' call lights were not within reach. CNA A stated that it was anyone, who entered the resident's room, responsibility to ensure call lights were within reach. CNA A stated if a resident's call light was not within reach, then the resident would not be able to call for assistance. During an interview with the CMA A on 05/20/2025 at 5:10 PM, CMA A stated she was present during my observation of Resident #3 call light. CMA A stated she observed Resident #3's call light near her nightstand and out of the resident's reach. CMA A stated that all staff were responsible for ensuring call lights were always within reach. CMA A stated that if a resident call light was not within reach the resident would not be able to call for assistance. During an interview with the DON on 05/20/2025 at 5:15 PM, the DON stated all residents call lights should be always within reach. The DON stated it was everyone's responsibility to ensure residents call lights were always within reach. The DON stated if a resident's call light was not within reach, the resident would not be able to receive assistance if they needed it. During an interview with the ADM on 05/20/2025 at 5:25 PM, the ADM stated call lights should always be within reach. The ADM stated it was everyone's responsibility to ensure the call light were within reach. The ADM stated if a resident call light was not within reach, then the resident's needs would not be met in a timely manner. The ADM stated her expectation was for staff members to ensure call lights were within reach prior to exiting the resident's rooms. A record review of the facility's Call Lights: Accessibility and Timely Response dated 2024 reflected, The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. 5. Staff will ensure the call light is within reach of a resident and secured, as needed .

Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 1 resident (Resident #4) reviewed for personal privacy and confidentiality of records. The facility failed to ensure the LVN provided privacy by closing the laptop and leaving the laptop unattended in the hallway which displayed Resident #4's information on 05/20/2025. This failure could place residents at risk of having medical information personal or care instructions exposed to others and misuse of personal information. The findings included: Record review of Resident #4's admission record, dated 05/20/2025, reflected an [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #4 had diagnoses which included: unspecified sequelae of cerebral infarction (having lingering problems or conditions as a result of a stroke), muscle weakness , muscle wasting and atrophy (a condition where muscle tissue shrinks and weakens, resulting in reduce muscle mass and strength), and unspecified convulsions (uncontrollable shaking that is rapid and rhythmic, with the muscle contracting and relaxing repeatedly) Record review of Resident #4's Annual MDS assessment, dated 03/31/2025, reflected the resident had a BIMS score of 08, which indicated moderate cognitive impairment. During an observation on 05/20/2025 at 2:00 PM., LVN A's laptop was left unattended with Resident #4's information on the screen. The ADM was present at the time of the observation. The ADM was observed closing the laptop and left to go talk with LVN A about the incident. During an interview with the LVN A on 05/20/2025 at 4:05 PM, LVN A stated she did not leave her laptop unattended with Resident #4 information on the screen. During an interview with the DON on 05/20/2025 at 5:15 PM, the DON stated the staff that used the laptop should ensure the resident's information was not displayed if not attended. The DON stated that a negative outcome would be that someone could see the resident personal health information or have access to it. The DON stated it was her expectation that staff locked their laptops when walking away from them. During an interview with the ADM on 05/20/2025 at 5:25 PM, the ADM stated she was present at the time of the observation of the unattended laptop. The ADM that the last user of the laptop was responsible for ensure the residents information was not displayed before leaving the laptop unattended. ADM stated a negative outcome would be the resident public health information could be released to the public. The ADM stated her expectation were for staff to follow policy and not leave the resident health information unattended. Review of the facility's Security of Portable Electronic Devices dated 2025 reflected To aid in prevention of disclosure of confidential information, our company has adopted procedures for the safety and security of confidential business and protect health information. The purpose of this policy is to define the requirements to safeguard sensitive data contained on portable devices and portable electronic storage media on or off company premises, and the procedures to be followed. This policy applies to all company employees and business associated that create, store, or access sensitive data. Policy Explanation and Compliance Guidelines: 1. All portable electronic devices, irrespective of device ownership, that are used in conjunction with any computer, data, or network device owned or managed by our company must follow our established policies and standards for the secure use of portable electronic devices (portable devices). This policy also includes personal portable devices that are used to access our company systems. 3. Employees (or authorized business associate) who use portable devices to access our company network must ensure that they keep the device, associated media, and its data secure at all times .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Aide L wore a hair net when standing over the clean dishes and when she placed the clean dishes on the food prep area in the kitchen. 2. The facility failed to ensure Dietary Aide K used proper hand hygiene during preparation of the lunch meal. These failures could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: 1. Observation on 04/08/2025 at 9:15 AM revealed Dietary Aide L was not wearing a hair net when placing clean dishes from the dishwasher room in the kitchen area. Interview on 04/08/2025 at 9:20 AM, Dietary Aide L stated she was not wearing a hair net when she was standing over clean dishes and when she moved the clean dishes from the dishwashing area to the kitchen on the food prep table. She stated it was a possibility hair may fall in the food while she was standing over the plates. She stated hair was considered to have germs on it and the germs may get on a plate. She stated if a resident was served their meal with a hair on the plate there was a possibility hair may transfer from the plate to the food. She stated there was a possibility a resident may become ill with stomach issues such as vomiting. Dietary Aide L stated she had been in-serviced on wearing hair nets. She did not recall the date of the in-service. 2. Observation on 04/09/2025 at 11:50 AM, Dietary Aide K was not wearing gloves. She picked up a disinfectant small kitchen towel with all of her finger on her right hand and wiped off a tray sitting on the meal tray rack. The Dietary Aide K placed the disinfectant kitchen towel with all of her fingers on her right hand on the food prep area She picked up a tray being used for resident lunch meal with all of her fingers on the right hand. Her middle, ring, little finger, and forefinger touched inside of the tray. Her forefinger and middle finger touched the napkin on the meal tray. The Dietary Aide K did not wash or sanitize her hands in between tasks. Interview on 04/09/2025 at 11:54 AM, Dietary Aide K stated she did pick up the dish towel and it did have disinfectant on the towel. She stated she did wipe a tray on the meal cart with the disinfectant towel. Dietary Aide K stated she placed the disinfectant towel on the food prep table, pick up a meal tray, and touched the napkin on the meal tray. She stated she never sanitized or washed her hands. Dietary Aide K stated she was expected to wash her hands when changing tasks or touching anything not sanitary. She stated the disinfectant kitchen towel was not sanitary and was contaminated with disinfectant. She stated the germs from the kitchen rag may transfer from her hands onto the meal tray and the napkin a resident would use when eating their lunch. She stated if a resident ingested any type of germs or bacteria, it was possible the resident may become ill with some type of stomach issues such as vomiting and diarrhea. Dietary Aide K stated she was in-serviced on hand hygiene when working in the kitchen. She did not recall the date of the in-service. Interview on 04/10/2025 at 10:15 AM, the Dietary Manager stated all staff were expected to wear hair nets in the kitchen. She stated there was a possibility hair may fall on the food, the food preparation table, and clean dishes. She stated if hair was on the food or plate and a resident ingested the hair, there was a potential a resident may become ill with some type of stomach illness. She stated there was bacteria on people's hair and hair was considered contaminated. The Dietary Manager stated all staff were required to wash hands between tasks and whenever they touched anything contaminated. She stated the kitchen towel, with disinfectant on it, was considered contaminated. The Dietary Manager stated the staff was in-serviced on hand hygiene and wearing hair nets. She stated she did not recall the date of the in-service. Interview on 04/10/2025 at 9:20 AM, the Administrator stated any staff working in the kitchen was expected to wear a hair net. She stated it was a possibility hair may fall onto clean dishes, food prep area, or food being prepared for meals. The Administrator stated if a resident ingested the hair the resident may become sick with some type of stomach issue. She stated the Dietary Manager was responsible to monitor the kitchen and she was over the Dietary Manager. The Administrator also stated she expected the dietary staff to wash their hands in between tasks or when they touched any contaminated item. She stated if dietary staff did not wash their hands after touching anything considered contaminated, there was a potential a resident may become ill if they ingested any type of bacteria in their food. The Administrator stated without knowing the type of bacteria, it would be difficult to determine what type of illness. Review of the facility's policy on Handwashing Guidelines for Dietary Employees, dated 2025, reflected Hand washing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean hands in a sink used for food preparation, ware washing, or in a service sink used for the disposal of mop water or similar waste. Compliance Guidelines: 1. Dietary employees shall keep their hands and exposed portions of their arms clean. 2. Frequency of Handwashing: Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: a. Every time an employee enters the kitchen; at the beginning of the shift; after returning from break; after using the toilet. b. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. c. After hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.). d. After coughing, sneezing, or blowing your nose, using tobacco products, eating, or drinking. e. After handling chemicals and before beginning to work with food. f. While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve nutritive value for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure Dietary [NAME] M did not add an unmeasured amount of milk to the bread puree. This failure could place residents at risk of decreased food intake, hungry, unwanted weight loss, and diminished quality of life. Findings included: Observation and interview on 04/09/2025 at 11:05 AM revealed Dietary [NAME] M placed milk into the puree blender. She did not measure the milk. Dietary [NAME] M began to add bread to the puree blender on top of the milk. She stated there were three residents on puree diets and she added four pieces of bread to the pureed blender. Dietary [NAME] M stated the Dietary Consultant trained her that all puree was to be the consistency of something to drink. The puree bread was of liquid consistency. Interview on 04/09/2025 at 11:10 AM, the Dietary Manager stated the Dietary Consultant did re-train all the cooks, however, she did not hear him say to puree food in a liquid consistency. The Dietary Manager stated there had not been any puree food delivered to any resident in a liquid consistency . She stated Dietary [NAME] M did not puree the bread correctly and she would be re-trained on how to puree food. The Dietary Manager stated she was responsible for monitoring the dietary department including the dietary staff. Interview via phone on 04/16/2025 at 1:10 PM, the Dietary Consultant stated he did train Dietary [NAME] M on how to puree food. He stated he did not document the training. The Dietary Consultant stated it was approximately 2 months ago when he did the training. He stated he gave examples of any puree consistency to be of the same texture of pudding. He stated he never trained any dietary cook including Dietary cook M to puree food in liquid consistency where a person could drink the puree. Review of the facility's policy on Puree Food Preparation, dated 2025, reflected It is the policy of this facility to provide puree food that has been prepared in a manner to conserve, nutritive value, palatable flavor, and attractive appearance. Food attractiveness refers to the appearance of the food when served to residents. Food palatability refers to the taste and/or flavor of the food. Proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk of scalding or bums. Puree means that all food has been ground, pressed and/or strained to a consistency of a soft, smooth, thick paste similar to a thick pudding. Puree foods should be prepared in such a manner to prevent lumps or chunks. The goal is a smooth, soft, homogenous consistency similar to soft mashed potatoes.

