Every finding on record at Avir at Pecos

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 5 residents reviewed for care plans. (Resident #1, and #2)The facility failed to ensure Resident #1's care plan included fall precautions.The facility failed to ensure Resident #2's care plan included his medical diagnoses, conditions, and special diet order.This failure had the potential to affect residents by placing them at risk for unmet care needs. Findings included: Resident #1 Record review of Resident #1's admission Record dated 07/21/2026 revealed an [AGE] year-old male with admission date 04/22/2026. Record review of Resident #1's history and physical dated 04/21/2026 revealed a medical history of ambulation dysfunction (abnormal, uncoordinated or difficult walking pattern). Record review of Resident #1's Quarterly MDS dated [DATE], revealed a BIMS of 06, indicating the resident had severe cognitive impairment. Under Section J-Health Conditions, indicated Resident #1 had a recent fall since admission without any injury. Record review of Resident #1's Care Plan dated 04/23/2026, did not address fall interventions being implemented. In an observation of Resident #1's room on 07/21/2026 at 11:00am, revealed to have fall mat folded and placed against the wall. It was not in use as the resident was not in the room at that time. Resident #2 Record review of Resident #2's face-sheet dated 07/21/2026 revealed an [AGE] year-old male with admission date 05/22/2026. Record review of Resident #2's Comprehensive MDS dated [DATE] revealed a BIMS of 11, indicating moderate cognitive impairment. Record review of Resident #2's history and physical dated 04/23/2026 revealed a medical history of: Chronic Kidney Disease (a long-term condition in which the kidneys gradually lose their ability to function properly); Gait disturbance (normal walking pattern is altered); and Hypertension (high blood pressure). Resident #2's diet order dated 04/23/2026 reflected Cardiac AHA diet (a heart-healthy eating pattern rich in fruits, vegetables, whole grains, plant-based proteins, and unsaturated fats while limiting sodium, added sugars, saturated fats, and ultra processed foods). Record review of Resident #2's care plan with date initiated 05/26/2026, and revision date 07/14/2026, revealed the care plan did not include or address Resident #2's medical diagnoses, or his special diet. In an interview on 07/21/2026 at 5:11pm with LVN A, she stated any fall precautions that were being implemented such as low bed, call light within reach and fall mat needed to be included in the care plan. She stated that a resident's diagnosis should have been included in the care plan as well. She stated that it was important for fall precautions to be included so that the staff knew about the fall preventions that were being implemented. She stated that health information needed to be included in the care plan as well to monitor the progression of their health conditions and to establish a baseline. She stated that a risk of not including fall preventions and health conditions would be the staff not knowing what precautions to take with the residents and more of the same incidents such as falling could continue to happen. She stated that the care plan was updated every three months by the MDS nurse. She stated that the MDS nurse recently quit and that the facility did not have an MDS nurse onsite at the moment. She stated that she believed that there was a corporate MDS nurse covering while the facility hired another MDS nurse. In an interview on 07/21/2026 at 5:41pm with the DON she stated that any falls and fall preventions should be updated in the care plan. She stated that health conditions were to also be included in the care plan so that all staff were aware of the Residents' entire health conditions and implementations of fall precautions to avoid further incidents. She stated that there was a nurse that was helping with MDS but she left in June 2026 before she could teach the nurses how to complete a careplan. She stated that it was the responsibility of the MDS nurse to update the care plans but since she left it became the responsibility of herself, and the ADONs. She stated she was checking them weekly, but she stopped doing that because there was a lot going on. She stated that the corporate MDS nurse was responsible for overseeing them and ensuring that care plans were being updated as needed. In an interview on 07/21/2026 at 6:20pm with the corporate MDS nurse, He stated that the purpose of the care plan was to set forth goals for patient care. It should have included MDS triggers. It also includes interventions to keep the Residents safe. He stated that falls, fall precautions, and health conditions were to be included in the care plan. He stated that nursing was responsible for creating the baseline care plan in 48 hours within admission and monitored at least quarterly. He stated that the remote MDS nurse was responsible for updating care plans daily, and he was responsible for overseeing the remote MDS nurse weekly. In an interview on 07/21/2026 at 7:05pm with the Administrator he stated that falls, fall precautions and health conditions were to be included in the care plan so that all the staff was aware of the interventions that were in place for the Residents. He stated that he, the DON and the MDS nurse were all responsible for ensuring that the care plans were being updated and completed correctly. He stated that the corporate MDS nurse oversees them weekly. He stated that the risk was care not being properly delivered to the resident if not all staff were aware of the health conditions or fall precautions to be used. Review of the Nursing Facility's Care Plans, Comprehensive Person-Centered policy, dated with revision date 03/2022, read in part, under Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and implemented for each resident. Under Policy Interpretation and Implementation, read in part: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within 7 days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. It continued to read in part: 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASSAR recommendations; and (3) which professional services are responsible for each element of care. C. includes the resident's stated goals upon admission and desired outcomes.

Based on observation, interviews and records review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to take actions aimed at performance improvement and after implementing those actions, measure its success, and track performance to ensure that improvements were realized and sustained.-The facility failed to monitor and track performance of the black debris presence in the 300-hall shower room.The failure could place residents within the facility at risk for potential illness.An observation was made on 07/21/2026 at 3:05 PM in the 300-hall shower room of the inner bottom corners of the shower with white paste that was open with black debris underneath.Record review of the Nursing Facility's Quality Assessment and Performance Improvement Plan 2026, dated 06/2026, read in part under Environmental Rounds: Monitored by Administrator/Maintenance. No additional comments regarding or addressing the environment or the shower rooms were noted.In a phone interview on 07/21/2026 at 4:45 PM with the Maintenance Supervisor, he stated he was aware of the black debris in the 300-hall shower room. The Maintenance Supervisor stated the Nursing Facility had cleaned the observed black particles on 300-hall shower's inner floor corners, which was done with a chemical and a wire brush. The Maintenance Supervisor stated he had removed the black particles from the 300-hall shower floor corners and applied Caulking (a waterproof filler or sealant used for buildings or repair) and was not aware of any black particles in the shower room until today 07/21/2026. The Maintenance Supervisor stated he was unable to recall the date the black particles were removed and stated he did not have invoices or receipts relating to the shower room. The Maintenance Supervisor stated he had conducted weekly rounds and did not have any concerns. He stated he did not document his rounds or their findings, including anything relating to the 300-hall shower room. The Maintenance Supervisor stated it was an expectation that he had documented identified concerns within the Nursing Facility and their resolution including any repairs made. He stated documentation and receipts would reflect the Nursing Facility's attempts to resolve identified concerns including the black debris observed in the 300-hall shower. The Maintenance Supervisor stated the identified concern of the black debris in the 300-hall shower was discussed during the supervisors daily rounding of the environment.In an interview on 07/21/2026 at 7:10 PM with the Administrator, he stated the Maintenance Supervisor and himself, as the Administrator, would round the Nursing Facility weekly to conduct environment checks including the 300-hall shower. The Administrator stated this was a part of their QAPI plan after the 300-hall shower was identified with black debris during their recent annual survey, exit 05/21/2026. The Administrator stated he did not document his weekly rounding and did not have any documentation reflecting monitoring of the shower during their rounds. The Administrator stated Maintenance would be responsible for documenting the monitoring and findings of the 300-hall shower room since he was responsible for reporting it to their regional office. The Administrator stated the purpose of documenting their rounding and findings of identified concerns included the Nursing Facility's monitoring rounds when completed and any findings. The Administrator stated he was not aware of any complaints of black particles observed in the 300-hall shower room until this day, 07/21/2026, and stated it had been believed to be resolved by the Maintenance Supervisor. Record review of the Nursing Facility's Plan of Correction, corrected 06/12/2026, included; the Administrator would monitor weekly that the . maintenance services maintain a sanitary, orderly and comfortable environment. The bathroom in 300 halls now is clean and free from black particles on the floor and shower room.Record review of the Nursing Facility's Quality Assurance and Performance Improvement (QAPI) Program, with revision date 02/2020, under Policy statement, read: This Facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Under Policy Interpretation and Implementation, it read in part: The objectives of the QAPI program are to: 1. provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. Under Implementation, it read in part: 1. The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee. 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. tracking and measuring performance; b. establishing goals and thresholds for performance measurement; c. identifying and prioritizing quality deficiencies; d. systematically analyzing underlying causes of systemic quality deficiencies; e. developing and implementing corrective action or performance improvement activities; and f. monitoring or evaluating the effectiveness of corrective action/performance improvements activities, and revising as needed. 3. The committee meets monthly to review reports, evaluate data and monitor QAPI-related activities to make adjustments to the plan.

