Every finding on record at Avir at Memorial

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1, Resident #2) of five residents reviewed for infection control. -The facility failed to ensure Resident #1 and Resident #2, who were on Enhanced Barrier Precautions, were protected as evidenced by nursing staff not wearing personal protective equipment during care. This failure placed all residents at risk for the spread of infections and decreased quality of life.Findings include: Record review of Resident #1's face sheet dated 05/02/2026, reflected the resident was a [AGE] year old male admitted to the facility on [DATE]. Resident #1 had DX which included: nontraumatic intracerebral hemorrhage (stroke), encephalopathy (overall brain dysfunction), hypertension (high blood pressure), congestive heart failure (heart cannot pump blood effectively leading to fluid buildup), and acute respiratory failure (lungs cannot provide enough oxygen to the blood). Record review of Resident #1's admission MDS assessment dated [DATE], reflected he had a BIMS score of 99 indicating the resident was unable to complete the interview. The MDS assessment under Section C - Cognitive Patterns reflected his ability to make decisions regarding tasks of daily life was severely impaired. Further review of the MDS assessment under Section GG - Functional Abilities, reflected Resident #1 required supervision and was dependent on staff for all ADLs. Record review of Resident #1's care plan dated 03/19/2026, reflected that the resident had no current plan for discharge and will remain in the facility as permanent residence. The resident was full code status with interventions to ensure staff were aware of Resident #1's advance care planning decisions. The resident had a communication problem with interventions to anticipate and meet needs. The resident had impaired cognitive function or impaired thought processes with interventions to administer medications as ordered and keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. In an observation on 05/02/2026 at 11:29 AM with LVN C, upon entry to Resident #1's room, LVN C did not wash her hands or dress in PPE as required for EBP. An observation on 05/02/2025 at 11:29 AM on a bedside table next to Resident #1's bed, several medications were noted to be crushed and in un-labeled, clear medicine cups with clear liquid. LVN C did not wash her hands. She had long artificial nails on fingertips of both hands. She could not recall the facility Enhanced Barrier Precautions policy or procedure for a resident on EBP. LVN C disconnected the feeding tube from Resident #1's gastric port and draped the tube over the feeding pump pole without capping the end of the tube. The end of the tube touched the surface of the feeding pump machine pole holding the empty Jevity and water bags contaminating the tip of the feeding tube that connected to Resident #1's gastric port. LVN C did not change her gloves before adding clear liquid from a previously opened, undated, 64 ounce bottle into a four ounce plastic water cup. LVN C did now wash her hands after providing care for Resident #1. An interview on 05/02/2026 at 12:05 PM with Resident #1's family member, who arrived during the medication administration pass reflected this was her first time to visit this facility and Resident #1 since he was admitted . She said she had no information to share for the interview. She said she was not aware of EBP and was not told by facility staff she needed to gown and glove prior to entering Resident #1's room for infection control purposes. Record review of Resident's #2's face sheet dated 03/18/2026, reflected a [AGE] year old female admitted to this facility on 01/21/2026 with the following DX: Right leg fracture, pressure injury to the right heel and pressure injury to the left heel, urinary tract infection, metabolic encephalopathy (overall brain dysfunction), anxiety disorder, dementia, and major depressive disorder. Record review of Resident #2's admission MDS assessment dated [DATE] reflected under Section C - Cognitive Patterns she had a BIMS score of 03 which indicated she was severely cognitively impaired. Under MDS Section GG - Functional Abilities reflected she required moderate supervision and moderate assistance with all ADLs. She required a wheelchair for mobility. Under Section K - Bowel and Bladder reflected she was incontinent of both. Under Section K - Swallowing and Nutritional Status reflected she was admitted with an established gastric tube status. Under MDS Section M - Skin Conditions reflected she was admitted with two pressure injuries to the right and left heels. Record review of Resident #2's care plan dated 01/27/2026 reflected the resident required EBP; interventions reflected in part the following interventions: Staff must use gown and gloves during high-contact resident care activities that could possibly result in transfer of MDROs to hands and clothing or staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices). Gowns will be available outside of room or in room for staff to don when performing direct care with resident. Sign for EBP will be outside resident's room to alert staff of precautions with direct care procedures. Staff are to wash hands with soap and water, or use alcohol based gel when entering and exiting the resident room. Staff will take trash bag into room for disposing of gown, tie bag, and carry to trash receptacle. Record review of Resident #2's skin/wound treatment sheet dated 04/29/2026 reflected three different pressure injuries as follows: Injury #1 was identified as unstageable pressure injury to the right heel; 1.8 cm by 1.5 cm by 0.1 cm. Treatment order read to cleanse with wound cleanser apply Iodosorb Gel and bordered dressing daily. Nurse documented to be improving without complications. Injury #2 was identified as stage three pressure injury to left heel 0.6 cm by 0.5 cm by 0.1 cm. Treatment order read to cleanse with wound cleanser, apply Betadine and leave open to air daily. Nurse documented to be healing without complications. Injury #3 was identified as a stage two pressure injury to the Sacrum; 2.0 cm by 2.0 cm by 0 cm documented as new and acquired in house on 04/29/2026. Treatment order to cleanse with wound cleanser, apply Hydrocolloid dressing, leave open to air three times per week and PRN. Nurse documented to be healing without complications. In an interview on 05/03/2026 at 1:32 PM with RN J reflected the facility had a wound care vendor that came weekly on Wednesday and provided assessments, wound care, clinical documentation updates, and wound orders. RN J said she worked here on weekends. In an observation on 05/03/2026 at 1:45 PM, RN J gathered wound care supplies and carried them into Resident #2's room and placed them on a clean bedside table. A red bag was opened for trash and placed on the resident's bed. Resident #2 was noted to be on EBP as evidenced by a sign outside her door and PPE available. She was observed lying in bed after receiving personal care for an incontinence episode by CNA K and CNA L, who was observed to not have on PPE prior to entering Resident #2's room. RN J was observed not washing her hands or putting on PPE for EBP before entering Resident #2's room. RN J entered the residents' room, explained what she was going to do, put on clean gloves and performed wound care to left heel. RN J changed gloves without hand hygiene and performed wound care to the right heel. RN changed gloves without hand hygiene and performed wound care to the wound on the posterior sacrum wound. RN J disposed of trash, took off her gloves, left the resident's room without washing her hands. Interview on 05/03/2026 at 11:00 AM with CNA D who worked every weekend for about six months. She said there had not been an in-service on EBP recently, and she could not remember what the EBP policy and procedure covered. She was not aware of which residents require the use of PPE prior to providing high-contact care activities. She could not give an example of a multi-drug resistant organism associated with EBP. Interview on 05/03/2026 at 11:32 AM with LVN E who has worked here for three years. He said there was enough PPE to protect himself and residents but an in-service on EBP has not been given recently. He could not say what EBP policy and procedure covered. He could not name an example of a multi-drug resistant organism associated with EBP. He was not aware of which residents require the use of PPE prior to providing high-contact care activities. Interview on 05/03/2026 at 12:07 PM with the housekeeping supervisor who is Spanish speaking only reflected the conversation was conducted through translator app on her phone. She had worked here for two years. She said there is enough PPE to protect herself and the residents but could not explain what the EBP policy and procedure covered. She could not name an example of a multi-drug resistant organism associated with EBP. She was not aware of which residents require the use of PPE prior to providing high-contact care activities such as bathing, dressing, and helping with ADLs. Interview on 05/03/2026 at 12:15 PM with CNA H who had worked here for one year. She said there is enough PPE to protect herself and the residents. She could not remember what the EBP policy and procedure covered and could not remember a recent EBP in-service provided in the last two months. She could not name an example of a multi-drug resistant organism associated with EBP. She was not aware of which residents require the use of PPE prior to providing high-contact care activities like helping with ADLs. Interview with DON on 05/03/2026 at 3:00 PM revealed the ADON was the facility Infection Preventionist. The DON said she (the DON) was the expert staff for training on Enhanced Barrier Precautions. The ADON was not available for interview. Record review of the facility's policy entitled Enhanced Barrier Precautions dated 02/25/2025 reflected in part the following:Policy Statement - Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.Policy Interpretation and Implementation - Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. Examples of high-contact resident care activities requiring the use of gowns and gloves for EBPs include:DressingBathing/showeringTransferringProviding hygieneChanging linensDevice care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care or any skin opening requiring a dressing. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. Staff are trained prior to caring for residents on EBPs. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required. PPE for EBP's is available outside or inside of the resident rooms. Residents, families and visitors are notified of the implementation of EBPs throughout the facility.

Based observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect when (Resident #1) was not provided with goods and services to avoid harm when LVN C observed previous shift had not started feeding pump that required scheduled enteral feeding of food and water for 1 of 2 residents requiring tube feedings. -The facility failed to ensure one (Resident #1) of two residents, received required enteral food and hydration according to physician orders. This failure placed two of two residents requiring enteral food and hydration administration due to inability to orally swallow fluids, at risk of being dehydrated.Findings include: Record review of Resident #1's face sheet dated 05/02/2026, reflected the resident was a [AGE] year old male admitted to the facility on [DATE]. Resident #1 had DX which included: nontraumatic intracerebral hemorrhage (stroke), encephalopathy (overall brain dysfunction), hypertension (high blood pressure), congestive heart failure (heart cannot pump blood effectively leading to fluid buildup), and acute respiratory failure (lungs cannot provide enough oxygen to the blood). Record review of Resident #1's admission MDS assessment dated [DATE], reflected he had a BIMS score of 99 indicating the resident was unable to complete the interview. The MDS assessment under Section C - Cognitive Patterns reflected his ability to make decisions regarding tasks of daily life was severely impaired. Further review of the MDS assessment under Section GG - Functional Abilities, reflected Resident #1 required supervision and was dependent on staff for all ADLs. Record review of Resident #1's care plan dated 03/19/2026, reflected that the resident had no current plan for discharge and will remain in the facility as permanent residence. The resident was full code status with interventions to ensure staff were aware of Resident #1's advance planning decisions. The resident had a communication problem with interventions to anticipate and meet needs. The resident had impaired cognitive function or impaired thought processes with interventions to administer medications as ordered and keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion.Record review of Resident #1's consolidated physician orders dated 04/24/2026, reflected the following:Jevity 1.5 at 50 ML/HR for 22 hours plus water flushes at 50 ML/HR via feeding pump.Pump down for 2 hours for ADLs on the day shift.Change enteral bag every 24 hours.Allergies were Alprazolam, diazepam, Levaquin, Avocado, Banana, Strawberry, Tape. Record review for Resident #1's initial nutritional assessment by a Registered Dietitian was not found in the EMR. Standards of Care reflected that a Registered Dietitian must collaborate with the physician to calculate calories, fluid needs, protein and all components of nutrition and hydration for residents requiring enteral feeding due to inability to swallow oral food and fluids and take oral medications. Record review on 05/02/2026 of Resident #1's weight record reflected current weight history was not found in the EMR. Standards of Care per Lippincott Nursing manual reflected upon admission to a Long-Term Care facility; residents are weighed weekly for four weeks then monthly and as needed to establish a baseline weight measurement for ongoing weight gain or weight loss monitoring. In an observation on 05/02/2026 at 10:00 AM, Resident #1 was in his bed. He could not participate in conversation due to mental status. His enteral feeding and water bags were noted to be completely empty with tubing connected to the resident. Resident #1 was also noted to be on EBP for infection control purposes. In an interview on 05/02/2026 at 10:30 AM with LVN C who stated she worked every weekend. She stated she was the charge nurse for Resident #1 and would come get this surveyor when it was time to administer enteral medications for Resident #1. In an observation on 05/02/2026 at 11:29 AM with LVN C, upon entry to Resident #1's room, LVN C did not wash her hands or dress in PPE as required for EBP. She did not knock before entering the resident's room, did not speak to Resident #1 or explain what service was going to be provided. Jevity 1.5 at 50 ML/HR and water bag for free flow water administration continued to be empty with the feeding pump turned to the off position. Feeding tube observed to have formula in the tubing and was connected to the resident's gastric port. On a bedside table next to Resident #1's bed, several medications were noted to be crushed and in un-labeled clear medicine cups with clear liquid. LVN C did not wash her hands. She had long artificial nails on fingertips of both hands. LVN C said she could not remember what medication was in each cup because she preset them prior to notifying the surveyor it was time to administer the medications. Other medication cups were observed to be on the bedside table with clear liquid in each cup she identified as water. She could not recall the facility Enhanced Barrier Precautions policy or procedure required for Resident #1. LVN C was stopped and asked to discard all medications and start over. Her laptop with the MAR was left in the resident's room. She did not wash her hands after discarding the pre-set medications. She went to the medication cart to start the process over. LVN C checked Resident #1's medications against the MAR, removed individual doses from blister packaged medication cards, placed the medication in clear bags, crushed each medication individually and placed them in labeled medication cups. LVN C took the medication cups into the resident's room and placed them on the bedside table. LVN C did not put on PPE that was required for enhanced barrier precautions for Resident #1 while providing care. LVN C disconnected the feeding tube from Resident #1's gastric port and draped the tube over the feeding pump pole without capping the end of the tube. The end of the tube touched the surface of the feeding pump machine pole holding the empty Jevity and water bags. LVN C opened the packaged 60 cc syringe, pulled 20 ccs of air into the syringe, connected the end of the syringe into the gastric port, placed her stethoscope over the stomach area and pushed the air and listened for tube placement. She checked for stomach content residual by pulling back on the plunger of the 60 cc syringe. There was no residual feeding formula or water observed in the syringe. LVN C did not change her gloves before administering the enteral medications. LVN C did not add extra water to completely administer each medication dose. Residual medication was noted in each cup indicating in the full dose of medication was not administered. A 10cc water flush was given after each individual medication. At the end of all medication administration LVN C reconnected the feeding tube with the contaminated tube tip back into the resident's gastric port. There was no Jevity 1.5 or intermittent water flush hung at that time to administer to the resident per physician orders. In an interview on 05/02/2026 at 12:00 PM with LVN C about the empty Jevity 1.5 and water bags. She said RN B workedthe 10 PM to 6 AM shift and was supposed to hang a new Jevity 1.5 formula bag and water flush bag before leaving theshift at 6:00 AM; but she left without completing the task. LVN C said after discovering the Jevity 1.5 and water flushes were not started by the off going nurse, that she (LVN C)should have started feeding and water when she began the 6 AM to 2 PM shift but she did not. She said this caused Resident #1 who was totally dependent on staff for all ADLs to be without nourishment and water for approximately six hours andher inaction would be considered neglect of Resident #1. Administering enteral medications, enteral feedings and water by a feeding pump was within LVN C's scope of practice according to the Texas Board of Nursing Rule 217.11 Standards of Nursing Practice. LVN C was unable to determine what the residents' nutritional and hydration needs were. She could not say how to ensure the residents' nutritional and hydration needs were met. She could not determine whether the tube feeding was adequate to maintain acceptable nutrition and hydration parameters. Standards of Nursing Practice reflect all unclear orders must be clarified by the physician. Interview on 05/02/2026 at 12:30 PM with ADON reflected RN B was the nurse on duty on 05/02/2026 for the 10:00 PM to 6:00 AM shift. A phone number was provided for RN B with no response to the call on 05/02/2026 at 12:40 PM and again at 2:45 PM. In a brief telephone interview on 05/03/2026 at 10:45 AM with the facility medical director, he stated he was aware the tube feeding was down for Resident #1 for multiple hours on 05/03/2026; however, he was unable to say what staff notified him or give the time of the notification or any details to be followed up by interview, observation, or record review. Interview on 05/03/2026 at 11:00 AM with CNA D who worked every weekend for about six months. She said an example of resident neglect would be not feeding the residents, answering call lights, or bathing and other basic care needs. Interview on 05/03/2026 at 11:32 AM with LVN E who has worked here for three years He said not following physician orders like providing food and fluids to residents would be considered neglectful. Interview on 05/03/2026 at 11:48 AM CNA F who worked on the memory unit. She's worked in this building for 32 years. She said not feeding or providing fluids for all residents would be considered neglectful Interview on 05/03/2026 at 11:57 AM with CNA G who worked weekends said if the facility failed to feed or hydrate residents, would be neglectful as well as not providing other care to resident dependent on nursing staff for all ADLs. Interview on 05/03/2026 at 12:15 PM with CNA H who had worked here for one year stated not giving food and hydration to any resident was neglectful. Interviews on 05/03/2026 at 12:49 PM revealed the Administrator and DON strongly agreed that failure by nursing staff to provide food and hydration to a resident totally dependent on staff for all ADLS per physician orders was considered neglectful. Record review on 05/02/2026 of undated ANE policy reflected in part the following; Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents; neglect of residents; and/or theft, exploitation or misappropriation of resident property. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. Implement measures to address factors that may lead to abusive situations, for example: adequately prepare staff for caregiving responsibilities; provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation; instruct staff regarding appropriate ways to address interpersonal conflicts; and help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. Establish and implement a QAPI review and analysis of reports, allegations or findings of abuse, neglect mistreatment or misappropriation of property. Record review on 05/02/2026 of undated Enteral Feeding Policy reflected in part the following: The interdisciplinary team, including the Dietitian, will conduct a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings. The assessment will include:Evaluation of the resident's current nutritional status;Evaluation of the resident's current clinical status;Relevant functional and psychosocial factors; andA review of interventions to maintain oral intake prior to the use of a feeding tube and the resident's response to them. The recommendation to initiate the use of a feeding will be based on the results of the comprehensive nutritional assessment, and will be consistent with current standards of practice, the resident's advance directives, treatment goals and facility policies. Enteral nutrition will be ordered by the Physician based on the recommendations of the Dietitian. If a feeding tube isordered, the Physician and interdisciplinary team will document why enteral nutrition is medically necessary. The decision to continue or discontinue the use of the feeding tube will be made through collaboration between the interdisciplinary team, the Physician and the resident.

Based on observations, interviews, and record review, the facility failed to ensure the medication was stored properly in locked compartments or provided a safe and secured storage with limited access for 1 (Resident #4) of 8 residents reviewed for medication storage. The facility failed to ensure a bottle of Milk of Magnesia (liquid medication used to treat constipation) was not on the nightstand next to Resident #4's bed on 12/03/2025. This failure could place the residents at risk of accidental overdose or misuse of medication.Findings included: Record review of Resident #4's Face Sheet, dated 12/03/2025, reflected an [AGE] year-old female who admitted on [DATE]. The resident had diagnoses which included osteoarthritis (joint pain and stiffness) and repeated falls. Record review of Resident #4's Quarterly MDS Assessment, dated 09/21/2025, reflected the resident was cognitively intact with a BIMS score of 13. Record review of Resident #4's Comprehensive Care Plan, dated 09/27/2025, did not reflect the resident self-administered her medication.Record review of Resident #4's Physician's Orders did not reflect an order for Milk of Magnesia or for the resident to self-administer medication. During an observation and interview on 12/03/2025 at 9:06 AM, Resident #4 was lying in bed awake. A bottle of Milk of Magnesia was observed on the nightstand next to the bed. Resident #4 stated she did not use it very often but had it in case she needed it. In an interview on 12/03/2025 at 9:32 AM, LVN A stated the bottle of Milk of Magnesia should not have been at the bedside in Resident #4's room. LVN A stated Resident #4 might take too much of the medicine. She stated another resident might take it that had an allergy to the medication or overdose. She went to the resident's room and asked her about the medication. Resident #4 stated that a family member brought the bottle of medicine. Resident #4 stated she had rubbed a little in her mouth when she had a place that bothered her, and it helped. LVN A explained medication could not be left in her room and removed it. In an interview on 12/03/2025 at 1:20 PM, the DON stated the resident's family brought the medication to Resident #4 but did not make anyone aware. She stated the medication was removed from Resident #4's room and the resident was educated on why the medication could not be left in the room. She stated unless an assessment to self-administer medication was completed and approved by the physician, a resident could not have medication at the bedside. She stated it was also a safety concern for other residents who wandered by and saw it. The DON stated the social worker contacted the family to ensure they did not bring medication to the resident. In an interview on 11/18/2025 at 1:57 PM, the ADON stated the medication should not have been in Resident #4's room. She stated the resident might take too much. She stated it was important for staff to monitor any medication the resident took. Record review of the facility's policy Self-Administration of Medication, revised February 2021, reflected Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for 1 (Resident #1) of 12 residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1's room was in a position accessible to the resident on 12/02/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #1's Face Sheet, dated 12/03/2025, reflected the resident was an [AGE] year-old male who admitted on [DATE]. Resident #1 had diagnoses of atherosclerotic heart disease (disease that affects arteries supplying blood to the heart muscle) and diabetes mellitus (the body does not use insulin properly which leads to elevated blood glucose levels). Resident #1 received hospice care services.Record review of Resident #1's Quarterly MDS (tool used to measure health status) Assessment, dated 09/15/2025, reflected severely impaired cognition with a BIMS (tool used to measure cognitive status) score of 00. Section GG (Functional Abilities) indicated Resident #1 was dependent on staff for self-care and mobility needs. Record review of Resident #1's Comprehensive Care Plan, dated 10/04/2025, reflected history of falling related to immobility, chronic pain, incontinence, and decreased cognition. One intervention was to keep call light in reach at all times. During an observation on 12/2/25 at 9:43 AM, Resident #1 was lying in bed asleep. The call light was hanging behind the nightstand and not within the resident's reach. During an observation and interview on 12/02/2025 at 9:59 AM, LVN B entered Resident #1's room. She clipped the call light on Resident #1's bed within his reach. She stated it was important for staff to ensure the call light was in reach when rounding in case the resident needed to call staff. She stated Resident #1's call light was in reach earlier when she gave his medication. During an interview on 12/02/2025 at 2:09 PM, CNA C stated Resident #1's call light should have been within reach. She stated it was important for all residents to be able to let staff know if they needed something. During an interview on 12/03/2025 at 11:59 AM, the Administrator stated Resident #1's call light should have been within reach. He stated staff would not know when the residents needed something if they did not have access to their call lights. He stated call light should always be within reach. During an interview on 12/03/2025 at 1:36 PM, the DON stated Resident 1's call light should have been within reach. She stated the expectation was for all residents' call lights to be in reach whether they were in their bed or sitting in their wheelchair. She stated it was important for the safety of the residents. During an interview on 12/03/2025 at 1:57, the ADON stated the call light should have been within Resident #1's reach. She stated it should be on everyone's mind to monitor residents' call lights. She stated a resident might need something and not be able to reach anyone. She stated it was important for their comfort and to help residents feel safe knowing they could reach someone. Record review of the facility's policy Call System, Residents, updated January 2025, reflected Each resident is provided with a means to call staff directly for assistance form his/her bed, from toileting/bathing facilities and from the floor.