Based on observation, interview, and record review, the facility failed to ensure in accordance with State and Federal Laws, all drugs and biologicals were stored in locked compartments, and had current expiration dates for 1 of 1 medication storage rooms, 1 of 2 medication carts (A Hall medication aide cart), and 1 of 1 treatment carts reviewed for medication storage. A) The facility failed to ensure two medications in the storage room behind the nurse's station were not expired and one medication in the A Hall cart was not expired. B) The facility failed to ensure the wound care treatment cart was locked. These failures could place residents in the facility at risk of receiving expired and ineffective medications, and misuse of medications. Findings include: A) Observation on 04/08/2025 at 3:00 PM in the medication storage room behind the nurse's station revealed two bottles of Fish Oil 1000 mg supplements, expiration dates of 03/2025, and one 8 fluid ounce bottle of liquid Acetaminophen 500 mg/15 ml. Observation on 04/09/2025 at 8:31 AM in the A Hall medication aide cart of revealed one bottle of Vitamin E 500 mg, expiration date 02/2025. In an interview on 04/09/2025 at 2:29 PM, MA E stated she had worked at the facility for almost five years. She stated the medication aide staff checked the medication carts for expired medications and the ADON checked the carts. She stated sometimes the DON checked the carts as well. She could not give specific times the carts were checked. In an interview on 04/10/2025 at 8:20 AM, the ADON stated she ordered medication every week and she tried to check for expired medications at that time. She stated she audited the medication carts once or twice a week. She stated expired medications would not be as effective as they should be, and the resident would not get as much benefit from the medications. In an interview on 04/10/2025 at 10:06 AM, the DON stated the nurses and medication aides should be checking the carts to ensure medications are not expired. She stated expired medications would be discarded by the pharmacist. She further stated nurses and medication aides were supposed to check their own carts. The DON did not specify how often staff should be checking for expired medications. In an interview on 04/10/2025 at 12:27 PM, the ADM stated expired medications should be removed the day they expired or the day before. She stated the residents could become ill from ingesting expired medications. B) Observation on 04/09/2025 at 2:24 PM in D Hallway revealed the treatment cart was unlocked and the drawers were facing the hallway. Observation on 04/09/2025 at 2:24 PM in D Hallway revealed the treatment was unlocked and the drawers were facing the hallway. No staff were in the vicinity of the cart. LVN B came out of a room and stated the treatment cart was supposed to be locked. In an interview on 04/09/2025 at 2:29 PM, LVN B stated by leaving the treatment cart unlocked and facing the hallway, a resident could have grabbed items out of the cart that could have potentially hurt them. She stated there was wound cleanser in the cart that would not be comfortable if a resident sprayed it in their eyes. In an interview on 04/10/2025 at 8:20 AM, the ADON stated carts were supposed to be locked when not in use. She stated there could be wound care cleaner in the cart and residents could have consumed it or put it in their eyes. She stated that could have caused harm to them and possibly could have caused an allergic reaction. In an interview on 04/10/2025 at 10:06 AM, the DON stated a treatment or medication cart should never be left unlocked if unattended. She stated anyone could get into the cart and ingest a medication or spray it into their eyes. She stated an individual could have an allergic reaction if exposed to the medications, it could affect their vision if sprayed in their eyes, and they could be hospitalized . In an interview on 04/10/2025 at 12:27 PM, the ADM stated the treatment cart should be kept locked if the nurse was not using it and within eyesight of it. No policy and procedure specific to keeping treatment carts locked, or specific to removing expired medications was provided prior to exit from the facility.

Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living (ADL) to maintain good grooming and personal hygiene for 4 of 4 Residents (Residents #65, Resident 56, Resident #22, and Resident #24) reviewed for ADL care. The facility failed to ensure Resident #65, Resident #56, Resident #22, and Resident #24's nails were trimmed, cleaned, and filed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: Record review of Resident #65's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (stroke where part of the brain is damaged or dies due to lack of blood supply). Record review of Resident #65's Quarterly MDS dated [DATE] reflected he had a BIMS score of 10 indicating moderate cognitive impairment. Section GG - Functional Abilities reflected he had impairment on both upper extremities that interfered with daily functions. He required supervision and setup with personal hygiene. Record review of Resident #65's Care Plan dated 02/20/2025 reflected he had an ADL self-care performance deficit r/t activity intolerance. He required set up for hygiene tasks. In an interview and observation on 04/08/2025 at 10:38 AM Resident #65 stated he had asked the aides to clip his toenails and they never had. Observation of his bilateral feet revealed the first through fourth toes were approximately 1/2 inch long past the end of his toes and the nails on his fifth toes (little toes) were curling under and poking into the skin on the bottom of his toes. In an interview on 04/09/2025 at 2:06 PM of Resident #65 stated no one had trimmed his toenails. In an interview on 04/09/2025 at 2:09 PM CNA I looked at Resident #65's toenails and noted they were long and needed trimming. She stated his right foot's little toenail was long and could grow into the skin and cause an infection that could get into the blood stream. Record review of Resident #56's undated Face Sheet reflected he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Cerebral Infarction (stroke where part of the brain is damaged or dies due to lack of blood supply) and Expressive Language Disorder (difficulty using language both written and spoken). Record review of Resident #56's Quarterly MDS dated [DATE] reflected he had a BIMS score of 13 indicating intact cognitive status. Section GG - Functional Abilities reflected he required Substantial/maximal assistance for personal hygiene where the helper provides more than half of the effort. Record review of Resident #56's Care Plan dated 09/29/2023 and revised on 10/01/2024 reflected he was at risk for a decline in and ADL self-care performance r/t right hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), and impaired balance. Interventions/Task: Personal hygiene: Check nail length if applicable and trim and clean on bath day and as necessary. Observation on 04/08/2025 at 10:26 AM of Resident #56's fingernails on both hands revealed his fingernails were approximately 1/2 to 3/4 inches long and jagged. An interview was attempted but Resident #56 was unable to verbalize, however, he kept holding his hands up to show the surveyor. Observation on 04/09/2025 at 2:04 PM of Resident #56 whose nails on both hands were still long and jagged with brown debris underneath. Record review of Resident #22's undated Face Sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus (long term condition in which the body has trouble controlling blood sugar and using it for energy) with Diabetic Neuropathy (a type of nerve damage that can occur with diabetes most often affecting the legs and feet), Muscle weakness (generalized), and Blindness right eye. Record review of Resident #22's Quarterly MDS dated [DATE] reflected he had a BIMS score of 15 indicating intact cognitive status. Section GG: Resident required partial/moderate assistance for personal hygiene. Record review of Resident #22's Care Plan dated 11/19/2024 reflected he had an ADL self-care performance deficit r/t right hand 2nd finger amputation, weakness. Personal hygiene: needs assistance of one staff. He is at risk for impairment to skin integrity r/t fragile skin. Avoid scratching, keep fingernails short. In an observation and interview on 04/08/2025 at 11:29 AM, Resident #22's nails on bilateral hands were approximately 1/4 to 1/2 inch long past the fingertips. There was brown, crusty debris under the four fingernails on each hand. He was missing his fourth finger on each hand. He stated he lost his legs and his fingers due to a blood infection. In an observation and interview on 04/09/2025 at 2:08 PM Resident #22's toenails were still long, and he stated no one had trimmed his nails. In an interview on 04/09/2025 at 2:09 PM CNA I stated she had become a CNA in June 2024 but had worked as an aide for ten years. She stated aides were supposed to clean resident's nails, trim them with clippers, and use a cuticle stick to clean dirt from under the nails. She stated she performed those tasks every time she assisted a resident with a bath. She observed Resident #56's nails and noted they were jagged and could use trimming and cleaning. She stated Resident #22 needed to have his fingernails trimmed and his nails would need to be soaked to get some of the crust out from underneath. She stated there could be bacteria from his nails that could get into his mouth when he was eating. Review of Resident #24's face sheet, dated, 04/09/2025, reflected a [AGE] year-old female who was admitted on [DATE]. Resident #24 had diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ( memory loss, difficulty with communication, and problems with reasoning without any behaviors), limited activities due to disability (restrictions or reductions in a person's ability to perform daily activities because of a disability such as chronic diseases, injuries, and mental health disorders), and unspecified lack of coordination (a motor - skill impairment where movements are uncoordinated) Review of Resident #24's Annual MDS, dated [DATE], reflected the resident had a BIMS score of 3, which indicated his cognition was severely impaired. Resident #24 required partial/moderate assistance (helper does less than half the effort) with personal hygiene, and upper body dressing. She required substantial/maximal assistance (helper does more than half the effort) with showers and lower body dressing. Resident #24 was dependent on staff for toileting. Resident #24 did not reject any care. Review of Resident #24's Comprehensive Care Plan, with completion date of 01/24/2025 reflected Resident #24 had an ADL Self Care Performance Deficit related to dementia, and impaired balance (a condition where a person feels unsteady or dizzy). Adjust assistance and support to accommodate immediate needs. Interventions: Personal hygiene- Resident #24 required assistance of one staff. Check nail length. Trim and clean on bath day and as needed. Observation and interview on 4/08/2025 at 11:20 AM, revealed Resident #24 was in the common area sitting in her wheelchair. She had thick blackish substance underneath all nails on her right and left hands. Resident #24 was not interview able. Observation and interview on 04/09/2025 at 10:30 AM, revealed Resident #24 was sitting in her wheelchair in the therapy room. She had hard thick blackish substance underneath all nails on her right and left hands. Resident #24 was not interview able. Observation and interview on 04/09/2025 at 10:45 AM revealed COTA speaking to Resident #24. The COTA stated Resident #24's nails were very dirty underneath all her nails and it was black substance. COTA stated she was not responsible to assist any resident who was not on her case load. She stated Resident #24 was not on her case load and she was not allowed to touch her or do anything for her. In an interview on 04/10/2025 at 10:50 AM LVN B stated nurses were responsible for residents with diagnosis of diabetes with nail care such as trimming, cleaning, filing. She stated the CNAs were responsible for all other residents' nail care. LVN C stated if a resident had blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill such as stomach problems nausea and vomiting. LVN C stated if a resident refused any type of care, the nurse would document the refusal in the nurse's notes. She stated no one had reported to her Resident #24 refused nail care. She stated she had been in- serviced on nail care, however, she did not recall the date. In an interview on 04/10/2025 at 11:45 AM, CNA H stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA H stated the residents nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea. CNA H stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident #24, and she was not aware of Resident #24 refusing nail care. CNA H stated Resident #24 was more receptive of nail care when staff used a warm bath cloth and washed her hands and put it on her fingernails. CNA H stated Resident #24 did put her hands in her diaper when she had a bowel movement and she had reported this to a nurse a few weeks ago, however, she did not recall the nurse's name. She stated if any resident refused care it was reported to the nurse and the nurse would document the refusal in the nurses note. She stated she was in-serviced on nail care, and she did not recall the date of the nail care in-service. In an interview on 04/10/2025 at 8:17 AM the ADON stated she had worked for the company for one year. She stated she tried to get the aides to check nails every day. She stated some residents would not allow staff to trim their nails. She stated if the resident refused, they would have to come up with other ways to get the residents to let them trim their nails. She stated if a resident's toenails are curling over into the skin, it could cause harm to them. She stated residents with long nails could scratch themselves or someone else and the scratches could get infected. She stated there were all kinds of bacteria under the nails that could lead to an infection and if the resident put their fingers in their mouth, the bacteria could make them sick. In an interview on 04/10/2025 at 10:06 AM the DON stated long nails and toenails could puncture the skin and cause an entryway for microbes (bacteria). She stated the resident could scratch themselves and it could lead to infection. She further stated if they put dirty nails in their mouth they could get a GI upset. She stated the CNAs do ADLS and the DON, ADON and floor nurses should be checking up after them. In an interview on 04/10/2025 at 12:27 PM the ADM stated she expected fingernails and toenails to be trimmed and filed if jagged. She stated the CNAs and Nurses were responsible for performing that task. She stated the potential risk to the resident of long nails could be infection, and cuts, scrapes from nails cutting into the skin. She stated it could cause discomfort. She stated there could be fungus and bacteria under the nails that could lead to infection. Review of a facility policy and procedure titled Nail Care dated 2024 reflected, The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing will be provided on a regular schedule. 6. A. Nails should be kept smooth to avoid skin injury. B. Only licensed nurses shall trim or file fingernails of residents with diabetes. 32452 40884