Based on interviews and record reviews, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 3 days of 30 days reviewed for nursing services.The facility failed to have a registered nurse working on [DATE], [DATE], and [DATE].This failure could place residents at risk of not receiving advanced nursing skill of a registered nurse.The findings included:Record review of the Nursing Facility's Daily Staffing dated [DATE], [DATE], and [DATE], revealed there was no RN assigned during those shifts.In an interview on [DATE] at 05:49 PM with the DON, she stated there were potential risks to residents not having an RN to provide services at least 8 hours a day, every day. The DON stated the potential risks to residents included the example of LVN's unable to call time of death, only an RN could, and if a resident was DNR (Do not Resuscitate), the LVN would still have to perform CPR.In an interview on [DATE] at 7:00 PM with the Administrator, he stated the Nursing Facility was attempting to contract Registered Nurses via advertisement. The Administrator stated the Nursing Facility was currently short of Registered Nurses now, which was why there were documented days of not having an RN daily in 05/2026. He stated the potential risk of the Nursing Facility not having an RN on-site was having the lack of a higher trained nursing staff that could pronounce time of death, for example.Record review of Nursing Facility's Staffing, Sufficient and Competent Nursing policy, with revision date 08/2022, read in part under Policy Interpretation and Implementation, Sufficient Staffing: 3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.CFR 483.35(b)(1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Based on interview, observation, and record review, the facility failed to ensure the resident was offered sufficient fluid intake to maintain proper hydration and health for 3 (Resident #23, #27, #33) of 3 residents reviewed for access to hydration. The facility failed to ensure staff provided access to hydration and provide fresh water and ice at bedside for Residents (#23, #27, and #33) .This deficient practice could place residents at risk of being dehydrated.Findings include:Resident # 23Record review of Resident # 23's admission record dated 05/13/26 revealed an [AGE] year-old female with an initial admission date of 09/01/25 and a readmission date of 10/06/25. Record review of Resident #23's diagnosis list dated 05/13/26 revealed a diagnosis of dementia without behavioral disturbance (cognitive decline severe enough to impact daily functioning but exact cause cannot be definitively diagnosed). Record review of Resident # 23's Quarterly MDS assessment dated [DATE] revealed a BIMS of 03 indicating severe cognitive impairment. Section GG-Functional Abilities revealed Resident # 23 needed setup or clean up assistance meaning the helper set up or cleaned up, resident completed activity, helper assists only prior to or following the activity while performing eating activity. Record review of Resident #23's care plan revised 02/17/26 revealed Resident #23 had memory loss related to dementia. Goals included living in a safe, nurturing, and stimulating environment. Care plan also stated that Resident # 23 had a self- care performance deficit. Interventions included that resident was able to feed self. An observation on 05/13/26 at 11:42 a.m. revealed no hydration jug in room, available for resident.An observation on 05/13/26 at 1:47PM revealed no hydration jug in room available for resident.An observation on 5/14/26 at 10:30AM and at 11:12 AM revealed no hydration jug in room available for resident. In an interview, Resident #23 could not express if she received water other than with medications, she stated she received water with her pills sometimes.Resident # 27 Record review of Resident # 27's admission record dated 05/14/2026 revealed a [AGE] year-old female with an initial admission date of 06/12/24 and a readmission date of 12/08/24. Record review of Resident # 27's diagnosis list dated 05/14/2026 revealed a diagnosis of vascular dementia (changes to memory, thinking and behavior resulting from conditions that affect the blood vessels in the brain). Record review of Resident # 27's Comprehensive MDS assessment dated [DATE] revealed a BIMS of 00 indicating severe cognitive impairment. Section GG-Functional Abilities revealed Resident # 27 needed setup or clean up assistance meaning the helper set up or cleaned up, resident completed activity, helper assists only prior to or following the activity while performing eating activity. Record review of Resident #27's care plan revised 04/12/2026 revealed risk for falls related to impaired cognitive function and physical limitations. Interventions included providing a safe environment with: (Ex: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach). Care plan also stated that Resident # 27 had a self- care performance deficit. Interventions included that resident was able to feed self. An observation on 05/13/26 at 11:42 a.m. revealed no hydration jug or cup of water in room, available for resident.An observation on 05/13/26 at 1:47PM revealed no hydration jug or cup of water in room available for resident.An observation on 5/14/26 at 10:30AM and at 11:12 AM revealed no hydration jug or cup of water in room available for resident.Resident #33Record review of Resident # 33's admission record dated 05/13/2026 revealed a [AGE] year-old female with an initial admission date of 02/21/2023 and a readmission of 11/11/2025. Record review of Resident #33's diagnosis list dated 05/13/2026 revealed a diagnosis of dementia without behavioral disturbance (cognitive decline severe enough to impact daily functioning but exact cause cannot be definitively diagnosed). Record review of Resident #33's Quarterly MDS dated [DATE] revealed a BIMS of 04 indicating severe cognitive impairment. Section GG-Functional Abilities revealed Resident # 33 needed setup or clean up assistance meaning the helper set up or cleaned up, resident completed activity, helper assists only prior to or following the activity while performing eating activity. Record review of Resident #33's Care plan revised 04/12/26 revealed a communication problem related to impaired cognition. Interventions included to anticipate and meet needs. Care plan also stated that Resident # 33 had a self- care performance deficit. Interventions included that resident was able to feed self. An observation on 05/13/26 at 11:42 a.m. revealed no hydration jug in room, available for resident.An observation on 05/13/26 at 1:47PM revealed no hydration jug in room available for resident.An observation on 5/14/26 at 10:30AM and at 11:12 AM revealed no hydration jug in room available for resident.In an interview on 05/14/26 at 10:30 AM with Ombudsman, she stated that in the memory care unit, residents did not receive drinks regularly, she stated that they kept one pitcher and it would take a while for Residents to receive more water if the pitcher was empty, because the staff would have to walk out of the memory care unit and go to the hydration room to fill up the water and bring it back. She stated that residents in the memory care unit were at risk for dehydration because they could not voice needs as other residents could.In an interview on 05/14/26 at 10:50AM with CNA A, revealed that the unit had one pitcher of water and they would provide water for the residents in plastic cups if they asked for it. She stated that they were provided other types of drinks during activities if they asked for them. She stated that the water pitchers were washed out and refilled with fresh water on Monday, Wednesday and Friday. She stated that Residents were provided fluids with breakfast lunch and dinner and when taking medications. She stated that if they wanted something else to drink between that then they could ask the staff and they would pour them the cup of water. She stated that it was the responsibility of the CNAs and nurses to ensure the residents were provided with water or fluids to prevent dehydration.In aan interview on 05/14/26 at 11:17 AM with RN D, she stated that the water pitchers were passed out three days out of the week on Monday Wednesday and Friday. She stated that Residents should be provided with fresh water and ice daily or multiple times a day, but that she was told by supervisors that water pitchers were to only be filled on Monday, Wednesday and Fridays. She stated that other than that residents received fluids with meals and with mediations. She stated that residents were at risk of dehydration because a lot of them took medications that could cause dehydration as well such as diuretic. She stated that CNAs were responsible for passing out fresh water but that she believed that all staff were responsible for ensuring the residents had water readily available.In an interview on 05/14/2026 at 5:38PM with the DON, she stated fresh water was passed Monday, Wednesday and Friday by CNAs. She stated that the pitchers were brought out Monday morning and on the Tuesday night they were taken to the kitchen by night staff for them to be washed and refilled on Wednesday morning and so on. She stated that Residents were provided with fluid with meals, medications and if they asked for water. She stated that of course water could be refilled throughout the day if needed she stated that the Monday, Wednesday and Friday schedule was only for washing the pitchers. She stated that she would have to provide clarification to her staff. She stated that the risk of not offering fluids regularly would be dehydration. She stated that it was the responsibility of the CNAs and nurses to ensure residents were receiving water.In an interview on 05/14/2026 at 6:03 PM with the Administrator, he stated that water was provided to residents with meals and CNAs would pass water to residents throughout their shift. He staedstated that water was provided in the grey jugs for each resident to have available to them. He stated that it was the responsibility of nursing and CNAs to ensure water was being passed daily. He stated that a risk would be dehydration and urinary tract infections. Record review of the Nursing Facility's Resident Hydration and Prevention of Dehydration policy dated 10/2017, read in part: This facility will strive to provide adequate hydration and to prevent and treat dehydration. Under Policy Interpretation and Implementation, it read in part: 6. Nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 (Residents #37, Resident #39 and #49) of 6 residents observed for oxygen management. The facility failed to ensure Oxygen (O2) in use signage was posted on the doorways of Resident #37, Resident #39 and Resident #49 to ensure smoking was prohibited. This failure could place residents at risk of This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health and at risk of fire hazards by not posting oxygen signs outside the residents' rooms. Resident #37Record review of Resident #37's admission Record dated 05/12/2026 revealed a [AGE] year-old male with admission date 04/22/2026. Record review of Resident #37's history and physical dated 05/12/2026 revealed a medical history of the following: Acute Respiratory Failure with Hypoxia (where the lungs fail to deliver sufficient oxygen to the blood, leading to low oxygen levels in tissues). Record review of Resident #37's Comprehensive MDS dated [DATE], revealed a BIMS of 05, indicating the resident had severe cognitive impairment. Under Section O-Special Treatments, indicated Resident #37 had Oxygen Therapy. Record review of Resident #37's Care Plan did not address Oxygen Therapy. Record review of Resident #37's Order Summary Report as of 05/14/2026, revealed a Physician Order for Oxygen Continuously via Nasal Cannula (a thin, flexible tube with two prongs that fit into the nostrils, delivering oxygen from a source such as an oxygen concentrator), may titrate 2 Liters- 5 Liters for Shortness of Breath or pulse oximetry less than 90 percent. An observation of Resident #37's room on 05/12/2026 at 1:43 p.m. revealed an oxygen concentrator at bedside. There was no oxygen signage posted outside the door. Resident # 39 Record review of Resident # 39's admission Record dated 05/13/2026 revealed a [AGE] year old female with an initial admission date of 06/06/2023 and a readmission date of 02/05/25. Record review of Resident #39's history and physical dated 02/04/26 revealed a diagnosis of chronic obstructive pulmonary disease (progressive, irreversible lung disease that restricts airflow and makes breathing difficult). Record review of Resident #39's Comprehensive MDS assessment dated [DATE] revealed a BIMS of 12 indicating moderate cognitive impairment. Section O- special treatments, indicated use of oxygen therapy.Record review of Resident # 39's Care plan revised on 04/01/26 revealed Resident #39 had chronic obstructive pulmonary disease with history of pneumonia. Interventions included to give nebulizer treatments and oxygen therapy as ordered. Record review of Resident # 39's Physician Orders with a start date of 04/10/2025 revealed an active order for oxygen at 2 liters per minute via nasal canula. An observation and interview with Resident #39's room on 05/12/2026 at 1:30 p.m., revealed a oxygen concentrator at bedside and a nebulizer machine on bedside table, resident was able to verbalize that she used oxygen throughout the day. There was no oxygen signage posted outside the door. Resident # 49Record review of Resident # 49's admission record dated 05/13/2026 revealed an initial admission date of 07/19/2019 and a readmission date of 06/12/2025.Record review of Resident # 49's diagnosis list dated 05/13/2026 revealed a diagnosis of chronic obstructive pulmonary disease (progressive, irreversible lung disease that restricts airflow and makes breathing difficult). Record review of Resident #49's Quarterly MDS assessment dated [DATE] revealed a BIMS of 00 indicating severe cognitive impairment. Section O- Special Treatments, indicated use of oxygen therapy. Record review of Resident #49's care plan revised on 02/17/2026 revealed Resident #49 had a cough related to chronic obstructive pulmonary disorder. Interventions included administering oxygen as ordered. Record review of Resident #49's Physician Orders with a start date of 04/11/25, revealed an active order for oxygen therapy at 2-4 liters per minute via nasal canula.An observation of Resident #49's room on 05/12/2026 at 1:40 p.m. revealed an oxygen concentrator at bedside. There was no oxygen signage posted outside the door. In an interview on 05/12/2026 at 2:41 PM with CNA A, she stated residents on oxygen should have aan Oxygen sign posted outside of their room. CNA A stated she believed the Administration or Nursing supervisors were responsible for ensuring Oxygen signs were posted outside of the rooms of residents with oxygen. CNA A stated the potential risk of not having Oxygen signs posted included staff not being aware of who was at risk in case of an emergency such as a fire. In an interview on 05/14/2026 at 10:00 AM with LVN C, she stated the DON was responsible for ensuring Oxygen signs were posted outside of the rooms with oxygen. LVN C stated the potential risk to residents was Oxygen being a fire hazard. In an interview on 05/14/2026 at 10:59 AM with RN D, she stated the oxygen signs were fixed on the walls and were not removable. RN D stated the oxygen signs had been fixed on the wall for years. She stated all staff were responsible for making sure residents with oxygen had a sign posted outside of their room. RN D stated the potential risks for residents not having oxygen signs posted outside of the rooms; it was potential fire hazard. In an interview on 05/14/2026 at 5:53 PM with the DON, she stated the nursing staff were responsible for the oxygen postings outside of resident rooms who were ordered oxygen. The DON stated that the purpose of the Oxygen postings was to inform others of oxygen being in the room. The DON stated that the Nursing Facility staff noticed the oxygen signs were not placed correctly and had them removed on 05/13/26. The DON stated that it was a potential fire hazard for not having oxygen signs posted on the rooms of the residents with oxygen. Record review of the Nursing Facility's Oxygen Storage policy, with no date, read in part: It is the policy of this center to maintain appropriate and safe storage of oxygen. Under Procedure- Exterior, 5. No smoking signage will be posted to prohibit smoking within fifty (50) feet of the storage area. Under Procedure- Interior, it read 1. Storage areas will be clearly identified with a no smoking sign posted on the door.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 medication carts (200-hall) viewed for pharmacy services.