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 2 (Resident #2 and Resident #3) of 10 residents reviewed for respiratory care.The facility failed to ensure Resident #2's oxygen tubing (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 12/02/2025.The facility failed to ensure Resident #3's oxygen tubing was properly stored when not in use on 12/02/2025.These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Resident #2Record review of Resident #2's Face Sheet, dated 12/03/2025, reflected a [AGE] year-old female who admitted on [DATE]. The resident had diagnoses which included COPD (lung condition that makes it difficult to breathe) and end stage renal disease (the kidneys do not function).Record review of Resident #2's Quarterly MDS Assessment, dated 09/11/2025, reflected the resident was cognitively intact with a BIMS score of 14. Section O (Special Treatments, Procedures, and Programs) reflected Resident #2 received oxygen therapy. Record review of Resident #2's Comprehensive Care Plan, dated 10/24/2025, reflected a risk for respiratory distress related to diagnoses of asthma (airway narrows and can make breathing difficult) and COPD. One intervention was to keep the oxygen cannula, mask, and tubing bagged when not in use. Record review of Resident #2's Physician Order, dated 11/17/2025, reflected Oxygen at 3 LPM per nasal cannula every shift. An observation and interview on 12/02/2025 at 9:26 AM, revealed Resident #2 sitting up in bed. Resident #2 was receiving oxygen via oxygen tubing connected to an oxygen concentrator. Resident #2's wheelchair was near the bed and had a portable oxygen tank on the back. Oxygen tubing was connected to the portable oxygen tank and looped around the handle of the wheelchair. The oxygen tubing was not in a bag. Resident #2 stated it was usually in a bag. During an observation and interview on 12/02/2025 at 10:05 AM, LVN A entered Resident #2's room and stated the oxygen tubing on the wheelchair should have been stored in a bag. She stated she would replace the oxygen tubing and ensure it was stored in a bag. She was it was important for infection control. Resident #3Record review of Resident #3's Face Sheet, dated 12/03/2025, reflected an [AGE] year-old male who admitted on [DATE]. Resident #3 had diagnoses which included COPD (lung condition that makes it difficult to breathe) and diabetes (the body does not use insulin effectively and causes blood sugar levels to rise). Record review of Resident #3's Quarterly MDS Assessment, dated 11/16/2025, reflected the resident had severely impaired cognition with a BIMS score of 05. Section O (special treatments, procedures, and programs) indicated Resident #3 received oxygen therapy.Record review of Resident #3's Baseline Care Plan, dated 11/26//2025, reflected the resident received oxygen therapy while a resident. During an observation and interview on 12/02/2025 at 10:20 AM, Resident #3 was sitting in the wheelchair in his room. The resident was receiving oxygen via a nasal cannula connected to an oxygen cannister on the back of his wheelchair. An oxygen concentrator was on the floor behind the wheelchair. Oxygen tubing was connected to the concentrator and draped over the top of the concentrator. The oxygen tubing was not bagged. An interview was attempted but the resident was unable to answer questions appropriately due to his cognitive status. During an interview on 12/02/2025 at 10:26 AM, LVN A entered Resident #3's room and stated the oxygen tubing should have been in a bag. She stated she would replace the tubing and place it in a bag. LVN A stated it was important to keep the tubing covered because it collected bacteria which could cause respiratory problems for the resident. During an interview on 12/03/2025 at 11:59 AM, the Administrator stated the oxygen tubing should have been stored in bags when not in use. He stated it was important for infection control. He stated staff were provided in-service training. During an interview on 12/03/2025 at 1:36 PM, the DON stated the expectation was for all respiratory items to be stored in a bag when not in use. She stated staff were re-educated to monitor for placement of respiratory tubing when rounding. She stated it was important for infection control. She stated it was an important measure to help prevent upper respiratory infections. During an interview on 12/03/2025 at 1:57 PM, the ADON stated respiratory items should be bagged when not in use. She stated it was important for staff to keep respiratory items as clean as possible to prevent infection because they did not know what was in the air. Review of the facility's policy Oxygen Administration, revised October 2010, reflected Oxygen/nebulizer tubing/masks to be changed by nursing department, weekly, and documented in the electronic health record. The policy did not reflect storage of respiratory tubing when not in use.

Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for two of three residents (Resident #20 and Resident #54) reviewed for accident hazards/supervision/devices 1.The Facility failed to ensure CNA D used a gait belt correctly when transferring Resident #20 from his wheelchair to the bed. 2. The Facility failed to ensure Resident #54's windowsill (a ledge or sill forming the bottom part of a window) was repaired when it had the outer edge broken off exposing approximately 1 inch of raw jagged wood across the entire width of the windowsill and exposing nails. These failures could affect the residents by placing the residents at risk for discomfort, pain, falls, injuries, and skin tears.Findings included: 1. Record review of Resident # 20's Face sheet dated 09/11/25 reflected an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included an unspecified fracture of right femur (thigh bone) and Alzheimer's disease. Record Review of Resident #20's Significant Change in status MDS assessment, dated 08/15/25, reflected he was severely cognitively impaired with a BIMs score of 4. He was dependent on transfers, toileting, and personal hygiene and required the assistance of 2 people. He was always incontinent of urine and frequently incontinent of bowels. Review of Resident #20's care plan revised on 05/29/25 reflected, ADLs functional status/rehabilitation potential.transfers extensive two-person assistance.Interventions.Assist with transfer as needed. In an observation and interview on 09/09/2025 at 9:27 a.m. Resident #20 was observed being assisted from his bed to his wheelchair by CNA D. Resident #20 was able to stand up with the assistance of CNA D holding on to his arm while the resident grabbed for the arm of the wheelchair. Resident #20 was very unsteady and shaky. No gait belt was used during the transfer. CNA D stated the resident had a fall a few weeks ago and broke his hip. She stated he was doing a little better but stated he would still try and get up without assistance. In an observation on 09/09/2025 at 11:55 a.m. CNA D and CNA E were observed taking Resident #20 to his room to perform incontinence care. CNA E placed a gait belt around Resident #20's waist and tightened the belt. CNA E placed her hands on the front and back of the gait belt while CNA D placed one hand in front and the other under the resident's right arm pit and they lifted him from the wheelchair and transferred him to bed. Both staff provided incontinence care. After completion of care, both staff sat the resident up on the bedside. CNA E placed the gait belt around the resident's waist and again placed one hand in front and the other in back, while CNA D placed on hand in front the other hand under the resident's arm pit. The resident was unsteady and continually reaching for the arm of the wheelchair. In an interview of 09/09/2025 at 12:00 p.m. with CNA D and CNA E, both stated they were not supposed to lift residents under their arms because it could cause injury to their shoulders. CNA D stated she tried not to put her hand directly under his arm pit to prevent injury. She stated she did not know she was supposed to grab the back of the gait belt when doing a 2-person transfer. She stated she had been trained on gait belt transfers but had forgotten that part. She stated the resident had progressed a great deal since he had been in therapy and was starting to try and transfer himself again. She stated you had to be really quick or he would try and get up by himself and sometimes you did not have enough time to put a gait belt around him. In an attempted interview with Resident #20 on 09/09/25 at 12:05 p.m. the resident could not understand the question when asked if he had experienced pain during the transfer, he just smiled and stated he was doing OK. In an interview with the DON on 09/11/25 at 08:23 a.m. she stated staff were to use gait belt when transferring a resident. She stated they had been trying to get each of the staffs training and check offs done. She stated they had just completed skills checks of on gait belt and mechanical lift transfers a few months ago. She stated she had the Director of Rehab assist with that training. She stated the risk of staff not following the correct procedure was injury to a resident's shoulders and arm and or the risk of the resident falling. In an interview with the DOR on 09/11/25 at 11:20 a.m. she stated she did the gait belt training in the facility. She stated she does one annually or as needed. She stated the last one she had done was June of 2025. She stated she actually had the staff use her as resident and place the gait belt on her to make sure they knew how it should be positioned and where they were supposed to place their hands. She stated it was not acceptable to lift someone under their arm pits due to the potential for injury. She stated it increased the risk of falls, fractures and nerve damage. Record review of CNA D's staff education/ orientation checklist reflected she had been skills checked for gait belt transfers on 06/18/25 and had met the criteria for proper technique. 2. Record review of Resident #54's quarterly MDS assessment reflected a [AGE] year-old male with an admission date of 03/17/25. Staff assessment of resident's mental status reflected he was severely cognitively impaired, required substantial assistance with all activities of daily living and had diagnosis of cerebral vascular accident (stroke) and seizure disorder (brief episode of abnormal electrical activity in the brain). Record review of Resident #54's care plan revised on 07/08/25 reflected, [Resident #54] is at risk for Pressure Injury related to incontinence, immobility, decreased cognition, and history of poor nutrition.Goal.Skin will remain intact.Interventions.CNA to inspect skin, especially over bony prominences, during bathing and personal care and report finding to Licensed Nurse.Licensed Nurse to complete skin assessment weekly. Record review of the facility's maintenance log from 03/25/25 through 09/10/25 did not reflect any repair needs for Resident #54's windowsill. An observation on 09/09/2025 at 2:35 p.m. revealed Resident #54 asleep in his bed. The bed was pushed up against the windowsill which had the outer edge broken off exposing approximately 1 inch of raw jagged wood across the entire width of the windowsill and exposing nails. Resident #54's arm was approximately 12 inches from the exposed wood. An observation on 09/10/2025 at 3:00 p.m. revealed CNA F entered Resident #54's room to provide incontinence care. CNA F asked the resident to roll on his left side toward the window. Resident #54 rolled on his left side and placed his hand in the windowsill where the broken wood and exposed nail was located. No skin tears were observed on the resident's hand or arm. In an interview with CNA F on 09/10/25 at 03:10 p.m. she stated she was not usually assigned to Resident #54, but stated she does assist with his care when needed. She stated she had not noticed the broken wood on the windowsill. She stated they were supposed to put anything in the maintenance log that needed to be repaired. In an observation and interview with LVN H on 09/10/2025 at 3:12 p.m. of Resident #54's windowsill he stated he was not aware of the broken windowsill and stated it was a hazard since the resident's bed was up against the windowsill. He stated he had not noticed during his care of Resident #54. In an observation and interview with the facility's Maintenance Director 09/10/2025 at 3:20 p.m. of Resident #54's windowsill he stated he had not been made aware of the broken windowsill. He stated with the exposed nail and the roughness of the broken wood posed a risk to the resident. He stated he would get it repaired as soon as possible. He stated staff were supposed to place any required maintenance in the maintenance book kept at the nurse's station. In an observation and interview made with the Administrator on 09/10/2025 at 3:26 p.m. of Resident #54's windowsill, he stated it needed to be repaired immediately. He stated it placed the resident at risk of injury. He stated they would move the resident so the repairs could be made. He stated there was no excuse and could not understand how staff would not have noticed it, especially while providing care to the resident. He stated in addition to that they had administrative staff assigned to each resident's room for overall checks. He stated they needed to do much better at noticing needed repairs. He stated staff were required to report any hazard that could potentially cause harm to a resident or staff member. In an interview with CNA G on 09/10/25 at 3:30 p.m. she stated she was assigned to Resident #54 often. She stated the windowsill had been broken since she had been here, which was about 3 months. She stated they were supposed to write things in the maintenance book that needed repaired but stated since it was that way when she started working at the facility she did not think about putting it in the book. She stated she should have said something and stated it could pose a risk to the resident. An observation on 09/11/2025 at 09:15 a.m. revealed Resident #54 had been moved to another room. Repairs had started, and the exposed wood and nail of the windowsill were covered. Record review of the facility's undated policy, Use of Gait Belts , reflected, It is the policy of this facility to use gait belts with resident that cannot independently ambulate or transfer for the purpose of safety.Each nursing department employee will be given a gait belt during orientation.It will be the responsibility of each employee to ensure they have it available for use at all time when at work. Record review of the facility's undated policy, Accidents and Supervision, reflected, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes''' Identifying hazard(s) and risk(s).Implementing interventions to reduce hazard(s) and risk(s).Hazards refers to elements of the resident environment that have the potential to cause injury or illness.Risk refers to any external factor, facility characteristic (e.g., staffing or physical environment) or characteristic of an individual resident that influence the likelihood of an accident.The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents.These sources may include, but are not limited to.Environmental rounds.Individual observation.This information is to be documented and communicated across all disciplines.

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 4 of 13 residents (Resident #36, Resident #14, Resident #54, and Resident #48) observed for infection control and 1 of 5 staff (CNA I) observed during meal tray delivery. 1. The facility failed to ensure LVN B sanitized the blood pressure cuff, pulse oximeter and electronic thermometer after using equipment on Resident #36 during medication pass on 09/10/25. 2. The facility failed to ensure LVN A did not cross contaminate Resident #14's medication and piston syringe used for medication administration via the residents' g-tube during a medication pass on 09/10/25 and failed to sanitize the blood pressure cuff after use. 3. The facility failed to ensure CNA F used the required PPE for Resident #54, who was on enhanced barrier precautions due to his urinary catheter and failed to perform hand hygiene while providing incontinent care on 09/10/25. 4. The facility failed to ensure the Treatment Nurse performed hand hygiene during wound care for Resident #48 on 09/10/25. 5. The facility failed to ensure CNA I performed hand hygiene between 4 residents after delivering food trays during lunch service in the memory care unit on 9/9/25. These failures placed residents at risk of cross-contamination and the development of infection.Findings included: 1.Record review of Resident #36's face sheet, dated 09/11/25, reflected a [AGE] year-old male with an admission date of 01/17/25. Diagnosis included dementia and diabetes. During a medication pass observation on 09/10/25 at 07:52 a.m., LVN B was observed at the medication cart. LVN B sanitized her hands and picked up the wrist blood pressure cuff, a pulse oximeter (device used to test the amount of oxygen in the blood) and an electronic thermometer. LVN B entered the dining area of the memory care unit and took Resident #36's blood pressure and then applied the pulse oximeter to the resident's finger to obtain the oxygen saturation level and held the electronic thermometer to the resident's forehead to obtain his temperature. LVN B then returned to the medication cart and laid the contaminated equipment on the top to the medication cart. LVN B sanitized her hands and pulled Resident #36's scheduled medications and then administered the medications to the resident. LVN B then checked the computer for the next resident who required medication administration. In an interview with LVN B on 09/10/2025 at 8:04 a.m. she stated she was supposed to sanitize the equipment she used on any resident immediately after use. She stated she failed to do that and by placing the equipment on her medication cart she had also cross contaminated her cart. She stated they had recently switched to electronic records, and she was so focused on that, she forgot to sanitize the equipment. She stated the risk to the residents when they did not sanitize the equipment was the spread of germs. 2. Record review of Resident #14's Quarterly MDS assessment, dated 08/29/25, reflected a [AGE] year-old female with an admission date of 06/15/18. Staff assessed her mental status as severely cognitively impaired. Diagnoses included coronary artery disease (damage or disease in the heart's major blood vessels), hypertension (high blood pressure) and quadriplegia (paralysis that affects the ability to voluntarily move the upper and lower body). Resident received over 51 % of her total calorie intake through the feeding tube. During a medication pass observation on 09/10/25 at 07:52 a.m., LVN A was observed at the medication cart. LVN A sanitized her hands and picked up the wrist blood pressure cuff and entered Resident #14's room to obtain her blood pressure. LVN A then returned to the medication cart and laid the contaminated blood pressure cuff on the top to the medication cart. LVN A sanitized her hands and pulled Resident #14's scheduled medications, placing each pill in a separate cup. LVN A then went to pour one pill into a plastic sleeve to crush the medication when she dropped the pill on the cart. LVN A picked up the pill and placed it back in the cup and then placed it in the sleeve and crushed the pill for administration. After pulling all of Resident #14'a medications, LVN A sanitized her hands, put on a gown and gloves and entered the resident's room. LVN A turned off the feeding pump and placed the piston syringe (a calibrated barrel with a plunger) on the end of the feeding tube and checked for residual and removed the piston from the barrel of the piston syringe and poured 60 ccs of water to flush the tube. LVN A then proceeded with administering the resident's medication. After completion of the medication administration, LVN A removed the piston syringe and went to place it back in the plastic bag for storage when she dropped it on the floor. LVN A picked up the piston syringe and went to the resident's bathroom and rinsed it in the bathroom sink and returned it to the plastic bag to be used for the next medication administration. LVN A then reconnected the pump, removed her gown and gloves and performed hand hygiene. In an interview with LVN A on 09/10/2025 at 8:40 a.m., she stated she thought rinsing the piston syringe after dropping it on the floor would be sufficient, but stated she should have just discarded it and got a new one. She stated she should have discarded the pill she dropped on the medication cart but reactively picked it up not thinking. She stated she was supposed to sanitize the blood pressure cuff after each use and by not doing so, she had cross contaminated her medication cart. She stated all of this was considered cross contamination and she risked spreading germs to other residents. In an interview with the DON on 09/10/25 at 03:55 p.m. she stated staff needed to make sure all equipment was cleaned with appropriate germicidal wipes between patient use. She stated this failure placed residents at risk of the spread of germs and cross contamination. She stated no medication was to be handled with bare hands and any medication dropped should be discarded. She stated any disposable item dropped on the floor should be discarded. She stated they had done training on infection control with the focus on enhanced barrier precautions. She stated they will re-Inservice on proper sanitization of resident use equipment. She stated she thinks with LVN A coming back just today after a hiatus from work, she was just a little overwhelmed. 3. Record review of Resident #54's quarterly MDS assessment reflected a [AGE] year-old male with an admission date of 03/17/25. Staff assessment of resident's mental status reflected he was severely cognitively impaired, required substantial assistance with all activities of daily living and had diagnosis of cerebral vascular accident (stroke) and seizure disorder (brief episode of abnormal electrical activity in the brain). The resident had a urinary catheter and was always incontinent of bowel. An observation on 09/10/2025 at 3:00 p.m., revealed CNA F entered Resident #54's room without performing hand hygiene or putting on a gown, to check if he needed incontinent care. CNA F put on gloves, unfastened the residents brief, and asked the resident to roll on his left side toward the window. CNA F unhooked the catheter drainage bag and laid it on the bed while Resident #54 rolled on his left side revealing he had a moderate bowel movement. CNA F opened the residents' bedside chest of drawers looking for peri-wipes and stated she would have to go get supplies to provide incontinent care. CNA F left the catheter drainage bag on the bed, removed her gloves and left the room without performing hand hygiene. CNA F returned to the resident's room with the supplies. She put on gloves without performing hand hygiene and did not put on a gown. CNA F wiped the resident's anal area several times changing wipes, from front to back. She removed her gloves one time due to excessive soiling and put on clean gloves without sanitizing hands. After she competed the cleaning of the resident's anal area, she placed a clean brief under the resident wearing the same soiled gloves and had him roll back onto his back and she wiped his groin, penis and scrotal area with a few wipes since the resident began to resist. CNA F then closed the resident's brief, still wearing the same gloves, replaced his top sheet and straightened his blanket and attached the catheter drainage bag to the bed rail. She then gathered the trash, removed her gloves and left the room without performing hand hygiene. CNA F walked down the hallway and deposited the trash in a rolling cart and then used the wall hand sanitizer in the hallway. In an interview with CNA F on 09/10/25 at 03:10 p.m. she stated she was not usually assigned to Resident #54, but stated she does assist with his care when needed. She stated she did not notice the sign outside of his door indicating he was on enhanced barrier precautions. She stated she honestly was not sure why a resident would be on enhanced barrier precautions, she guessed it was for the risk of spreading germs. She stated she thought the only time she had to perform hand hygiene was before and after care. She stated she was unaware she had to change her gloves during care and did not know she could not place the catheter bag on the bed. She stated she had only worked at the facility for about a month. 4. Record review of Resident #48's face sheet dated 09/11/25, reflected a [AGE] year-old female with an admission date of 07/17/24 and a re-admission date of 09/08/25. Diagnoses included diabetes and viral pneumonia (lung infection caused by a virus that inflames one or both lungs). An observation on 09/10/2025 at 09:00 a.m. of wound care for Resident #48 revealed the Treatment Nurse washed her hands and put on gown and gloves. The Treatment nurse cleaned the pressure ulcer with peri wipe. The area was approximately the size of a pencil eraser with no apparent drainage and no signs of infection. After cleansing the wound, the Treatment nurse applied the treatment of zinc and collagen powder without changing her gloves or performing hand hygiene. The Treatment Nurse then removed her gown and gloves and left the room to obtain hand sanitizer. The Treatment Nurse then re-entered the room, sanitized her hands and put on gown and gloves to continue the wound care on Resident #48's toes and knee. The Treatment nurse removed her gloves and sanitized her hands after cleaning wounds and before applying the treatment to the areas on her left knee and the resident's toes. In an interview on 09/10/25 at 09:20 a.m. with the Treatment Nurse, she stated she had forgotten her hand sanitizer and realized it when she had finished cleaning the first wound. She stated she was thrown completely off and stated she was supposed to remove her gloves and perform hand hygiene after she cleaned the wound. She stated she could have gone to the sink and washed her hands, but stated all she could think about was she needed hand sanitizer. She stated she should have washed her hands before she left the room. She stated the risk to the resident was the spread of germs and infection. In an interview with the DON on 09/10/25 at 4:00 p.m., she stated any resident who had any type of indwelling medical device was placed on Enhanced Barrier precautions to help reduce the spread of MDRO's. She stated signage was posted outside to the door, which explains what PPE was to be worn and for what task the PPE was to be worn for. She stated any contact with a resident with a wound or a catheter required the use of gown and gloves. She stated the staff had received trainings on the use of Enhanced Barrier Precautions. She stated regardless of if the staff were assigned to a resident they were expected to follow the necessary precautions. She stated staff were to perform hand hygiene before care, when going from dirty to clean, and after care and prior to leaving the resident's room. She stated the ADON was the infection preventionist for the facility and conducted several in-services to make sure the staff were following the infection control protocol. She stated they still had some work to do. In an interview with the ADON on 09/11/25 at 03:25 p.m., she stated she was the infection preventionist for the facility. She stated she had in serviced the staff on Enhanced barrier precautions and the use of Personal Protective Equipment. She stated she was monitoring for compliance by doing spot checks and skills checks on the employees for competency in infection control. She stated she should have already done a skills check on CNA F since she was a new hire recently. She stated staff were instructed to perform hand hygiene before and after care and any time a glove change was required. She stated all the residents who required Enhanced Barrier Precautions had signs posted outside of their room and the necessary supplies outside of their room. She stated they would continue to monitor and do skills checks as needed. 5. Observation of CNA I on 9/9/25 at 12:12 p.m. passing out food trays in the memory care unit dining room. CNA I delivered a tray to a resident in the dining room, removed the food from the tray and placed the meal on the table in front of a resident, returned to the cart, got a sweetener and gave the sweetener to the resident. CNA I then returned to the cart, got another food tray for a resident without sanitizing or wash her hands. She delivered the tray to a resident and returned to the cart and got another tray. CNA I walked the tray down the hall and delivered it to a resident in their room. She returned and did not sanitize or wash her hands. When she returned to the cart, she got an iced tea from the cart and walked it down the hall to a resident. CNA I went back to the cart and another staff member handed her a food tray and she did not sanitize her hands before she got the tray and delivered it. A bottle of hand sanitizer was observed on the top of the cart with the food trays. In an interview with CNA I on 09/09/2025 at 12:30 p.m., she stated she was supposed to sanitize her hands between each tray delivery. CNA I stated she had not sanitized her hands between tray delivery because she did not have any hand sanitizer. She stated she had not seen any sanitizer on the cart or in the hallways. CNA I stated the risk to the resident of not sanitizing their hands between tray delivery was bacteria and cross contamination. During an interview with the ADON, who was the infection preventionist for the facility, on 09/10/2025 at 9:04 a.m., she stated she was unsure of the expectation of hand hygiene for delivery of food trays but believed hand washing or use of hand sanitizer should be done between each tray delivery. The risk to the resident of not sanitizing between trays was staff could pass bacteria or a bug from a sick resident to another resident. Interview with LVN B on 9/10/25 at 1:39 p.m., revealed the expectation of hand hygiene during food delivery was staff should sanitize their hands between each tray delivery. She stated the risk of not doing so was infection and cross contamination. In an interview with CNA D on 9/10/25 at 1:53 p.m., it was revealed the expectation was staff should sanitize their hands between each tray and keep the food cart door closed while delivering trays. She stated the risk to the resident of not sanitizing correctly was cross contamination. CNA D stated she always delivered food trays in the memory care unit and there was always sanitizer on the top of the food cart and on the rail by the dining room door. Interview with CNA J on 9/11/25 at 11:12 a.m., revealed staff needed to sanitize between each food tray delivery. CNA J stated she carried her own sanitizer in her pocket. She stated the risk of not sanitizing between each tray delivery was cross contamination. Interview with the DON on 9/11/25 at 11:53 a.m., revealed the expectation of hand hygiene with food tray delivery was hand sanitizing between trays and between residents. The risk to the resident of improper hand hygiene was infection and cross contamination. Interview with the Administrator on 9/11/25 at 1:16 p.m., revealed the expectation for food delivery trays was staff must perform hand hygiene between every tray delivery. The Administrator stated there was hand sanitizer on top of each food cart every time food was delivered to the memory care unit. The risk to the resident of improper hand hygiene was infection, cross contamination and germs. Record review of the Facility's policy, Cleaning and Disinfection of Resident-Care Equipment, dated 09/10/25, reflected, Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendation.equipment is categorized based on the dree of risk for infection.Non-critical items come in contact with intact skin, but not mucous membranes. These items require cleaning followed by low/intermediate-level disinfection (i.e., use of EPA- registered disinfectants) .Multiple-resident use equipment shall be cleaned and disinfected after each use. Record review of the Facility's undated policy, Medication Administration, reflected, .Remove medication from source, taking care not to touch medication with bare hand. Record review of the Facility's undated policy, Hand Hygiene, reflected, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.Hand hygiene.Between resident contact.After handling contaminated objects.Before applying and after removing personal protected equipment including gloves.Before and after handling clean or soiled dressing, linens, etc.during resident care, moving from a contaminated body site to a clean body site.When in doubt. Record review of the Facility's undated policy titled, Enhanced Barrier Precautions, reflected, Enhanced Barrier Precautions (EBPs) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.All staff received training on enhanced barrier precautions upon hire and at least annually.An order for enhanced barrier precautions will be obtained for resident with any of the following.wounds.feeding tubes.urinary catheters.even if the resident is not known to be infected or colonized with a MDRO.High contact resident care activities include.Providing hygiene.changing linens.Changing briefs.device care or use.Wound care. Record review of the facility's policy Food Safety Requirements revised in 2025 reflected .Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. Strategies include but are not limited to.Washing hands properly before distributing trays. Washing hands between contact with residents and after collecting soiled plates and food waste.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for two (Dietary [NAME] L and Dietary Aide M) of two dietary staff reviewed for food service safety. The facility failed to ensure Dietary [NAME] L and Dietary Aide M wore effective hair restraints during lunch meal preparation on 09/10/2025. This failure placed residents at risk for food-borne illness and food contamination. Findings included: During an observation on 09/09/2025 at 12:12 PM and 12:26 PM during lunch meal service revealed Dietary [NAME] L's hair restraint was not covering about 2 inches of the back of her hair below the restraint and 1.5 inches on both sides of her hair in front while she was plating food for resident lunch. During an observation on 09/09/2025 at 12:15 pm and 12:27 PM revealed Dietary Aide M's hair restraint was not covering about 1 inch hair on both sides in front of her ear and about 0.5 inch of hair in the back below the hair restraint while she was putting condiments on plate and silverware and back about 0.5 inches for dining room hall trays. Interview on 09/09/25 at 12:50 PM with Dietary Aide M revealed she was not aware of her hair restraint not covering her hair. She stated she had taken the food handler's course. She stated she should have had her hair restraint covering her hair during lunch meal service. Interview on 09/10/25 at 12:52 PM with Dietary [NAME] L revealed she was not aware hair hair restraint was not fully covering her hair on the sides and back of her hair. She stated the hair restraint must have slipped up. She stated she was aware the hair restraints should be covering her hair completely. Interview on 09/10/25 at 1:02 PM with Dietary Manager revealed he expected hair restraints to fully cover all hair for dietary staff. He stated he would monitor and in-service his dietary staff on hair restraints policy. He stated he had not recently in-serviced the dietary staff on hair restraints. Interview on 09/10/25 at 1:30 PM with Dietary Manager revealed the importance of hair restraints was to keep the hair out of resident food and placed food at risk for cross contamination. Review of facility's policy Safe Food Handling, dated 08/01/20, reflected, Proper food handling is essential in preventing foodborne illness.8.Anyone working in the kitchen during normal food production hours is expected to war appropriate hair restraints (such as hats, hair covers or nets, beard restraints).