Based on observation, interviews and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 of 10 residents (Resident #21, Resident #65, Resident #10 and Resident #7) and 1 of 1 shower rooms (A Hall) reviewed for resident rights. A) The facility failed to ensure Resident #21's room and shower was clean. B) The facility failed to ensure the A Hall shower room was clean and free of mold, trash and soiled washcloths. C) The facility failed to ensure Resident # 65's tray table was in good repair. D) The facility failed to ensure there were intact privacy curtains in Resident #10 and Resident #7's room. These failures could place residents at risk of not having a safe, clean, sanitary, comfortable and homelike environment. Findings included: A) Record review of Resident #21's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Malignant neoplasm of Larynx (cancerous cells in the voice box), Tracheostomy (opening in the neck to insert a tube into the trachea or windpipe that acts as a passageway for air to and from the lungs), and cognitive communication deficit (communication difficulties stemming from underlying thinking processes). Record review of Resident #21's Quarterly MDS dated [DATE] reflected he had a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #21's Care Plan dated 12/19/2024 reflected he had a communication problem r/t hearing deficit. The care plan dated 02/09/2025 reflected he had an enteral nutritional tube for an alternate method of nourishment. Observation on 04/08/2025 at 9:11 AM in Resident # 21's room revealed debris on the floor including two plastic drink tops, a packaged enteral syringe, 2- 4 X 4 gauze pad packages, and an insect egg casing. The shower floor had brown, black grime and a soiled wet washcloth on the shower seat. B) Observation on 04/08/2025 at 9:25 AM in the A Hall shower room revealed a soiled washcloth on a shower seat, a used, inside out glove on the floor under the sink, and a soiled washcloth on the floor. The shower stall had black mold on all the grout from waist level down and on the floor. There was a soiled, wadded up Band-Aid on the shower floor. Observation on 04/09/2025 at 8:14 AM revealed the A Hall shower room still had black mold in the shower and the soiled Band-Aid was in a different location and still stuck on the shower floor. C) Record review of Resident #65's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (stroke where part of the brain is damaged or dies due to lack of blood supply). Record review of Resident #65's Quarterly MDS dated [DATE] reflected he had a BIMS score of 10 indicating moderate cognitive impairment. Observation and interview on 04/08/2025 at 10:38 AM in Resident #65's room revealed his tray table was missing a wheel and was wobbly. Resident # 65 stated he had asked aides to fix his tray table and they said We'll look into that but they never got back with him. D) Record review of Resident #10's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, without behavioral disturbance (decline in mental process involved in knowing, learning and understanding things where the specific cause or type is not identified), and Cognitive Communication Deficit (communication difficulties stemming from problems with underlying thinking processes). Record review of Resident #10's Quarterly MDS dated [DATE] reflected he was unable to complete a BIMS assessment. Record review of Resident #7's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Undifferentiated Schizophrenia (hallucinations, delusions, disorganized thinking and difficulties with daily functioning), and Cognitive Communication Deficit (communication difficulties stemming from problems with underlying thinking processes). Record review of Resident #7's Quarterly MDS dated [DATE] reflected he had a BIMS score of 13 indicating intact cognitive status. Observation on 04/08/2025 at 11:54 AM in Resident #10 and Resident #7's room revealed the privacy curtain between their beds was hanging down and broken. In an interview and observation on 04/10/2025 at 9:35 AM the Housekeeping Supervisor observed the broken curtain and missing curtain in Resident #10 and Resident #7's room. She stated they would be replaced. In an interview on 04/10/2025 at 9:45 AM the Housekeeping Supervisor stated the staff were supposed to clean the shower rooms twice a day. She stated the floors in every room were supposed to be mopped and cleaned every day and her staff had been trained to do this. She stated she had spoken to the Maintenance Supervisor about the curtains that were broken and missing in Resident #10 and Resident #7's room. In an interview on 04/10/2025 at 12:27 PM the ADM stated there should be privacy curtains in the rooms. She stated cleanliness was a high priority and there should be daily sweeping and mopping of each room. She stated the showers should be kept clean. She stated residents should not be taking a bath in someone else's filth and it was an issue with infection control. She further stated it was a safety issue with the dirty gloves and used Band-Aid being on the floor in the shower room on Hall A. In an interview on 04/10/2025 at 2:40 PM CNA H stated she had worked at the facility since November 2022. She stated if she sees something that needs fixing, she will go to the Maintenance man or put it in the Maintenance book. In an interview on 04/10/2025 at 2:41 PM CNA G stated she had worked at the facility for almost one year and she knew to put any needed repairs into the repair log. Record review of the work request log on 04/10/2025 at 2:00 PM reflected none of the repair issues observed during the survey had been put into the log. In an interview on 04/10/2025 at 2:45 PM the Maintenance Director stated if the staff had a request, they would write it in the work request log and unless it was an emergency he would repair it within 24 hours. He stated he made rounds on the halls, but did not generally pay attention to the curtains. He stated he thought the CNAs would notice what needs to be repaired. He stated he checked the work request log when he arrived at the facility and before going home. Upon exit on 04/10/2025, no policy specific to facility maintenance had been received from the facility.

Based on observation, interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the front door of the facility and had adequate supervision. This failure could place residents at risk of accidents, and injuries due to a lack of supervision. The noncompliance was identified as PNC IJ. The IJ began on 08/12/2024 to 08/24/2024/ and ended on 08/24/2024. The facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. Findings included: Record review of Resident #1's Face Sheet dated, 08/18/2024, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 was discharged from facility on 08/13/2024. Resident #1 had diagnosis of Alzheimer's disease with late onset ( symptoms first appear in someone who is 65 or older - a brain disorder that causes the gradual loss of memory and thinking skills. Symptoms: changes in behavior, language and personality), cognitive communication deficit ( communication problems that are caused by underlying cognitive impairments, rather than speech or language deficits), difficulty in walking ( there are many reasons why someone may have difficulty with walking such as : injuries, foot problems, joint issues, nervous system disorder and brain disorders - the part of the brain that controls balance and coordination), essential hypertension (high blood pressure), and unsteadiness on feet ( when you have trouble walking in a steady, smooth manner). Record review of Resident #1's Quarterly MDS assessment, dated July 12, 2024, reflected Resident #1 had a BIMS score of 4 indicating her cognition was severely impaired. Resident #1 did not have any wandering behavior. She was independent with walking. Record review of Resident #1's Comprehensive Care Plan, dated on 07/17/2024, reflected Resident #1 was a wander risk related to confusion. Intervention: observe for any signs or symptoms of agitation, pacing, and restlessness. Resident #1 had impaired cognitive function related to dementia ( the loss of cognitive functioning, thinking, remembering, and reasoning- it interferes with a person's daily life and activities) Intervention: Break tasks into short segments. Assured that residents wishes were understood by being patient. Record review of Resident #1's Comprehensive Care Plan, revised on 08/12/2024, reflected Resident #1 was an elopement risk as evidence by leaving the facility unsupervised on 08/12/2024. Intervention: Distract Resident #1 from wandering by offering pleasant diversions, structured activities, food , conversation, television, and sitting with her son. Perform elopement assessment, on admission/readmission, quarterly, and with any change of condition. Provide structured activities such as :toileting, walking inside and outside supervised. Resident was to have a staff to be with Resident #1 at all times supervision until placement on a secure unit. Record review of Resident #1's Nurses Notes, dated 08/12/2024, reflected This nurse was passing meds at the end of the hall on C and received a phone call from ADON whom stated that someone had seen resident nearby the school. Immediately after, this nurse goes to nurses' station and informs nursing staff that there is a missing resident and instructed the nursing assistants to search the facility for missing resident. DON and RP ( responsible party) were notified. Shortly after, Police Department arrive to facility with resident and stated that they found resident nearby and that they would contact administrator regarding this incident. This nurse told [local] PD that the front door doesn't have a security system in place Resident is alert and confused due to dementia diagnosis and is assisted back into the facility. Upon head-to-toe assessment, no injuries are present nor does the resident complain of any pain or any signs/ symptoms of distress. Vital signs at this time are: bp 126/70, p- 66 regular, 18 respirations, temp 97.6F. Q15 min checks are in progress with a sitter present at all times. Full range of motion to all extremities. Nurse practitioner notified as well. Furthermore, resident is taken to ER for further evaluation, RP notified. At around midnight, resident is brought back to facility and no new orders at this time. This nurse also notified ADON and DON that she was last seen around 7:30 PM. Resident is awaiting transfer to a lock down unit signed by LVN A. Record review of Resident #1's Nurses Notes, dated 08/13/2024, reflected CP ( Care Plan) meeting was held today. SW discussed the recent elopement, and explained that for her safety, she would need to be moved to a secure unit. Guardian was ok with this and thankful. SW sent guardian the contact info for the new facility. Record review of Resident #1's Nurses Notes, Dated 08/13/2024 at 14:24, Resident #1 was discharged to a sister facility with all personal belongings and medications via facility transport van in stable condition. Signed by LVN B. Record review of Resident #1's Facility Investigation dated, 08/18/2024, reflected the incident date occurred on 08/12/2024 at 7:30 PM. Her ambulation was independent. She was interview able , however unable to make informed decisions. Resident #1 did not have a history of similar allegations. Resident #2 was a witness. Resident #1 went on an unsupervised outing. Resident #1 did not have any injury. Resident #1 was transferred to theER on [DATE] and returned to the facility on [DATE]. In the facility investigation record reflected the incident was not reported to the police. There was a head count of all facility residents completed with no others identified missing. Immediate notification of guardian and attending physician. Resident#1 was placed on 1:1 when she re-entered the facility. All resident's elopement assessments were updated Investigations Findings were confirmed. On 08/13/2024 resident was transferred to another facility to reside on secure unit. Resident #1 had continuous staff supervision until such date. Signed by [NAME] President of Clinical Operations. Record review of Resident #1's incident report , dated 08/12/2024, reflected Resident #1 returned to facility escorted by the police. Resident #1 was located by a school approximately 1 mile from the facility. Resident #1 was last seen at 7:30 PM by Resident #2. Resident #1 stated she was going for a walk to Resident #2. Immediate action taken: Resident #1was placed on 1:1 supervision. Skin assessment completed and revealed no area of concern. Vitals signs within normal limits. Resident #1 was able to speak in clear sentences. Resident #1 was not taken to hospital. Resident #1 did not have any injuries at time of incident ( elopement). Resident #1 was able to recall some information. Her BIMS score was a 4 ( her cognition was severely impaired). Resident #1 was not in any pain. The incident location was outside. [NAME] President of Clinical Operations prepared the incident report. Record review of Resident #1's hospital report, dated 08/12/2024, reflected Resident #1 skin was warm, dry, and normal in color. Her mucous membranes pink, moist. Resident #1 was well-groomed. She denied any pain. 1. Neuro: GCS - Resident #1's eyes opening: spontaneous, verbal: confused , Motor: obeys commands, Upper extremity strength strong and lower extremity strength strong, no associated dizziness present. No associated nausea. 2. Respiratory/Chest: respiratory assessment findings include respiratory effort easy, respirations regular, conversing normally, neck and chest exam findings include chest expansion equal and chest movement symmetrical. 3. Cardiovascular: Assessment findings include heart rate normal. 4. Abdomen: abdomen soft, non-tender, no associated nausea or vomiting. 5. Left and Right Upper and Lower Extremity: findings include capillary refill (a physical exam technique that measures how long it takes for color to return after pressure applied) less than two seconds, skin color, muscle tone, skin temperature to hand was normal. Distal sensation intact and muscle tone normal. 