-The facility failed to maintain a locked medication cart in the 200-hallway on 5/12/26.This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents.Findings included:An observation on 05/12/2026 at 8:36 AM of an unlocked medication cart on the 200-hall There were no residents or staff observed in the hall.In an interview on 05/14/26 at 09:05 AM LVN C stated the Nurse or the Medication Aide administering medications at the time were responsible for making sure their Medication Cart was locked when left unattended. LVN C stated the potential risks of leaving medication carts unlocked include HIPAA or privacy violations. LVN C also stated other potential risk of leaving a medication cart unlocked included confused residents taking unknown medications and having different potential reactions.In an interview on 05/14/26 at 10:10 AM with RN D, she stated nursing staff were responsible for ensuring their assigned medication cart was locked. RN D stated all staff were also responsible for locking it if it was observed open. RN D stated the potential risk of unlocked medication carts included residents taking unknown medications, or staff taking residents' medications which would make the medications unavailable for the residents.In an interview on 05/14/26 at 5:39 PM with the DON, she stated that the medication aides and the nurses assigned to the medication carts were responsible for making sure they were locked when not in use. The DON stated that the ADON and herself as the DON were responsible for monitoring the medication carts which were done daily. The DON stated the potential risks of the Nursing Facility having medication carts unlocked included residents potentially consuming medications that were not theirs which was a medication error.In an interview on 05/14/26 at 6:04PM with the Administrator, He stated that medication carts were to be locked anytime the nurse would be stepping away from it. He stated that this was done to prevent anyone that was not authorized from handling medication from being able to easily access it. He stated that this was a potential risk for residents as well because they could possibly get into the medication cart and accidentally ingest medications or get a hold of sharps. He stated that it was the responsibility of the nurse using the cart to ensure it was locked. Record review of the Nursing Facility's Security of Medication Cart, revised 04/2007, read in part: Policy statement- The medication cart shall be secured during medication passes. It continued to read, Policy Interpretation and Implementation- 1. The nurse must secure the medication can during the medication pass to prevent unauthorized entry. Also, it read, 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen.-The facility failed to label food items in the refrigerator and in the freezer on 5/12/2026 -The facility failed to keep containers of food in the refrigerator free of dried drippings on 5/12/2026-The facility failed to keep lids of containers free of dust in the dried food storage area on 05/12/2026-The facility failed to ensure kitchen staff used hair nets properly on 05/13/26 and 05/14/26-The facility failed to keep overflowing garbage in a container away from clean dishes on 05/12/2026 These failures could place residents at risk of food-borne illnesses from cross-contaminated food and beverages. Findings included: In an observation on 5/12/2026 at 8:32 AM a container of soy sauce located in the refrigerator had an unknown yellow jelly substance smeared on the container. In an observation on 5/12/2026 at 8:33AM a container of ranch dressing and a container of salad dressing located in the refrigerator were observed to have dried drippings around the lid of the containers.In an observation on 5/12/2026 at 8:34AM a tray of prepared fruit desserts, a tray of glasses full of tea and a tray with glasses of milk located in the refrigerator were observed to not be dated or labeled. In an observation on 5/12/2026 at 8:38AM the lid of a storage container in the dry storage room was observed to have dust on the lid. In an observation on 5/12/2026 at 8:46AM a container of vanilla ice cream located in the freezer was observed to have dried drippings on the side of the container. In an observation on 5/12/2026 at 8:47AM a package of pork loin meat and 4 packages of red meat and a bag of chopped broccoli was observed in the freezer to not be labeled or dated. In an observation on 05/12/2026 at 8:49AM a box of potatoes was observed in the dry food storage area, there was a potato that was sprouting roots mixed in the same box with other potatoes. In an observation on 5/12/26 at 8:49 red peppers located in the drawers of the refrigerator were observed to not be labeled or dated and were not in original packaging. In an observation on 5/12/26 at 8:53 AM the drink dispenser was observed to have dried residue on the handle and the nozzle.In an observation on 05/12/26 at 8:54 AM revealed an overflowing garbage container that was in the dish washing area next to a cart of clean dishes.In an observation on 5/13/2026 at 10:50AM and 5/14/2026 at 9:57AM [NAME] E was observed to be in the kitchen with her hair net not fully covering her hair. In an interview on 5/14/26 at 1:36PM with [NAME] E, she stated that all food needed to be dated and labeled with the expiration date, usually 3 days after opening. She stated that this was done to ensure that they were not using expired ingredients. The foods like the desserts that were prepared forth day should be labeled and dated as well for staff to know when they were made, she stated that if this was not done it could make the resident sick. She stated that all containers were to be wiped down after use to prevent cross contamination. She stated the hair nets needed to be holding back all of the hair to prevent any from falling into the food and contaminating the food. She stated that the dietary manager was responsible for ensuring that the food was labeled and dated she stated that the dietary manager was also responsible of discarding any foods that were not good to be used and to clean the containers in the dry food storage. In an interview on 5/14/26 at 1:56 PM with the Dietary Manager, she stated that all the kitchen staff was responsible for ensuring that all food was dated and labeled. It was also everyone's responsibility to ensure cleanliness of the kitchen to include the drink dispenser and the dry food storage. She stated that all staff in the kitchen needed to wear hairnets to prevent hair falling into the food and being contaminated and hair needed to be secured under the hair net. She stated that it was her responsibility to ensure that all of this was being completed by the kitchen staff. she stated that it was unacceptable for the trash to be overflowing in any area of the kitchen but especially where clean dishes were being placed. She stated that all the kitchen staff were responsible for ensuring that the trash was disposed of properly meaning the trash was placed in the trash can and not overflowing. She stated that if the can was getting full, staff was supposed to throw that bag away and replace it with a new bag. She stated that the trash overflowing in an area where clean dishes were was a risk of contaminating the clean dishes that residents use. She stated that she verbally reminded the staff to ensure that the trash was thrown away before the can became full, but she could not be consistently telling them all the time. she stated that it was something that the staff should know to do. In an interview on 05/14/26 at 6:03 PM with the Administrator, he stated that the staff was supposed to date and labeled all food items upon receiving them to ensure that it was used by the appropriate date to prevent residents getting sick. He stated that all staff needed to be wearing hair nets to restrain their hair to prevent it from falling into the food and contaminating the food. He stated that the overall cleanliness of the kitchen was the responsibility of all the staff and should be over seen by the dietary manager. He stated that trash should be disposed of in a timely manner before it overfills the trash can. He stated that it was the responsibility of the Dietary Manager to ensure that the trash is properly disposed of. He stated that a risk would be cross contamination of clean dishes and residents were at risk of becoming sick if they used those dishes. Review of the facility policy titled Food Receiving and Storage revised on 11/2022 read in part . food services or other designated staff, maintain clean and temperature/ humidity- appropriate food storage area at all times Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date) . Review of facility policy titled Waste Disposal dated 2023 read in part containers will be emptied as often as necessary throughout the day and at the end of each day .TFER S228.43 states that food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. It does not apply to food employees such as counter staff who only serve beverages and wrapped or packaged foods, hostesses, and wait staff if they present a minimal risk of contaminating exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

Based on interview and record review the facility failed to develop a QAPI (Quality Assurance and Performance Improvement) plan that described the process for conducting quality assessment and assurance activities, including the process on how the committee would identify and correct quality deficiencies. The facility failed to have documentation and evidence of its QAPI plan being ongoing and comprehensive.This failure could affect all residents and result in quality deficiencies not being recognized and corrected.Findings included: Record review of the Nursing Facility's QAPI plan, the Nursing Facility's meeting template documents for 02/2026, 03/2026, and 04/2026, revealed the areas documented: Goal, Interventions, and Progress, were blank. The PIP (Performance Improvement Plan) for the mentioned 3 months had the same handwritten notes that read, past LSC (Life Safety Code) and Annual Surveys from 03/25/25-03/28/25, all deficiencies were identified with no current issues. The PIP also included ANE in-services were completed for the months mentioned.In an interview and observation on 05/14/2026 at 11:30 AM with the DON, she stated that the facility was unable to provide the requested in-services that were noted on the PIP. The DON reviewed handwritten notes from QAPI. The DON stated those were the Administrator's notes, and he copied and pasted from one month to the next. The DON stated that it could be considered false documentation which could affect the residents because the QAPI notes do not reflect current monthly training or progress on issues. She stated there was no trending and tracking identified in the plan. In an interview on 05/14/2026 at 11:31 AM with the Regional Corporate Nurse, she stated she had just started her role in 03/2026, and there were no action plans until 04/2026. In an interview on 05/14/2026 at 6:20 PM with the Administrator, he stated he was responsible for QAPI. He stated the department supervisors, self as the Administrator, the DON, and the Medical director, participated in QAPI meetings on a monthly basis. The Administrator stated any identified concerns or trends regarding residents and the Nursing Facility was discussed and identified. Record review of the Nursing Facility's Quality Assurance and Performance Improvement (QAPI) Program with revision date 02/2020, read in part: Policy Statement- This Facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Under Policy Interpretation and Implementation, it read in part: The objective of the QAPI program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. Under Implementation, it read in part: 1. The QAPI committee oversees implementation of our QAPI plan, which is written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee. 2. The Qapi plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. tracking and measuring performance; b. establishing goals and thresholds for performances measurement; c. identifying and prioritizing quality deficiencies; d. systematically analyzing underlying causes of systematic quality deficiencies; e. developing and implementing corrective action or performance improvement activities; and, f. monitoring or evaluating the effectiveness of corrective action or performance improvements activities and revising as needed. Under Coordination, the policy read: 1. The QAPI coordinator manages QAPI committee activities and changes to the QAPI plan. 2. The QAPI coordinator assists other committees, individuals, departments, and/or services in developing quality indicators, monitoring tools, assessment methodologies and documentation, and in making adjustments to the plan. 3. The QAPI coordinator serves as a liaison between the QAPI committee and indiciduals, services, and/or departments regarding QAPI activities.

Based on interview and record review, the facility failed to implement the facility's Quality Assessment and Performance Improvement (QAPI) plan and program, in which data was to be gathered and analyzed, and plans of action were to be developed, implemented, and evaluated to address adverse events related to potential deficient practice for 1 of 1 QAPI programs reviewed.The facility failed to conduct at least one performance improvement project (PIP) annually that focused on high risk or problem prone areas identified by the facility, through data collection and analysis.This failure could place residents of the facility at risk of the facility not developing, monitoring and implementing corrective actions for identified areas of improvement.Findings included: Record review of the Nursing Facility's QAPI plan, the Nursing Facility's meeting template documents for 02/2026, 03/2026, and 04/2026, revealed the areas documented: Goal, Interventions, and Progress, were blank. The PIP (Performance Improvement Plan) for the mentioned 3 months had the same handwritten notes that read, past LSC (Life Safety Code) and Annual Surveys from 03/25/25-03/28/25, all deficiencies were identified with no current issues. The PIP also included ANE in-services were completed for the months mentioned.In an interview and observation on 05/14/2026 at 11:30 AM with the DON, she stated that the facility was unable to provide the requested in-services that were noted on the PIP. The DON reviewed handwritten notes from QAPI. The DON stated those were the Administrator's notes, and he copied and pasted from one month to the next. The DON stated that it could be considered false documentation which could affect the residents because the QAPI notes do not reflect current monthly training or progress on issues. She stated there was no trending and tracking identified in the plan. In an interview on 05/14/2026 at 11:31 AM with the Regional Corporate Nurse, she stated she had just started her role in 03/2026, and there were no action plans until 04/2026. In an interview on 05/14/2026 at 6:20 PM with the Administrator, he stated he was responsible for QAPI. He stated the department supervisors, self as the Administrator, the DON, and the Medical director, participated in QAPI meetings on a monthly basis. The Administrator stated any identified concerns or trends regarding residents and the Nursing Facility was discussed and identified. Record review of the Nursing Facility's Quality Assurance and Performance Improvement (QAPI) Program with revision date 02/2020, read in part: Policy Statement- This Facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Under Policy Interpretation and Implementation, it read in part: The objective of the QAPI program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. Under Implementation, it read in part: 1. The QAPI committee oversees implementation of our QAPI plan, which is written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee. 2. The Qapi plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. tracking and measuring performance; b. establishing goals and thresholds for performances measurement; c. identifying and prioritizing quality deficiencies; d. systematically analyzing underlying causes of systematic quality deficiencies; e. developing and implementing corrective action or performance improvement activities; and, f. monitoring or evaluating the effectiveness of corrective action or performance improvements activities and revising as needed. Under Coordination, the policy read: 1. The QAPI coordinator manages QAPI committee activities and changes to the QAPI plan. 2. The QAPI coordinator assists other committees, individuals, departments, and/or services in developing quality indicators, monitoring tools, assessment methodologies and documentation, and in making adjustments to the plan. 3. The QAPI coordinator serves as a liaison between the QAPI committee and individuals, services, and/or departments regarding QAPI activities.