Based on observations, interviews, and record review, the facility failed to ensure that residents have the right to have reasonable access to use the telephone for 7 (Resident #30, Resident #50 and 5 anonymous residents from a group interview) of 12 residents reviewed for resident rights. 1. The facility failed to ensure there was a working phone system to receive and make calls for Resident #30, Resident #50 and 5 anonymous residents on 9/9/25 through 9/11/25. 2. The facility failed to ensure relatives of Resident #30 had a working phone number to reach the resident and facility staff. These failures could place the residents at risk of feelings of isolation and mental decline. 1. Record review of Resident #50''s face sheet dated 9/10/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (group of thinking and social symptoms that interferes with daily functioning), psychotic disorder, dysphagia (difficulty swallowing) and personality change due to known physiological condition. Record review of Resident #50's most recent admission MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and had a BIMS of 5. Resident #50 displayed behaviors of inattention, disorganized thinking and physical behavioral symptoms directed toward other residents. In an interview with Resident #50's relative on 09/10/2025 at 10:27am revealed she had not gotten through to the facility by phone for several days. She stated Resident #50 could not call her and she could not call him. She stated she had been notified by staff using an anonymous number that Resident #50 had gone to the hospital on 9/4/25. When she tried to contact the facility back because she was concerned, she could not reach them at the facility phone number. The relative stated she was very concerned about the phones, as Resident #50 had returned to the facility on 9/8/25 and she had not been able to reach the facility since then. In an interview with CNA D on 9/10/25 at 1:53pm revealed a relative for Resident #50 had complained to her about not having gotten through on the facility phones to check on the resident. CNA D provided the relative her cell phone number and told Resident #50's relative she could leave messages on her phone for a call back. CNA D stated there was a resident who asked to call a family member daily because the facility phone was not working. CNA D stated they had been in-serviced about the phones not working and were told to use their personal phones to contact family members for notifications or when there was a problem with the residents. 2. Record review of Resident #30's face sheet dated 9/10/25 reflected a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses that included Pancreatitis (inflammation of the pancreas), Dysphagia (difficulty swallowing), Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways) and Depression. Record review of Resident #30's Quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired with a BIMS score of 11. Resident #30 needed partial assistance with some ADLs such as dressing, showering and toileting. In an interview with Resident #30 on 09/09/2025 at 10:17am revealed he had a relative who had been trying to call the facility phones several times a day, for several weeks but had not been able to reach the facility and speak to staff about a concern they had. On 09/09/25 at 2:34pm, the surveyor attempted to speak to the relative but was unsuccessful in reaching them. [SP1] 3. In a confidential group interview of 5 residents on 9/10/25 at 11:08am revealed there had been a big issue with the phone lines not working at the facility for several weeks. The issues included calling out of the facility and calling into the facility. The residents were concerned the phones were not working at the nurses' station and wondered how their doctors had gotten in touch with facility staff. Some residents had cell phones but there were several residents that did not have a cell phone and relied on the facility phones to call their loved ones. In an interview with the Ombudsman on 09/09/25 at 12:58pm revealed she had received a call last week from a resident's family member who had been trying to speak to a resident at the facility and had not been able to. The relative complained about the phone lines not working. The Ombudsman stated she was aware the phones had not been working for several weeks. On 09/10/2025 at 10:14am Surveyor called the facility number listed on google (903-465-7442) and the phone rang numerous times, no one answered and there was nowhere to leave a message. In an interview with LVN B on 9/10/25 at 1:39pm revealed she was aware of the phone issues, she stated she had been able to call out on the facility phones, but she had heard families state their calls to the facility had not gone through. She stated the Administrator and DON had told staff about the phone issues and in-serviced them. LVN B stated she had told relatives to call her cell phone if they had not gotten through on the facility phone. The risk of not having had working phone lines was residents' family members were not able to talk to resident or may not have been informed of residents' changes in condition.On 9/11/25 at 10:44am Surveyor called the phone number on google for the facility (903-265-7442) and it rang. The surveyor stayed on the phone for 2 minutes and the phone would ring but there was no answer or nowhere to leave a message. In an interview with LVN K on 9/11/25 at 10:59am revealed residents and relatives had asked her what the problem was with the phones. She stated the administration was aware of the issues with the phones and the directive was to let residents use staffs' personal phones. LVN K stated she was using her cell phone to call resident relatives and doctors. She stated the medical director had most of the staffs' cell phone numbers. LVN K did not believe there was a risk to the residents of not having a working phone because staff had cell phones to call 911 and communicate with relatives. She stated there was a problem however for relatives trying to reach their loved ones. In an interview with the ADON on 9/11/25 at 11:24am revealed the facility had been having issues with the phones for about 3 weeks. The directive to staff about phones was to use their personal cell phones (blocking their number when they dialed) to maintain the staff's privacy. She stated the facility also had an on-call cell phone staff could use to make phone calls to relatives. The ADON was not sure what phone number had been provided to resident relatives but believed staff had gave out their cell phone numbers to relatives that needed to call the facility. The ADON stated she had not had any complaints from relatives about the phones not working. She stated residents had not complained to her about the phones not working either. She believed an in-service was provided to staff about the phone issues. The risk to the residents of not having working phones would be they could not talk to their family, which was their right. She stated it would be worrisome to her if she was a relative and could not reach her loved one.In an interview with the DON on 9/11/25 at 11:53am revealed the issues with the phones had been for 3 to 4 weeks. The problems were with making and receiving calls. The Administrator had been working with the phone company to resolve the issues, but the issues had continued. The directive to staff had been to use personal cell phones to contact physicians and family. In the last week the facility purchased a on-call phone staff and residents could use. The DON stated she did not know if relatives had been notified of the phones not working or what they had been told regarding the phones. She stated she had spoken to a few relatives and told them to call her cell phone if they needed to contact the facility but was unsure of how many relatives she had spoken to. She stated the physician was provided her number to call when needing to contact the facility staff. The DON stated there was no risk to the residents of not having working phones at the facility because they had an on-call phone and some of the staff had allowed residents to use their cell phones to call their family. The DON stated it was the resident's right to be able to call friends and family and not having access to a working phone would be violating their right.In an interview with the Social Worker on 9/11/25 at 12:15pm revealed she had several complaints from relatives and residents about the phones not working. The Social Worker stated the resident council had talked about the issue with staff and had been on ongoing issue. She stated the aides were letting residents use their cell phone or allowing the residents to use the on-call cell phone to make personal phone calls. The Social Worker stated she had posted on their Facebook page the phones were down at the facility to help notify relatives of the issue. She stated they had not called, sent letters or emails notifying relatives of the phone issues. She stated they had a plan in place for providers and doctors to be able to reach the facility that included calling staffs' personal cell phones. For the hospital discharges she was the point of contact and the case managers from the hospital would contact her and she had the assigned nurse call the hospital back. The doctors' offices had the facility transportation's personal cell phone number because she oversaw appointments and transportation needs for residents. The risk to the residents of not having had working phone would be a sense of isolation. In an interview with the Administrator on 9/11/25 at 1:09pm revealed the phone issues started in the beginning of August 2025. He stated the phone company told him initially it was a copper line that took a few weeks for the phone company to repair, however it only worked for a few days and the phone had been down ever since. He stated the phone company, and their affiliated company had been out to the facility several times, but they could not determine the cause of the phone problem. The Administrator stated facility staff had attempted to call some family members from blocked cell phone numbers to maintain the staff members' privacy but had not gotten responses due to the numbers being blocked. He stated they had not attempted to call all resident family members. He stated they were recently able to access the facility Facebook account because they had been locked out, due to transitioning from one corporate account to another, and they had updated the page to notifying people the phone lines were down. He stated some staff were letting residents use their personal cell phones to make phone calls or they were allowing the residents to use the on-call staffing phone. Regarding Resident #30's relative, the Administrator stated the resident's emergency contact had spoken to him personally and he had given them his cell phone number. The Administrator stated the risk to the resident of not having working phone lines was a feeling of isolation[SP2] . Record Review of facility in-service record titled Phones Lines dated 8/13/25 reflected Objectives of the in-service: Facility phone lines are out of service at this time. Notifications to physician, family members or other contacts needed should be done with personal phones or contact DON and DON will assist as possible. Record review of facility's Resident Rights policy revised on 4/25/25 reflected .h. The resident has the right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard.Record review of facility's Communication within and External to the facility policy revised in 2025 reflected Policy: The facility will protect and facilitate the resident's rights to communicate with individuals and entities within the external to the facility.The facility will provide reasonable access to a telephone, including TTY and TDD services.Record review of facility's Facility Responsibility policy revised 6/27/25 reflected Policy: It is the policy of this facility to uphold and comply with the facility responsibilities. The facility will ensure that staff members are educated on the rights of the residents and the responsibilities of a facility to properly care for its residents. Policy Explanations and Compliance Guidelines: 1. Resident Rights - the resident has a right to a dignified existence, self-determination and communication and access to person and services inside and outside the facility.

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 6.25 %, based on 2 errors of 32 opportunities, which involved one of six residents (Residents #14) and one of three staff (LVN A) reviewed for medication errors, in that: LVN A failed to administer Resident #19's Digoxin 250 mcg with Digoxin 125 mcg for a total dosage of 375 mcg daily and failed to administer Ergocalciferol 1.25 mg on 09/10/25 as ordered by the physician. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings include: Record review of Resident #14's Quarterly MDS assessment, dated 08/29/25, reflected a [AGE] year-old female with an admission date of 06/15/18. Staff had assessed her mental status as severely cognitively impaired. Diagnoses included coronary artery disease (damage or disease in the heart's major blood vessels), hypertension (high blood pressure), and quadriplegia (paralysis that affects the ability to voluntarily move the upper and lower body). A record review of Resident #14's Physician's order summary report, dated 09/11/2025, reflected Resident #14 was to receive the following medications: Digoxin Oral Tablet 250 mcg (used to improve the strength and efficiency of the heart) Give 1 tablet via G-Tube one time a day related to tachycardia (rapid heart rate) Hold for pulse <60. Give with Digoxin 125 mcg to equal 375 mcg with a start date 08/28/25.Ergocalciferol (Vitamin D2 supplement) 1.25 mg (5000 UT) Give 1 capsule via G-Tube one time a day every Wednesday for supplement with a start date of 08/28/25 During a G-Tube medication pass observation on 09/10/25 at 08:08 a.m., revealed LVN A administered the following medications to Resident #14: Digoxin 125 mcg 1 tabletCoreg 6.25 mg 1 tabletDocusate 100 mg 1 tabletCyclobenzaprine 10 gm 1 tabletHydrochlorothiazide 25 mg 1 tabletLactulose oral solution 100 mg/ml -10 mlMetoclopramide oral solution 5 mg/ml -5 ml MiraLAX oral powder 17 gm/ scoop -1 scoopLevetiracetam oral solution 100 mg/ml -10 mlLVN A did not administer Digoxin 250 mcg 1 tablet, or Ergocalciferol 1.25 mg 1 capsule as ordered for daily administration. Record review of Resident #14's September 2025 medication administration record on 09/10/25 at 12:00 p.m. reflected Digoxin 250 mcg tablet at AM (7) and Ergocalciferol 1.25 mg AM (7) on Wednesday were signed out as given by LVN A on 09/10/25. In an interview with LVN A on 09/10/2025 at 12:48 p.m. she stated she had not administered any additional medications to Resident #14 since her morning medication administration. Upon reviewing the medication administration record she acknowledged she had not administered the Digoxin 250 mcg or the ergocalciferol 1.25 mg but had signed them out as administered. She stated she remembered the resident had that combination of Digoxin back in December, which was the last time she had worked at the facility. She stated today was her first day back. She stated the facility had asked her if she needed some additional training before doing the medication pass this morning and she told them no, she felt like she had been a nurse for many years and was familiar with Resident #14. She stated by her signing the medication off as given, it would not have triggered to indicate it still needed to be administered and no one would be aware the medication was missed. She stated the risk of not administering the resident's medication as ordered would be the resident would not receive the full therapeutic value of the medication that was ordered for her. In an interview with the DON on 09/11/25 at 08:22 a.m., she stated she expected the staff to follow the 5 rights of medication administration which were right drug, right dose, right route, right patient, and right time. She stated failing to follow these rights put residents at risk of not receiving all their medications or could lead to drug interactions if the correct medication or dosage was not given. She stated they do skills checks annually and the pharmacy consultant observed medication administration. She stated they had now flagged the digoxin order for Resident #14 since it is listed as 2 separate drug administrations and was easy to overlook. She stated they had also clarified the order for the Ergocalciferol 1.25 mg 1 capsule since it was a gel capsule and stated she was not sure how the staff were administering via the G-tube. She stated they had since ordered the liquid solution to be used going forward. Record review of the facility undated policy titled Medications Administration, reflected, .Ensure that the six rights of medication administration are followed.Right residentRight drugRight dosageRight routeRight timeRight documentationReview MAR to identify medication to be administered.Compare medication source (bubble pack, vial, etc.,) with MAR to verify resident name, mediation name, form, dose, route, and time.Sign MAR after administered.