6. Psych/ Social: psychiatric/ social assessment findings include affect normal. 7. Notes: Emotional support needed and given. Physical Exam: 1. Vital signs reviewed, Resident #1 was afebrile ( free from fever), and pulse , blood pressure, hypertensive, respiratory rate- all normal. Resident #1 was non-toxic and pain- free. She was oriented to person. 2. Head: head exam included findings of head atraumatic ( not causing injury or trauma) and normocephalic ( a person's head and major organs are normal without significant abnormalities) 3. Eyes, Neck, respiratory chest, cardiovascular, abdomen, back upper and lower extremity was all normal. Discharge Notes: 1. Resident #1 was in no distress; she was resting quietly. She would be discharged back to the facility. 2. Doctor notes; Resident #1 had dementia. She did not have any complaints of pain. Resident #1 had no outward signs of trauma. She did not require further exam. Resident #1 was sent back to the nursing facility where she would be monitored. Record review of Resident #1's Assessment reflected Resident #1 did not require an Elopement Assessment prior to 08/12/2024. Record review of Resident #1's SBAR ( situation, background, assessment, and recommendation), dated 08/12/2024, reflected the change of condition , symptoms, or signs was elopement from nursing facility. Started on 08/12/2024. Resident #1 was evaluated such as : vital signs, B/P, pulse, and or apical heart rate, temperature, respiratory rate, oximetry, and finger stick glucose, if indicated. Things that make the condition worse : wandering. Things that make the condition or symptom better: redirection. Blood Pressure 132/72, Pulse 82, Respiration 18.0, Temperature: 98.9, O2 SATS 96.0 percent room air. Assessment / nurse narrative progression of Alzheimer's Disease. Family member and Physician notified on 08/12/2024. Signed by LVN A. Record review of Resident #1 Elopement Nurses' Note Assessment record , dated 08/12/2024 , reflected this was Resident #1's initial elopement assessment. Resident #1 was unaware of situation due to dementia diagnosis. 1. Initial episode- elopement from the facility. 2. She exited the facility from the front door. 3. Follow- up- no further elopement attempt and Resident #1 was calm. 4. New orders : Resident #1 did not have any new orders. 5. Physician and Family was notified. 6. Interventions: Resident #1 was placed on 1:1 monitoring. Signed by LVN A Record review of Resident #2's Quarterly MDS Assessment, dated 09/20/2024, reflected Resident #2 had a BIMS score of 15 indicating his cognition was intact. Record review of elopement in-service / elopement drill on 08/13/2024 reflected the staff received in-service on elopement and an elopement drill was completed with the staff. Record review of elopement in-service and elopement drill on 08/26/2024 reflected the staff received in-service on elopement and an elopement drill was completed with staff. There were 36 employees signed the in-service. Record review on 10/03/2024 reflected the elopement binder located at the nurse's station revealed the residents at risk for elopement, each resident's information, and a picture in the binder. Record review of Resident #1's 1:1 supervision log reflected Resident #1 received 1:1 supervision began on 08/12/2024 at 8:45 PM until 08/13/2024 at 1:00 PM. Resident #1 was discharged from the facility on 08/13/2024 at 1:00 PM to a sister facility approximately 45 minutes away to a secure unit. Observation on 10/03/2024 throughout the day revealed the front door alarms and other door alarms was working. In an interview on 10/03/2024 at 8:45 AM, the Social Worker stated she was not involved with the investigation of the elopement of Resident #1. She stated she was involved with the discharge planning and discharge of Resident #1 to a secure unit at a sister facility. Social Worker stated Resident #1's Guardian was explained the incident with the elopement. She stated Resident #1's Guardian was aware of the elopement and was notified on 08/12/2024. Social Worker stated she spoke with Resident #1's Guardian on 08/13/2024. She stated Resident #1's Guardian was concerned of Resident #1's safety. Resident #1's elopement and agreed transferring Resident #1 to a secure unit. Social Worker stated the Guardian believed she would benefit being on a unit with other residents with Alzheimer's. She stated she emailed the guardian the contact information for the new facility. She stated she was in-serviced on elopement and participated in elopement drills in September 2024. Social Worker stated she learned an elopement was when a resident left the facility and wandering was when a resident did not have a goal; they wandered in the facility without a specific place they were wanting to go. In an interview on 10/03/2024 at 10:10 AM, CNA B stated she was working the night of 08/12/2024. She stated she was not assigned to Resident #1 on 08/12/2024 when the resident eloped from the facility. She stated Resident #1 did not exit seek or attempt to leave the facility prior to 08/12/2024. CNA B stated she would walk inside the facility and visit other residents but never attempted to leave the facility unsupervised. CNA B stated she saw Resident #1 around 7:15 PM walking toward the nurse's station. CNA B stated she ( CNA B) was walking down C Hall to continue her rounds on the residents she was giving care to on 08/12/2024. CNA B stated she did not notice anything unusual about Resident #1. She stated Resident #1 was placed on 1:1 supervision when she returned to the facility and after she returned from the hospital. CNA B stated she was in-serviced on elopement and how to use the alarm on the front door . She stated she participated in elopement drills. CNA B stated the facility had several elopement drills and she did not recall the exact date of the first elopement drill. She stated she thought it was the next day after the elopement of Resident #1. She stated she learned the difference between elopement and wandering. She stated elopement was when a resident left the facility without anyone with them and wandering was when they walked in the facility and did not have somewhere they wanted to go. In an interview on 10/03/2024 at 10:25AM, CNA C stated she never witnessed or heard of Resident #1 eloping from the facility except in August 2024. She stated she did not recall the exact date and she was not in the facility when Resident #1 eloped. CNA C stated Resident #1 never attempted to leave the facility or exit seek. She stated she was surprised when she heard Resident #1 eloped due to never attempting to elope in the past. CNA C stated she had been in- serviced on elopement and she had participated in elopement drills. She stated after Resident #1 eloped an alarm was placed on the front door. There were alarms already in place on the other doors. and the other doors already had alarms. She stated she was in-service on how to use the alarm on the front door. She stated she learned when an alarm sounded to immediately go to the location of the alarm and to make sure a resident had not left the facility. CNA C stated the staff immediately began to count the residents and make sure all residents were in the facility. She also stated they were to take directions from the supervisor to prevent all staff going on the same hall. The staff needed to be divided to search entire facility. In an interview on 10/03/2024 at 10:49 AM, LVN D stated Resident #1 did not have a history of exit seeking and never eloped from the facility until the elopement in August 2024. She stated she did not recall the exact date. LVN D stated Resident #1 enjoyed walking in the facility sometimes during the day, but she never exits sought or attempted to leave the facility. LVN D stated she was in-service on elopement, neglect, and abuse. She stated she participated in elopement drills and new alarm was placed on the front door. She stated she was in-service on how to use the alarm. In an interview on 10/03/2024 at 11: 15 AM, the ADON stated she was at home and heard on the police scanner an elderly lady was found at the high school. She stated she immediately called the facility and alerted LVN A to check the residents. She stated she did not come to the facility or go to the high school. ADON stated she was not involved in the investigation; the Corporate Nurse Consultant was notified and she came to the facility and did the investigation for the facility. ADON stated a front door alarm was installed, and Resident #1 was placed on supervision. In a phone interview on 10/03/2024 at 11:45 AM, [NAME] President of Clinical Operations stated she came to the facility when she was called ( did not remember who called her about Resident #1), and had been working at the facility and was in town when the incident with Resident #1 occurred on 08/12/2024. She stated she immediately came to the facility and spoke with Resident #1. She stated Resident #1 pointed to the right of the road when asked the direction she walked to the school. [NAME] President of Clinical Operations stated she went to the right and then she took another right and went to the first school. She stated she knew she went to the first school because that was the nearest school to the facility. [NAME] President of Clinical Operations stated she completed skin assessment. She stated Resident #1 did not have any injuries, bruising, or skin tears. She stated she wanted Resident #1 to be transferred to the ER for evaluation to ensure Resident #1 did not have any injuries. The [NAME] President of Clinical Operations stated the last person who saw her was Resident #2. She stated Resident #2 stated he saw her around 7:30 AM, and she was wanting to go for a walk. She stated Resident #1 was immediately placed on 1:1 supervision when she returned to the facility by the police from the emergency room . [NAME] President of Clinical Operations stated the time frame of Resident #1's unsupervised outing was between 7:30 AM and she returned to the facility approximately 8:30 PM. She stated it was not dark; it was still daylight and it had began getting dark around 8:30 PM. She stated the meaning of unsupervised outing was a resident leaving the facility unsupervised such as elopement. She stated a CNA did see Resident #1 between 7:00 PM and 7:20 PM, but she did not recall the CNA's name. She stated in-services and elopement drills immediately began September after Resident #1 eloped. The [NAME] President of Clinical Operations stated Resident #1 was on 1:1 supervision until she was discharged to a sister facility on a secure unit. In an interview on 10/03/2024 at 12:20 PM, Resident #2 stated he remembered a female resident saying she wanted to go for a walk. He said he remembered he had to answer questions when he saw her. Resident #2 stated it was about 7:30 PM when she said that and he stated he learned she left the facility and went on a walk to a school. In an interview on 10/03/2024 at 12:45 PM, the Administrator stated she began working at the facility on 08/23/2024. She stated she continued with in servicing and elopement drills after she began working at the facility. The Administrator stated she was in-service on elopement by the [NAME] President of Clinical Operations during orientation. She stated she was not an employee at the facility when Resident #1 eloped. She stated she was responsible for updating the elopement binder whenever there was a new admit. The Administrator stated any new staff including agency would not be allowed to begin working with the residents until the elopement in-service was completed. She stated there was not any new staff or new residents since 08/12/2024. The Administrator stated since she has been an administrator, the alarms were being monitored at least 5 times a week by the Maintenance Supervisor . She stated she developed the elopement binder. The Administrator stated elopement drills would be ongoing on both shifts and she would continue in-services on elopement. She stated she could not respond to question of what occurred on 08/12/2024 when Resident #1 eloped from the facility. She stated she read the investigation. In an interview on 10/03/2024 at 12:45 PM, The Director of Nurses stated she was not an employee at this facility when Resident #1 eloped on 08/12/2024. She stated her first day of work at this facility was on 09/23/2024. The Director of Nurses stated she would be involved with the elopement in-services and drills. She stated she would ensure all residents' elopement profiles would be updated in the elopement binder as needed. The Director of Nurses stated she did receive an in-service on elopement when she began working at the facility. In an interview on 10/03/2024 at 1:15 PM, Policewoman stated a citizen ( did not know the name of the citizen) called the police station about a concern of a female at the high school near the football field. The Policewoman stated she was with another policewoman ( did not give this person's name) and they arrived at the high school approximately 8:05 PM. She stated Resident #1 did not know her name or where she lived. The Policewoman stated she had to look in her purse to identify Resident #1. She stated Resident #1 was afraid, did not know where she was, and disoriented. She stated it was not dark at the time Resident #1 was found. The Policewoman stated when Resident #1 was transported by her to the facility, it began getting dark, they arrived at the facility at 8:30 PM. She stated Resident #1 did not have any visible injuries or bruises. She stated a nurse came to outside and assisted the resident into the facility. In an interview on 10/03/2024 at 1:40 PM, the Maintenance Supervisor stated he checked the alarms to ensure they were working and he installed the alarm on the front door as part of the plan to ensure another resident did not elope after the elopement of Resident #1. He stated it was installed within few days of 08/12/2024. In an attempt to contact Resident #1's Guardian on 10/03/2024 at 4: 40 PM was unsuccessful. Record review of the facility's policy on Elopement and Wandering Residents, not dated, reflected This facility ensures that residents who exhibit wandering behavior and/ or at risk for elopement receive adequate supervision to prevent, accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/ or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The noncompliance was identified as PNC IJ. The IJ began on 08/12/2024 to 08/24/2024 and ended on 08/24/2024. The facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation.