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 3 of 7 residents reviewed for care plans. (Resident #4, Resident#37 and #49)The facility failed to ensure Resident #4's care plan included ADLs.The facility failed to ensure Resident #49's care plan addressed smoking,The facility failed to ensure Resident # 37's care plan addressed oxygen use This failure had the potential to affect residents by placing them at risk for unmet care needs. Record review of Resident #37's admission Record dated 05/12/2026 revealed a [AGE] year-old male with admission date 04/22/2026. Record review of Resident #37's history and physical dated 05/12/2026 revealed a medical history of the following: Acute Respiratory Failure with Hypoxia (where the lungs fail to deliver sufficient oxygen to the blood, leading to low oxygen levels in tissues). Record review of Resident #37's Comprehensive MDS dated [DATE], revealed a BIMS of 05, indicating the resident had severe cognitive impairment. Under Section O-Special Treatments, indicated Resident #37 had Oxygen Therapy. Record review of Resident #37's Care Plan did not address Oxygen Therapy. Record review of Resident #37's Order Summary Report as of 05/14/2026, revealed a Physician Order for Oxygen Continuously via Nasal Cannula (a thin, flexible tube with two prongs that fit into the nostrils, delivering oxygen from a source such as an oxygen concentrator), may titrate 2 Liters- 5 Liters for Shortness of Breath or pulse oximetry less than 90 percent. An observation of Resident #37's room on 05/12/2026 at 1:43 p.m. revealed an oxygen concentrator at bedside. There was no oxygen signage posted outside the door. Record review of Resident # 49's admission record dated 05/13/2026 revealed an initial admission date of 07/19/2019 and a readmission date of 06/12/2025. Record review of Resident # 49's diagnosis list dated 05/13/2026 revealed a diagnosis of unspecified dementia with other behavioral disturbance (cognitive decline severe enough to impact daily functioning but exact cause cannot be definitively diagnosed and is accompanied by disruptive behavioral symptoms.) Record review of Resident #49's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 indicating severe cognitive impairment. Record review of Resident #49's care plan revised on 02/17/2026 did not address Resident #49's smoking. An observation on 05/12/2026 at 11:15AM revealed Resident #49 outside in the smoking area smoking a cigarette. In an interview on 05/14/2026 at 4:38 PM with the DON she stated that the purpose of the care plan was so that staff knew the needs of the resident and how to take care of them. She stated that the facility had transitioned from one system to another and that she assumed that everything in the care plan transferred over. She stated that smoking should be a part of the care plan so that the staff could be aware for safety reasons. She stated that the facility does not have a current in house MDS nurse but corporate MDS nurse has been taking over until new MDS nurse was done training. She stated that care plans were reviewed by nursing and corporate MDS weekly. She stated that Resident #49 was the only resident that smoked at the facility. In a phone interview on 05/14/2026 at 5:00PM with the MDS Regional Nurse, she stated that the purpose of the care plan was to provide information on how to care for the residents. She stated that smoking should be included in the care plan so that staff was aware that resident was a smoker and any adaptive equipment that would be needed for safety. She stated that a potential risk would be miscommunication about residents care. She stated that nursing and herself were responsible for ensuring care plans were up to date. She stated care plans were reviewed quarterly and as needed. In an interview on 05/14/2026 at 6:03 PM with the Administrator he stated that the purpose of the care plan was a way to show what care the Resident was receiving. He stated that if the resident was a smoker, that would have needed to be included in the care plan for safety purposes. He stated that nurses, social worker and the DON were responsible for ensuring that the care plans were updated. He stated that these care plans were reviewed quarterly and as needed. He stated that the potential risk of not including smoking in the care plan would be that the new staff would not be aware of the care needed. He stated that Resident #49 was the only resident at the facility that smoked. Record review of the Nursing Facility's Care Planning Policy, with revision date 12/2024, read in part: The Interdisciplinary team is responsible for the development of resident care plans. It continued, 1. Resident care plans are developed according to the timeframes and criteria established by [state regulation] 483.21 Record review of State Regulation 483.21(b) Comprehensive Care Plans, read in part, (b)(1) The facility must develop and implement a comprehensive care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Findings included: Record review of Resident #4's face sheet dated 05/13/2026, revealed the resident was a [AGE] year-old male with an admission date 04/24/2026. Record review of Resident #4's Physician progress note dated 05/04/2026 revealed a past medical history of the following: Peripheral Vascular Disease (a condition that develops when the arteries that supply oxygen-rich blood to the internal organs, arms, and legs become completely or partially blocked). Record review of Resident #4's Comprehensive MDS dated [DATE], revealed Resident #4 had a BIMS of 15, indicating the resident was cognitively intact. Under Section GG- Functional Abilities – Admission, it was noted Resident #4 was completely Dependent, meaning the helper does all the work to complete the task, for personal hygiene. Record review of Resident #4's care plan with revision date 05/12/2026 did not include ADLs. In an interview and observation on 05/12/2026 at 11:45 AM with Resident #4, he stated he would like his nails cut or trimmed since it was becoming long and uncomfortable. Resident #4 stated he had not been offered a nail trim or cut since being in the Nursing Facility. Resident #4's jagged nails were observed a quarter inch long. In an interview on 05/14/2026 at 09:06 AM with LVN C, she stated MDS nursing or an RN was responsible for the initial care plan which was completed within 48 hours of admission. She stated nursing was responsible for monitoring care plans. She stated the potential risk to residents not having their baseline care plan included not addressing a resident's ADL needs. She stated this could cause a resident to not have the assistance they need. LVN C stated this could also affect the resident's self-esteem or mobility. In an interview on 05/14/2026 at 10:07 AM with RN D, she stated the floor RN would be responsible for the initial care plan. RN D stated if the RN was unavailable, the ADON also assisted and was responsible for the residents' initial care plan and monitoring it, though she was unsure how often it was monitored. RN D stated the potential risks for a resident not having an initial care plan included not addressing a resident's plan of care and the assistance required for ADLs which is a safety concern.

Based on observation, interview and record review, the facility failed to ensure that residents had the right to a safe, clean, comfortable and homelike environment, for 2 of 4 halls observed for environment.The facility failed to ensure the shower room in the 300 hall was clean and free from black particles on the floor of the shower. The facility failed to ensure that the shower room in the memory care unit was free from exposed piping under the sink.The facility failed to ensure that four resident rooms were free from exposed piping under the sink.The facility failed to ensure that one resident room did not have a closet door off its hinge.This failure could place residents, who resided on the 300 and memory care unit, at risk for injury due to exposed piping and missing tiles and decrease in quality of life.Finding included:Resident #5 Record review of Resident # 5's admission record dated 05/13/2026 revealed a [AGE] year-old male with an initial admission date of 05/05/21 and a readmission date of 12/29/25. Record review of Resident # 5's diagnosis list dated 05/13/26 revealed a diagnosis of unspecified dementia with other behavioral disturbances (cognitive decline severe enough to impact daily functioning but exact cause cannot be definitively diagnosed and is accompanied by disruptive behavioral symptoms.) Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed no BIMS score. Record review of Resident #5's care plan revised 02/17/26 revealed Resident #5 had a communication problem related to dementia. Interventions included Ensuring/providing a safe environment, Call light in reach, Adequate low glare light. An observation on 05/12/26 at 9:36 a.m. revealed missing tiles under the sink in the resident #5's restroom leaving exposed piping. Resident #23Record review of Resident # 23's admission record dated 05/13/26 revealed an [AGE] year-old female with an initial admission date of 09/01/25 and a readmission date of 10/06/25. Record review of Resident #23's diagnosis list dated 05/13/26 revealed a diagnosis of dementia without behavioral disturbance (cognitive decline severe enough to impact daily functioning but exact cause cannot be definitively diagnosed). Record review of Resident # 23's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 03 indicating severe cognitive impairment. Record review of Resident #23's care plan revised 02/17/26 revealed Resident #23 had memory loss related to dementia. Goals included living in a safe, nurturing, and stimulating environment. An observation on 05/12/26 at 10:53 a.m. revealed missing tiles under the sink in the resident #23's restroom leaving exposed piping. Resident # 27 Record review of Resident # 27's admission record dated 05/14/2026 revealed a [AGE] year-old female with an initial admission date of 06/12/24 and a readmission date of 12/08/24. Record review of Resident # 27's diagnosis list dated 05/14/2026 revealed a diagnosis of vascular dementia (changes to memory, thinking and behavior resulting from conditions that affect the blood vessels in the brain). Record review of Resident # 27's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 00 indicating severe cognitive impairment. Record review of Resident #27's care plan revised 04/12/2026 revealed risk for falls related to impaired cognitive function and physical limitations. Interventions included providing a safe environment with: (Ex: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach). An observation on 05/12/26 at 11:01 a.m. revealed missing tiles under the sink in the resident #27's restroom leaving exposed piping. Resident #33 Record review of Resident # 33's admission record dated 05/13/2026 revealed a [AGE] year-old female with an initial admission date of 02/21/2023 and a readmission of 11/11/2025. Record review of Resident #33's diagnosis list dated 05/13/2026 revealed a diagnosis of dementia without behavioral disturbance (cognitive decline severe enough to impact daily functioning but exact cause cannot be definitively diagnosed). Record review of Resident #33's Quarterly MDS dated [DATE] revealed a BIMS score of 04 indicating severe cognitive impairment. Record review of Resident #33's Care plan revised 04/12/26 revealed a communication problem related to impaired cognition. Interventions included to anticipate and meet needs. An observation on 05/12/26 at 11:06 a.m. revealed missing tiles under the sink in the resident's #33 restroom leaving exposed piping. Resident # 44 Record review of Resident # 44's admission record dated 05/13/2026 revealed a [AGE] year-old female with an initial admission date of 09/02/2008 and a readmission of 12/09/2024. Record review of Resident #44's diagnosis list dated 05/13/2026 revealed a diagnosis of dementia without behavioral disturbance (cognitive decline severe enough to impact daily functioning but exact cause cannot be definitively diagnosed). Record review of Resident #44's Quarterly MDS dated [DATE] revealed no BIMS score. Record review of Resident #44's Care plan revised 04/12/26 revealed a communication problem related to Alzheimer's dementia and depression. Interventions included to anticipate and meet needs. An observation on 05/12/26 at 10:18 a.m. revealed the closet door off the hinge impeding it from opening and closing properly in Resident #44's room. An observation of the shower room in the 300 hallway on 05/12/26 at 10:27a.m., revealed unknown black particles on the tiles of the shower floor. An observation of the shower room in the memory care unit on 05/12/26 at 11:13am revealed missing sheetrock under the sink leaving the pipes exposed. In an interview on 05/14/26 at 3:24 PM with the Maintenance Director he stated the holes under the sink had been there for 6 months or more due to the pipelines being repaired on that side of the building. He stated the missing sheet rock and tiles were never replaced. He stated the pipes had been repaired about one year ago. He stated that he was responsible for ensuring that the holes were repaired. He stated that exposed piping in the bathrooms posed no risk to the resident. He stated that the shower room in the 300 hall had mold on the tiles of the shower room floor. He stated it had been there for about one week. He stated that housekeeping was responsible for cleaning this up. Regarding the off hinged closet door, he stated that this had not been reported to him. He stated he has a book where all requests for repair were logged in he stated that he looks at the book on every start of the shift daily. He stated that any employee was able to log in what needed repair. He stated that the mold in the shower could potentially affect residents by causing infection. He stated that there had not been any tests conducted to determine if it was mold. In an interview on 05/14/26 at 3:50 PM with Housekeeping Director, she stated that the shower room in the 300-hallway has had mold for more than 3 months. She stated that she has reported this to the administrator in morning meetings. She stated that she has tried non harsh chemicals to try and clean it up but it has not worked. She stated that the residents were at risk for infections. She stated that she was responsible for ensuring that the environment was clean, but that the administrator was also in charge of ensuring that proper cleaning measures were in place. She stated that to her knowledge there had not been any tests conducted to determine if it was mold. In an interview on 05/14/2026 at 4:38 PM with the DON, she stated that the black particles on the tiles and the wall of the 300-hallway shower room were hard water stains. She stated that the tiles from the shower room were changed in 2023 and they needed to be changed again. She stated that the shower rooms were cleaned daily by housekeeping, and housekeeping was responsible for ensuring that all shower rooms were cleaned. She stated that the staff had not reported these hard water stains to her. She stated that these hard water stains posed a risk to the residents as they could cause infection and skin irritation. She stated that there have not been any tests done to determine if it was mold since it was hard water stains. She stated that that shower room was still in use and no residents had been affected. In an interview on 05/14/2026 at 6:07 PM with the Administrator, he stated that he did not know what the black particles on the tiles of the shower room floor and wall were. He stated that the house keeping director has reported that the tiles had some kind of black particles, but that she had tried chemicals to try to clean it up and it had not worked. He stated that the unknown black particle stain had been present for about 5 months. He stated that there was a possible risk to residents as they could be harmed by breathing this in. He stated that it was the responsibility of housekeeping to ensure the shower rooms were maintained clean. He stated that the missing tiles and sheet rock were because a couple of months ago the plumbing was fixed on that side of the building, and they needed access to pipes. He stated that the tiles and sheet rock had to be replaced as soon as the plumbing was fixed. He stated that not having the environment in good repair put the residents at risk for a non-homelike environment, He stated that he and maintenance were responsible for ensuring that these repairs were done. He stated that there have not been any tests done to determine if it was mold. He stated that that shower room was still in use and no residents had been affected. Review of the Nursing Facility's Resident Rights policy, with no date, read in part: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existense; b. be treated with respect, kindness, and dignity.