Based on interview and record review, the facility failed to ensure the resident's right to participate in the development and implementation of his or her person-centered plan of care and facilitate the inclusion of the resident and/or resident representative for 1 of 8 residents (Resident #10) reviewed for resident rights. The facility failed to ensure Resident #10's representative was offered the opportunity to participate in Resident #10's care plan meeting via telephone. This failure could place residents at risk of not being informed of resident's plan of care and a decline in quality of life. Findings included: Review of Resident #10's Quarterly MDS assessment dated reflected Resident #10 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimers disease (progressive brain disorder that causes gradual decline in memory, thinking and language), coronary artery disease (condition in which the arteries that supply blood to the heart become narrowed or blocked) and epilepsy (neurological disorder characterized by recurrent, unprovoked seizures). Resident #10 had a BIMS of 1 indicating she was severely cognitively impaired. Resident #10 required substantial/maximal to total dependent with ADLs. Review of Resident #10's face sheet undated reflected Resident #10 was not her own responsible party and had a responsible party listed. Review of Resident #10's comprehensive care plan last updated 07/15/25 reflected Resident #10 had a diagnosis of Alzheimer's.at risk for an increase in confusion and decline in ADL's as the disease progresses. Review of Resident #10's care plan conference letter for the last year addressed to Resident #10's representative completed by social worker to responsible party reflected the following:- Dated 01/06/25 reflected If you can not attend this meeting, but have issues you need to discuss, please call at any time so we can address these issues in a timely manner. The care plan meeting was scheduled for 01/21/25 at 2:30 PM. It did not reflect option for responsible party to be called for the care plan meeting.- Dated 03/27/25 reflected If you can not attend this meeting, but have issues you need to discuss, please call at any time so we can address these issues in a timely manner. The care plan meeting was scheduled for 04/17/25 at 2:45 PM. It did not reflect option for responsible party to be called for the care plan meeting. Interview on 09/10/25 at 12:24 PM with Resident #10's representative revealed she was provided notice of Resident #10's care plan meeting by letter and was unable to come in person to meetings. She stated when she called the facility the phone was difficult for them to get hold of anyone and it would just keep ringing at times. She stated when someone answered the phone she would ask about Resident #10 and seemed like he or she did not know much about resident. When they were able to get hold of someone, she was given excuses of Resident #10's charge nurse was not available at this time. Resident #10's representative stated she had not been provided the opportunity to be available by phone for care plan meetings. She stated she would like to be involved in care plan meetings but by phone. Interview on 09/11/25 at 2:15 PM with the Social Worker revealed Resident #10 was not her own responsible party and had a representative. The Social Worker stated Resident #10's representative should be provided the option of phone for care plan meetings. She had not discussed with Resident #10's representative the option of phone call for care plan meetings. She stated moving forward will update the care plan letter going out to the facility to ensure resident's representative were offered the option of phone for care plan meetings. Interview on 09/11/2025 at 2:51 PM the DON stated she was not aware of phone option being provided or not provided to resident family for care plan meeting. She stated it was important for resident's representative to give their insight and if they were any concerns that need to be improved. The DON stated the care plan meetings can give the resident's representative an opportunity to be updated about their resident care. She stated the social worker was responsible for contacting resident's representative to ensure they were notified for care plan meetings. She stated resident's representative should be offered the option of phone for care plan meetings. Review of the facility's policy Care Planning-Resident Participation dated 2024 reflected This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care).The facility will honor the resident's right to participate in . the plan of care. 10. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences.The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative.

Based on interview and record review the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident #3) of 8 residents reviewed for comprehensive care plans. The facility failed to develop and implement a comprehensive care plan for Resident #3 to address the resident's left pelvic fracture and to address Resident #3's falls. This failure could place residents at risk for not receiving care required to meet their individualized needs and place them at risk for falls and injury. Findings included:Review of Resident #3's face sheet undated reflected Resident #3 was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnose of dementia (group of conditions that cause a decline in cognitive abilities, memory and thinking skills that interfere with daily life), generalized muscle weakness, unsteadiness on feet, repeated falls and lack of coordination. Review of Resident #3's admission MDS assessment dated [DATE] reflected Resident #3 had a BIMS of 2 indicating he was severely cognitively impaired. Resident #3 had 1 fall with no injury since last assessment or since admission. Review of Resident #3's comprehensive care plan last revised 07/18/25 reflected Resident #3 was at risk for falling [related to] muscle weakness, decreased cognition and vision problems. The care plan did not reflect Resident #3's actual falls. It did not reflect Resident #3's left pelvic fracture. Review of Resident #3's Incident/Accident Reports for July and August 2025 reflected the following:- Dated 07/09/25 Resident #3 had a witnessed fall at 8:50 AM Resident stood up out of [wheelchair] and was trying to move dining room table chair feet slipped out from under him resulting in a fall Resident #3 had injury of a red area on mid back. - Dated 08/12/25 Resident #3 had an unwitnessed fall at 5:01 PM observed resident on the floor in a fetal position laying on his right side.Head to toe assessment completed: laceration to [right] side of forehead. First aid administered. resident was yelling upon movement to [left] leg. Prn medication Tylenol #3. Resident #3 was sent to local hospital emergency room for further evaluation and treatment. - Dated 08/18/25 Resident #3 had an unwitnessed fall Nurse passing medications opened resident's door, observed resident sitting on the floor beside bed. No injures noted. Review of Resident #3's reportable incident 1029158 provider investigation report dated 08/15/25 reflected on 08/06/25 at 12:35 AM Resident #3 was found lying on the floor in his room with his dinner tray on the floor also. CNA just rounded and visited with resident and he was coming out of his room with his tray. Upon noticing he didn't come out she went back to check on him and found him on the floor. Assessment at time of incident reflected full body assessment by nurse with no concerns of pain. On 08/08/25 Resident #3 complained of pain to the middle/left side of his buttocks while transferring to a [wheelchair].Resident was sent out 911 to [local hospital]. Upon report from the hospital x-rays indicated resident had a fracture to his left superior/inferior pubic bone.' Interview on 09/11/2025 at 2:46 PM with the DON revealed she was responsible to ensure Resident #3 care plans addressed his falls and fracture. She stated she may not have completed Resident #3's care plan to address the pelvic fracture and when reviewing the care plan she could not find the fracture on the care plan. She stated she thought Resident #3's care plan addressed Resident #3's actual falls prior to incident. She stated he had a fall on 08/18/25. The DON stated she usually updated the care plan for falls. She stated she was responsible to ensure Resident #3's fracture was care-planned. She stated it was important to care plan to include interventions in place to address the falls and fractures. Review of the facility's policy Care Planning-Resident Participation dated 2024 reflected .6.The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences. Review of the facility's policy Comprehensive Care Plans dated 2025 reflected to develop and implement a person-centered care plan for each resident.that includes measurable objectives and timeframes to meet a resident's medical, nursing.and all services that are identified in the resident's comprehensive assessment and meets professional standards of quality.

Based on observation, interview 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 resident's goals and preferences for 1 of 5 (Resident #39) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #39's oxygen was administered at the correct setting of 2 liters per minute on 9/9/25 and 9/10/25 as ordered by the physician. This failure could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. Record review of Resident #39's admission record dated 10/10/25 reflected an [AGE] year-old female with an admission date of 9/11/24. Resident #39 was diagnosed with chronic obstructive pulmonary disease (constriction of the airways with difficulty breathing).Record review of Resident #39's Annual MDS assessment dated [DATE] reflected Resident #39's BIMS score was 14 which implied she had little to no cognitive impairment. Resident #39 was marked as receiving oxygen therapy while at the facility. Record review of Resident #39's Physician Order Report dated 8/1/25-8/31/25, reflected an order on 9/11/24 O2 at 2 liters per minute via nasal cannula every shift; shift 1, shift 3, shift 1.Record review of Resident #39's person-centered care plan revised 6/27/25 reflected .Problem Start Date: 9/23/24 Resident #36 is at risk for respiratory distress/SOB due to DX of COPD. Edited 6/27/25.Approach Start Date: 9/23/24 Apply O2 as ordered.Observation of Resident #39 on 09/09/2025 at 10:12am revealed resident was asleep; oxygen concentrator was on at 3 liters per minute, but the resident did not have the oxygen on her face. Observation and interview of Resident #39 on 9/9/25 at 2:07pm revealed resident was awake with oxygen via nasal cannula and the concentrator was set at 3 liters per minute. Resident #39 stated she needed to have the oxygen on but sometimes the nose piece bothers her. Observation of Resident #39 on 09/10/2025 at 8:31am revealed she was asleep with oxygen on via nasal cannula. The concentrator was set at 3 liters per minute.Interview and observation with LVN A on 9/10/25 at 2:10pm revealed it was her first day at the facility, since a long leave of absence. LVN A was assigned to Resident #39 but did not know if she had an oxygen concentrator and whether Resident #39 was ordered to have oxygen. LVN A checked Resident #39's electronic medical record and could not locate an order for oxygen. She then called LVN H, who had just started his shift, to help verify whether Resident #39 had an order for oxygen. Interview and observation with LVN H on 9/10/25 2:13pm revealed he was starting his shift and Resident #39 was assigned to him. He provided a copy of Resident #39's order from her paper file. He stated Resident #39 received oxygen and should have gotten 2 liters per minute continuously. Surveyor requested LVN H read Resident #39's concentrator and he stated it was set a 3 liters per minute. He stated that was incorrect as Resident #39 should have had her concentrator set at 2 liters per minute to match the physician orders. He was unaware of the reason the concentrator was set at a higher rate. He stated at times the family would visit resident and would put water in the concentrator and adjust it. He stated the concentrator should have been checked during every shift, but he had just started his shift and hadn't checked Resident #39's concentrator yet. He was observed adjusting the oxygen concentrator to 2 liters per minute. He was unable to state when he last checked Resident #39's concentrator. He stated for sure they checked the level on the concentrator on Sunday when the tubing was changed. LVN H stated he was not the person who changed the tubing on Sunday. LVN H stated the risk to the resident of having had received more oxygen then was orders could have been more breathing complications or respiratory distress. Interview with LVN K on 9/11/25 at 10:59am revealed the expectation at the facility was the oxygen concentrator be checked weekly, however some residents required as needed checks. LVN K determined the amount of oxygen given by the physician order. The risk to the resident of not following the order would be not administering enough oxygen or over oxygenating the resident. Too much oxygen could have lead to respiratory distress. Interview with the ADON on 9/11/25 at 11:24am revealed the expectation for a resident with continuous oxygen was the concentrator be checked weekly when the tubing was changed. Staff should have been following the orders when determining the amount of oxygen given to residents. For residents who received continuous oxygen, the nurses needed to check oxygen stats every shift to ensure the residents were receiving enough oxygen. If the staff determined the resident had not gotten enough oxygen, then they needed to call the physician for a new order. The ADON's expectation from the nurses would be for them to check the concentrator every shift to ensure it matched the order. The risk of administering too much oxygen would be it could affect the resident's COPD and if it was too low the resident may not have gotten enough oxygen. Interview with the DON on 9/11/25 at 11:53am revealed nurses determined levels for oxygen concentration based on orders. The concentrator should have been checked every shift to make sure it matched the orders. The risk to the resident of not having received the oxygen as ordered would be they may have gotten to little or too much oxygen thus affecting the accuracy of the O2 stats. Review of facility's policy Oxygen Administration revised 2025 reflected.Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.

Based on observation, interview, and record review the facility failed to provide food that was served at an appetizing temperature, and prepared by methods which conserved the nutritive value, flavor, and appearance for one (Lunch 09/10/25) of one meals observed for food palatability. The facility failed to ensure egg salad was served at an appetizing temperature for lunch on 09/10/25. This failure could place residents at risk of food borne illness and a decline in their quality of life. Findings included: In a confidential group interview with five residents on 09/10/25 at 11:00 AM revealed residents' concerns with their food not being served at the right temperatures. Observation on 09/10/25 at 11:57 AM, revealed Dietary [NAME] L took the food temperature using a thermometer and food temperature of the pureed egg salad at 51.5 degrees Fahrenheit and 12:03 PM egg salad 42.3 degrees Fahrenheit. There was no ice under the egg salad containers. Dietary [NAME] L left the egg salad sandwiches and pureed egg salad on the serving line. Dietary [NAME] L did not take the food temperature of the egg salad. She documented the food temperatures on the log. At 12:08 PM, Dietary [NAME] L started plating food including egg salad to the residents' lunch plates in the dining room. Observation of a lunch test tray on 09/10/25 at 12:39 PM revealed the last hall resident meal tray was served on Hall 3 to a resident. Observation on 09/10/25 at 12:40 PM of a lunch test tray revealed egg salad was slightly warm to touch and tasted warm. Interview on 09/10/2025 at 1:10 PM Dietary [NAME] M revealed she was not trained on what the food temperatures should be and what to do if temperatures were not cold or hot enough. She stated this time she put the egg salad on the slider buns and then put them in refrigerator about an hour ago prior to serving. She stated she had not completed the food temperature of the egg salad until it was ready to be served. She stated she had to put boiled eggs in the egg salad for the pureed she stated this could have affected the food temperature. Interview on 09/10/25 at 1:30 PM with Dietary Manager revealed the egg salad should be served at 41 degrees Fahrenheit or below. He stated the cold food temperatures need to be followed to not place residents at risk of bacteria. Review of food temperature log dated 09/08/25 to 09/10/25 reflected on 09/10/25 at lunch regular entree was 42.3 F and pureed entree was 51.3 F. Review of Egg Salad on Croissant Recipe reflected under procedures 4. Chill egg salad until service.5. Chill to 41 F or below and keep refrigerated until serving. Review of facility's policy Safe Food Temperatures, dated 06/20/23, reflected, food temperatures will be maintained at acceptable levels during food storage, preparation, holding, serving, delivery.PROCEDURES: 6.Hold cold foods at 40 F or lower during meal service (on the trayline).

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 8 residents (Resident #7) reviewed for the storage of drugs and biologicals. The facility failed to ensure Resident # 7's Clobetasol Propionate external cream 0.05% was stored properly. This failure could place residents at risk of medication misuse, administration of incorrect dosage of medications which could result in non-therapeutic treatments or injuries. Findings included: Record review of Resident #7's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female with an admission date of 10/22/13. The resident had a BIMS score of 12 which indicated she was moderately cognitively impaired and had refused care 4-6 days out of the week. Resident #7 required supervision assistance with bathing and partial to moderate assistance with personal hygiene and dressing. Diagnoses included post-traumatic stress disorder (mental health condition that's caused by an extremely stressful event), cerebral vascular accident (stroke), peripheral vascular disease (blood vessels supplying the limbs and other body parts become narrowed or blocked) and hypertension (high blood pressure). There was no indication of skin disorders. Record review of Resident #7's care plan, dated 05/29/25, reflected, .Skin concerns.Psoriasis vulgaris (autoimmune skin condition characterized by raised, red, scaly patches of skin) with risk of flare up with risk of infection and further skin breakdown.Interventions.Monitor areas for flare up.discomfort, administer treatment as needed monitor for relief. Record review of Resident #7's Physicians Order Summary Report dated 09/11/25 reflected, Clobetasol Propionate (high potency topical corticosteroid used to treat sever inflammatory skin and scalp conditions like psoriasis) External Cream 0.05%. Apply to affected area topically every 12 hours as need start date 06/10/25. There were no orders for resident to have medication at bedside. An observation and interview on 09/09/2025 at 10:15 a.m. revealed Resident #7 in her room lying in bed watching television. A box containing a tube of Clobetasol Propionate 1% cream was observed on her overbed table. Resident #7 stated she kept the medication at bedside for her psoriasis. She stated she was not sure who brought it to her. She stated she does not recall the last time she used it. An observation 09/10/2025 at 1:30 p.m. revealed the tube of Clobetasol Propionate 1% cream was still in Resident #7 room on her bedside table. In an observation and interview with the DON on 09/10/2025 at 1:55 p.m. in Resident #7's room, the DON picked up the tube of Clobetasol Propionate 1% cream and asked the resident if she could read the instructions on the box for medication. The resident looked at the box and stated no she could not read it. The DON asked her if she knew how often she was using the medication and she stated she just put it on when she needed it. Resident #7 stated LVN C had given it to her. Resident #7 stated she did not care if the staff kept the medication and brought it to her when she needed it. The DON removed the medication and stated it should not have been left in the room. In an interview with the DON on 09/10/25 at 02:00 p.m., she stated for them to be able to leave medication at the bedside they have to complete a resident assessment to determine if the resident understands the directions for the use of the medication and the resident still must let the nurse know when they had administered the medication so it could be documented in the record. She stated Resident #7 did not have the capacity to manage her own medications. She stated the risk of leaving medications at the bedside was the resident could use the medication improperly, or some other resident could have access to a medication not prescribed for them. She stated it was the staff's responsibility to ensure the medications were kept secure and stored properly. She stated LVN C had been on medical leave for several weeks. In an interview with LVN C on 09/11/25 at 03:00 p.m. she stated she was returning to work this week after being off for several weeks. She stated she never left a tube of Clobetasol Propionate 1% cream in Resident #7's room. She stated when she had flares of her psoriasis she would place a small amount of cream in a medication cup and take it into her room to be applied to the affected areas. She stated medications were not to be stored at bedside. Record review of the facility undated policy Medication Storage, reflected, It is the policy of this facility to ensure all mediations house on our premises will be stored in the pharmacy and/medication rooms according to the manufacturers recommendations.All drugs and biologicals will be stored in locked compartments(i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperatures controls.Only authorized personnel will have access to the keys to locked compartments.During a medication pass, medications must be under the direct observation of the person administering mediations or locked in the medication storage area/cart.

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 2 of 13 residents (Resident #1 and Resident #2) observed for infection control. 1. The facility failed to ensure RN A used the required PPE for Resident #1, who was on enhanced barrier precautions due to his wounds and foley catheter during a wound care observation on 05/20/25. 2. The facility failed to ensure Agency CNA C performed hand hygiene while providing incontinence care to Resident #2 on 05/20/25. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1.Record review of Resident #1's undated face sheet reflected a [AGE] year-old male with an admission date of 01/15/25 and a readmission date of 05/07/25. Record review of Resident #1's 5-day MDS assessment dated [DATE] reflected resident had a BIMs of 15 which indicated he was cognitively intact, had a foley catheter and was always incontinent of bowel. Diagnosis included: septicemia (a systemic infection where bacteria invade the bloodstream), paraplegia (loss of motor and sensory function in both legs), and pressure ulcers of sacral area (area at the base of the spine) An observation on 05/20/25 at 9:55 a.m. of wound care revealed RN A outside of Resident #1's room preparing supplies needed for the resident's wound care. An EBP (Enhanced Barrier Precautions) sign was posted outside of the room next to the door. There was no supply of PPE observed outside of the room or inside of the room. RN A sanitized the resident's overbed table, placed a barrier on the table and placed her wound care supplies on the barrier. RN A entered the room, performed hand hygiene, and put on gloves, but did not put on a gown. RN A proceeded with the extensive wound care, changing her gloves, and performing hand hygiene between each wound. After completion of wound care, RN A retrieved the resident's wheelchair. RN A emptied Resident #1's urinary drainage bag, and then assisted him into his wheelchair. RN A gathered the trash, removed her gloves, and performed hand hygiene and left the room. In an interview with RN A on 05/20/25 at 11:00 a.m. who stated any resident with wounds and a foley catheter were supposed to be in Enhanced Barrier Precautions. She stated she should have worn a gown when she entered the room. She stated she did not see any PPE outside of the room, which was why she probably overlooked it. RN A stated she was not sure why there was no PPE outside of his room. RN A stated someone must have moved it because he had been in EBP since his admission. She stated the risk of not following Enhanced Barrier Precautions was the spread of MDRO's. In an interview with the DON on 05/20/25 at 4:35 p.m. she stated any resident who had any type of indwelling medical device was placed on Enhanced Barrier precautions to help reduce the spread of MDRO's. She stated signage was posted outside to the door, which explains what PPE was to be worn and for what task the PPE is to be worn for. She stated any contact with a resident with a wound or a catheter required the use of gown and gloves. She stated the staff had received trainings on the use of Enhanced Barrier Precautions. She stated there should have been PPE outside of Resident #1's room. She stated she was not sure who moved it but would make sure all of the residents who were on EBP had the necessary supplies for the staff. 2. Record review of Resident #2's MDS, dated [DATE], reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Muscle wasting and atrophy (gradual decline in body tissue), Dementia and Alzheimer's disease. Resident#2 had a BIMS score of 05 which indicated severe cognitive impairment. His Functional status reflected he was dependent on staff for toileting hygiene including incontinent care. Record review of Resident #2's care plan, dated 03/31/25, reflected Problem. Category: ADLs Function Status [Resident#2]'s ADL functions . Toileting . Goal: [Resident#2] will maintain a sense of dignity by being clean, dry, odor free, and well-groomed over the next 90 days. Approach: Assist with ADLs as needed . Observation on 05/20/25 at 10:37 a.m. of Resident #2's incontinent care, provided by Agency CNA C, and CNA D, revealed Resident#2 was on his bed asleep. Both CNAs entered Resident#2's room, CNA D awakened Resident #2, explained to him the procedure and adjusted the bed. Both CNAs washed their hands and put on gloves. CNA D folded Resident#2 cover toward the foot of the bed, pulled his pants down, and unfasten the brief. CNA D then instructed and assisted Resident#2 to roll towards her. Agency CNA C then clean the Resident's buttocks area using one wipe per stroke. Agency CNA C removed the soiled brief and threw it in the trash can, and then removed the under pad and put it in a separate plastic bag. Agency CNA C changed her gloves without performing hand hygiene. Agency CNA C then placed the new brief and clean under pad under the Resident's buttocks. CNA D rolled the Resident to the other side and adjusted the under pad and brief. Both CNAs then assisted the resident onto his back. Agency CNA C cleaned Resident #2 groin area using one wipe per stroke. CNA C changed gloves without performing hand hygiene. Both CNAs fastened the brief, then pulled Resident #2's pants up and pulled the blanket to his chest. Both CNAs removed their gloves and washed their hands. CNA D took the plastic bags and disposed of them in the dirty linen room in the hallway. Interview on 05/20/25 at 10:47 a.m., CNA C acknowledged she had changed her gloves without performing hand hygiene during Resident#2 incontinent care. CNA C stated she was supposed to follow proper hand hygiene and should have cleaned the resident's groin area before the buttocks. She emphasized that adhering to proper hand hygiene and correct perineal care procedures was important to prevent the spread, and development of infection to residents. In interview on 05/20/25 at 3:07 p.m. the DON stated infection control was important during residents' care. The DON stated during care the staff were to use the hand sanitizer or wash their hands if they were physically soiled. The DON stated the staff were expected to complete hand hygiene before care and after care, she also stated during incontinent care the staff were supposed to change gloves and use hand sanitizer. The DON stated hand hygiene was to be completed for infection control. The DON stated staff were trained to follow proper steps during residents' care to prevent cross contamination. Record review of the Facility's policy titled, Isolation Precautions including Standard/Universal Precautions, and Enhanced Barrier Precautions, revised August 2022, reflected, Enhanced Barrier Precautions (EBPs) .expand the use of PPE (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP will be implemented for All residents with the following .Wounds and/or indwelling medical devices .urinary catheter .regardless of MDRO colonization status .The facility will post signage on the door or wall outside of the room indicating the type of precautions and required PPE (gowns and gloves) .The facility will provide gowns and gloves immediately outside of the resident' room and position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care another resident in the same room . Record review of the facility's policy titled, Hand Hygiene/Handwashing, dated May 2023, reflected, .Hand Hygiene/Hand washing is the most important component for preventing the spread of infection .Hand Hygiene/Hand Washing is done before: .resident contact before performing an aseptic task After .contact with soiled or contaminated articles, such as articles that are contaminated with body fluids .resident contact .assisting other with toileting .after removal of medical /surgical or utility gloves .