Based on observations, interviews, and record review, the facility failed to ensure that residents had comfortable and safe temperature levels for two of four halls, in that: The facility failed to ensure the facility was maintained at a comfortable and safe temperature level and maintain a temperature range of 71 to 81 F, when 5 of the 12 AC/Heater units were not functioning (since May 2022) and the mobile air units put into place on B and D halls were not able to heat the halls or resident rooms and the temperature in resident rooms was between 56-66 degrees. This failure placed residents at risk for loss of body heat, risk for hypothermia and an uncomfortable environment leading to a decreased quality of life. This failure resulted in an Immediate Jeopardy (IJ) situation on 12/27/2022. While the IJ was removed on 01/02/2023, 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 scoped at a pattern, due to staff needing more time to monitor the plan of removal for effectiveness. Findings Included: Observation on 12/27/2022 at 8:15 AM revealed Hall B with two mobile air units with return air venting into hallway with the air temperature measuring 61 degrees. In an interview and observation on 12/27/2022 at 8:30 AM Resident #360 stated Saturday night was cold. Temperature at vent in room was 60 degrees. In an interview on 12/27/2022 at 8:36 AM Resident #6 stated, it's cold in here. In an interview on 12/27/2022 at 8:46 AM, LVN T stated the facility was having problems with the heating systems on B and D Hall. She stated there was no heat on these halls. In an observation on 12/27/2022 at 8:47 AM Resident #41's vent room temperature was 63 degrees. In an interview on 12/27/2022 at 8:50 AM, the ADMIN stated the Regional Manager had ordered replacement parts for the heater and was not sure when they would be fixed. He stated he had been at the facility for two weeks and the system had been down since he started. The ADMIN stated the contractor who brought the mobile units must have set them up in the hallway. Review of an estimate dated 05/10/2022 from a heating and air service company reflected an estimate for the repair of 5 A/C-Heating units. The facility did not provide a purchase agreement for the estimate $76,834.65 for system installation. In an interview on 12/27/2022 at 8:55 AM, Maintenance Director stated the heaters were not enough to keep the rooms warm and the contractors set up the heaters in the hallways like that (with cold exhaust venting out into hall.) He stated the facility lost power on 12/23/2022 from 4:00 PM to 7:00 PM. He was not sure what the temperature in the facility was at the time. He further stated that the current heating units were not enough to heat the halls or keep the rooms warm. In an interview on 12/27/2022 at 8:58 AM, ADMIN stated they were going to contract for more until they could get the central unit fixed. The ADMIN stated the current units were not able to heat the resident rooms or hall ways. Observation on 12/27/2022 at 9:00 AM on B-hall revealed to have two mobile air units in the hall turned on heat with the return air blowing into the hall. Warm air was felt coming out of the front of the unit with cold air blowing out of the return air. The air blowing from the return air was measured to be 56 degrees. The room temperatures on B-hall ranged from 60 to 63 degrees. In an interview on 12/27/2022 at 9:01 AM, LVN A stated she was monitoring the residents every 2-4 hours but only taking the resident temperatures one time a shift. Observation on 12/27/2022 at 9:30 AM on D-hall revealed one mobile air unit in the hall. The return air was blowing back into the hall and measured 50.6 degrees. The room temperatures on D-hall ranged from 52 to 65 degrees. In an interview on 12/27/2022 at 9:31 AM, LVN B stated she observed the residents every 1-2 hours and made sure they had blankets. She stated she only took the body temperature one time per shift. She had one resident complain of being cold and she got her more blankets. In an interview on 12/27/2022 at 9:58 AM, Resident #57 stated it had been cold more than 4 days. She stated she used blankets and the staff brought her some extra blankets. Resident #57 stated it was so cold after midnight that when she would wake up the blankets would not be working to keep her warm and stated she was shivering. She stated the heater was not working in her room. In an interview and observation on 12/27/22 at 10:05 AM, Resident #15 stated it had been cold in her room a week and it was cold at night. Resident #15 did not have extra blankets in her room. In an interview on 12/27/22 10:12 AM, Resident #24 stated she was cold at night. She stated she was not cold now but got cold at night. She stated she was tired and needed to sleep. Observation on 12/27/2022 of room temperatures on D-Hall revealed temperatures at 10:23 AM in RM D 58 to be 59.2 degrees. Observation and interview on 12/27/22 at 10:27 AM revealed room [ROOM NUMBER] on D Hall's temperature was 62.2 degrees. Resident #56 stated it was cold in his room. He stated he had on a sweatshirt and another coat on top and still he was not warm, and it got really cold at night. He stated he stayed out of his room a lot during day to stay warm. Further observation revealed he had three blankets on his bed, and he stated that was not enough at night. In an interview on 12/27/2022 at 11:15 AM, the Administrator stated the facility was waiting on parts to fix the heating units and he did not have a specific date the heating units would be fixed. He stated the company that brought the units told him that the units were not configured for the building and stated that yes, they were blowing cold air out the back of the units and stated he got the units because it was either them or nothing and stated that no they are not working properly and are not heating the halls. He stated the facility was not keeping a temperature log of the areas of the facility without heat. He stated they were doing spot checks only to check the facility's temperature. Observation on 12/28/2022 at 9:00 AM revealed 3 rooms on B-hall and 2 rooms on D-hall with space heaters in the resident rooms. In an interview on 12/28/2022 at 9:20 AM, the ADMIN stated he did not know you could not use space heaters in rooms. He stated they were placed in the resident rooms because they had complained about the cold. He stated he would remove them. In an interview on 12/29/2022 at 3:05 PM, the Maintenance Director stated the facility had 12 heating and AC units for the facility and 5 were not functioning. He stated he was not sure which parts of the building or which rooms had functioning units. Review of the facility maintenance repair log from 04/01/2022 through 12/29/2022 reflected no entries regarding the heating system. Review of the website weather.com on 12/27/2022 reflected temperature over the past 2 weeks to have lows at 12 degrees with temperatures below freezing on 7 days of the 14 days. Review of the facility policy dated 12/2009 Winter [NAME] Safety Precautions reflected Personnel shall follow established winter storm safety precautions .Make sure heating system is operable, make sure emergency heating equipment is on hand or can be readily obtained . Review of the facility policy dated 08/2018 Emergency Procedure- Utility outage; Severe Cold Weather procedures: Utilize the following procedures if there is a loss of heating function (the facility temperature reaches 65 degrees Fahrenheit and remains so for four hours) to prevent hypothermia .Monitor body temperatures. Monitor environmental thermometers. Evacuate residents if temperature remain low and residents' safety and welfare are jeopardized . An immediate Jeopardy (IJ) was identified on 12/27/2022 at 2:08 PM, due to the above failures. The Administrator was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. The Plan of Removal was accepted on 12/29/2022 at 4:35 PM and is as follows: Plan of Removal Immediate Jeopardy 60 Residents have the potential to be affected by the deficient practice. On 12/27/2022 an abbreviated survey was initiated at Adar Healthcare. On 12/27/2022 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. 1.The residents on B & D hall are at risk of loss of body heat and risk of hypothermia, or hyperthermia, and\or are uncomfortable for the residents. Action: Corrective Measure: Remove residents in hall B & D to exclude room D60 (connected to a/c unit that serves the lobby and is working) where the heating and cooling units are not working, to halls A & C where the heating and cooling unit is working. Six residents will be transferred to Golden Creek Healthcare & Rehabilitation Centers of [NAME] County, Navasota, TX or Coral Rehabilitation and Nursing of Arlington, Tx. No new residents will be admitted until the A/C unit in halls B & D are working correctly, the residents will be transported to new facilities by Adar Healthcare company van. We have two patient transport vans. We have a bed for all residents except for six residents, the six residents will be transferred by Adar Healthcare transportation driver to one of two facilities Golden Creek Healthcare & Rehabilitation Centers of [NAME] County, Navasota, TX and / or Coral Rehabilitation and Nursing of Arlington, Tx. Start Date: 12.29.22 Completion Date: 12.30.22 Responsible: Administrator Action: Speak with the facility residents in halls B & D and explain why the resident must temporally change rooms and address any concerns. Start Date: 12.29.22 Completion Date: 12.29.22 Responsible: Administrator Action: Speak with the resident representative in halls B & D and explain why their loved one must temporally change rooms. Start Date: 12.29.22 Completion Date: 12.30.22 Responsible: Social Worker Action: Monitor the weather channel for projected temperatures. Start Date: 12.29.22 Completion Date: Ongoing until A/C units is B & D hall are repaired. Responsible: Administrator 2.The facility needs to ensure the facility's ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia, or hyperthermia, or and is comfortable for the residents. Action: Monitoring System: The facility will monitor and log Air Temperatures in halls A & C, residents' rooms on A & C wing, common areas and dining areas to ensure the temperatures stay in the range of 71 to 81 degrees. If facility temperature goes outside of ambient temperature of 71 to 81 degree, all staff will be in serviced to call the maintenance supervisor. Start Date: 12.29.22 Completion Date: On going Responsible: Maintenance Monday - Friday / Weekends: House Keeping Staff on duty. Action: Inservice on how to keep facility temperature logs. The facility temperature logs will be kept on housekeeping supervisor computer, we will log the time temperature was taken, location where temperature was taken and any resident comments about facility temperature. Start Date: 12.29.22 Completion Date: 1.06.22 Responsible: House Keeping Supervisor 3. Identify other individuals who have the potential to be affected by the same deficient practice and how the facility will act to protect individuals in similar situations. Action: The facility will monitor and log the temperature in different areas 3 times a day A & C wings the front of the wing the middle of the wings and the end of the wings, at 0800, 1200 and 1800. The facility will ask three residents in each wing if they are cold or hot 3 times a day, rooms A04, A07, A03, C32, C34 and C41. All information will be given to housekeeping supervisor log on her CPU. Start Date: 12.29.22 Completion Date: Ongoing. Responsible: Maintenance Supervisor and House Keeping Supervisor. Program put in place to monitor the continued effectiveness of the system change to ensure that solutions are permanent. Action: We will cover ambient temperature in our QAA meeting monthly Start Date: 01.09.22 Completion Date: Ongoing Responsible: QAA Committee All Department Heads House Keeping/Dietary, Maintenance Supervisor, Activities, DON, BOM, AP/HR, Social Service and Medical Records. The Survey team monitored the plan of removal as follows: Monitoring was conducted from 12/29/2022 through 01/02/2023. In an interview on 12/31/2022 at 11:14 AM, the ADMIN stated trainings for room temperature are 100% for onsite staff with trainings continuing prior to staff working their next shift. Review of the temperature checks logs dated 12/30/2022 PM and 12/31/2022 AM reflected no temperatures were documented outside of 71 -81 range. In an interview on 12/30/2022 at 1:30 PM, the Maintenance Director stated he had a map of the heating/ A/C units and was able to provide surveyor with a list of rooms that were provided air by each unit. He stated he had mapped out and designated rooms that could be used to move residents off the units without heat to units with heat. In an interview on 12/31/2022 at 11:31 AM, the Maintenance Director provided sign in sheets for temperature training - estimates 80% of all staff completed. Provided sign in sheets for evacuation training -estimates 70% of staff completed. The Maintenance Director stated the 6:00 PM shift would be trained that afternoon before starting their shift. In an interview on 12/31/2022 at 11:47 AM, CNA L stated she received training on temperature checks. She stated to check with the residents - if they are cold, check thermostat - increase heat setting until the residents are comfortable. She stated she was responsible for Hall C and for helping on Hall B. She denied any concerns regarding her training. In an interview on 12/31/2022 at 12:01 PM CNA M, N and O stated they were trained on temperature checks to ensure the residents are comfortable. All stated they are to check the temperatures in the rooms and halls until the units are fixed and to report to the charge nurse if the temperature is below 72 and to offer the residents blankets or move residents to rooms with heat, if needed. In an interview on 12/31/2022 a 12:10 PM, LVN A and B stated they were trained on heating and cooling the nursing home and the necessary precautions needed if the temperatures fall out of range. They stated they were trained to take temperatures in the hall and various room on halls at 8 AM, 12 PM and 6 PM around the clock to see if the temperature range is between 71 and 81 degrees and to adjust the thermostat and notify the ADMIN or Maintenance Director. In an interview on 12/31/2022 at 12:19 PM, HSK P and Q stated they had received training on monitoring and adjusting the facility temperature to ensure the temperature remains between 71 and 81 degrees and to notify maintenance if the temperature is out of range or if the residents complain about being hot or cold. Review of the facility temperature monitoring logs reflected no temperatures documented outside the required temperature range. Observations on 12/31/2022 through 01/01/2023 revealed the facility air temperatures on B and D Hall measuring between 71 and 81 degrees. Review of the website weather.com on 01/01/2023 reflected the temperatures ranged from 82 degrees to 40 degrees from 12/31/2022 through 01/01/2023. In an interview on 01/01/2023 at 5:51 PM, LVN J and C stated she received training on monitoring facility temperatures. She stated they are to monitor the temps on the halls - rooms at the beginning, middle and end of the hallway. If temps fall below 71 or above 81, they are to adjust the thermostat and notify maintenance of any issues. In an interview on 01/01/2023 at 5:45 PM, Resident #34 and Son in his room stated the facility temperatures were ok at this time. Review of the facility's in-service attendance record dated 01/01/2023 reflected 80% of the staff had been trained on monitoring the facility's temperature and ensuring the temperatures are within the safe range of 71 to 81 degrees. On 01/02/2022 at 1:00 PM at exit the facility was notified that the IJ was lowered. However, the facility remained out of compliance at a severity level no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observations, interviews, and record review the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 1.The facility failed to ensure that an emergency transfer agreement was in place in the event an evacuation was necessary (The facility did not have operational heating units on 2 of the 4 halls and did not have enough rooms to move all the residents to rooms with functional heating units). 