Based on observation and interview the facility failed to post in a location available for all residents, contact information including telephone numbers of the Long-Term Care Ombudsman program for the facility's postings for 53 residents reviewed for resident rights. The facility's single Ombudsman Program sign was posted on a posterboard on a sticker with small print in the hallway that led to the 200 hall and was not viewable to residents. This failure could place residents at risk of not having access to signs informing them of their rights and resident advocacy groups.The findings include: Observation on 05/12/2026 at 3:00 PM revealed, the ombudsman contact information was posted on the wall leading into the 200 hallway, the contact information was small print on a white sticker. In a confidential interview, 4 of 6 residents did not know how to contact their ombudsman and did not know where they could find her information in the facility. An interview on 05/14/26 at 5:38 PM with the DON, she stated that postings had to be in a visible area where residents and family members could see it. She stated that it had to be large enough for the residents to see and at eye level. She stated that the ombudsman information might be too small for residents to see, but they could always ask any staff member, and they could provide that information to them. She stated that a potential risk would be residents feeling as if they were not able to voice concerns and get the help needed. In an interview on 05/14/26 at 6:07 PM with the Administrator, he stated that the posting had to be posted in an area where it was easily accessible to residents. He stated that the print should be large enough for residents to see, and it should be at eye level for residents in wheelchairs as well. He stated that the current ombudsman information was potentially too small and that it was something that could be fixed. He stated that a potential risk to the residents would be the residents not being able to exercise the right to contact the ombudsman if needed. At 05/14/2026 at 5:11 PM, the DON stated the Nursing Facility did not have a policy regarding the Ombudsman posting.

Based on interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 1 facility reviewed for dignity.-The facility failed to maintain a working air conditioner in the facility van impeding the residents from being able to be taken out into the comunity to do activities. This failure could place residents at risk of diminished quality of life and compromise residents' dignity. Findings included:In a confidential group interview 4 of 6 residents voiced that they were not able to be taken into the community to do activities due to the air conditioner in the van not working. They stated that it had been about 6 months that it had been broken. They stated that it would be nice to be able to go out to the store or to do activities in the community.In an interview on 5/14/2026 at 3:24 PM with the Maintenance Director he stated that the air conditioner in the van had not been working for a year now. He stated that he has taken the van on 2 occasions out to a shop in Midland, he could not recall the name, but that the owner told him that he had too much work and to bring it back another day. There was no documentation provided because the van was not touched by the shop. It was taken for an estimate but again on both occasions that it was taken the van was not touched due to the shop having too much work. He stated that he was able to find another person on Monday 05/11/2026 that was able to pick up the van and take it to be fixed. He stated that the van would be returned with a fixed air conditioner by either today 05/14 or tomorrow 05/15. He stated that at that time the invoice would be provided. He stated that he did not remember the name of the shop that was fixing it and that the administrator would know. He stated that since residents weren't being taken out they may feel like they do not have the means to be taken out to have fun. He stated it was his responsibility and the responsibility of the administrator to ensure that the equipment was working.In an interview on 05/14/26 at 4:38 PM with the DON she stated that she did not know since when the air conditioner was broken. She stated that to her knowledge the van was taken to a shop to be fixed but it was sent back due to the shop having too much work. She stated that the van wasis getting fixed this week and should be back by tomorrow with a new air conditioner. She stated that they stopped using it in the hot months because of the risk to the residents health and possibility of heat stroke. She stated that they could potentially feel sad because they were not able to go out to do activities. She stated that it was the responsibility of the maintenance director and the administrator to ensure equipment was working properly. The option was for residents to have an outing early in the morning before the temperature was too hot. She stated that appointments were kept via ambulance transportation.In an interview on 05/14/26 at 6:03 PM with the Administrator he stated that the air conditioner had not been working for 5 months now. He stated that the maintenance director reported it to him and at that time the van was placed out of commission for resident safety. He stated that the van was taken for air conditioner repair estimate a couple of times out to Midland. He stated that there was no documentation of that because the van was not touched. He stated that the van was taken on 5/11 for repair of the air conditioner and at the time that it was brought back the invoice would be given to them. He did not know the name of the shop. He stated that the maintenance director would know. He stated that it was his responsibility and the maintenance director to ensure that the air conditioner was in working condition for residents. He stated that the residents had a right to go out to the community and this could affect the way they felt. Record review of the Nursing Facility's Resident Rights Policy with revision date 02/2021, read in part: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. dignified existence.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment was as free of accident hazards as possible for 1 of 2 shower rooms reviewed for accidents.-The facility failed to properly store/dispose razors in the community shower room in the 300-hallway on 5/12/26.This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents.Findings included:300 hallway community showerAn observation on 5/12/2026 at 10:28AM revealed a white plastic trash bag tied closed containing multiple disposable razors sitting on top of a container mounted on the wall in the 300 hallway community shower room. In an interview on 05/14/2026 at 8:30 AM with CNA B, she stated aides or the nursing staff were responsible for disposing razors in the sharps containers which were in the shower. CNA B stated the CNAs, and the aides were trained to notify the floor nurse if the sharps containers were filled or closed to be filled so they could be replaced. CNA B stated the potential risk of having exposed razors that were not properly disposed of, including residents wandering in and grabbing the razors and possibly injuring themselves. In an interview on 05/14/2026 at 9:00 AM with LVN C, she stated razors were to be disposed of in the sharps box in the shower room- the aides should dispose of them . She stated if the share containers were overfilled they should notify nursing or other staff to have it removed she stated that this was a risk for injury and infection. In an interview on 05/14/2026 at 10:10 AM with RN D, she stated CNAs were to dispose of razors in the Sharps Container after a one time use on the residents. RN D stated if a Sharps container was observed full or close to full, the CNAs were to notify nursing so it could be replaced. RN D stated not having razors disposed of properly in the Sharps container would put residents at risk for injury to themselves or other residents.In an interview on 05/14/26 at 6:03PM with the Administrator, he stated that all disposable razors were to be disposed of in the sharps container for safety of the residents and saftey of the staff. He stated that it was not acceptable to dispose of them in a plastic bag and to have left them in a place where they were easily accessible to residents because they could potentially hurt themselves. He stated that nursing was responsible for ensuring that razors were disposed of properly. Record review of Nursing Facility's Sharps Disposal policy, dated 2001, read in part: Policy Statement- This facility shall discard contaminated sharps into designated containers. Policy interpretation and Implementation- 1. Whoever uses contaminated sharps will discard them immediately or as soon as feasible into the designated containers. 2. Contaminated sharps will be discarded containers that are: a. closable; b, puncture resistant; c. leakproof on sides and bottom; c. leakproof on sides and bottom; d. labeled or color-coded in accordance with our established labeling system; and, e. impermeable and capable of maintaining impermeability through final waste disposal.

Based on observation, interview, and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living, received the necessary services to maintain good grooming, and personal hygiene, for 1 Resident of 7 residents (Resident #4) reviewed for activities of daily living.The facility failed to provide Resident #4 with nail care on 05/12/2026.This failure could place residents at risk for embarrassment, injury, and infections.The findings included:Record review of Resident #4's face sheet dated 05/13/2026, revealed the resident was a [AGE] year-old male with an admission date 04/24/2026.Record review of Resident #4's Physician progress note dated 05/04/2026 revealed a past medical history of the following: Peripheral Vascular Disease (a condition that develops when the arteries that supply oxygen-rich blood to the internal organs, arms, and legs become completely or partially blocked).Record review of Resident #4's Comprehensive MDS dated [DATE], revealed Resident #4 had a BIMS of 15, indicating the resident was cognitively intact. Under Section GG- Functional Abilities - Admission, it was noted Resident #4 was completely Dependent, meaning the helper does all the work to complete the task, for personal hygiene.Record review of Resident #4's care plan with revision date 05/12/2026 did not include ADLs.In an observation and interview on 05/12/2026 at 11:45 AM with Resident #4, his nails of both hands were observed jagged and a quarter inch long from the nail bed. Resident #4 stated he would like his nails trimmed since it was becoming long and uncomfortable. Resident #4 stated he had not been had been offered to have his nails trimmed since being in the facility. Resident #4 stated he had not been offered a nail trim or cut since being in the Nursing Facility.In an interview on 05/12/2026 at 3:41 PM with CNA A, she stated the nurses provided nail cutting or trims to residents. CNA A stated the nursing aides were to notify the Nurses if a resident was observed with long nails during shower days, which was twice a week or as needed, or if the resident requested a nail trim. CNA A stated the potential risk for residents having long nails or dirty nails included residents scratching themselves causing injury and possible bacteria under the nails, making it an infection control issue.In an interview on 05/14/2026 at 9:36 AM with LVN C, she stated resident fingernails were monitored by the nurses' aides during the residents' shower days. LVN C stated the residents shower 2-3 times a week or as needed. LVN C stated nurses were responsible for trimming diabetic resident nails. LVN C stated residents having long or dirty fingernails was an infection control issue as the residents use their hands to eat or touch their face.In an interview on 05/14/2026 at 11:05 AM with RN D, she stated she did not believe the nursing aides provided nail care. RN D stated nursing aides did notify the floor nurses if residents were observed with long and/or dirty nails so the nurses could follow up. RN D stated the potential risk of long nails included skin tears. RN D stated that if the resident nails were to be dirty, the debri observed under the nails was potentially bacteria which could place the resident at risk for infection.In an interview on 05/14/2026 at 5:41 PM with the DON, she stated that nursing staff were responsible for monitoring and grooming the residents' nails. The DON stated the Floor Nurses were to review the residents' fingernails during the weekly skin assessment, and the nursing aides should be monitoring resident nails daily. The DON stated the potential risks for residents having long fingernails included a cut or infection, if the nails were dirty.In an interview on 05/14/2026 at 6:03 PM with the Administrator, he stated that the residents' fingernails were trimmed as needed and that nursing was responsible for ensuring fingernails were. He stated this was true specifically for the charge of nurses as they monitor the nursing aides. He stated that resident s with long nails could hurt themselves by scratching themselves.Record review of the Nursing Facility's Care of Fingernails/Toenails policy with revision date 10/2010, read in part: Purpose: the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Under General Guidelines, it read in part: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aide in the prevention of skin problems around the nail bed. and, 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 7 (Resident #4) residents reviewed for base line care plans.The facility failed to develop Resident #4's baseline care plan within 48 hours of admission.This failure placed newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.Finding included:Record review of Resident #4's face sheet dated 05/13/2026, revealed the resident was a [AGE] year-old male with an admission date 04/24/2026.Record review of Resident #4's Physician progress note dated 05/04/2026 revealed a past medical history of the following: Wound to the right fingers, Peripheral Vascular Disease (condition characterized by narrowed arteries that reduce blood flow to the limbs, primarily the legs, leading to symptoms like leg pain and cramping), and GERD (a condition causing stomach acid flows back up into the esophagus and causes heartburn).Record review of Resident #4's Comprehensive MDS dated [DATE], revealed Resident #4 had a BIMS of 15, indicating the resident was cognitively intact. Under Section GG- Functional Abilities - Admission, it was noted Resident #4 required the following assistance for ADLs: Setup or cleanup assistance with eating; Partial/moderate assistance with oral hygiene; and Resident #4 was completely dependent, meaning the helper does all the work to complete the task, for personal hygiene, toilet hygiene, showering/bathing, upper and lower body dressing.Record review of Resident #4's care plan with revision date 05/12/2026, with 3 areas of focus which read: (1) resident will do in room and lobby activities, 3 times a week. (2) resident will do in room and lobby activities 3x week. Lastly, (3) the resident has actual impairment to skin integrity of the left lower extremity related to surgical wound (date initiated 05/12/2026, date of Survey Entrance). The care plan did not address resident's medical conditions or ADLs.In an observation and interview on 05/12/2026 at 11:45 AM with Resident #4, his nails of both hands were observed jagged and a quarter inch long from the nail bed. Resident #4 stated he would like his nails trimmed since it was becoming long and uncomfortable. Resident #4 stated he had not been had been offered to have his nails trimmed since being in the facility. Resident #4 stated he had not been offered a nail trim or cut since being in the Nursing Facility.In an interview on 05/14/2026 at 09:06 AM with LVN C, she stated MDS nursing or an RN was responsible for the initial care plan which was completed within 48 hours of admission. She stated nursing was responsible for monitoring care plans. She stated the potential risk to residents not having their baseline care plan included not addressing a resident's ADL needs. She stated this could cause a resident to not have the assistance they need. LVN C stated this could also affect the resident's self-esteem or mobility.In an interview on 05/14/2026 at 10:07 AM with RN D, she stated the floor RN would be responsible for the initial care plan. RN D stated if the RN was unavailable, the ADON also assisted and was responsible for the residents' initial care plan and monitoring it, though she was unsure how often it was monitored. RN D stated the potential risks for a resident not having an initial care plan included not addressing a resident's plan of care and the assistance required for ADLs which is a safety concern.In a phone interview on 05/14/2026 at 2:56 PM with the MDS Regional Nurse, she stated the initial care plan would be completed by the DON. She stated that the floor nursing staff would update as needed. She stated a resident's ADLs were to be included in a care plan. The MDS Regional Nurse stated the potential risk for residents not having their ADLs included in the care plan was a risk for staff improperly transferring to a resident.Record review of the Nursing Facility's Care Planning Policy, with revision date 12/2024, read in part: The Interdisciplinary team is responsible for the development of resident care plans. It continued, 1. Resident care plans are developed according to the timeframes and criteria established by [state regulation] S483.21Record review of State Regulation S483.21(a), read in part: Basline Care Plans (a)(1) The facility must develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) be developed in 48 hours of a Resident's admission. (ii) include the minimum healthcare information necessary to properly care for a resident including but not limited to- (A) initial goals based on admission orders. (B) Physician orders. (C) Dietary Orders. (D) Therapy Services. (E) Social Services. (F) PASARR recommendation, if applicable.