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment for secure unit dining room, main dining room and for 14 of 27 residents (Resident #2, Resident #39, Resident #12, Resident #13, Resident #14, Resident #17, Resident #22, Resident #25, Resident #28, Resident #34, Resident #35, Resident #43, Resident #47, Resident #48) reviewed for environment and resident rights, in that, The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and did not ensure resident rooms were clean, sanitary and free of food debris and drink spills to prevent ants, gnats and flies. There were ants, gnats, flies in resident rooms and resulted in 102 ant bites on Resident #2's upper middle chest, over the right breast, right side of the neck, right shoulder, right arm, and right elbow. An IJ was identified on 08/08/24. The IJ template was provided on 08/08/24 at 4:11 PM. While the IJ was removed on 08/12/24, the facility remained out of compliance at a scope of pattern and severity level of potential for more than minimal harm because all staff had not been trained on clean, sanitary, and homelike environment. These failures placed residents at risk of living in an unsanitary and unhomelike environment. Findings included: 1. Review of Resident #2's face sheet, dated 08/07/24, revealed she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Hypertension (high blood pressure), diabetes mellitus, Acute and chronic respiratory failure with hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), Quadriplegia (paralysis of all four limbs), Cognitive communication deficit, aphasia following cerebral infarction (type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain), chronic pain, and adult failure to thrive. Review of Resident #2's MDS quarterly assessment, dated 04/28/24 revealed Resident#2's BIMS score of 00 indicating severe cognitive impairment. Resident #2 had a feeding tube with over 51% or more received through tube feeding. Review of Resident #2's care plan, dated 03/29/23, and updated 08/08/24, reflected the following Problems: Resident #2 has scattered insect bites (ant bites) on her right neck, right shoulder, right arm, and right breast. Goal: Resident #2 insect bites will heal without complications over the next 90 days. Approach: Monitor for s/s of infection and report findings to MD. Treatment as ordered. Record review of Resident #2's weekly skin assessment, dated 07/29/2024, revealed Resident #2's skin was intact. Record review of Resident #2's skin assessment, dated 07/30/2024, revealed Resident #2 had redness, bites/welts on the right shoulder, and right arm. Record review of Resident #2's physician order dated 07/30/2024 revealed Resident #2 had an order for, Kenalog cream apply to right of neck and right forearm three time a day till healed. Record review of Resident #2's nursing progress note, dated 07/30/2024 at 06:00 p.m., revealed a note reflecting Resident #2 . Approximately 06:00 pm walked into resident's room to administer medication via G tube (gastrostomy tube is a tube that is surgically inserted through the abdominal wall and into the stomach to provide an alternative way to deliver nutrition, fluids, and medications directly to the stomach) and noted ants on resident R arm/elbow, and right side of her face. Removed ants as quickly as possible, assessing resident and noted resident to have reddened welts to R elbow, and bend of AC (Antecubital - the area on the front side of the upper part between the arm and forearm) and to the right side of her neck. Notified Doctor (Resident primary doctor) new order received to apply Kenalog three time a day. Resident moved to another bed in another room. Notified DON. Notified resident representative . Vital signs: Blood pressure: 118/75, Heart rate, Temperature: 98.2 F, Respiratory rate: 20. Record review of Resident #2's nursing progress note dated 07/31/2024 at 01:00 am., revealed a note stating Resident #2 currently in bed resting no signs and symptoms of pain or discomfort noticed, small bites to right inner elbow, no edema (swelling caused by too much fluid trapped in the body's tissues) noted to the areas. Record review of Resident #2's nursing progress note, dated 08/01/2024 at 09:00 a.m., revealed a note reflecting Resident #2 . new order Benadryl 25 mg via peg tube bid for 7 days . Record review of Resident #2's nursing progress note, dated 08/7/2024 at 10:00 a.m., revealed a note reflecting Resident #2 . day 7/7 Benadryl r/t insect bites Record review of Resident #2's Doctor orders revealed Resident #2 had an order dated 06/01/2024 for Tylenol-Codeine #3 (Acetaminophen with codeine, pain medication) one tablet every four hours as needed for pain via G-tube feeding. Record review of Resident #2's MAR revealed Resident #2 received Tylenol-Codeine #3 (prescription drug used to relieve mild to moderately severe pain that is not well-controlled with over-the-counter medication) one tablet on 07/31/24 at 08:00 a.m., 08/01/24 at 08:00 a.m., and 08/02/2024 at 08:00 a.m. via G-tube feeding, with the note of pain level 6/10, and pain reassessment after medication revealed effectiveness. Observation on 08/06/2024 at 09:13 AM of Resident #2's room revealed Resident #2's bed was located next to the window. Resident#2 was up in the wheelchair and connected to G-tube feeding. Ant bites were visible on Resident#2's right side of her neck, and right arm around the anti-cubital fossa (the area on the anterior side of the upper part between the arm and forearm). Observation revealed the ants bites were either clear fluid filled raised areas and/or scabbed raised areas in the affected area. Resident #2's G tube had feeding formula spots on the floor, and the on the G tube pump pole, and electric wire. Observation and Interview with the ADON on 08/06/24 at 4:13 PM revealed skin assessment with ADON on Resident #2. Resident had multiple healing ant bites on her right arm, upper chest, neck and face. ADON stated when she came in that night (07/30/24) after the incident it broke her heart to think of Resident #2 lying there, not being able to speak, not being able to call out for help. She stated the ants were crawling on the resident and crawling in the bed linens. She stated the ants were everywhere. Observation on 08/07/2024 at 10:07 am of Resident #2's Skin assessment by LVN B with the help of CNA I revealed : 8 ant bites at the middle chest by the neck; 9 ant bites over the right breast; 15 ant bites on the right side of resident neck; 25 ant bites on the right shoulder; 30 ant bites in top of the right arm in front of the elbow; 15 ant bites on the resident's right elbow. Observation and interview revealed Resident # 2 sustained a total of 102 ant bites. Resident #2's G tube feeding formula pole was next to resident's bed with drip spots on the floor, and on the G tube pump support, pole, and power cord. Interview on 08/07/2024 at 10:16 AM with LVN B revealed Resident #2's equipment looked like it needed cleaning from the G Tube formula drip stain, and it was the responsibility of everyone to clean the formula drips stain, CNAs, nurses, and housekeeper. She stated was going to clean it right way. Interview on 08/07/2024 at 10:18 AM with CNA I revealed Resident #2's equipment needed good cleaning and did not know whose responsibility it was to do it. She stated she mentioned it to the housekeeper few days ago, but the housekeeper replied that it was the nurses' responsibility to clean residents' equipment. Telephone Interview on 08/07/2024 at 11:13 am over the phone with Resident #2's family member revealed she saw ants in the resident room on 07/21/24. Interview revealed she asked a facility staff member to clean the dirty floor and clean up the G-Tube formula drip stains on the floor. The family member stated the facility did not do anything on 07/21/24. The family member stated on 07/26/24, she saw ants in the resident room. Interview revealed she asked a housekeeping staff member to clean up the floor and the floor mat to remove the G Tube formula drip stains. The family member stated housekeeping did not clean the floor. The family member stated she moved the resident bed , kneeled to clean up the floor and floor mat on 07/26/24. Interview with the family member revealed she visited the resident on the day of the incident, 07/30/24 for about 30 minutes. She stated she did not uncover the resident to look at the resident. The family member stated she saw G Tube feeding formula drip stains on the floor and feeding tube equipment each time she visited the resident. Interview revealed she did not inform the Administrator about the ants, the dirty floor and dirty resident equipment. Interview over the phone on 08/07/2024 at 1:22 pm with agency LVN M revealed she saw G Tube formula drip stains on the floor and G Tube equipment. She stated it was not her responsibility to clean the floor and equipment. Interview revealed she did not know whose responsibility it was to clean the floor and resident equipment. Agency LVN M stated at around 6:00PM on 07/30/24, she went to Resident #2's room to administer scheduled medications to Resident #2. Interview revealed she noted ants crawling on the right side of Resident #2's face. She uncovered the resident and there were ants crawling on Resident #2's right arm and right leg. Agency LVN M stated she saw ant bites around Resident #2's neck and arm. Agency LVN M stated she saw black big ants and black small ants crawling on the resident and ants crawling in the linens. She stated she removed the top linens off the resident. Agency LVN M stated she used her hands to remove the ants that were crawling on the resident. Agency LVN M stated she called CNA H to help her. Interview on 08/08/2024 at 2:45 PM with the Administrator revealed the G-tube feeding formula spill spots on the resident's linen, floor, and the pump pole was a food source for ant and gnats, and the facility reeducated the staff to clean the area and keep G tube feeding residents' rooms free of any G tube feeding formula dripping spots. An interview with LVN B on 08/09/24 at 01:20 p.m., revealed, she stated on 07/31/2024 at 08:00 am she noticed Resident #2 grimacing and grinding her teeth. She said she assessed her pain, called Resident #2's primary doctor and got orders for Benadryl 25 mg via G-Tube feeding to ease the skin irritation related to ant bites, apply Kenalog to the affected area three times a day, and continuous with pain medication order Acetaminophen with codeine one tablet via G tube feeding every four hours as needed for pain. An interview with Resident #2's primary doctor on 08/09/24 at 01:35 PM, revealed, he stated he was notified of Resident #2's ant bites incident on July 30, 2024, and ordered Kenalog cream to apply to the affected area three times a day to ease the skin irritation from the ant bites. He stated the Nurse Practitioner assessed Resident #2 the next day after the incident (07/31/2024) of ant bites. He stated he saw Resident #2 on 08/01/24 and noted small red ant bites on Resident #2's right shoulder, right arm, and elbow. 2.Review of Resident #39's undated face sheet reflected a [AGE] year-old female with and admitted [DATE] and a re-admitted [DATE]. Diagnoses included dehydration, dysphagia (difficulty swallowing), cerebral vascular accident (stroke), contractures, and unspecified severe protein-calorie malnutrition. Review of Resident #39's quarterly MDS assessment, dated 04/26/24, reflected Resident #39 had BIMS score of 0 which indicated she was severely cognitively impaired. She was totally depended on all ADLs and always incontinent of bowel and bladder and she received 51% or more of total calories through a feeding tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Record review of Resident #39's care plan with a revision date of 07/01/24 reflected, .[Resident #39] require PEG feeding . Observation and interview on 08/07/24 at 11:32 AM revealed three ants were in Resident #39's window blinds and 1 brown/black ant on window seal crawling. Resident #39 was connected to g-tube feeding while lying in her bed next to window where brown/ black ants were located. LVN A was notified by surveyor about the brown/black ants in Resident #39's room. LVN A moved Resident #39's bed away from the window. Resident #39's g-tube pole had drops of feeding on the middle of pole and along the bottom of the pole and stand along with 4 to 5 drops of feeding to the right of the g-tube pole on the floor next to resident's bed. Interview with LVN A revealed the g-tube feeding pole did have drops of feeding on the g-tube pole and it needed to cleaned along with the floor. LVN A stated she would move Resident #39 to another room due to ants in the resident window. Observation on 08/08/24 at 10:43 AM revealed Resident #39 was in the new room. She was lying in bed and her g-tube pole had drops of feeding on the pole and on the bottom of the g-tube pole. 3) Review of Resident #28's face sheet undated reflected Resident #28 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Bipolar disorder, Dysphagia (Swallowing disorder), Cognitive Communication deficit, Chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), Respiratory Failure, Schizoaffective disorder (mental health condition combining symptoms of schizophrenia and mood disorders), diabetes and heart failure. Review of Resident #28's Quarterly MDS assessment dated [DATE] reflected Resident #28 had a BIMS score of 12 indicating he was moderately cognitively impaired. Observation and interview on 08/06/24 at 9:26 AM revealed Resident # 28 was in his room lying across his bed dressed. Resident #28 was surrounded by clutter. There were numerous gnats noted swarming around his chest of drawers and bedside table. There was a dirty sheet wadded up on the floor with brown substance. Resident #28 stated he had spilt some of his coffee on the floor. Resident #28's room smelled of urine. There was a milk crate with dirty clothes. Interview on 08/06/24 at 9:32AM with Contract Housekeeping Supervisor S revealed housekeeping had Resident # 28's room on their high priority cleaning schedule. She stated he hoarded a lot of paper and other stuff. She stated they clean the Resident #28's room twice a day and deep cleaned it once a week. She stated she knew there were gnats in his room. Observation on 08/06/24 at 10:52 AM of Resident #28's room revealed there was a strong smell of urine and a swarm of small flying insects on the resident's privacy curtain, on his bedside table, his dresser top and on his bed. There was a swarm of flying insects on soiled linens tangled and lying on the floor. There were over 25 small flying insects on Resident #28's bedside table with sticky residue and crumbs of food and debris. Observation of Resident #28's bathroom revealed his toilet had a yellow liquid that smelled strongly of urine. Interview on 08/06/24 at 10:54 AM with LVN A revealed she was aware of the state of Resident #28's room and that he commonly clogged the toilet and hoarded food and trash in his room. Observation on 08/08/24 at 9:17 AM in Resident #28's room revealed there was soiled linen wrapped and lying on the floor with 5 small flying insects on top. There were large crumbs of food on his bed spread with two flies on top. Observation on 08/09/24 at 2:22 PM of Resident #28's room revealed he was still in the same room and there was a sticky residue on the bedside table with 18 small flying insects on the bedside table. Observation on 08/11/24 at 2:25 PM of Resident #28's room revealed he had been moved to a different room. Resident #28 was not in his room, and it had a bed that was placed away from the wall and window with a privacy curtain, night stand, bedside table with mini soda's, instant coffee and a loveseat on the wall next to the entry door. Observation of the floor under Resident #28's loveseat revealed food crumbs and paper trash. Interview on 08/11/2024 at 2:30 PM with CNA X, revealed it was her first day at the facility and she worked for a staffing agency. She stated she had been in-serviced on pests and cleaning of resident rooms and knew there was a binder they put any pest sightings or housekeeping concerns in. She stated that she observed what looked to be food residue on Resident #28's bed spread, a live fly on the bed spread, and that it did not look like the floor under the loveseat had been swept,- there were food crumbs and small paper trash. She stated she had not looked at the windowsills of the resident's room yet and planned to at the end of her shift. 4. Review of Resident #25's face sheet dated 08/08/24 reflected Resident #25 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Diabetes, Chronic Obstructive Pulmonary Disease (lung disease causing restricted airflow and breathing problems), Dysphagia (Swallowing disorder), Hemiplegia (Paralysis) on left side, End Stage Renal Disease, Seizure Disorder, Heart Failure and Legal Blindness. Review of Resident #25's quarterly MDS assessment dated [DATE] reflected Resident #25 had a BIMS score of 15 indicating he was cognitively intact. It reflected Resident #25 required substantial/maximal assistance with toileting. Review of Resident #25's Comprehensive Care Plan last updated 06/24/24 reflected Resident #25 was at risk for falling R/T (related to) impaired mobility and impaired vision. Has left bka (below knee amputation) with prothetic. Intervention included Assure the floor is free of glare, liquids, foreign objects. Observation and interview on 08/06/24 at 12:01 PM revealed Resident #25's room had a yellowish stain on the floor from the closet and inside closet there was wetness on closet floor with Resident #25's clothing on floor. There was a strong odor in the resident room and 2 flies on bedside table and landed on his bed while Resident #25 was sitting in the middle of the bed. There was bubbling paint on the wall between window and the closet. There was bubbling paint on walls between closet and bathroom door for Resident #25. Resident #25's bed was next to window and window seal had particles and small dead black bugs on the window sill Resident #25 revealed he was blind and could not see if there were any ants in his room. He stated he had flies and gnats in his room and knew they were there because the flies landed on him and his face. He stated he knew there had been a leak recently in his room from the closet but did not know what they had done. Observation on 08/06/24 at 12:04 PM of Resident #25's bathroom revealed sink was dripping into a plastic cup with spoon in it and his toilet had yellowish/brownish stains in the toilet with floor having yellowish/brownish stains around the toilet on the floor. Resident #25's bathroom floor was sticky with stains and wetness covering the floor. Observation on 08/08/24 at 9:40 AM revealed Resident #25's room had food debris noted on the floor, empty cracker wrapper on the floor and empty medication cup on the floor. 5. Review of Resident #17's face sheet undated reflected Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Emphysema (a lung condition that causes shortness of breath), Psychotic disorder, Neuropathy (nerve damage that causes weakness, numbness and pain, usually in your hands and feet), Stroke, Hemiplegia (Paralysis on right side), heart failure and schizoaffective disorder. Review of Resident #17's quarterly MDS assessment dated [DATE] reflected Resident #17 had a BIMS score of 13 indicating he was cognitively intact. Resident #17 required supervision with ADLs. Resident #17 was continent with bowel and bladder. Observation on 08/06/24 at 11:54 AM revealed Resident #17's window was cracked open with windowsill next to his bed full of debris, dead black bugs, and crumbs. His bathroom had blackish stains on floor near toilet and around the toilet bowl. The wall in the bathroom had bubbling paint and was wet. Bathroom cabinet door was sitting on floor leaned against the wall below the toilet roll. Bathroom cabinet had no door with toilet seat lid sitting under the bathroom sink with yellowish/brownish stains along with black particles and bugs covering the toilet seat lid. Observation on 08/06/24 at 11:53 AM revealed Resident #13 shared a room with Resident #17 and was lying in his bed. Interview on 08/06/24 at 2:20 PM with Resident #17 revealed housekeeping did not clean his room including his bathroom on the weekends at all. He stated he had flies and gnats in his room. Interview on 08/07/24 at 2:31 PM with Contract Housekeeping Supervisor S revealed, Resident #28 stored and hoarded alot of stuff in his room and spilt drinks in his room. She stated Resident #17's bathroom had spills due to Resident #17 urinated on floor. She stated both Resident #17 and #28's rooms were required to be cleaned twice daily including bathrooms. She stated these rooms were to be cleaned first and then come back later in the day to follow up to look for spills, debris and clean. She stated Resident #17's bathroom floor was black and stained. She stated she spoke to Maintenance Director about a month ago about Resident #17's toilet seat lid needing to be replaced and bathroom cabinet door was off needing to be replaced. She stated she did not clean the toilet lid since it was off needing to be replaced by Maintenance. She stated she noticed the yellowish stain on Resident #25's bedroom floor near the closet about 2 weeks ago and it required more deeper cleaning. She stated they would have to have resident move out of room in order to clean up the floor of Resident #25. She stated the toilet stains required stronger cleaning supplies to get rid of stained inside toilet. She stated Resident #28's room had flies and gnats in his room since he hoarded food and other items in his room. She stated she had noticed the flies in Resident #17's room. She stated she would have to bring the mop and bucket to clean the secure unit common area and dining room floors in the secure units. She stated she had not cleaned the common areas of the secure unit yet. 6. Observation on 08/06/2024 at 11:25 AM of the outside of the secure unit (hall 200) and hall 100 revealed there was a flattened cardboard box approximately 2 feet wide by 4 feet long with one corner touching the foundation wall underneath the window of the secured unit's living room windows with improperly stored unused electrical equipment. Observation revealed a trail of ants crawled along the length of the foundation of Hall 100 to the secured unit foundation and up and along the window frame of the secured unit living room windows which were cracked open up to a half of an inch wide and a trail of ants crawled into inside of the window frame into the secure unit common area. Observation of a crepe [NAME] tree approximately 6 feet from the secure unit and Hall 100 revealed numerous ants of different types crawled around the perimeter of the tree and crawled up the trunk of the tree. Observation on 08/06/24 at 11:36 AM revealed the first window in the common area of the secure unit had ants coming in through one window. Ants were noted on inside of the window of secure unit common area and on the bottom of window and top of window near latch. Six residents were sitting in the common area. There was a brownish stain below this window in the common area. Observation on 08/06/24 at 11:40 AM of the Maintenance Director revealed he picked up the unused electrical equipment and there were hundreds of ants that crawled all over on the flattened cardboard box. He picked up the flattened cardboard box turning it on the side and shook off the ants and walked away with the flattened cardboard box. Interview on 08/06/2024 at 11:41 AM with the Maintenance Director revealed he stated the ants were sugar ants, they did not bite and were nothing to worry about. He stated they were not able to prevent ants or them coming into the building. The Maintenance Director stated Pest Control Company N came to the facility regularly and had already come out to spray for the ants. Observation and interview with the Maintenance Director in the secure unit living room revealed there were ants entering through the cracks in the window frame and the Maintenance Director stated he did not need to look because he was going to spray them and would see them when he sprayed. Observation of the main dining room on 08/06/2024 at 1:55 PM revealed all the dining room tables had various amounts of food crumbs, smears, and drink residue on their surfaces and there were 2 flies in the dining room. In confidential group interview on 08/06/2024 at 2:00 PM with 9 residents revealed their biggest concern regarded housekeeping which they had brought up in previous meetings with the Activity Director. Another resident stated that the gnats and flies were another concern and that the gnats really bothered her when they fly around her face or landed on her. Resident in the group stated that the flies bothered her a lot and that housekeeping had not wiped down the dining room tables after lunch, which was about 2 hours ago, and there was still food residue and crumbs and sticky drink residue on the tables. All of the residents stated there were numerous flies and gnats throughout the facility, in the common areas, and sometimes in their rooms but they had not observed ants. One resident stated that it seemed like the cleaning wasn't done on the weekend at all. Another resident agreed with the resident and stated that he observed a housekeeper clean his toilet with a rag and then wipe down his sink with the same rag. A resident stated the housekeeper did not understand English when he tried to tell her that it was unsanitary, and he complained to staff. Resident stated that he had someone help him make a sign in Spanish which told the housekeeper not to use the same rag used on the toilet in the sink and a staff member came and showed the housekeeper how to clean his bathroom properly but the door was closed and he did not see what they showed her-so he kept the sign up to be on the safe side. All residents in the confidential group meeting stated they felt that the lack of housekeeping quality and frequency bothered them greatly because it felt gross when things were dirty. Interview on 08/07/24 at 8:25 AM with Maintenance Director revealed he would attempt to contact the main number to get hold of Pest Control Service Tech P for surveyor. He stated Pest Control Company N was not scheduled to come out to the facility. Interview on 08/07/24 at 10:13 AM with Pest control Service Tech P revealed on 07/31/24 when he came to the facility Resident #28's room had stickiness and spilled soda on the floors. He did not see any ants in rooms but it was reported to him that ants had been seen in the room. He stated the risk to the residents for pests was the ants can bite if threatened. He stated the fire ants bite. He stated any type of ants can bite if threatened. He stated he was not made aware of ants being found in the facility yesterday (08/06/24). He stated he came out for his monthly visit on 08/03/24 and treated the kitchen drain for gnats. He stated the facility needed to treat the source of the gnats/flies to address the pests. He stated the gnats and flies have been an ongoing issue and he tried to knock it down. He stated the facility was not on a program for small flies. He stated the ongoing issues with lack of sanitation and cleanliness make it difficult to address the pests especially when going into resident rooms that had pest activity revealing food debris, food stickiness and drink spills. He stated he was aware of Resident #28's room having ants and gnat activity. He stated the ants were attracted to food and water sources. He was not aware of any ants in resident room currently and the facility had not notified him of ants coming inside. He treated on 07/31/24 and 08/03/24 but did not see any ants at this time. Interview on 08/07/24 at 4:35 PM with Pest Control Company O Service Tech revealed he did rounds with the Executive Director on 08/07/24. He stated in Resident #44's room he found about 6 fire ants near the window. He stated he treated Resident #44's window with sealant for the cracks inside and outside of resident rooms where he found trails of ants on the foundation. He stated he spot treated resident rooms and treated the outside of the facility for ants. He stated ants can bite. He stated he did not treat for gnats today. He stated he did not find ant activity in Resident #39's room. Record review of the grievance summaries revealed an undated document titled June Grievances that stated rooms were not being cleaned on the weekends and were not being cleaned thoroughly under beds and behind furniture. Grievance Summary revealed an incident dated 07/23/2024 and reported date 08/06/2024 revealed resident council had a grievance of rooms not cleaned on the weekends with no other details under the sections for resolved date, resolved note, summary of investigation, summary of findings, or summary of action taken. Record review of the resident council meeting notes dated 06/28/2024 revealed an issue of weekend housekeeping slacking. 7. Review of Resident #14's face sheet undated reflected Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Cerebral palsy, protein-calorie malnutrition, Heart failure, and Dysphagia. Review of Resident #14's quarterly MDS assessment dated [DATE] reflected Resident #14's cognition was severely impaired and had a feeding tube. Resident #14 was dependent for all ADLs. Review of Resident #14's Comprehensive Care Plan with problem start date of 03/09/24 and revised on 08/09/24 reflected Resident #14 requires feeding tube R/T (related to) recurrent aspiration pneumonia. Observation on 08/08/24 at 10:45 AM revealed Resident #14's g-tube pole had drops of feeding and stained on bottom of g-tube pole while Resident #14 was connected via g-tube. Interview on 08/08/24 at 10:48 AM with the ADON revealed Resident #39 and #14's g-tube poles and floor should be free of spills from the feeding. She stated both residents were total dependent. She stated she expected nursing to clean the g-tube poles and floor when feeding spilled on it. She stated the g-tube poles not being cleaned placed residents at risk of attracting pests. She stated housekeeping should be cleaning the floor daily to ensure g-tube feeding not on floor. 8. Review of Resident #47's quarterly MDS assessment dated [DATE] reflected Resident #47 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of heart failure, hypertension, Kidney Failure and Parkinson's Disease, Resident #47 had a BIMS score of 12 indicating she was moderately cognitively impaired. Resident #47 required partial/moderate assistance with most ADLs. Review of Resident #48's quarterly MDS assessment dated [DATE] reflected Resident #48 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertension, diabetes and seizure disorder. Resident #48 had a BIMS score of 13 indicating she was cognitively intact. Resident #48 required supervision with ADLs. Interview with Resident #47 and Resident #48 on 08/06/24 at 2:20 PM revealed Resident #47 stated that she and Resident #48 were roommates, and their sink was clogged for at least a month, and they were not able to use the sink. Resident #4 [TRUNCATED]