2. The facility failed to ensure a facility assessment was completed to determine what resources were necessary to care for the residents or to ensure staff were trained on emergency procedures in the event a evacuation was necessary. These failures placed residents at risk of not having necessary resources and services available to them during day-to-day operations and emergencies which could result in lack of care, exposure to the elements and loss of life during an emergency. This failure resulted in an Immediate Jeopardy (IJ) situation on 12/27/2022. While the IJ was removed on 01/02/2023, 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 IJ scoped at a pattern, due to staff needing more time to monitor the plan of removal for effectiveness. Findings Included: Observation on 12/27/2022 at 9:00 AM on B-hall revealed to have two mobile air units in the hall turned on heat with the return air blowing into the hall. Warm air was felt coming out of the front of the unit with cold air blowing out of the return air. The air blowing from the return air was measured to be 56 degrees. The room temperatures on B-hall ranged from 60 to 63 degrees. In an interview on 12/27/2022 at 8:55 AM Maintenance Director stated the heaters were not enough to keep the rooms warm and the contractors set up the heaters in the hallways like that (with cold exhaust venting out into hall.) He stated the facility lost power on 12/23/2022 from 4:00 PM to 7:00 PM. He was not sure what the temperature in the facility was at the time. He further stated that the current heating units are not enough to heat the halls or keep the rooms warm. In an interview on 12/27/2022 at 8:58 AM ADMIN stated they were going to contract for more until we can get the central unit fixed. The ADMIN stated the current units were not able to heat the resident rooms or hallways. The ADMIN further stated he did not have enough empty rooms in the facility to move all the residents from B and D hall to rooms with heat. In an interview on 12/27/2022 at 11:15 AM, the Administrator stated heating units were not working when he started at the facility. He stated the company that brought the units told him that the units were not configured for the building and stated that yes, they were blowing cold air out the back of the units and stated he got the units because it was either them or nothing and stated that no they are not working properly and are not heating the halls. He stated the facility was not keeping a temperature log of the areas of the facility without heat. Review of the facility's emergency transfer agreement for evacuation purposes dated 09/16/2016 reflected a transfer agreement with another facility. No other transfer agreement was provided. The transfer agreement did not reflect a effective timeframe. In an interview on 12/28/2022 at 1:00 PM, the Administrator stated the emergency transfer agreement, dated 9/16/2016, was the only agreement he was aware of. He stated he was going to get with the Regional Director to see if the agreement was still in place. In an interview on 12/28/2022 at 2:30 PM, the Administrator stated he spoke with the Regional Director. He stated he contacted the Administrator at the receiving facility, and she stated the contract was still viable. In an interview on 12/28/2022 at 3:35 PM, the Administrator stated the facility assessment given to surveyor was the only one he had. Titled Hazard Vulnerability Analysis that was 2 pages and did not address facility demographic or resident care levels (not dated). He stated he was working on one but there was not one when he started at the facility two weeks ago. He stated he understood that it was a problem regarding staffing and training of staff to ensure residents needs were met. In an interview on 12/28/2022 at 6:00 PM, the Administrator at the transfer facility stated she was not aware of any emergency transfer agreement with facility and did not have a contract the facility to house the residents in the event of an emergency. She stated her facility is contracted with another facility in her corporation. In an interview on 12/29/2022 at 9:10 AM, the Administrator stated the facility assessment was used to give the demographics of the facility and how it functioned and what care is needed for the residents including staffing. The Administrator stated without a facility assessment the facility would not be able to ensure all care for the residents was being provided and what the residents needs would be during an evacuation. The Administrator stated he did not know why the facility did not have a facility assessment, but one would definitely be needed during an evacuation situation to know how many buses were needed for transportation, who was on oxygen, and the resident care needs. In an interview on 12/29/2022 at 9:14 AM, the Regional Director stated he was surprised that the Administrator at the transfer facility said there was no contract. He stated the contract should be updated annually by the administrator to ensure the contract is viable. Review of the facility's history for the contract facility reflected the facility underwent a change in the facility management companies on 4/23/2019. Review of the facility's history reflected they underwent a CHOW on 11/01/2019. Review of the facility's in-service training for the past year provided by the facility reflected no emergency preparedness in-service training. In an interview on 12/29/2022 at 11:08 AM, CNA E stated she worked at the facility one year and knows to take residents out of danger, but she didn't know anything about what to do for evacuations. She stated, I've never been here for anything like that. No training that I can remember. In an interview on 12/29/2022 at 11:11 AM, LVN A stated she had not been in-serviced on Emergency Plan or Emergency Evacuation. In an interview on 12/29/2022 at 11:13 AM ,Housekeeper G stated they she had practiced fire drills. She stated they go to the parking lot, and someone would have to pick them up and take them to the hospital, or the other nursing home, across town, but the nursing home is gone because of the tornado. She stated she would assist residents out of the building and to wherever they are supposed to be. In an interview on 12/29/2022 at 11:15 AM, the BOM stated she had worked at the facility for 3 years and had no training on evacuations. She stated there was no current contract with another facility to take residents in case of a n emergency. In an interview on 12/29/2022 at 11:18 AM, CNA D stated I'm not for sure about emergency evacuation or the emergency plan. I don't know if I have been told about evacuations or how to handle an evacuation. Review of the facility's policy (not dated) Facility Assessment Policy reflected the intent of the facility assessment is for the facility to evaluate its resident's population and identify the resources needed to provide the necessary person-centered care and services the residents require .The facility must review and update this assessment annually or whenever there is/the facility plans for any change that would require a modification to any part of this assessment. Review of an emergency preparedness checklist dated 12/2013 (not filled out or completed) provided by the facility on 12/28/2022 as their emergency plan reflected Develop emergency plan . Multiple pre-determined evacuation locations (contract or agreement) with a like facility have been established, with suitable space, utilities, security and sanitary facilities for individuals receiving care, staff and others using the location, with a least one facility being 50 miles away. A back up may be necessary if the first one is unable to accept evacuees Review of the facility's policy dated 12/2009 Winter [NAME] Safety Precautions reflected Personnel shall follow established winter storm safety precautions .Make sure heating system is operable, make sure emergency heating equipment is on hand or can be readily obtained . Review of the facility's policy dated 08/2018 Emergency Procedure- Utility outage; Severe Cold Weather procedures: Utilize the following procedures if there is a loss of heating function (the facility temperature reaches 65 degrees Fahrenheit and remains so for four hours) to prevent hypothermia .Monitor body temperatures. Monitor environmental thermometers. Evacuate residents if temperature remain low and residents' safety and welfare are jeopardized . An immediate Jeopardy (IJ) was identified on 12/29/2022 at 2:56 PM, due to the above failures. The Administrator was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. The Plan of Removal was accepted on 12/31/2022 at 1:59 PM and is as follows: Plan of Removal Immediate Jeopardy 60 Residents have the potential to be affected by the deficient practice. On 12/27/2022 an abbreviated survey was initiated at Adar Healthcare. On 12/29/2022 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The facility residents are at risk of not having the necessary resources to care for them during day-to-day operations and emergencies. Action: The facility will complete a facility assessment. Responsible For Action: Maintenance Supervisor Start Date: 12.30.22 Completion Date: 1.04.23 Responsible: Administrator Action: The facility will update the facility assessment quarterly Responsible For Action: Maintenance Supervisor Start Date: 12.30.22 Complete Date: Ongoing Responsible: Administrator Action: QAA Team will QA the facility assessment annually Responsible For Action: QAA Team The facility Department Heads Start Date: 01.02.23 Completion Date: Ongoing Responsible: Administrator Action: Complete an evacuation transfer agreement, that will allow us to transfer our residents to another Long-Term-Care Facility. The transfer agreement will have charter bus and ambulance services. Responsible For Action: Regional Manager Start Date: 12.29.22 Completion Date: 12.29.22 Responsible: Administrator Note: Transfer agreements have been made with Golden Creek Healthcare & Rehab Center of [NAME] County Navasota, TX. Coral Rehab and Nursing of Arlington, TX Action: Emergency transportation, all residents will be transported by Charter UP Charter Company and Texas EMS in the event of an emergency. Responsible For Action: Regional Manager Start Date: 12/30/22 Completion Date: 12/30/22 Responsible: Administrator The facility needs to ensure the facility is administered in a manner that enables it to ensure that services necessary to provide the needs of the residents are in place and staff are trained on emergency procedures. Action: The facility will conduct fire drills with all employees quarterly, per shift. Responsible For Action: Maintenance Supervisor Start Date: 12.30.22 Completion Date: 1.04.23 Responsible: Administrator Action: QAA Team will ensure all employees complete quarterly fire drills. Responsible For Action: QAA Team The facility Department Heads Start Date: 01.04.23 Completion Date: Ongoing Responsible: Administrator Action: All employees will complete emergency training on Adar Central our computer-based training system. Fire Drill Procedure, Fire Extinguisher, Carries & Drags Training, Earthquake Preparedness Training Flood Training, Tornado Disaster Simulation and Bioterrorism Training. Staff will complete training by 30 days of hire, certificates will keep by the Training Coordinator. Responsible For Action: Training Coordinator Start Date: 12.29.22 Completion Date: 1.05.23 Responsible: Administrator Action: The facility will complete a Facility Emergency Plan, that meets all state and federal requirements. Responsible For Action: Maintenance Supervisor Start Date: 12.30.22 Completion Date: 1.01.23 Responsible: Administrator The Survey team monitored the plan of removal as follows: Monitoring was conducted from 12/31/2022 through 01/02/2023. Review of the temperature checks logs dated 12/30/2022 PM and 12/31/2022 AM reflected no temperatures were documented outside of 71 -81 range. (indicating the resident's did not need to be moved at the time.) Review of the facility's Transfer agreements dated 12/29/2022 reflected the facility had updated agreements with two separate entities that would accept the facility's residents in the event of a need for evacuation. In an interview on 12/31/2022 at 11:14 AM, the Administrator stated trainings were 100% for onsite staff in the building with trainings continuing prior to staff working their next shift. Reviewed the temperature checks for 12/30/22 PM and 12/31/22 AM and no temps outside of 71 - 81 range. Spoke briefly about the disaster / evacuation plan. He stated training was still in progress. In an interview on 12/31/2022 at 11:31 AM the Maintenance Director provided sign in sheets for evacuation training - estimates 70% of staff completed. 6:00 PM shift will be trained before starting their shift. In an interview on 12/31/2022 at 11:47 AM, CNA L stated she received training on evacuations. Evacuation training - know where everyone is working - get bed patients out first then go from there. She stated in a tornado to take residents to the center of facility and away from the windows. In an interview on 12/31/2022 at 12:01 PM CNAs M, N and O stated they had received evacuation and emergency preparedness training today from the facility. In an interview on 12/31/2022 at 12:10 PM LVN B and A and MA stated they received training over the disaster and evacuation plans. All stated they felt the evacuation plan was solid and the facility had enough staff to carry it out. In an interview on 12/31/2022 at 12:19 PM ,HSK P stated she had received the disaster and evacuation training and felt the staff could get all residents out. In an interview on 12/31/2022 at 1:07 PM, HSK Q stated he had received the disaster and evacuation training and felt the staff could get all residents out. In an interview on 12/31/2022 at 1:45 PM with the Administrator and Maintenance Director they stated training for the evacuation planning was at 80% and disaster preparedness starting today goal will be to be finished by tomorrow 01/01/2023 or the first of next week at the latest. In an interview on 01/01/2023 at 5:51 PM, LVN J stated she received training on the evacuation/ emergency plan that they have practiced fire drills - confident residents can be evacuated safely and timely. In an interview on 01/02/2023 12:14 PM, CNAs R, E and D and LVNs C and S stated they had been in serviced regarding the disaster plan and were aware of excavation procedures and the procedures for monitoring room temperatures and were to move residents if their rooms were to hot or too cold. On 01/02/2022 at 1:00 PM at exit, the facility was notified that the IJ was lowered. However, the facility remained out of compliance at a severity level no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their plan of removal.