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 to help prevent the development and transmission of communicable diseases and infections for 1 of 2 shower rooms reviewed for infection control. -The facility failed to ensure plastic urinal that was hanging in the community shower room/ bathroom in the 300 hall was not full of urine. This failure could place residents at risk for cross contamination and the spread of infection.Finding included: In an observation on 5/12/2026 at 10:27AM of community bathroom in the 300 hallway revealed a plastic urinal hanging from the grab bar next to the toilet, it contained yellow tinged urine. In an interview on 5/13/2026 at 10:17 AM with CNA A, she stated that urinals were emptied and rinsed out after each use and should not be left in the shower room. She stated that that it was the responsibility of the CNAs to ensure this was being done. She stated that the risk would be that residents might use the urinal with urine already in it; they might spill it in themselves; or drink it. In an interview on 5/14/2026 at 9:00AM with LVN she stated that urinals should not be left in the shower room due to cross contamination possibility. She stated that it was the responsibility of the CNAs and nurses to ensure that the urinals were either disposed of or in the residents room. In an interview on 5/14/2026 at 4:38 PM with the DON she stated that urinals were not to be left in the community shower room due to possibility of cross contamination. She stated that CNAS were to empty it , record output and document it, then rinse out the urinal and taken back to the residents room. She stated that it was the responsibility of the CNAs to ensure that the urinals were not left in the shower room. In an interview on 05/12/2026 at 6:03 PM with the Administrator he stated that urinals were not to be left in the shower room due to infection control. He stated that CNAs were responsible for ensuring that urinals were empty and returned to resident room. He stated that if it were left in the shower room any resident could get a hold of it and possibly ingest the urine.Review of the facility policy titled Infection Prevention and Control Policies and Procedures revised May 15th 2023, read in part . Health care workers will implement universal/standard precautions whenever there is occupational exposure to blood and bodily fluids . designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health for 2 resident 12 residents (Resident #7 and Resident #49) reviewed for foot care.The facility staff CNAs and licensed nurses failed to provide foot care for Resident #7 and Resident # 49 on 05/12/2026This failure could affect residents by placing them at risk for poor foot health, decreased personal hygiene, and a decline in their quality of life.Findings included:Resident #7Record review of Resident #7's face sheet revealed resident was [AGE] year-old male with initial admission date 11/21/24 and re-admission date 10/10/25.Record review of Resident #7's Quarterly MDS dated [DATE], revealed a BIMS of 0, indicating Resident #7 was severely cognitively impaired. Under Section GG- Functional Abilities, it was noted Resident #7 was completely dependent with his personal hygiene, meaning the helper does all the effort to complete the task while the resident does none of the effort.Record review of Resident #7's Health and Physical dated 09/18/25, revealed a medical history of: Alzheimer's disease with behavioral disturbance and Generalized muscle weakness.Record review of Resident #7's care plan with dated 11/21/24 revealed he required assistance with ADL's including personal hygiene.Resident #49Record review of Resident # 49's admission record dated 05/13/2026 revealed an initial admission date of 07/19/2019 and a readmission date of 06/12/2025.Record review of Resident # 49's diagnosis list dated 05/13/2026 revealed a diagnosis of unspecified dementia with other behavioral disturbance (cognitive decline severe enough to impact daily functioning but exact cause cannot be definitively diagnosed and is accompanied by disruptive behavioral symptoms.)Record review of Resident #49's Quarterly MDS assessment dated [DATE] revealed a BIMS of 00 indicating severe cognitive impairment. Section GG- Functional Abilities revealed Resident #49 needed supervision or touching assistance meaning the helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity when completing personal hygiene.Record review of Resident #49's care plan revised on 02/17/2026 revealed Resident #49 has an ADL self-care performance deficit. The interventions included assistance by 1 staff member with personal hygiene.An observation on 05/12/2026 at 10:43a.m., revealed resident #49's toenails to be long, extending about an inch from nail bed. He stated that he would like to get his toenails trimmed, he denied pain. Resident #49 stated he had not been offered to have his toenails trimmed since being in the facility.In an interview on 05/12/2026 at 3:41 PM with CNA A, she stated nursing aides monitor for residents' toenail length twice a week or more, during shower days. CNA A stated nursing aides were responsible for notifying the Nurses if residents' toenails were long or if the resident requested their toenails to be trimmed. CNA A stated the potential risk to the resident included pain and discomfort, especially when wearing shoes.In an interview on 05/14/2026 at 10:06 AM with RN D, she stated that a podiatrist came to the facility about four times a year but that there was no set schedule. She stated that if needed they can refer residents out to see a podiatrist as well. She stated that the risk of having long toenails were ingrown toenails and a potential for infection. She stated that it was the responsibility of the nurses to help schedule residents for these appointments.In an interview on 05/14/2026 at 6:03 PM the administrator stated that a podiatrist comes to the facility every 6 months. The Administrator stated the nurses monitor residents' nails and toenails but was unsure how often. He stated that long toenails can cause pain and shoes not fitting properly.Record review of the Nursing Facility's Care of Fingernails/Toenails policy with revision date 10/2010, read in part: Purpose: the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Under General Guidelines, it read in part: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aide in the prevention of skin problems around the nail bed. and, 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on interview and record review, the facility failed to show evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 2 of 5 residents (Resident #7 and #44) reviewed for injuries of unknown origin.The facility investigated but failed to report to the State Survey Agency when Resident #7 had an unwitnessed fall on 05/02/2026 that resulted in a laceration on the left side of the resident's forehead, and left wrist. The facility failed to investigate an injury of unknown origin for Resident #44 resulting in bruising around the right eye and a laceration above the right eyebrow on 05/09/2026. These failures could place residents in the facility with dementia at risk of not receiving timely investigations and reporting of injuries of unknown origin. Resident #44 Record review of Resident # 44's admission record dated 05/13/2026 revealed a [AGE] year-old female with an initial admission date of 09/02/2008 and a readmission of 12/09/2024. Record review of Resident #44's diagnosis list dated 05/13/2026 revealed a diagnosis of dementia without behavioral disturbance (cognitive decline severe enough to impact daily functioning but exact cause cannot be definitively diagnosed). Record review of Resident #44's Quarterly MDS dated [DATE] revealed no BIMS score. Section GG- Functional Abilities revealed Resident #44 needed substantial/ maximal assistance meaning helper did more than half the effort. Helper lifts or holds or supports trunk or limbs, but provides more than half the effort for rolling left and right, sit to lying position and sit to standing position. Record review of Resident #44's Care plan revised 04/12/26 revealed a communication problem related to Alzheimer's dementia and depression. Interventions included to anticipate and meet needs. Resident #44 had the potential for injury related to history of falls and was at risk for further falls related to cognitive impairment due to short term memory deficit and impaired safety awareness. Interventions included Ensure staff was aware of safety needs of the resident Record review of incident progress note dated 05/09/26 stated that the CNA entered the room to provide incontinent care and noticed that the resident had brusing to right eye and a small skin tear above the right eyebrow and on the side of the right eye. It also stated that resident had hit head on bedside dresser. Record review of Incident Report dated 5/9/2026 stated a skin tear above right eyebrow and side of right eye was cleansed with normal saline and it was reported to the DON and Physician. Record review of 15 minute Neurological Evaluations dated 05/09/2026 and 05/10/2026 revealed Resident #44 did not have any neurological changes. Record review of 30 minute Neurological Evaluations dated 05/10/2026 revealed Resident #44 did not have any neurological changes Record review of 1 hour Neurological Evaluation dated 05/10/2026 revealed Resident #44 did not have any neurological changes Record review of 4 hour Neurological Evaluation dated 05/10/2026 and 05/11/2026 revealed Resident #44 did not have any neurological changes. Record review of 8 hour Neurological Evaluation dated 05/11/2026, and 05/12/2026 revealed Resident #44 did not have any neurological changes An observation on 5/12/2026 at 12:15 p.m., of Resident #44 in the dining room revealed she had bruising around the right eye and a small laceration above the right eyebrow. She was not able to verbalize to surveyor what had happened or how she had obtained these injuries Findings include: Record review of Resident #7's face sheet revealed resident was [AGE] year-old male with initial admission date of 11/21/24 and re-admission date of 10/10/25. Record review of Resident #7's Quarterly MDS dated [DATE], revealed a BIMS score of 0, indicating Resident #7 was severely cognitively impaired. Record review of Resident #7's Health and Physical dated 09/18/25, revealed a medical history of: Alzheimer's disease with behavioral disturbance (a form of dementia, a progressive brain disorder that primarily affects memory, thinking, and behavior); and, Generalized muscle weakness. Record review of Resident #7's Care Plan revision date 05/13/26 revealed Resident #7 was at risk for falls due to his Alzheimer's disease and generalized muscle weakness, which included staff interventions of fall mat on the floor, call light within reach, and bed in lowest position. Record review of Resident #7's Incident Report (IR) dated 05/02/26, completed by LVN C, noted she was alerted by Nurse Aide that Resident #7 was found on the floor in the middle of his room facing his bed (Bed A, closest to the resident's room door). He was found with a 1 cm approximation facial laceration to his left side of forehead and a small laceration on his left wrist with bleeding observed from both sites. LVN C completed a physical assessment and treated Resident #7's bleeding per IR. LVN C notified Responsible Part of Resident #7, ADON, DON, Administrator, and Resident #7's physician. Resident #7 was ordered to be further evaluated and treated at the Hospital for post-fall. Record review of Resident #7's Progress notes revealed Resident #7 returned to Nursing Facility 05/02/26. Hospital documentation dated 05/02/26 revealed Resident #7 was negative for acute findings for CT scan of Head and Left Arm. There were no new orders noted related to Resident #7's fall. An observation was made on 05/12/26 at 9:10 AM of Resident #7 who was lying in bed covering his face, upper body, and most of his lower body. A fall mat was observed placed on the floor next to his bed, resident had call light within reach. Resident #7 did not answer this Surveyor during an interview attempt. Resident #7 did not have a roommate during incident or during HHSC State Survey 05/12/2026. In an interview on 05/14/26 at 10:15 AM with LVN C, she stated she was notified by a Nurse Aide that she heard a noise and went to Resident #7's room when Resident #7 was found in the middle of his room's floor. LVN C stated the Nurse Aide notified her immediately while still staying with him and not moving the resident. LVN C stated Resident #7 was assessed and there was a small amount, drops of blood, on Resident #7's left side of his forehead, and left wrist. LVN C stated the ADON, DON, Administrator, Physician, and Resident #7's Responsible Party were notified after the fall. She stated Resident #7 was sent to the E.R. via ambulance and came back that day with no acute findings or acute physical injuries. LVN C stated Resident #7 does not communicate or able to explain what caused the fall. She stated Resident #7 was a fall risk and was rounded every 2 hours or as needed. In an interview on 05/14/2026 at 12:40 PM with LVN G she stated that on the night of 05/09/26 she was called by one of the CNAs to Resident #44's room, the CNA stated to her that she had hit her head on the night stand that was on the right side of her bed because she was restless and moving a lot. She stated that this was told to her by the CNA, however this incident was unwitnessed and the CNA believed this had happened since the injuries were on the right-side of the residents face. She stated that neurological checks were initiated, the physician, DON, and administrator were contacted. Resident was to be monitored and no other orders given. She stated that resident was not capable of stating what had happened due to her cognition. In an interview on 05/14/2026 at 4:38 PM with the DON she stated that LVN G reported to her that the resident #44 had hit her head on the side table to the right of the residents bed. She stated that the incident was unwitnessed but it was the only thing that could have caused it because it was the closest object to the resident that could have caused injury because residents head was positioned towards bedside table She stated that the resident did not have a fall. She stated that she investigated the situation by asking the staff present that night what had happened and based on their knowledge of the resident she stated that she knows that the resident moves in bed a lot and tries to get out of bed. This was the reason why she did not believe at the time that it had to be reported to State Survey Agency. She stated that based on the Abuse and Neglect policy, this incident would have had to have been reported to the State Survey agency due to the incident being unwitnessed and the Resident not being capable of voicing what had happened due to her cognition. She stated that a risk for the residents would be a safety issue. The DON stated Resident #7 was unable to explain what happened and answers with guidance, such as answering yes or no questions, but he will not always answer. The DON stated a CNA found Resident #7 on the floor in his room and notified the floor nurse. The DON stated Resident #7 was assessed and sent to the hospital for further evaluation or treatment. There were no acute physical injuries reported including fractures. The DON stated Resident #7 was found by himself in the room and he was unable to explain what happened. The DON stated for unwitnessed falls, it was to be reported to their Administration including herself, and to HHSC. She stated Administration was responsible for investigating allegations of abuse, neglect, and injuries of unknown origin. In an interview on 05/14/2026 at 6:03 PM with Administrator he stated that this incident was not reported to him, he did not know that the Resident #44 had an incident. He stated that when an unwitnessed incident happens, the staff was to report to DON and to himself, as he was the Nursing Facility's Abuse Coordinator, so that they can initiate an investigation. He stated that he would have needed to report this incident to the State Survey Agency because it was unwitnessed, and the resident could not verbalize what had happened. He stated that lack of investigation and reporting could potentially put the resident at risk further for potential abuse if there was a perpetrator. The Administrator stated he was notified of Resident #7's fall incident by the nurse on shift via phone. He stated he recalled Resident #7 did not have fractures or acute injuries. The Administrator stated Resident #7 could not explain what happened to the him when found in the floor, and Resident #7 did not have a roommate. The Administrator stated Resident #7 needs redirection during conversations. The Administrator stated it was an unwitnessed fall so it warranted for an investigation. The administrator stated if Resident #7's fall resulted in injury, it would be reported to HHSC but was unsure if unwitnessed falls were to be reported to HHSC. Record review of Nursing Facility's Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating Policy, dated 09/2022, read in part: All reports of resident abuse (including injuries of unknown origin),neglect . are reported to local, state and federal agencies (as required by current regulations)and thoroughly investigated by facility management. Findings of all investigations are documented and reported. It also read under Investigating Allegations, 7. All allegations are thoroughly investigated. The Administrator initiates the investigations. 8. Investigations may be assigned to an individal trained in reviewing, investigating and reporting such allegations. 9. The administrator provides supporting documents and evidence related to the alleged incident to the individual incharge of the investigation. Under Follow-Up Report, it read,1. Within five business days of the incident, the administrator will provide a follow-up investigation report.