47690 Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests for 16 of 26 residents (Resident #2, Resident #13, Resident #17, Resident #25, Resident #28, Resident #39, Resident#44 and 9 Confidential Group Residents) reviewed for pest control, in that: 1. The facility failed to ensure an effective pest control program was in place to keep ants out of resident rooms, resulting in 102 ant bites on Resident #2's upper middle chest, over the right breast, right side of the neck, right shoulder, right arm, and right elbow. 2. The facility failed to maintain an effective pest control to address the outside of hall 100 and hall 200 for ant activity. The facility failed to ensure resident secure unit common area windows were free of ants on 08/06/24 and 08/07/24. 3. The facility failed to ensure Resident #13 and #17's room was free of pests and failed to ensure their window was closed. 4. The facility failed to ensure Resident #28 room was free of gnats, flies, and ants. 5. The facility failed to ensure Resident #39's room was free of ants. 6. The facility failed to ensure Resident #25's room was free from flies and gnats. 7. The facility failed to ensure kitchen and dining room was free of flies and gnats. 8. The facility failed to ensure Resident #44's room was free of gnats and ants. On 08/08/2024 at 4:11 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/12/2024 at 4:20 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal (POR). These failures placed residents at risk for injury related to ant bites, and infection from pests. The findings included: 1. Review of Resident #2's face sheet, dated 08/07/24, revealed she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Hypertension (high blood pressure), diabetes mellitus, Acute and chronic respiratory failure with hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), Quadriplegia (paralysis of all four limbs), Cognitive communication deficit, aphasia (a language disorder that affects a person's ability to communicate.) following cerebral infarction (type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain), chronic pain, and adult failure to thrive (a syndrome that describes a decline in older adults that can be caused by many factors.) Review of Resident #2's MDS quarterly assessment, dated 04/28/24 revealed Resident#2's BIMS score of 00 indicating severe cognitive impairment. Review of Resident #2's care plan, dated 03/29/23, and updated 08/08/24, reflected the following Problems: Resident #2 has scattered insect bites (ant bites) on her right neck, right shoulder, right arm, and right breast. Goal: Resident #2 insect bites will heal without complications over the next 90 days. Approach: Monitor for s/s of infection and report findings to MD. Treatment as ordered. Record review of Resident #2's weekly skin assessment, dated 07/29/2024, revealed Resident #2's skin was intact. Record review of Resident #2's skin assessment, dated 07/30/2024, revealed Resident #2 had redness, bites/welts on the right shoulder, and right arm. Record review of Resident #2's physician order dated 07/30/2024 revealed Resident #2 had an order for, Kenalog cream apply to right of neck and right forearm three time a day till healed. Record review of Resident #2's nursing progress note, dated 07/30/2024 at 06:00 p.m., revealed a note reflecting Resident #2 . Approximately 06:00 pm walked into resident's room to administer medication via G tube (gastrostomy tube is a tube that is surgically inserted through the abdominal wall and into the stomach to provide an alternative way to deliver nutrition, fluids, and medications directly to the stomach) and noted ants on resident R arm/elbow, and right side of her face. Removed ants as quickly as possible, assessing resident and noted resident to have reddened welts to R elbow, and bend of AC (Antecubital - the area on the front side of the upper part between the arm and forearm) and to the right side of her neck. Notified Doctor (Resident primary doctor) new order received to apply Kenalog three time a day. Resident moved to another bed in another room. Notified DON. Notified resident representative . Vital signs: Blood pressure: 118/75, Heart rate, Temperature: 98.2 F, Respiratory rate: 20. Record review of Resident #2's nursing progress note dated 07/31/2024 at 01:00 am., revealed a note stating Resident #2 currently in bed resting no signs and symptoms of pain or discomfort noticed, small bites to right inner elbow, no edema (swelling caused by too much fluid trapped in the body's tissues) noted to the areas. Record review of Resident #2's nursing progress note, dated 08/01/2024 at 09:00 a.m., revealed a note reflecting Resident #2 . new order Benadryl 25 mg via peg tube bid for 7 days . Record review of Resident #2's nursing progress note, dated 08/7/2024 at 10:00 a.m., revealed a note reflecting Resident #2 . day 7/7 Benadryl r/t insect bites Record review of Resident #2's Doctor orders revealed Resident #2 had an order dated 06/01/2024 for Tylenol-Codeine #3 (Acetaminophen with codeine, pain medication) one tablet every four hours as needed for pain via G-tube feeding. Record review of Resident #2's MAR revealed Resident #2 received Tylenol-Codeine #3 (prescription drug used to relieve mild to moderately severe pain that is not well-controlled with over-the-counter medication) one tablet on 07/31/24 at 08:00 a.m., 08/01/24 at 08:00 a.m., and 08/02/2024 at 08:00 a.m. via G-tube feeding, with the note of pain level 6/10, and pain reassessment after medication revealed effectiveness. Observation of Resident #2's assigned room at the facility, on 08/06/2024 at 09:13 AM, revealed Resident #2's bed was located next to the window. Resident #2 was up in the wheelchair, cleaned, groomed, wearing appropriate attire, and connected to G-tube feeding. Ant bites were visible on Resident #2's right side of her neck, and right arm around the anti-cubital fossa (front of the elbow). There were G tube feeding formula spots on the floor, and on the G tube pump pole, and electric wire. No ants were observed in the room. Resident#2 was unable to participate in interview related to severe cognitive impairment. Observation and Interview with the ADON on 08/06/24 at 4:13 PM revealed skin assessment with ADON on Resident #2. Resident had multiple healing ant bites on her right arm, upper chest, neck and face. ADON stated when she came in that night (07/30/24) after the incident it broke her heart to think of Resident #2 lying there, not being able to speak, not being able to call out for help. She stated the ants were crawling on the resident and crawling in the bed linens. She stated the ants were everywhere. Interview on 08/07/24 at 09:51 AM with CNA I revealed she was assigned to care for Resident # 2 on the day of the incident (07/30/2024). CNA I stated during her last rounds on 07/30/24 around 1:00pm, Resident #2 was incontinent of bowel and bladder. CNA I stated she cleaned Resident #2. CNA I stated she did not see ants in Resident # 2's room and/or the Hall 300 hallway on 07/30/24. She stated she could not see if there were ants in the window because the resident's family member covered the window with a blanket. Interview on 08/07/2024 at 10:03 am of LVN B revealed at around 12:45 PM on 07/30/24, she administered routine medication via the G Tube to Resident #2. Interview revealed she pulled the linens away from the resident to administer the G-Tube medication. LVN B stated she did not notice anything on the resident. Observation on 08/07/2024 at 10:07 am of Resident #2's Skin assessment by LVN B with the help of CNA I revealed : 8 ant bites at the middle chest by the neck; 9 ant bites over the right breast; 15 ant bites on the right side of resident neck; 25 ant bites on the right shoulder; 30 ant bites in top of the right arm in front of the elbow; 15 ant bites on the resident's right elbow. Observation and interview revealed Resident # 2 sustained a total of 102 ant bites. Observation on 08/07/2024 at 10:07 am revealed Resident #2's G tube feeding formula drip spots on the floor, and on the G tube pump support, pole, and power cord. Interview on 08/07/2024 at 10:16 am of LVN B revealed Resident #2's equipment looked like it needed cleaning from the G Tube formula drip stains. LVN B said it was the responsibility of everyone to clean the formula drip stains, including CNAs, Nurses, and Housekeepers. She stated was going to clean it right way. Interview on 08/07/2024 at 10:18 am of CNA I stated Resident #2's equipment needed a good cleaning from the G tube formula drip stains. Interview revealed she did not know whose responsibility it was to clean the G tube formula drip stains on residents' equipment. She stated she mentioned it to the housekeeper a few days ago, but the housekeeper replied that it was the nurses' responsibility to clean residents' equipment. Interview on 08/07/2024 at 11:13 am over the phone with Resident #2's family member revealed she saw ants in the resident room on 07/21/24. Interview revealed she asked a facility staff member to clean the dirty floor and clean up the G-Tube formula drip stains on the floor. The family member stated the facility did not do anything on 07/21/24. The family member stated on 07/26/24, she saw ants in the resident room. Interview revealed she asked a housekeeping staff member to clean up the floor and the floor mat to remove the G Tube formula drip stains. The family member stated housekeeping did not clean the floor. The family member stated she moved the resident bed , kneeled to clean up the floor and floor mat on 07/26/24. Interview with the family member revealed she visited the resident on the day of the incident, 07/30/24 for about 30 minutes. She stated she did not uncover the resident to look at the resident. The family member stated she saw G Tube feeding formula drip stains on the floor and feeding tube equipment each time she visited the resident. Interview revealed she did not inform the Administrator about the ants, the dirty floor and dirty resident equipment. Interview on 08/07/2024 at 1:14 with CNA H revealed he did not see ants on Resident #2 during his initial rounds on 07/30/24 between 2:30 PM- 3:00PM. CNA H stated at around 4:00pm, he changed Resident #2's brief and that he did not see ants on the resident at that time. CNA H stated at around 6:00PM, the nurse called him to clean the resident and to move Resident # 2 to a different room. CNA H went to the room of Resident # 2 and saw black, tiny ants crawling on Resident # 2. He cleaned the ants off the resident and then moved the resident to a different room. Interview over the phone on 08/07/2024 at 1:22 pm with agency LVN M revealed she saw G Tube formula drip stains on the floor and G Tube equipment. She stated it was not her responsibility to clean the floor and equipment. Interview revealed she did not know whose responsibility it was to clean the floor and resident equipment. Agency LVN M stated at around 6:00PM on 07/30/24, she went to Resident #2's room to administer scheduled medications to Resident #2. Interview revealed she noted ants crawling on the right side of Resident #2's face. She uncovered the resident and there were ants crawling on Resident #2's right arm and right leg. Agency LVN M stated she saw ant bites around Resident #2's neck and arm. Agency LVN M stated she saw black big ants and black small ants crawling on the resident and ants crawling in the linens. She stated she removed the top linens off the resident. Agency LVN M stated she used her hands to remove the ants that were crawling on the resident. Agency LVN M stated she called CNA H to help her. Interview on 08/08/2024 at 08:16 am with contracted Housekeeper II via phone interpreter line with Spanish speaking interpreter revealed she did not see ants in the facility or resident rooms. She denied Resident #2's family member showing her the ants and the request to clean the resident room. Housekeeper II stated another housekeeper told her that in the past, she saw ants in the 200 and 300 Halls. Attempted interview on 08/08/2024 at 08:28 am with contracted Housekeeper HH via phone interpreter line with a Spanish speaking interpreter. There was no answer and a voicemail with instruction to call back was left. No call back received from Housekeeper HH by the date and time of exit. Interview on 08/08/2024 at 10:40 am with contracted Housekeeper Supervisor S stated she had never been notified by housekeeping staff or the other facility staff about ants in the building. She denied been notified of residents' rooms needing to be cleaned. She stated she was made aware of ants in the building on the day of the reported incident (07/30/2024). Interview on 08/08/2024 at 10:44 am with contracted Housekeeper JJ revealed she saw some ants in the last room by the emergency exit door in the Hall #100. She stated maybe there were ants because the resident in that room urinated on the floor sometimes. She stated she did not report it to Contract Housekeeping Supervisor S. Interview on 08/08/2024 at 2:45 pm with the Administrator revealed she did not personally see ants in the facility. The Administrator stated in April 2024, she and the Maintenance Director were notified about ants in the building. Interview revealed the facility called pest control and that pest control came in and treated the building. She stated after that the Maintenance Director would do spot treatments in the facility for pests if anybody reported ants to her. The Administrator stated no resident's family member asked for room cleaning or notified her of ants in the facility. Interview with the Administrator revealed Resident #2's bed was next to the window per the resident's family request. She stated that when she was notified of Resident #2's ant bites incident on 07/30/24, the facility conducted an incident internal investigation. The Administrator stated the investigation process included moving Resident #2 and her roommate to a clean room; notifying Resident #2's family, and primary doctor; and conducting a full skin sweep for all residents in Hall 300. She stated facility staff were in serviced on pest control. She stated the facility staff were instructed to make sure if they noticed ants or insects in the building to inform the management team; and make sure if there was food in the residents' rooms to seal it in a closed container. She stated the G-tube feeding formula spill spots on the resident's linen, floor, and the pump pole was a food source for ants and gnats, and the facility reeducated the staff to clean the area and keep the rooms of residents who had G tube feedings free of any G tube feeding formula dripping spots. Interview on 08/08/2024 at 03:09 pm with the DON revealed she denied seeing ants in the building or being notified by the staff, or residents' family member of the existence of ants. She stated the day of the incident (07/30/2024) Resident #2 was cleaned and removed with her roommate to a clean room. She stated skin, and pain assessments were done for the resident. She stated Resident #2's primary doctor was notified and ordered Kenalog cream to apply to the affected area to ease the skin irritation from ant bites, and continuous with the chronic pain medication order if any signs and symptom of pain and discomfort were noticed on Resident #2. She stated G Tube feeding formula drip spots on the resident's room floor could attract ants, and gnats. She stated she expected nurses, CNAs, and housekeepers to keep residents' rooms clean, and free of any kind of food that could attract ants and gnats. An interview with LVN B on 08/09/24 at 01:20 p.m., revealed, she stated on 07/31/2024 at 08:00 am she noticed Resident #2 grimacing and grinding her teeth. She said she assessed her pain, called Resident #2's primary doctor and got orders for Benadryl 25 mg via G-Tube feeding to ease the skin irritation related to ant bites, apply Kenalog to the affected area three times a day, and continuous with pain medication order Acetaminophen with codeine one tablet via G tube feeding every four hours as needed for pain. An interview with Resident #2's primary doctor on 08/09/24 at 01:35 PM, revealed, he stated he was notified of Resident #2's ant bites incident on July 30, 2024, and ordered Kenalog cream to apply to the affected area three times a day to ease the skin irritation from the ant bites. He stated the Nurse Practitioner assessed Resident #2 the next day after the incident (07/31/2024) of ant bites. He stated he saw Resident #2 on 08/01/24 and noted small red ant bites on Resident #2's right shoulder, right arm, and elbow. 2. Observation on 08/06/2024 at 9:55 AM revealed the living area in the secure unit had broken window blinds on the bottom 3 blinds of the right window and the window was cracked open about half an inch with about 6 residents in the room watching television. Observation on 08/06/2024 at 11:25 AM of the outside of the secure unit (hall 200) and hall 100 revealed there was a flattened cardboard box approximately 2 feet wide by 4 feet long with one corner touching the foundation wall underneath the window of the secured unit's living room windows with improperly stored unused electrical equipment. Observation revealed a trail of ants crawled along the length of the foundation of Hall 100 to the secured unit foundation and up and along the window frame of the secured unit living room windows which were cracked open up to a half of an inch wide and a trail of ants crawled into inside of the window frame into the secure unit common area. Observation of a crepe [NAME] tree approximately 6 feet from the secure unit and Hall 100 revealed numerous ants of different types crawled around the perimeter of the tree and crawled up the trunk of the tree. Observation on 08/06/24 at 11:36 AM revealed the first window in the common area of the secure unit had ants coming in through one window. Ants were noted on inside of the window of secure unit common area and on the bottom of window and top of window near latch. Six residents were sitting in the common area. There was a brownish stain below this window in the common area. Observation on 08/06/24 at 11:40 AM of the Maintenance Director revealed he picked up the unused electrical equipment and there were hundreds of ants that crawled all over on the flattened cardboard box. He picked up the flattened cardboard box turning it on the side and shook off the ants and walked away with the flattened cardboard box. Interview on 08/06/2024 at 11:41 AM with the Maintenance Director revealed he stated the ants were sugar ants, they did not bite and were nothing to worry about. He stated they were not able to prevent ants or them coming into the building. The Maintenance Director stated Pest Control Company N came to the facility regularly and had already come out to spray for the ants. Observation and interview with the Maintenance Director in the secure unit living room revealed there were ants entering through the cracks in the window frame and the Maintenance Director stated he did not need to look because he was going to spray them and would see them when he sprayed. Interview on 08/06/24 at 11:45 AM with LVN AA revealed the brownish stain below the secure unit window may be chocolate ensure. She stated housekeeping had not cleaned it yet nor the dining room. Observation on 08/06/24 at 5:08 PM revealed a trail of small ants crawled along the length of the foundation of Hall 100 with two windows cracked open and window screen bent near bottom of the windows. Observation of a crepe [NAME] tree approximately 6 feet from the secure unit and Hall 100 revealed numerous ants of different types crawled around the perimeter of the tree and crawled up the trunk of the tree. Observation on 08/07/2024 at 9:19 AM of the foundation line of Hall 100 revealed a line of small black ants that started from the middle of the building crawled up from cracks in the ground, along the concrete foundation of and below the first line of bricks. The ants entered into cracks in the concrete foundation and cracks between bricks and crawled along the foundation line along Hall 1 and the secure unit hall foundation. Observation on 08/07/24 at 9:29 AM of the outside of the secure unit living room second window revealed one of the secure unit's living room windows was opened and there was a trail of ants that crawled up and into both sides of the window frame. Observation on 08/07/24 at 9:30 AM revealed one resident window on the secure unit had the window opened about 1/8 of an inch, and 3 windows on Hall 100 had windows that were cracked open. Observation of one of the three windows on Hall 1 included window of Resident #13 and Resident #17's from outside revealed their window was cracked open with dead bugs between the window screen and window frame. 3. Review of Resident #28's face sheet undated reflected Resident #28 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Bipolar disorder, Dysphagia (Swallowing disorder), Cognitive Communication deficit, Chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), Respiratory Failure, Schizoaffective disorder (mental health condition combining symptoms of schizophrenia and mood disorders), diabetes and heart failure. Review of Resident #28's Quarterly MDS assessment dated [DATE] reflected Resident #28 had a BIMS score of 12 indicating he was moderately cognitively impaired. Observation on 08/06/24 at 9:26 AM revealed Resident # 28 was in his room lying across his bed dressed. Resident #28 was surrounded by clutter. There were numerous gnats noted swarming around his chest of drawers and bedside table. There was a dirty sheet wadded up on the floor with brown substance. Resident #28 stated he wasted some of his coffee. Resident #28's room smelled of urine. There was a milk crate with dirty clothes. Interview on 08/06/24 at 9:32AM with Contract Housekeeping Supervisor S revealed housekeeping had Resident # 28's room on their high priority cleaning schedule and it should be cleaned twice daily. She stated he hoarded a lot of paper and other stuff. She stated they clean the room twice a day and deep clean it once a week. She stated she knew there were gnats in his room. Observation on 08/06/2024 at 10:52 AM of Resident #28's room revealed there was a strong smell of urine and a swarm of small flying insects on the resident's privacy curtain, on his bedside table, his dresser top, on his bed, and on soiled linens tangled and laid on the floor. There were over 25 small flying insects on Resident #28's bedside table with sticky residue and crumbs of food and debris. Observation of Resident #28's bathroom revealed his toilet had a yellow liquid that smelled strongly of urine. Interview on 08/06/2024 at 10:54 AM with LVN A revealed she was aware of the state of Resident #28's room and that he commonly clogged the toilet and hoarded food and trash. Observation on 08/08/2024 at 9:17 AM of Resident #28's room revealed there was soiled linen wrapped and laid on the floor with 5 small flying insects on top. There were large crumbs of food on his bed spread with two flies on top. Observation on 08/09/2024 at 2:22 PM of Resident #28's room revealed he was still in the same room and there was a sticky residue on the bedside table with 18 small flying insects on the bedside table. Observation on 08/11/2024 at 2:25 PM of Resident #28's room revealed he had been moved to a different room. Resident #28 was not in his room and it had a bed that was placed away from the wall and window with a privacy curtain, night stand, and bedside table with mini sodas, instant coffee and a loveseat on the wall next to the entry door. Observation of the floor under Resident #28's loveseat revealed food crumbs and paper trash. Interview on 08/11/2024 at 2:30 PM with CNA X, revealed she had been in-serviced on pests and cleaning of resident rooms and knew there was a binder they put any pest sightings or housekeeping concerns in. She stated that she observed what looked to be food residue on Resident #28's bed spread, a live fly on the bed spread, and that it did not look like the floor under the loveseat had been swept as there were food crumbs and small paper trash. She stated she had not looked at the windowsills of the resident's room yet and planned to at the end of her shift. 4. Review of Resident #39's undated face sheet reflected a [AGE] year-old female with an admitted [DATE] and a re-admitted [DATE]. Diagnoses included dehydration, dysphagia (difficulty swallowing), cerebral vascular accident (stroke), contractures (abnormal and permanant shortening of muscle tissue resulting in reduces movement and flexibility of a part of the body), and unspecified severe protein-calorie malnutrition. Review of Resident #39's quarterly MDS assessment, dated 04/26/24, reflected Resident #39 had BIMS score of 0 which indicated she was severely cognitively impaired. She was totally dependent on all ADLs and always incontinent of bowel and bladder and she received 51% or more of total calories through a feeding tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Record review of Resident #39's care plan with a revision date of 07/01/24 reflected, .[Resident #39] require PEG feeding . Observation on 08/07/24 at 11:20 AM revealed while observing incontinent care of Resident #39 there was an ant crawling on the windowsill. Resident #39 was lying in her bed next to the windowsill. Observation on 08/07/24 at 11:25 AM revealed three ants were in Resident #39's open window blinds and 1 ant crawling on the windowsill. Resident #39 was connected to g-tube feeding while lying in her bed next to the window where ants were located. The surveyor notified LVN A about ants in Resident #39's room. LVN A moved Resident #39's bed away from window. Observation reveled Resident #39's g-tube pole had drops of feeding on the middle of the pole and on the bottom of the pole and stand along with 4 to 5 drops of feeding to the right of the g-tube pole on the floor. Interview on 08/07/24 at 11:32 AM with LVN A revealed the g-tube feeding pole did have drops of feeding on the g-tube pole and it needed to be cleaned along with the floor. LVN A stated she would move Resident #39 to another room due to ants in the resident's window. She stated she did not see any ants on the resident's bedding. 5. Review of Resident #25's face sheet dated 08/08/24 reflected Resident #25 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Diabetes, Chronic Obstructive Pulmonary Disease, Dysphagia, Hemiplegia (Paralysis) on left side, End Stage Renal Disease, Seizure Disorder, Heart Failure and Legal Blindness. Review of Resident #25's quarterly MDS assessment dated [DATE] reflected Resident #25 had a BIMS score of 15 indicating he was cognitively intact. It reflected Resident #25 required substantial/maximal assistance with toileting. Review of Resident #25's Comprehensive Care Plan last updated 06/24/24 reflected Resident #25 was at risk for falling R/T (related to) impaired mobility and impaired vision. Has left bka (below knee amputation) with prosthetic. Intervention included Assure the floor is free of glare, liquids, foreign objects. Observation on 08/06/24 at 12:01 PM revealed Resident #25's room had a yellowish stain on the floor from the closet and inside the closet there was wetness on the closet floor with Resident #25's clothing on the floor. There was a strong odor in resident room and 2 flies on the bedside table and landing on his bed while Resident #25 was sitting in the middle of the bed. There was bubbling on the wall between the window and the closet. There was bubbling on the walls between the closet and bathroom door for Resident #25. Resident #25's bed was next to the window and the window sill had particles and dead bugs on it. Interview with Resident #25 revealed he was blind and could not see if there were any ants in his room. He stated he had flies and gnats in his room and knew they were there because the flies landed on him. Observation on 08/06/24 at 12:04 PM of Resident #28's bathroom revealed the sink was dripping into a plastic cup with a spoon in it and his toilet had yellowish/brownish stains in the toilet with the floor having yellowish/brownish stains around the toilet on the floor. Resident #28's bathroom floor was sticky with stains and wetness covering the floor. Interview on 08/07/24 at 2:31 PM with Contract Housekeeping Supervisor S revealed Resident #28 stored a lot of stuff, spilled drinks and spits on the floor. She stated Resident #28 had flies and gnats in his room. She stated Resident #17's bathroom had spills on it and Resident #17 urinated on the floor. She was aware of flies in Resident #17's room before. She stated Resident #28 had flies and gnats in his room. Interview on 08/07/24 at 3:20 PM with the Administrator revealed she was aware of the gnats in Resident #28's room but the resident hoarded and kept food in his room. She stated she was not aware of any ants coming in residents' rooms since Resident #2 had gotten bit by ants and ants were found on her and her bedding. She stated Maintenance sprayed the ants that evening on 07/30/24 and pest control came out on 07/31/24 to spray ants. She stated DON in-serviced the staff after the incident with Resident #2 having ant bites and ants found in her room on 07/30/24. She stated she had not in-serviced housekeeping about pests and cleanliness. She stated Maintenance Director was addressing the pest control. 6. Observation and Interview on 08/06/24 at 10:02 AM revealed Resident #4 had noticed the flies and the gnats in her room since it had gotten warmer especially with her food left in her room. Gnat flying around landing on her styrofoam cup. Her breakfast tray was still in her room. 2 Flies noted in resident room landing on bedside table and bedding. Observation of the main dining room on 08/06/2024 at 1:55 PM revealed all the dining room tables had various amounts of food crumbs, smears, and drink residue on their surfaces and there were 2 flies in the dining room. In confidential group interview on 08/06/2024 at 2:00 PM with 9 residents revealed their biggest concern regarded housekeeping and they had brought up the concern in previous meetings with the Activity Director. Residents stated that the gnats and flies were another concern and that the gnats really bothered them when they flew around their face or landed on them. Residents stated that the flies bothered them a lot and that housekeeping had not wiped down the dining room tables after lunch, which was about 2 hours ago, and there was still food residue and crumbs and sticky drink residue on the tables. The residents stated there were numerous flies and gnats throughout the facility, in the common areas, and sometimes in their rooms. They stated they had not observed ants. All residents in the confidential group meeting stated they felt that the lack of housekeeping quality and frequency bothered them greatly because it felt gross when things were dirty. Interview on 08/07/24 at 8:25 AM with Maintenance Director revealed he would attempt to contact the main number to get hold of Pest Control Service Tech P for surveyor. He stated Pest Contr [TRUNCATED]

Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen, in that, 1. The facility failed to ensure chest freezer was free of ice accumulation. 2. The facility failed to ensure freezer items were labeled, dated and sealed. 3. The facility failed to ensure the kitchen was free of gnats and flies. 4. The facility failed to ensure steam table was not dripping. These failures could place residents at risk for food contamination. Findings include: 1. Observation on 08/06/24 at 9:26 AM revealed inside the chest freezer, which had turkeys and frozen popsicles in it, in the kitchen had ice accumulation of at least inch on the sides and back. Interview on 08/06/24 at 9:27 AM with Dietary Manager revealed he did not open the chest freezer very often and was unaware of ice accumulation in the chest freezer. 2. Observation on 08/06/24 at 9:28 AM of 1 of 3 freezers revealed three pizza crusts in a plastic bag not labeled, dated or sealed with a scoop of ice in the bottom of the opened plastic bag. Interview on 08/06/24 at 9:29 AM with Dietary Manger revealed the pizza crusts should be labeled, dated and sealed. He stated there was ice in the bottom of the plastic bag and he was unsure when the pizza crust was put in the freezer. 3. Observation on 08/06/24 at 9:20 AM revealed 2 flies in the kitchen lying on the counter and in dry storage. There were gnats flying and landing near the garbage disposal. There were flies in the dry storage and kitchen prep area, and two flies in the kitchen prep area landed on counters. Observation on 08/07/24 at 11:55 AM during lunch meal time revealed 3 gnats near the garbage disposal where food debris was inside of the garbage disposal. There were two flies in the kitchen landing on the counter. 4. Observation on 08/07/24 at 12:10 PM during lunch revealed the steam table was in use and was dripping under the faucet with two containers under with water in both. Interview on 08/09/24 at 10:35 AM with Dietary Manager revealed he had gnats/flies in the kitchen since it had gotten warmer. He stated he would tell Maintenance Director about it but was short staffed and did not know where to document about pests. He stated he had been short a dietary staff so he was having to help out daily. He stated Pest Control Company N treated the kitchen drain yesterday (08/08/24) for gnats. He had been aware of gnats and flies in the kitchen but it was difficult to keep them out of the kitchen especially during meal time when the doors are open to assist with meals. He stated Maintenance Director was aware of pests in the kitchen. He stated the steam table had been dripping for a couple of weeks and he put the containers under for the dripping. He stated Maintenance Director had fixed some of the dripping already but was awaiting parts to fix the rest of the dripping under the steam table faucets. Interview on 08/11/24 at 11:50 AM with Dietary Manager revealed Maintenance Director has addressed the freezer issue. He stated the freezer was not sealing properly allowing in air so the ice would build up on the sides and top of the freezer. He stated he had not had an opportunity to put the dripping under the steam table in the Maintenance Log since he had been working in the kitchen. He stated the steam table dripping had not been fixed yet. Interview on 08/11/24 at 12:10 PM with Executive Director revealed he and Dietary Manager would let Interim Maintenance Director know about the steam table to look at it. He was not aware of the steam table dripping until now. Review of facility's policy Cleaning the Freezer last revised 06/20/23 reflected Freezers will be clean and free of odors .3. Discard out-of-date products or products that have become freezer burned. 4. Verify that all products are labeled and correctly sealed. Review of facility's policy Safe Food Handling last revised 06/20/23 reflected .3. All food removed from the original packaging are stored in a closed container or tightly wrapped package and labeled with the common name of the item and the date it was opened.

Based on record review and interview the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect and exploitation for 7 of the 10 employees (Activity Director, LVN AA, CNA BB, LVN DD, CNA EE, CNA FF, CNA GG) reviewed for background screenings. The facility failed to screen, through the Employee Misconduct Registry (EMR)/Nurse Aide Registry (NAR), 7 employees, which included: the Activity Director, LVN AA, CNA BB, LVN DD, CNA EE, CNA FF, CNA GG. This failure could place residents at risk of care by staff who have been reported for misconduct such as abuse, neglect, or exploitation. Findings Included: Record review of facility's Abuse, Neglect, Exploitation, or Mistreatment prohibition policy titled Leadership Policies and Procedures Section III Organizational Ethics, dated 2019, reflected: Component I: Screening 1. Pre-employment background screening is mandated for all facility employees: A. Facility state-specific Background Investigation Policy is available through the facility's regional HR consultant. B. The facility may not employ any individual that has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. C. The facility may not employ any individual that has a finding entered into the State nurse aide registry concerning abuse, neglect exploitation, mistreatment of residents or misappropriation of property. D. The facility may not employ any individual that has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents and/ or misappropriation of resident' s property. 1. Record review of the Activity Director's employee file revealed a hire date of 02/28/2023 and no record of an annual EMR/NAR check. 2. Record review of LVN AA's employee file revealed a hire date of 03/02/2001 and no record of an annual EMR/NAR check. 3. Record review of CNA BB's employee file revealed a hire date of 11/11/2014 and no record of an annual EMR/NAR check. 4. Record review of LVN DD's employee file revealed a hire date of 12/28/2022 and no record of an annual EMR check. 5. Record review of CNA EE's employee file revealed a hire date of 03/15/2023 and no record of an annual EMR/NAR check. 6. Record review of CNA FF's employee file revealed a hire date of 05/11/2023 and no record of an annual EMR/NAR check. 7. Record review of CNA GG's employee file revealed a hire date of 06/22/2024 and no record of an annual EMR/NAR check. In an interview on 08/09/2024 at 2:20 PM with Human Resources, she stated she started working at facility in July 2024 and was still in training. She did not know what an EMR or NAR was and stated that she did not know the requirements on annual checks or who was responsible to conduct the checks. She stated she thought the Administrator ran the background checks and EMR/NAR when employees were hired and thought the corporation for the facility ran monthly checks on all employee licenses and arrests. She stated that screening was important because they needed to ensure those who had arrests or license bars were identified because it impacted resident care and safety. Interview on 08/12/2024 at 3:00 PM with Human Resources revealed she was unable to find the EMR/NAR checks prior to 08/12/2024 for the Activity Director, LVN AA, CNA BB, LVN DD, CNA EE, CNA FF, CNA GG The facility completed the EMR/NAR checks on 08/12/2024 and there were no bars to employment or license restrictions. Interview on 08/12/2024 at 3:47 PM with the Interim Administrator revealed she expected EMR/NAR checks were conducted before an employee is hired and then annually. She stated that the Human Resources at the facility was responsible to ensure the checks were completed annually. She stated that it was important to run the EMR/NAR checks annually to prevent residents from being abused and screen out employees that have abuse charges or other restrictions to their license or record. Record review of the facility's bars of employment policy titled Texas Bars of Employment related to Criminal Record, dated January 2015, reflected: Important Information: Nurse Aide Registry and Employee Misconduct Registry . At the time of hire and annually thereafter, Facility must verify that all certified nurse aides are listed in the nurse aid registry. Furthermore, the Facility must at the time of hire and annually thereafter ensure that all staff are not designated in the nurse aide registry or employee misconduct registry as having a finding of abuse, neglect, mistreatment or misappropriation . Facility must conduct nurse aide and misconduct registry checks annually as described above.

Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, for 1 (Resident #1) of six residents reviewed for quality of care. The facility failed to recognize and respond when Resident #1 had a significant change in condition. LVN B noted a change in condition at 7:00 AM on [DATE]. It was not until after 1:00 PM, 911 was called and Resident #1 was sent to the hospital unresponsive. Resident #1 was not sent for approximately six hours. An Immediate Jeopardy was identified on [DATE] at 11:56 AM. While the IJ was removed on [DATE] at 3:30 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems This failure could place residents at risk for delays in treatments and care which could result in clinical complications, further injuries and/or death. Findings included: Review of Resident Face Sheet for Resident #1, undated, revealed Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Review of Care Plan Conference Summary for Resident #1 dated [DATE], revealed Resident #1 was diagnosed with diabetes mellitus (persistent high levels of sugar/glucose in the blood), [CONDITION(S)] (enlarged prostate gland), dementia (memory loss), and congestive heart failure ([CONDITION(S)] that affects the pumping action of the heart muscles). Review of the Physician Telephone Orders for Resident #1, dated [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Another order, dated [DATE] May Straight Cath for UA CNS [sic]. And another to send to ER for evaluation and treatment. The orders were not timed as to when the orders were received. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1's blood sugar was 159. Review of Progress Notes for Resident #1 dated [DATE] revealed Resident had a decrease in oxygen saturations to 88%. He was placed on 2 liters of oxygen per an order from the Medical Director. NOTE: Resident #1 did not use oxygen continuously only as needed. Review of Respiratory Flowsheet for Resident #1 dated [DATE] revealed on [DATE] on 3rd shift Resident #1's oxygen saturation was 90%. On [DATE] on 1st shift Resident #1's oxygen saturation was 91%. Both oxygen saturations were taken by LVN D. Review of Nurse's Notes for Resident #1 dated [DATE] written by LVN B, revealed at 7:00 AM LVN B went to obtain Resident #1's vital signs and administer medications. Resident #1 was noted to be sleeping and was not able to be aroused. Resident #1 did not eat his breakfast and was still sleeping. LVN B documented notes change in condition. LVN B noted she called the physician regarding the change in condition. The physician ordered a STAT chest x-ray and stat labs. LVN B notified the DON of the change in condition and notified the family member of Resident #1. Further documentation indicated LVN B received confirmation of STAT Labs and received an order to straight cath [catheter-thin tube used to get urine to pass from the body] Resident #1 in order obtain urine for his labs. LVN B noted Resident #1's urine to be very dark red in color. LVN B later documented, untimed, Resident nonresponsive, family member wants to have him sent to ER .r/o [rule out] [CONDITION(S)]. Nurse called 911 to transport Review of SBAR Communication Form for Resident #1, dated [DATE], at 9:00 AM, revealed Resident #1 was noted to be unresponsive, decreased consciousness, labored breathing on oxygen at 3 Liters per minute, had a distended abdomen, decreased urine output and LVN B noted UA collected very dark red, may have [CONDITION(S)], [CONDITION(S)], pneumonia LVN B documented Resident #1's oxygen saturations were at 88% so he was placed on oxygen at 3 Liters per minute and increased his oxygen to 94%. Resident was nonresponsive sleeping and unable to wake up. Resident #1 was noted to be breathing, with vitals stable, oxygen saturations stable, and blood sugar stable at 9:00 AM. Review of X-ray Portal revealed on [DATE] at 11:33 AM an order was called in for a STAT x-ray on Resident #1. Review of Lab Portal revealed on [DATE] at 11:53 AM an order was called in for CBC, CMP, and UA C&S on Resident #1. The order was cancelled at 3:37 PM. Interview with the Family Member on [DATE] at 1:17 PM revealed, a nurse called her from the facility on [DATE] and she arrived approximately 1 hour after being notified and was told Resident #1 was unresponsive. The Family Member explained she was an RN as well. The Family Member stated she observed Resident #1 to be unresponsive, even to touch, painful touch (pinch or prick to the skin), and sternal rub (technique performed by rubbing the knuckles of a closed fist firmly and vigorously on the patient's stimuli, known as apply painful stimuli). The Family Member stated he had [CONDITION(S)] [swelling] to his hands and legs. The Family Member stated she was concerned he was septic, so she requested he be sent to the ER immediately. The Family Member stated Resident #1 was found to be septic and have an infected gallbladder. The Family Member stated she felt he should have been sent to the hospital immediately upon the nurse noting Resident #1 was unresponsive. The Family Member stated she had not been called about any other changes of conditions in the days prior. Resident #1 reportedly expired on [DATE] in the hospital. Review of the Accushield Log [sign in system] dated [DATE] revealed Resident #1's Family Member signed into the facility at 1:07 PM. Review of Post-Run/Call Report [911 Report] for Resident #1 dated [DATE] revealed LVN B placed the called to 911 at 1:17 PM. Review of Hospital emergency room Notes for Resident #1 dated [DATE] revealed Resident #1 presented with altered mental status and decreased responsiveness. Apparently the patient is hypoxic and so he is currently on a nonrebreather. Resident #1 was noted to have acute renal failure, altered mental status and acute pyelonephritis. Review of Hospital History and Physical for Resident #1 dated [DATE] revealed Resident #1 was sent to the hospital due to complaints of unresponsiveness. Resident #1 was diagnosed with acute hypoxic respiratory failure with hypercapnia secondary to sever [CONDITION(S)] pneumonia and a [CONDITION(S)]. Review of the Death Certificate for Resident #1 dated [DATE] revealed Resident #1 died of [CONDITION(S)], acute [CONDITION(S)], acute respiratory failure, and [CONDITION(S)]. Interview with LVN B on [DATE] at 11:08 AM revealed, she came to work on the morning of [DATE], did not receive report from the off-going nurse. LVN B noted the Resident #1 was usually sleeping in a recliner per his and his family's choice, but he was in the bed this morning. LVN B described Resident #1 as someone who was usually awake, smiling, and talkative in the morning but stated he was asleep that morning. LVN B stated she took his blood sugar, which was normal but did not think he was acting normal. LVN B stated she asked some of the staff about him having a change in condition and thought he might have been awake most of the night. LVN B notified the DON but did not know the specific time LVN B stated Resident #1 did not eat breakfast, which was not normal for Resident #1. LVN B stated she called the Medical Director and Resident #1's family member but did not remember exactly when. The Medical Director ordered a chest x-ray, labs, and a urinalysis. LVN B stated his vital signs were perfect but put him on oxygen because his oxygen saturation was low. LVN B stated she attempted to arouse Resident #1 but calling his name, touching his arm and attempted a sternal rub. LVN B stated she collected Resident #1's urine, called in the labs but they did not come before he left for the hospital. When Resident #1's family member showed up she wanted him sent out to the hospital. LVN B stated Resident #1's urine was really bad and thought he had a [CONDITION(S)]. She stated the urine was dark, thick, and purulent. LVN B explained Resident #1's family member called the facility after he went to the hospital and reported he was septic. LVN B expressed she was frustrated with the condition she found Resident #1 in. She stated his condition was not his normal state. LVN B said she assumed her shift following LVN D. An attempt to interview LVN D was made on [DATE] at 1:42 PM. There was no return call. Interview with CNA C on [DATE] at 1:56 PM revealed she worked with Resident #1 on the morning of [DATE]. CNA C stated she worked for a staffing agency, so she was not familiar with Resident #1's previous condition. CNA C stated she had to have assistance with cleaning Resident #1 due to him not waking up and he had defecated, diarrhea all over his bed. CNA C stated she spoke with LVN B who stated sometime before 8:00AM that Resident #1 was likely going to be sent out to the hospital. CNA C stated LVN B did a sternal rub to wake Resident #1, shortly after breakfast, but he did not arouse. Interview with the DON on [DATE] at 2:49 PM revealed, LVN B called once Resident #1 was sent to the hospital, from what I can remember. The DON stated LVN B reported a change in condition and noted Resident #1 was different from what LVN B knew him to be. Resident #1 was not eating and was not himself. The DON did not remember whether she was told by LVN B that Resident #1 would not wake up or he was unresponsive. The DON stated if a resident would not wake up or the nurse felt the resident was unresponsive, she would expect the resident to be sent out immediately. The DON reviewed the progress notes and SBAR from [DATE]. The DON stated if LVN B did a sternal rub and the resident did not arouse, 911 should have been called. The DON stated labs should have been ordered immediately upon receiving the order but noted the time was not documented in the progress notes. The DON stated LVN B's note of dark red or thick urine should have been reason for Resident #1 to be sent to the hospital emergently. The DON stated the Medical Director was quick to send residents to hospital when needed and if he had all the needed information to make that determination. Interview with the Medical Director on [DATE] at 10:01 AM revealed, he was called the morning Resident #1 was sent to the hospital but he did not remember the specific date regarding Resident #1 having a change in condition. The Medical Director stated the nurse reported to him that Resident #1 was unresponsive in the morning hours but he could not remember how LVN B explained unresponsive to him. The Medical Director stated he ordered, and chest x-ray and labs based on what he was originally told by the nurse. The Medical Director stated he did not remember LVN B telling him she attempted a sternal rub to wake Resident #1 and did not remember receiving a report of the very dark urine. The Investigator read the SBAR to the Medical Director and he stated Resident #1 should have been sent to the hospital but did not have to be emergent due to his vital signs being stable and he was not noted to be in distress but needed to be sent to the hospital because he was unresponsive and could have been septic. The Medical Director said he thought Resident #1 was sent to the hospital in the morning, shortly after the call with the nurse. The Medical Director was not aware Resident #1 was sent out to the hospital after 1:00 PM approximately six hours after Resident #1 was noted to be unresponsive. NOTE: The SBAR was completed after LVN B spoke with the Medical Director. The Medical Director did not receive all of the information on the SBAR to make an informed decision. Interview with LVN D on [DATE] at 5:37 AM, revealed she was the assigned nurse to Resident #1 twice prior to him going to the hospital. She said she worked the 10:00 PM to 6:00 AM shift on [DATE]. She said when her initial shift ended she worked a different hall from 6:00 AM to 2:00 PM and was in the facility when Resident #1 was sent to the hospital. LVN D explained the first time she cared for Resident #1, was a couple of weeks prior, he had hollered all night and would get up out of his recliner and had to be redirected. LVN D said a couple weeks later, when she worked with Resident #1 he was fine. LVN D stated she went in and checked on Resident #1 a couple of times to get his oxygen saturations throughout the night on [DATE] into [DATE]. LVN D stated at 4:00 AM Resident #1's oxygen saturation was 91%, Resident #1 was sleeping and audibly could be heard snoring. LVN D stated Resident #1 had [CONDITION(S)] in his legs. LVN D stated when sleeping a resident could have lower oxygen saturations, so she did not note a concern with Resident #1. LVN D stated the CNA did not report any concerns to her. At shift change LVN D stated she attempted to give report to LVN B but felt LVN B was not listening to her, so she just stopped giving report. LVN D stated she did not have information to pass on in report for Resident #1 as he did not have any acute changes on her shift. After shift change, she was reassigned from Hall 300 where Resident #1 resided to Hall 400. She stated CNA C came to her and asked her to assist with changing Resident #1, around 7:45 AM/8:00 AM, per Resident #1's uneaten breakfast tray. When she entered the room Resident #1 had the oxygen nasal cannula in his mouth. CNA C reported LVN B placed it there because his oxygen saturations were low. LVN D stated CNA C explained Resident #1 was hard to move and his oxygen was down. LVN D stated Resident #1 was not snoring when she assisted CNA C with incontinent care. LVN D stated Resident #1 was very hard to change. Resident #1 did not arouse and did not help with turning from side to side. Resident #1 was very dirty, soiled with urine and excessive feces. LVN D stated after Resident #1 was cleaned up she went to LVN B, as she did not know what had transpired since shift-to-shift report. LVN D said she asked LVN B if she had given Resident #1 his medications and LVN B reported she couldn't because he was not awake and was lethargic. LVN B reported Resident #1's oxygen saturations were low, so she placed the nasal cannula in his mouth. LVN D said she let LVN B know Resident #1 did not look good. LVN D overheard LVN B calling people, she wasn't for sure who, but had reported she had not received any information in report. LVN D stated she and LVN B then began bickering back and forth because LVN B felt she was being blamed for Resident #1's decline. LVN B stated Resident #1 had an acute change in condition. LVN D described it as Resident #1 went from snoring, to not snoring and his limbs moved earlier in the morning when she last took his oxygen saturation and then noted him to be stiff but breathing. LVN D stated she felt 911 should have been called due to the drastic change. LVN D did not call 911 herself as she was not the assigned nurse. LVN D stated LVN B told her I've been here several months, and I know the place better than you do. LVN D stated she walked off at this point. LVN D stated she only overheard LVN B ask for orders to labs and x-rays. Interview with LVN B on [DATE] at 7:46 AM, revealed when she arrived at work she made rounds on the assigned hall, gets report from the nurse, if there was anything that happened overnight. LVN B stated she then would go take blood sugars, and administer insulin to her diabetic residents. Then she would begin getting vital signs, start documentation. After breakfast LVN B would start wound care treatments on residents who had orders. LVN B stated she did not administer medications unless there was a PRN medications or no medication aide on duty. LVN B explained on [DATE] around 6:30 AM after taking blood sugars she noted Resident #1's oxygen saturation was low. LVN B stated she did not remember if Resident #1 had oxygen on at the time or if she had to put oxygen on Resident #1. LVN B stated she did not place the nasal cannula in Resident #1's mouth. LVN B stated Resident #1's oxygen saturation may have been 90% but couldn't remember. LVN B stated Resident #1's family member may have put the nasal cannula in his mouth. LVN B stated the family member came around 11:00 AM. LVN B stated when she called Resident #1's family member she reported he was still breathing but thought he may have had a rough night. LVN B stated every time she tried to wake Resident #1 up, he would not wake up. LVN B stated she could not get Resident #1 to arouse even with a sternal rub. LVN B stated she noticed Resident #1 did not eat his breakfast, when she was doing rounds. LVN B stated she attempted to wake Resident #1 because he was normally up, in the mornings, for breakfast. LVN B stated this was when she attempted the sternal rub and was patting Resident #1 and trying to wake him up. LVN B stated she remembered Resident #1 was snoring, did not show any signs of respiratory distress, breathing normally and appeared to be sleeping. LVN B stated she went to talk with LVN D, who worked overnight and gave her report at shift change. LVN D reported she did not observe any changes in Resident #1 overnight. LVN B stated she text other staff and attempted to backtrack and see what was going on with Resident #1. LVN B stated she wrote out the SBAR after calling the doctor. The Medical Director ordered STAT chest x-ray, labs, including a urinalysis. LVN B stated the lab took a long time to answer, so they had to wait to order labs and x-ray. LVN B stated she made an attempt to call the lab company as soon as she received the order but stated she had to call several times. LVN B stated she was frustrated but kept making attempts to call the lab. LVN B stated she called the ADON or the DON, she couldn't remember, to let them know about the changes. LVN B stated she could not remember if she reported her concerns over the delay with the lab. LVN B stated she went ahead and pulled the urine and stated when she saw the urine, she knew something more serious was going on, like [CONDITION(S)] LVN B stated the Family Member wanted Resident #1 sent to the hospital. When LVN B was presented with the lab requisition time she stated 11:00 AM is when they probably answered, but I had started calling earlier. LVN B stated she had difficulty with getting people to respond and this caused a delay in Resident #1 going to the hospital. LVN B stated, plus I was taking care of other patients and had to wait for return calls. LVN B stated the delays were with the lab, the Medical Director, and ADON/DON. LVN B stated she asked LVN D multiple times throughout the shift about Resident #1 overnight and LVN D told her there was no change to report. LVN B stated she stopped waiting on the lab and decided it was best to send Resident #1 to the hospital. LVN B stated if a resident had [CONDITION(S)], then as a nurse you should act immediately but stated with Resident #1 I had no idea until I pulled his urine, then I had to get back in touch with the doctor. LVN B stated [CONDITION(S)] could not be verified without getting the labs. LVN B stated she was concerned Resident #1 was possibly dehydrated, based on his urine. LVN B stated she wanted to know who last saw Resident #1 awake because he had not been drinking and he did not touch his breakfast. When asked why Resident #1 was not sent to the hospital emergently upon noting he would not arouse even with sternal rub LVN B stated, I have to wait to get an order from the doctor to send to the hospital. LVN B stated she called the Family Member to determine which hospital she wanted Resident #1 to be sent too. Resident #1's Family Member came to the facility and wanted Resident #1 to be sent out. LVN B stated she was supposed to call administration before sending anyone to the hospital. LVN B stated if I had known he [Resident #1] was in dire [NAME] I would have sent him out [to the hospital]. The urine was my biggest concern, and I was trying to gather more information. LVN B was asked what time she pulled the urine she stated she did not know if it was 9:00 AM, based on documentation on SBAR. LVN B stated she was working on other things and stated she did not have any other nurse assisting her or jumping in to help address. LVN B stated no one reported concerns with Resident #1 while they were attempting to change him. LVN B stated she heard Resident #1 had loose stools overnight, but LVN D did not give this information to her in shift to shift report. When LVN B was asked who could have been done differently she stated I personally wish I would've gotten a better report from the night before. I feel it would have made the difference. I would have preferred to send him out earlier if I had heard from the lab. When I saw the urine, I was concerned and felt I needed to do something. LVN B noted Resident #1's vital signs were normal. LVN B was not able to specify how many times she went to check on Resident #1 but stated it was several times, maybe ,d+[DATE] times per hour. LVN B stated, I feel like my whole shift was wrapped around him and getting ahold of people. Interview with DON on [DATE] at 9:22 AM, revealed she found out about Resident #1's change of condition via text message from LVN B. LVN B notified her first around 11:00 AM on [DATE]. The DON stated she thought the ADON had come to the building to check on another situation as she was out of town. The DON stated she was not told about Resident #1 being unresponsive and she was not notified about problems with the lab. The DON stated there had been problems with the lab in the past. The DON stated they could have done better with evaluating why Resident #1 went to the hospital at the time it happened. The DON stated hospital admissions were discussed in the Clinical Meetings that were to be held each morning. The DON stated she was starting more in-depth meeting, but this had not yet started. Interview with ADON on [DATE] at 9:55 AM, revealed she did not go to the facility and see Resident #1 on [DATE]. The ADON stated she spoke with LVN B who reported Resident #1's urine was dark and nasty. LVN B reported Resident #1 was asleep and was unable to arouse but his vital signs were stable. The ADON did not get a report of LVN B having difficulty getting labs ordered. The ADON was not aware LVN B attempted a sternal rub on Resident #1. The ADON stated after LVN B attempted the sternal rub and Resident #1 did not arouse, 911 should have been called and Resident #1 sent to the hospital. The ADON stated she did not remember discussing Resident #1 being sent out in the Clinical Meeting the following day. Interview the Administrator on [DATE] at 9:58 AM revealed she was not notified of the change of condition with Resident #1. The Administrator stated she spoke with the DON later but noted nothing significant. The Administrator stated there had been problems with the lab and staff not being able to get in contact with them. The staff members had been information to report any issues. The Administrator stated LVN B did not report any lab problems to her regarding Resident #1. The Administrator stated if Resident #1 were unresponsive then the resident should have been sent out 911. Review of Hospital emergency room Notes for Resident #1 dated [DATE] revealed Resident #1 presented with altered mental status and decreased responsiveness. Apparently the patient is hypoxic and so he is currently on a nonrebreather. Resident #1 was noted to have acute renal failure, altered mental status and acute pyelonephritis. Review of Hospital History and Physical for Resident #1 dated [DATE] revealed Resident #1 was sent to the hospital due to complaints of unresponsiveness. Resident #1 was diagnosed with acute hypoxic respiratory failure with hypercapnia secondary to sever [CONDITION(S)] pneumonia and a [CONDITION(S)]. Review of Physician and Other Communication/Change in Condition, dated [DATE] revealed POLICY: To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patient residents and their responsible party regarding change in condition. PROCEDURES:2. Complete SBAR 3. Notify the physician of the change in medical condition .The nurse will document all assessments and changes in the patient's/resident's condition in the medical record .7. All attempts to notify physicians and family members/legal representatives will be thoroughly documented in the patient's/resident's medical record. 8. In the event of life-threatening event-contact 911 immediately Review of Physician Communication Grid, dated [DATE] revealed Altered Mental Status: Treatment Required within 1 Hour: Sudden change in mental status - including LOC [level of consciousness] .Routine Physician Notification: Gradual change in mental status .Shortness of Breath: Treatment Required within 1 Hour: Acute onset or with chest pain, change in VS [vital signs], labored breathing, O2 [oxygen] saturation < [below] 95% An Immediate Jeopardy (IJ) was identified on [DATE] at 11:56 AM, due to the above failures. The Administrator was notified of the IJ and the IJ Template was provided on [DATE] at 12:02 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 1:00 PM and indicated the following: Date: [DATE] Time: 12:30pm Facility Name: [name of facility] F-684 Quality of Care It was alleged that the facility failed to respond timely when a resident had a change in condition. Resident was admitted to hospital on [DATE]. Residents with acute change of condition have the potential to be affected by this alleged deficient practice. A review of the 24-hour report for the past 72 hours will be completed by the Director of Nursing/designee to identify any resident who may have had a change of condition and validate that the physician was notified and orders carried out timely. If any identified the physician will be notified immediately for further direction. This will be completed by [DATE]. Findings of the audit were that any resident that had a change in condition had the physician, family/RP notified, acute documentation completed. Clinical Consultant and VP Regulatory Compliance completed a Train the Trainer with the Administrator, Director of Nursing and Assistant Director of Nursing on [DATE] related to appropriate identification, assessment and documentation of acute change of condition, notification expectations and prompt transfer to the hospital when indicated. Clinical Consultant completed train the trainer with Administrator, Director of Nursing and Assistant Director of Nursing on [DATE] related to clinical morning meeting, and care coordination meeting. Director of Nursing/Designee re-educated on [DATE] Social Worker, Dietary Manager, MDS Coordinator, Director of Rehab, Activity Director on the Care Coordination Meeting which is done weekly, and the goal is to plan and implement care to meet resident needs throughout the stay, compare chart documentation to Quality Measures and 802 triggers for accuracy, Opportunity to make corrections, opens communication between disciplines to provide optimal care. In addition, training completed on [DATE] regarding the Clinical Meeting which is held Monday through Friday and the agenda is a guideline to conduct an effective clinical morning meeting, reviewing crucial information and having documentation of that review. This form should also be used to make note of areas needing follow-up by members of nursing management as well as in Care Coordination Meeting. The clinical morning meeting should be Monday through Friday and should be separate from stand up. and the form are for a Monday thru Friday review, as part of the Facility Morning Standup and should be filed in a notebook or kept electronically for reference. Licensed nurses will be re-educated by the Director of Nursing/Designee on the appropriate identification, assessment and documentation of acute change in condition and how to respond to a change in condition and notification to the physician to prevent a delay in care. Change of condition education will include assessment of respiratory status and unresponsiveness, SBAR to be completed prior to calling the physician. Policy's used in re-education are 24-hour report, change of condition, Emergency-911 and CPR Code Blue. The 24-hour report will be used to identify suspected change in condition, in the morning clinical meeting Monday through Friday. This re-education will be initiated on [DATE] by the Director of Nursing / designee. Any licensed nurse not receiving this education by the end of this date will receive prior to next scheduled shift. An employee roster will be utilized to track education compliance. Scheduled agency personnel will receive this re-education prior to working scheduled shift. This will also be presented in new hire orientation. The next 10 shift changes a member of nursing management (Nurse Assessment Coordinator, RN Supervisor, Director of Nursing, Assistant Director of Nursing) will attend shift to shift report to validate that any resident that has had a change of condition has been assessed appropriately, physician notified and orders implemented promptly. The Director of Nursing/Designee and/or Manager on Duty will watch shift to shift report to validate that any resident that has had a change of condition has been assessed appropriately, physician notified, RP/Family notified and orders implemented promptly. The Resident Change of Condition Validation and Compliance Audit will be used to validate compliance. Any concerns will be addressed upon discovery and will be tracked through monthly QAPI meetings. Shift to Shift report to validate that any resident that has had a change of condition has been assessed appropriately, physician notified, RP/Family notified and orders implemented promptly will be done for 10 shifts then 3 shifts weekly for four weeks, then 1 shift weekly for eight weeks, then monthly thereafter Facility Administrator and Director of Nursing will be responsible for the overall implementation and validation of this plan. Facility Medical Director was notified of the Immediate Jeopardy and the contents of this plan on [DATE] and will be given progress updates. An Ad Hoc QAPI was held [DATE] to discuss the contents of this plan. The following interviews, observations and record reviews were conducted to verify the implementation of the Plan of Removal: Observations on [DATE] at 2:00PM revealed shift-to-shift reporting between nurses. The nurses were utilizing the 24-hour report and individually discussing each resident and any concerns or changes of condition. Observation on [DATE] at 2:15 PM revealed nurses providing shift-to-shift report. The nurses were utilizing the 24-hour report and individually discussing each resident and any concerns or changes of condition. Interview with LVN, B, LVN E CNA F, CNA G, Agency RN J, LVN K, LVN L, CNA M, LVN N, and Agency LVN O on [DATE] from 1:23 PM to 3:20 PM revealed they received education and were able to verbalize the following information correctly: shift-to-shift reporting, 24-hour report, watching for, assessing and understanding changes of condition, when to report changes or problems to nursing leadership or the Administrator. Nurse completion of the SBAR and notifying the physician. (Staff interviewed were staff who covered 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM including agency staff). Interview with the ADON, the DON and the Administrator on [DATE] from 1:56 PM to 3:24 PM revealed they had received education on shift-to-s [TRUNCATED]