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 nine (9) of 10 residents reviewed for COVID 19. (Resident #1, #2, #3, #4, #5, #6, #7, #8 and #9) A) The Facility failed to ensure they had a plan to separate and ensure they separated COVID 19 unknown residents, COVID 19 positive residents and COVID 19 negative residents or have designated staff for each cohort. The facility further failed to ensure residents of different COVID 19 status were identified by placing isolation precaution signs on the residents' room doors and ensure staff don and doffed PPE when caring for residents of different COVID 19 status. 1) Resident #1 was admitted to the facility on [DATE] and was not placed in quarantine for 14 days. 2) Resident #8 and Resident #9 were exposed to COVID 19 when their roommates tested positive for COVID 19 on 12/29/2020 and were not placed in quarantine. 3) Residents #2, #3, #4, #5, #6 and #7 tested positive for COVID 19 on 12/26/2020 and were not moved to a designated COVID 19 hall until 12/28/2020. B) The facility failed to ensure residents were screened and assessed every shift for signs and symptoms of COVID-19 for early detection of [MEDICAL CONDITION]. Resident's #2, #3, #4, #5, #6, and #7 did not have documentation of assessments and monitoring for signs and symptoms of COVID 19. An IJ was identified on 12/30/2020 at 3:50 PM. While the IJ was removed on 01/05/2021 at 3:20 PM, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not IJ identified as pattern due to the facility's need to evaluate the effectiveness of their plan of removal. These failures placed residents at risk of exposure to COVID-19, which could result in illness, hospitalization , or death. Findings included: A) 1) Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMs score of 14 indicating Resident #1 was cognitively intact. Resident #1 was further assessed to require extensive to dependent assist for all ADLs. Review of Resident #1's Comprehensive Care Plan (not dated) reflected no plan of care for new admission/ unknown COVID status or quarantine precautions. Observation on 12/29/2020 at 11:00 AM revealed no signs indicating zones (warm, hot or cold) in the facility. Two halls were noted with plastic barriers. No isolation signs were noted on any residents' doors or the plastic barriers. Observation on 12/29/2020 at 11:20 AM Resident #1's was in room [ROOM NUMBER]A on A-hall sleeping. Resident #1 was noted to have a roommate in the room. No contact precautions signs were noted on the door. Review of Resident #1's Nursing progress Notes reflected an entry on 12/29/2020 at 10:35 AM indicating Resident #1 tested positive for COVID 19. Further review of Resident #1's Nursing Progress Notes dated 12/29/2020 at 12:06 PM reflected Resident #1 was moved to the COVID unit. In an interview on 12/29/2020 at 12:30 PM, LVN A stated the facility was testing today and Resident #1 tested positive for COVID 19 and was moved to the COVID unit. When LVN A was asked if Resident #1 was in quarantine prior to testing positive she stated no that she had been in room [ROOM NUMBER]A on A-hall with a roommate for days. LVN A stated Resident #1 was not in quarantine prior to moving to A-hall. LVN A was asked if it was the facility's policy to put new admissions in quarantine for 14 days she stated she did not know. LVN A stated that the training was lacking in the facility on how to handle the outbreak and she was not getting a lot of guidance since most of the administrative nursing staff were out related to testing positive of COVID 19. In an interview on 12/29/2020 at 12:55 PM the Administrator stated she tested positive of COVID 19 and would be leaving the facility. Observation on 12/29/2020 at 3:30 PM revealed Resident #1 on the COVID 19 unit on C-hall. Resident #1 voiced no complaints and stated she was doing ok, but the facility told her she had COVID 19. In an interview on 12/30/2020 at 1:10 PM the AA was asked if the facility had a plan for quarantining residents and separating the different COVID 19 cohorts she stated no not that she was aware of. The AA stated the staff should use common sense and the staff should know to isolate residents and Resident #1 should have been placed in quarantine on admission. In an interview on 12/30/2020 at 4:40 PM, LVN B stated Resident #1 had been moved from C-Hall, to D-Hall then to A-Hall. LVN B stated Resident #1 should have been placed in quarantine and remained in quarantine for 14 days after she was admitted . LVN B stated she did not know why Resident #1 had not been placed in quarantine. 2) In an interview on 12/29/2020 at 12:30 PM LVN A stated the facility was testing the residents today. 3 more residents tested positive for COVID 19. LVN A was asked how she would handle the roommates of the residents that tested positive for COVID 19 (Resident #8 and Resident #9) and if they would be moved from A-hall to a warm unit or be quarantined she stated she did not know. Observation on 12/30/2020 at 9:45 AM revealed Resident #8 and Resident #9 remained on A-hall. No signs were noted on the resident's doors to indicate any isolation or contact precautions. Staff were observed wearing full PPE (gowns, mask, face shield) in hall and not changing while going from room to room. Observation on 12/30/2020 at 10:03 AM revealed CNA C on A-hall in full PPE. CNA C stated she worked with all the residents on A hall and D hall that were not on the COVID 19 units. When asked if she was instructed to change PPE when entering and exiting Resident #8 and Resident #9's room she stated no she was using the same PPE and treating all the residents on the hall as if they were positive. Observation/Interview on 12/30/2020 at 10:15 AM revealed CMA F passing medications on A-Hall. CMA F was observed going from room to room with the same PPE. When CMA F was asked if she was instructed on any isolation precautions for Resident #8 and Resident #9 she stated no. Observation on 12/30/2020 at 12:15 PM revealed C.NA E passing meal trays on A-Hall going from room [ROOM NUMBER]A (Resident #8) to room [ROOM NUMBER]A without changing PPE. In an interview on 12/30/2020 at 3:00 PM the AA stated she did not have a COVID 19 response plan for cohorting the residents based on COVID 19 status, or what isolation precautions to use. The AA stated the facility policy covers isolation of the COVID 19 positive residents. The AA stated the facility should quarantine residents exposed to COVID 19 for 14 days. 3) Review of Resident #2's Face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected she was assessed to have a BIMS score of 15 indicating she was cognitively intact. Further review reflected she was assessed to require extensive assist with ADLs. Review of Resident #2's Nursing Progress notes dated 12/26/2020 at 4:56 PM indicated Resident #2 tested positive for COVID 19 and that room will be moved to quarantine . Further review of Resident #3's Nursing Progress notes reflected no documentation of isolation precautions initiated or the resident being moved to the COVID 19 unit. Review of Resident #3's Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS dated [DATE] reflected Resident #3 was assessed to have a BIMS score of 3 indicating severe cognitive impairment. Resident #3 was further assessed to require dependent assist for all ADLs. Review of Resident #3's Nursing Progress notes dated 12/26/2020 at 3:57 PM indicated Resident #3 tested positive for COVID 19. Further review of Resident #3's Nursing Progress notes reflected no documentation of isolation precautions initiated or the resident being moved to the COVID 19 unit. Review of Resident #4's Face Sheet reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected Resident #4 had a BIMS score of 3 indicating severe cognitive impairment. Resident #4 was further assessed to require extensive assistance with ADLs. Review of Resident #4's Nursing Progress notes dated 12/26/2020 at 4:59 PM reflected Resident #4 tested positive for COVID 19. Further review of Resident #4's Nursing Progress notes reflected no documentation of isolation precautions initiated or the resident being moved to the COVID 19 unit. Review of Resident #5's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 was assessed to have a BIMS score of 99 indicating severe cognitive impairment. Resident #5 was further assessed to required dependent assist for ADLs. Review of Resident #5's Nursing Progress notes dated 12/26/2020 at 5:01 PM indicated Resident #5 tested positive for COVID 19. Further review of Resident #5's Nursing Progress notes reflected no documentation of isolation precautions initiated or the resident being moved to the COVID 19 unit. Review of Resident #6's Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #6's 5-Day PPS MDS assessment dated [DATE] reflected Resident #6 was assessed to have a BIMS score of 10 indicating moderate cognitive impairment. Resident #6 was further assessed to be independent with most ADLs. Review of Resident #6's Nursing Progress notes dated 12/26/2020 at 4:30 PM indicated Resident #6 tested positive for COVID 19. Further review of Resident #6's Nursing Progress notes reflected no documentation of isolation precautions initiated or the resident being moved to the COVID 19 unit Review of Resident #7's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #7's Significant Change MDS assessment dated [DATE] reflected Resident #7 was assessed to have a BIMS score of 13 indicating she was cognitively intact. Review of Resident #7's Nursing Progress notes dated 12/26/2020 at 4:52 PM indicated Resident #7 tested positive for COVID 19. Further review of Resident #7's Nursing Progress notes reflected no documentation of isolation precautions initiated or the resident being moved to the COVID 19 unit. In an interview on 12/29/2020 at 11:47 AM a Confidential Family member stated they did not think the facility was handling the outbreak very well. They stated that they were told on 12/26/2020 that their family member tested positive for COVID 19 and would be put on the COVID 19 unit. They stated they were concerned because it sounded like the facility did not have enough staff. They stated they called the facility on 12/27/2020 to check on their family member and found out the resident was not put on the COVID 19 unit but would be moved on 12/28/2020. In an interview on 12/29/2020 at 3:30 PM the EM RN (working the COVID 19 unit on C-Hall) stated when she arrived at the facility on 12/28/2020 the facility was not well organized and did not provide instructions on facility policies. The EM RN stated the facility had positive and negative residents together and she assisted the facility in setting up the COVID 19 unit on C-Hall and moving the residents from A-Hall. The EM RN stated the facility had beds available on the B-Hall COVID19 unit but stated to her the facility MD did not want residents together but wanted the residents to be in private rooms, so they would not have to witness their roommate code or became acutely ill. In an interview on 12/30/2020 at 10:30 AM LVN A stated she worked at the facility on 12/26/2020 and she tested all the residents and 6 more residents tested positive for COVID 19 (Resident's #2, #3, #4, #5, #6 and #7). LVN A stated it was only her and one aide working outside of the COVID 19 unit that was on B-Hall. LVN A stated because of that she did not move the residents from A-Hall that tested positive. She stated when she came in 12/28/2020 the residents were still on A-hall and when the state staff arrived at the building they moved the residents and set up a COVID 19 hall on C-hall. When asked if there was room on the COVID 19 unit on B-Hall to move the 6 positive residents she stated there were 12 residents on the unit and they were all in rooms alone and they did have 12 beds on the unit that were open. When asked if her and the staff changed PPE between residents during the time she had COVID negative and positive residents together she stated they were not. In an interview on 12/30/2020 at 10:45 AM, CNA C stated she worked on 12/27/2020 on A, C and D Halls. She stated she worked with both negative and positive residents. When asked if she changed her PPE between residents she stated she did not. When asked why she did not she stated she wears her jump suit and treats all the residents as if they are positive. B) Review of Resident #2's Face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #2's Nursing Progress notes dated 12/26/2020 at 4:56 PM reflected Resident #2 tested positive for COVID 19. No documentation of assessment or monitoring for signs and symptoms of COVID 19 was noted. Review of Resident #2's MAR indicated [REDACTED]. No documentation was noted on the MAR until 12/30/2020. Review of Resident#2's EMR reflected no documentation of assessment or monitoring for signs and symptoms of COVID 19 prior to the resident becoming COVID 19 positive on 12/26/2020. Further review reflected no documentation of monitoring for signs and symptoms of COVID 19 until 12/28/2020. Review of Resident #3's Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #3's Nursing Progress notes dated 12/26/2020 at 3:57 PM indicated Resident #3 tested positive for COVID 19. No documentation of assessment or monitoring for signs and symptoms of COVID 19 was