Based on observation, interview and record review, the facility failed to report an injury of unknown source, immediately, but not later than 2 hours after the allegation was made, to other officials in accordance with State law, including to the State Survey Agency for 2 of 5 residents reviewed for falls. (Residents #7, #44)The facility investigated but failed to report to the State Survey Agency when Resident #7 had an unwitnessed fall on 05/02/2026 that resulted in a laceration on the left side of the resident's forehead, and left wrist.The facility failed to report to the State Survey Agency when Resident #44 sustained an unwitnessed bruise to right eye and a laceration to forehead and was unable to state how the injury occurred on 05/09/2026.The facility failed to report when a pipe burst, and the sprinkler system malfunctioned on 01/27/2026. These failures could place residents who require assistance with mobility at risk for non-reported serious bodily injury. Resident #44 Record review of Resident # 44's admission record dated 05/13/2026 revealed a [AGE] year-old female with an initial admission date of 09/02/2008 and a readmission of 12/09/2024. Record review of Resident #44's diagnosis list dated 05/13/2026 revealed a diagnosis of dementia without behavioral disturbance (cognitive decline severe enough to impact daily functioning but exact cause cannot be definitively diagnosed). Record review of Resident #44's Quarterly MDS dated [DATE] revealed no BIMS score. Section GG- Functional Abilities revealed Resident #44 needed substantial/ maximal assistance meaning helper did more than half the effort. Helper lifts or holds or supports trunk or limbs, but provides more than half the effort for rolling left and right, sit to lying position and sit to standing position. Record review of Resident #44's Care plan revised 04/12/26 revealed a communication problem related to Alzheimer's dementia and depression. Interventions included to anticipate and meet needs. Resident #44 had the potential for injury related to history of falls and was at riskfor further falls related to cognitive impairment due to short term memory deficit and impaired safety awareness. Interventions included Ensure staff was aware of safety needs of the resident. Record review of incident progress note dated 05/09/26 stated that the CNA entered the room to provide incontinent care and noticed that the resident had brusing to right eye and a small skin tear above the right eyebrow and on the side of the right eye. It also stated that resident had hit head on bedside dresser. Record review of Incident Report dated 5/9/2026 stated a skin tear above right eyebrow and side of right eye was cleansed with normal saline and it was reported to the DON and Physician. Record review of 15 minute Neurological Evaluations dated 05/09/2026 and 05/10/2026 revealed Resident #44 did not have any neurological changes. Record review of 30 minute Neurological Evaluations dated 05/10/2026 revealed Resident #44 did not have any neurological changes Record review of 1 hour Neurological Evaluation dated 05/10/2026 revealed Resident #44 did not have any neurological changes Record review of 4 hour Neurological Evaluation dated 05/10/2026 and 05/11/2026 revealed Resident #44 did not have any neurological changes. Record review of 8 hour Neurological Evaluation dated 05/11/2026, and 05/12/2026 revealed Resident #44 did not have any neurological changes An observation on 5/12/2026 at 12:15 p.m., of Resident #44 in the dining room revealed she had bruising around the right eye and a small laceration above the right eyebrow. She was not able to verbalize to surveyor what had happened or how she had obtained these injuries. Findings include: Record review of Resident #7's face sheet revealed resident was [AGE] year-old male with initial admission date of 11/21/24 and re-admission date of 10/10/25. Record review of Resident #7's Quarterly MDS dated [DATE], revealed a BIMS score of 0, indicating Resident #7 was severely cognitively impaired. Record review of Resident #7's Health and Physical dated 09/18/25, revealed a medical history of: Alzheimer's disease with behavioral disturbance (a form of dementia, a progressive brain disorder that primarily affects memory, thinking, and behavior); and, Generalized muscle weakness. Record review of Resident #7's Care Plan revision date 05/13/26 revealed Resident #7 was at risk for falls due to his Alzheimer's disease and generalized muscle weakness, which included staff interventions of fall mat on the floor, call light within reach, and bed in lowest position. Record review of Resident #7's Incident Report (IR) dated 05/02/26, completed by LVN C, noted she was alerted by Nurse Aide that Resident #7 was found on the floor in the middle of his room facing his bed (Bed A, closest to the resident's room door). He was found with a 1 cm approximation facial laceration to his left side of forehead and a small laceration on his left wrist with bleeding observed from both sites. LVN C completed a physical assessment and treated Resident #7's bleeding per IR. LVN C notified Responsible Part of Resident #7, ADON, DON, Administrator, and Resident #7's physician. Resident #7 was ordered to be further evaluated and treated at the Hospital for post-fall. Record review of Resident #7's Progress notes revealed Resident #7 returned to Nursing Facility 05/02/26. Hospital documentation dated 05/02/26 revealed Resident #7 was negative for acute findings for CT scan of Head and Left Arm. There were no new orders noted related to Resident #7's fall. An observation was made on 05/12/26 at 9:10 AM of Resident #7 who was lying in bed covering his face, upper body, and most of his lower body. A fall mat was observed placed on the floor next to his bed, resident had call light within reach. Resident #7 did not answer this Surveyor during an interview attempt. Resident #7 did not have a roommate during incident or during HHSC State Survey 05/12/2026. In an interview on 05/14/26 at 10:15 AM with LVN C, she stated she was notified by a Nurse Aide that she heard a noise and went to Resident #7's room and found Resident #7 in the middle of his room floor. LVN C stated the Nurse Aide notified her immediately while still staying with him and not moving the resident. LVN C stated Resident #7 was assessed and there was a small amount, drops of blood, on Resident #7's left side of his forehead, and left wrist. LVN C stated the ADON, DON, Administrator, Physician, and Resident #7's Responsible Party were notified after the fall. She stated Resident #7 was sent to the E.R. via ambulance and came back that day with no acute findings or acute physical injuries. LVN C stated Resident #7 does not communicate or able to explain what caused the fall. She stated Resident #7 was a fall risk and was rounded every 2 hours or as needed. In an interview on 05/14/2026 at 12:40 PM with LVN G she stated that on the night of 05/09/26 she was called by one of the CNAs to Resident #44's room. The CNA stated to her that she had hit her head on the night stand that was on the right side of her bed because she was restless and moving a lot. She stated that this was told to her by the CNA, however this incident was unwitnessed and the CNA believed this had happened since the injuries were on the right-side of the residents face. She stated that neurological checks were initiated, the physician, DON, and administrator were contacted. Resident was to be monitored and no other orders given. She stated that resident was not capable of stating what had happened due to her cognition. In an interview on 05/14/2026 at 4:38 PM with the DON she stated that LVN G reported to her that Resident #44 had hit her head on the side table to the right of the residents bed. She stated that the incident was unwitnessed but it was the only thing that could have caused it because it was the closest object to the resident that could have caused injury because resident's head was positioned towards bedside table. She stated that the resident did not have a fall. She stated that she investigated the situation by asking the staff present that night what had happened and based on their knowledge of the resident she stated that she knows that the resident moves in bed a lot and tries to get out of bed. This was the reason why she did not believe at the time that it had to be reported to State Survey Agency. She stated that based on the Abuse and Neglect policy, this incident would have had to have been reported to the State Survey agency due to the incident being unwitnessed and the Resident not being capable of voicing what had happened due to her cognition. She stated that a risk for the residents would be a safety issue. The DON stated Resident #7 was unable to explain what happened and answers with guidance, such as answering yes or no questions, but he will not always answer. The DON stated a CNA found Resident #7 on the floor in his room and notified the floor nurse. The DON stated Resident #7 was assessed and sent to the hospital for further evaluation or treatment. There were no acute physical injuries reported including fractures. The DON stated Resident #7 was found by himself in the room and he was unable to explain what happened. The DON stated for unwitnessed falls, it was to be reported to their Administration including herself, and to HHSC. In an interview on 05/14/2026 at 6:03 PM with the Administrator he stated that this incident was not reported to him, he did not know that Resident #44 had an incident. He stated that when an unwitnessed incident happens, the staff was to report to DON and to himself, as he was the Nursing Facility's Abuse Coordinator, so that they can initiate an investigation. He stated that he would have needed to report this incident to the State Survey Agency because it was unwitnessed, and the resident could not verbalize what had happened. He stated that lack of investigation and reporting could potentially put the resident at risk further for potential abuse if there was a perpetrator. The Administrator stated he was notified of Resident #7's fall incident by the nurse on shift via phone. He stated he recalled Resident #7 did not have fractures or acute injuries. The Administrator stated Resident #7 could not explain what happened to him when found in the floor, and Resident #7 did not have a roommate. The Administrator stated Resident #7 needs redirection during conversations. The Administrator stated it was an unwitnessed fall so it warranted for an investigation. The administrator stated if Resident #7's fall resulted in injury, it would be reported to HHSC but was unsure if unwitnessed falls were to be reported to HHSC. Sprinkler system In an interview on 05/13/26 at 1:50 PM with the Administrator, he stated the sprinklers froze and burst over a weekend in January 2026. He stated he called in to report it to HHSC and followed the Nursing Facility protocol. The Administrator stated he left a message regarding the incident and when that happened, he typically received a call back the following Monday if a message was left but he did not receive a callback. The Administrator stated he did not follow up with the incident report with HHSC and he could not recall on why not. In an interview on 05/14/2026 at 3:24PM with the maintenance director, he stated that in January the sprinkler pipes froze due to weather and they burst. He stated that the alarms went off and the fire department came. He stated that the issue was fixed the next day and fire watches were initiated. He stated that he was not sure if the administrator reported this incident to the State Survey Agency, but he stated that it would have been something to report as malfunctioning of sprinklers could be a potential hazard to resident safety. In a follow up interview on 05/14/2026 at 6:05PM with the Administrator, he stated that regarding the sprinkler system, this incident happened back in January during freezing temperatures. He stated that one of the pipes burst and water was leaking out affecting the sprinkler system in the facility. The fire department was called to help with the situation, and the alarm company also sent someone out to shut off the alarm. He stated that he did report the incident via phone call, to the State Survey Agency but he did not follow up with it when he did not receive a phone call back because he was busy doing fire watches. He stated it took a total of 3 days to fix the issue. He stated that none of the residents were affected and that they did not need to evacuate the building. In a phone interview on 05/14/2026 at 3:51 PM with the Director of Regional Compliance, she stated she was notified of the Sprinkler system incident by the Administrator or a staff from the Regional team the day it happened. The Director of Regional Compliance stated it was repaired that day 01/27/2026, and no residents were evacuated. She stated there was no potential risk since the fire watch was initiated when the incident occurred that day. Record review of Nursing Facility's Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating Policy, dated 09/2022, read in part: All reports of resident abuse (including injuries of unknown origin),neglect . are reported to local, state and federal agencies (as required by current regulations)and thoroughly investigated by facility management. Findings of all investigations are documented and reported. It continue to read, Reporting Allegations to the Administrator and Authorities- 1. If resident abuse, neglect . or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines. 2. The administrator or the individal making the alllegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility.