noted. Review of Resident #3's EMR reflected no documentation of assessment or monitoring for signs and symptoms of COVID 19 prior to the resident becoming COVID 19 positive on 12/26/2020. Review of Resident #4's Face Sheet reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #4's Nursing Progress notes dated 12/26/2020 at 4:59 PM indicated Resident #4 tested positive for COVID 19. No documentation of assessment or monitoring for signs and symptoms of COVID 19 was noted. Review of Resident #4's EMR reflected no documentation of assessment or monitoring for signs and symptoms of COVID 19 prior to the resident becoming COVID 19 positive on 12/26/2020. Review of Resident #5's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #5's Nursing Progress notes dated 12/26/2020 at 5:01 PM indicated Resident #5 tested positive for COVID 19. No documentation of assessment or monitoring for signs and symptoms of COVID 19 was noted. Review of Resident #5's EMR reflected no documentation of assessment or monitoring for signs and symptoms of COVID 19 prior to the resident becoming COVID 19 positive on 12/26/2020. Further review of Resident #5's EMR reflected an entry on the MAR indicated [REDACTED]. Review of Resident #6's Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #6's Nursing Progress notes dated 12/26/2020 at 4:30 PM indicated Resident #6 tested positive for COVID 19. No documentation of assessment or monitoring for signs and symptoms of COVID 19 was noted. Review of Resident #6's EMR reflected no documentation of assessment or monitoring for signs and symptoms of COVID 19 prior to the resident becoming COVID 19 positive on 12/26/2020. Review of Resident #7's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #7's Nursing Progress notes dated 12/26/2020 at 4:52 PM indicated Resident #7 tested positive for COVID 19. No documentation of assessment or monitoring for signs and symptoms of COVID 19 was noted. Review of Resident #7's EMR reflected no documentation of assessment or monitoring for signs and symptoms of COVID 19 prior to the resident becoming COVID 19 positive on 12/26/2020. In an interview on 12/29/2020 at 2:00 PM LVN A was asked where the facility was documenting assessments and monitoring of the residents for COVID 19 signs and symptoms and what the facility's process was for the monitoring the residents. LVN A stated she was not sure what the process was and was not aware of any forms to document assessment for the residents. LVN A stated mostly they just take the residents temperatures and documented in the nursing progress notes. LVN A stated they had not changed the assessment process of the residents related to COVID 19 outbreak. In an interview on 12/29/2020 at 2:15 PM LVN B stated she was not sure where staff were documenting for monitoring of the residents. LVN B stated, in the progress notes, maybe? In an interview on 12/30/2020 at 4:40 PM the AA stated screening and assessments of the residents for signs and symptoms of COVID 19 should have been done and a system should have been in place for monitoring the residents. The AA agreed screening of the residents had not been done. The AA stated the facility was lacking in planning and staff education regarding processes to mitigate the spread of COVID 19 which was confounded when so many staff tested positive for COVID 19 including all of the administrative staff. The AA stated staff should have been better prepared to isolate the positive residents and make sure residents that were exposed or had unknown COVID 19 status were quarantined. Review of the facility's provided policy Preparing for COVID-19 in Nursing Homes dated 11/20/2020 reflected .Identify space in the facility that could be dedicated to care of residents with confirmed COVID-19 .Identify HCP who will be assigned to work only on the COVID-19 unit when it is in use. Have a plan for how residents in the facility who develop COVID-19 will be handled .Have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled . Further review of the facility's policy reflected no outlined plan by the facility for cohorting residents of different COVID-19 status, quarantine/ isolation precautions, or PPE to be used for each cohort or changing of the PPE between cohorts. On 12/30/2020 at 3:30 PM the AA and LVN B were notified the facility had an IJ situation for the above failures and provided with IJ template. The facility's first Plan of Removal (POR) was submitted by the AA on 12/31/2020 at 3:24 PM. The final POR was accepted by the survey team on 01/04/2021 at 10:14 PM. Accepted Plan of Removal Re: Plan of Removal of Immediate Jeopardy- Infection Control The following is a plan of removal, which has been immediately implemented at the facility, to remedy the immediate jeopardy because of the alleged deficient practices, which was given on December 30, 2020 at 3:30 PM Beginning December 30, 2020 and continuing until all staff is in-serviced on Infection Control, Donning/Doffing PPE hand washing, Social distancing Immediately by Acting Administration, and/or designee. All staff that is not present at time of in-service will not be permitted back to work until in-service and competency test is complete. Acting Administration will monitor 5 donning/doffing's per week for the next 4 weeks and randomly thereafter to ensure substantial compliance for properly donning and doffing PPE. Any abnormal findings will be immediately addressed, and additional teaching and competency implemented. All staff will be in-serviced on Screening Process immediately, by Acting Administration, and/or designee. All staff that is not present at time of in-service will not be permitted back to work until in-service and competency test has been completed. All visitors, vendors, employees, essential caregivers must be screened in prior to entry. Facility employee should ask these individuals all questions on the screening log prior to entry. All staff that is not present at time of in-service will not be permitted back to work until in-service and competency test is complete. Administrator and/or designee to monitor 5 screening practices per week for the next 4 weeks and randomly thereafter to ensure substantial compliance for the screening process. Any abnormal findings will be immediately addressed, and additional teaching and competency implemented. Staff was in-serviced on December 30, 2020 at 3:40 PM, by acting ADON and Corporate administration regarding the co-horting of a positive and a negative resident, to which was corrected, and the positive resident was moved to the COVID hall, a donning and doffing station was placed outside the door of the negative resident, there was dedicated staff that was called in to only care for the two residents that had been negative and had been co-horting with a positive resident. Therefore, limiting the possibility to infect other negative residents. Staff was also in-serviced on how to don and doff properly entering and exiting these specific rooms as well as other resident rooms. Signage was placed on residents' room doors informing staff of who was on isolation, who was not on isolation and what units were COVID positive. ALL STAFF after proper training and competency training will be able to demonstrate how to don proper PPE prior to entering residents' room, complete care of resident, and Doff PPE in proper receptacles provided by facility. DO NOT go from one resident room to another residents' room wearing the same PPE (PPE MUST BE changed EVERYTIME) Staff will be dedicated to work with COVID only, isolation only and non- inoculated residents only. Staff will be dedicated to work with NON-COVID residents. Dedicated staff will not intermingle with residents to ensure that there are not any cross-contamination. All residents with unknown COVID-19 status must be quarantined for 14 days. Isolate residents with positive cases. Communicate with residents, staff, and family when exposure to probable or confirmed cases occur in the facility. Keep an up-to-date list of all staff who work in other facilities. Require staff self-monitoring on days they work and on days they do not work. Follow physician's plan for immediate care of any resident with a positive case. Orders can include increased assessment frequency, increased monitoring of fluid intake and output, supportive care, a treatment plan, and what to do in case of a change in the resident's status. Dedicated or disposable noncritical resident-care equipment (e.g., blood pressure cuffs, blood glucose monitor equipment) is used, or if not available, then equipment is cleaned and disinfected according to manufacturers' instructions using an EPA-registered disinfectant for healthcare setting prior to use on another resident. Resident quarantining is on a case-by-case basis. If a resident is out of the facility but is not gone longer than 24 hours for example if they are a [MEDICAL TREATMENT] patient, then they do not have to be quarantined. If a resident is out of the facility for longer than 24 hours, they must be tested and quarantined for 14 days. Resident quarantining is required for 14 days, COVID testing must be done upon admission and/or reentry to the facility (NO EXCUSES) This must be charted! Every resident result must be charted. Vital signs must be charted Every shift. Record needs to be kept of ALL resident who is under quarantine and what day they are on. On December 30, 2020 at 3:40 PM, Nursing staff was in serviced that orders must be placed in residents' charts to reflect monitoring for signs and symptoms of COVID and documentation of vitals every shift. All residents will be monitored for signs and symptoms of COVID including vital signs every shift, and as needed more frequently if required. Residents are being assessed for signs or symptoms of COVID 19 per shift. Assessments of all charts will be completed to ensure that compliance is met by, January 4, 2021. All in-servicing is set to begin immediately, and all others prior to beginning of their shifts. The following is a list of all in-servicing pertaining to the alleged deficient practices: 1. All staff to be in-serviced on donning/ doffing PPE properly 2. All staff to be in-serviced on separating COVID unknown/positive/ negative residents, as well as those resident with cohorts. 3. All staff to be in-serviced on proper screening and assessing residents for signs and symptoms every shift for COVID, and having it documented properly. 4. All staff to be in-serviced on changing of PPE when coming in and out of rooms of residents. 5. All staff to be in-serviced on proper Infection Control and Emergency preparedness plan. 6. All staff to be in-serviced on proper quarantining of new residents and/ or those who have left facility for longer than 24 hours. The following is a list of competency checks and tests that will be required to be completed at the end of in-service: 1. Donning/doffing PPE 2. Knowing when to separate COVID unknown/positive/negative and cohorts 3. Screening processes 4. Assessing residents for signs and symptoms every shift/ documentation 5. Changing of PPE when entering and exiting resident rooms 6. Proper and infection control and emergency preparedness plan 7. Proper quarantining of new residents and out of facility longer than 24 hours This plan was initially implemented on December 30, 2020 at 4:30 PM and will continue to be monitored through our personal observations, as well as through completion of competency tests provided. The facility will follow the CDC guidelines outlined for COVID-19. Monitoring for the POR Observation and interview on 01/05/2021 at 11:00 AM revealed Resident #8 and Resident #9 in their rooms with the doors closed and signs on the door to indicate they were in quarantine and required contact and droplet precautions. The COVID positive halls were labeled with signs indicating isolation. Observation on 01/05/2021 at 11:10 AM CNA C was observed donning PPE prior to entering Resident #9's room. In interviews on 01/05/2021 at 11:15 AM CNA C, E, G and H revealed the staff were able to describe the different resident cohorts and staffing policy changes and were able to describe when a resident is to be placed in quarantine and or isolation and the precautions and PPE required. In interviews on 01/05/2021 at 11:40 AM LVN A, B and J revealed the LVNs were able to describe the resident cohort and staffing policy changes and were able to describe when a resident is to be placed in quarantine and the precautions and PPE required. The staff were able to describe the facility's new process for monitoring resident for signs and symptoms of COVID 19 and the documentation of the monitoring and vital signs every shift. Review of the facility's in-service training sign in sheet for designated staffing to the different COVID-19 resident cohorts, the facility's training on donning, doffing and proper use of PPE for quarantine, when quarantine is required and assessment and monitoring of residents for signs and symptoms of COVID 19 reflected all staff expect for positive staff were in-serviced and a system was put into place to in service all positive staff prior to returning to work. On 01/05/2020 at 3:20 PM the facility AA and LVN B were notified that the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their plan of removal