Based on interviews, observations and record reviews the facility failed to ensure residents were free from neglect for 1 (Resident #52) of 5 residents reviewed for neglect. The facility failed to ensure a system was in place to determine staff had been properly educated, had current documented training and were able to demonstrate proper procedures for securing a resident's wheelchair in the facility van. On [DATE], Certified Nurse Aide (CNA) A was transporting Resident #52, when the resident fell out of her wheelchair while coming to an abrupt stop and Resident #52 sustained multiple fractures to her left leg. The facility failed to ensure it followed its policy and procedure for investigating and reporting suspicious incidents when CNA A could not give a reasonable explanation of how Resident #52 fell from her wheelchair, there was no further investigation which resulted in CNA A continuing to transport residents in the facility van although she continued to be untrained on the proper procedures for securing a resident in a wheelchair from the time of the incident on [DATE] through her termination on [DATE]. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm at a scope of isolated due to the facility needing more time to monitor the plan of removal for effectiveness. These failures placed the residents who were to be transported in the facility van at risk for serious injury or death if not secured properly. Findings included: Record review of the facility's policy undated titled Abuse policy indicated in part: The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure. The facility administrator is appointed abuse coordinator and in his/her absence a designee will be appointed. Abuse is a willful infliction of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or paint to a resident; or sexual abuse. The administrator and/or designee are responsible for maintain ALL facility policies that prohibit abuse, neglect and misappropriation of funds/personal belongings, involuntary seclusion or corporal punishment. Screen potential employees - Train all employees - Identification of possible problems that need investigation - Investigating allegations - Reporting incidents, investigations and facility response to results of investigation with mandated time frames. Training: All employees are required to be trained in issues related to abuse prohibition practices. Training includes orientation and ongoing sessions. Staff will be knowledgeable in recognizing suspicious bruising, swelling, pain or other injuries. Documentation of this training will be available upon request. Prevention: The facility has in place policies and procedures to aid in the prevention of abuse, neglect, mistreatment, exploitation, involuntary seclusion and misappropriation of resident property. The following will be done. Each employee receives the standard of conduct which includes the standard for prohibiting abuse or neglect of a resident and the reporting of any suspected abuse or neglect of a resident. Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation. Upon notification of an allegation of physical or mental abuse, neglect or involuntary seclusion, the facility will conduct interviews that include documented statements summaries from the alleged perpetrator, the alleged victim, family members, visitors who may have made observations, roommate and any staff who worked prior to and during the time of the incident. Interviews may include employees of various departments and shifts. Investigations will focus on determining if the abuse occurred, the extent of the abuse and potential cause(s). All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown injury must be reported immediately or not later than 2 hours of alleged violation. The abuse coordinator with the Director of Nursing/designee will investigate all allegations and use the appropriate forms to document the investigation and turn it in to HHS within 5 calendar days. Upon completion of an investigation, the Director of Nursing and Administrator will analyze the occurrences and determine what changes, if any, are needed to prevent further occurrence. All documentation of investigation must be protected and made available upon request. When there is no resolution to the suspected abuse, but there is indication that the abuse occurred, the facility will immediately conduct an in-service on abuse and will notify staff that there is strong suspicion of abuse occurring and it will not be tolerated. Record review of Resident #52's admission record dated [DATE] indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #52's order summary report for (MONTH) 2020 indicated in part: ADL - Mobility: up in w/c or rolling recliner, as tolerated, may use Hoyer lift prn, assist x2/transfer x2. Fall precautions at all times. Every shift. (PRN = as needed. ADL = activities of daily living). Record review of Resident #52's Minimum Data Set ((MDS) dated [DATE] indicated in part: Brief Interview Mental Status (BIMS) = 14 indicating the resident was cognitively intact. Functional status: Resident was total dependence for transfers. Resident was a 2 plus persons for physical assist. Mobility devices = resident used wheelchair for mobility. Record Review of a facility Incident and Accident Report dated [DATE] at 7:00pm and revised on [DATE] at 7:36pm indicated the following; Resident #52 had been out of the facility /during a transport. Nursing Description: Resident slid out of her wheelchair while in the facility van returning from a doctor appointment. Resident Description: Per resident, slid off of wheelchair due to netting from lift. Landed on her bottom directly in front of her wheelchair. Immediate Action Taken: Upon return to facility, the resident was assessed. Resident denies pain at this time. V/S 98.1, 80, 20, ,[DATE]. Small dark purple bruise noted to left lower extremity 3.5cm X 1.4cm fading purple bruise noted to left lower extremity. Resident was not taken to the hospital. Injuries Observed at Time of Incident: Bruise to Left lower leg. Level of Pain: 5 (On scale of ,[DATE]). Level of consciousness: Alert, Oriented to person, place, time and situation. Denies pain at this time. Record review of the facility's Provider Investigation Report (PIR) regarding Resident #52 indicated there was no PIR for the incident that occurred on [DATE]. Record review of the facility's PIR dated [DATE] indicated in part: Who made this allegation? Individual/Patient. When? [DATE]. Name: Resident #52. Alleged Perpetrator: CNA [NAME] Description of the allegation: On [DATE]. 2020 Resident #52 alleged that she wasn't strapped in the van during transportation and that she was going to sue the facility because that's how she fell . Description of injury: On [DATE]. 2019 the community received phone call from CNA [NAME] Stated that she was driving facility vehicle after leaving orthotics appointment and came to a stop light. Stated when she came to a complete stop, resident slid out of the wheelchair. Per CNA A wheelchair remained in place as it was secured to the vehicle with straps. CNA A stated she was unable to solely transfer resident back to wheelchair, so she called EMS for assistance, Per CNA A EMS staff examined esident and found everything to be ok. With the assistance of EMS resident was transferred back to wheelchair, secured they made their way back to the community. Upon arrival to the community Resident #52 was assessed by charge nurse LVN F, resident denies any pain or showed any signs or symptoms of emotional distress. Date [DATE] Time 7:00pm. Investigation summary: On [DATE]. 2019 the community received phone call from CNA [NAME] Stated that she was driving facility vehicle after leaving orthotics appointment and came to a stop light. Stated when she came to a complete stop, resident slid out of the wheelchair. Per CNA A wheelchair remained in place as it was secured to the vehicle with straps. CNA A stated she was unable to solely transfer resident back to wheelchair, so she called EMS for assistance, Per CNA A EMS staff examined esident and found everything to be ok. With the assistance of EMS resident was transferred back to wheelchair, secured they made their way back to the community. Upon arrival to the community Resident #52 was assessed by charge nurse LVN F, resident denies any pain or showed any signs or symptoms of emotional distress. Per LVN F resident stated that she slides out the wheelchair because of her sling. The following day resident complained of pain to left lower leg. Per resident stated that she was strapped in and that CNA A always strapped her in. Per resident she stated that slide out right in front of the chair on her butt. On [DATE] Administrator and Assistant Director of Nurses (ADON) interviewed CNA A who was transporting Resident #52. Per CNA A I always strapped the residents in before I leave and I did the two finger check, then I asked her if it was tight and she said no the seatbelt was not tight When CNA A was asked how did the resident fall stated that she slide put her wheelchair and was laying in front of the wheelchair. Investigation findings: Confirmed. Signed by Administrator on [DATE]. Review of Resident #52's Nursing Progress Notes dated [DATE] at 6:02pm indicated the following; Received phone call at this time from CNA [NAME] Stated she was driving facility vehicle after leaving orthotics appointment and came to a stop light. Stated when she came to a complete stop, resident slid out the wheelchair. Per CNA A wheelchair remained in place as it was secured to the vehicle with straps. CNA A stated she was unable to solely transfer resident back to wheelchair, so she called EMS for assistance. Record review of Resident #52's nurses notes dated [DATE]. 10:30am indicated in part: CNA C reported resident complain of pain to left leg. Upon assessment, resident with [MEDICAL CONDITION]/bruise to left leg below knee. Per resident has pain with movement of left leg. MD aware, ordered x-ray to left leg. Mobile imaging contacted for x-ray. Review of a Mobile Medical X-Ray Services report dated [DATE] indicated the following significant findings; ---IMPRESSION: Acute appearing proximal tibial fracture, as described. Suspicion of extension of the fracture 10 the proximal tibial articular surface. Joint effusion, Clinical correlation recommended. I strongly recommend consideration of further assessment of this fracture with CT. Pretibial soft tissue swelling hematoma, as above. Remote-appearing distal femoral fracture with medial plate and multiple screw fixation. The findings at the fracture site are worrisome for partial non-union. Clinical correlation recommended. ---IMPRESSION: Please see report of left knee radiographs for findings at the distal femur, knee, and proximal tibia and fibula. Nondisplaced acute appearing distal fibular shaft fracture, Soft tissue swelling, I recommend further assessment with CT. Review of Resident #52's Nursing Progress Notes dated [DATE] at 10:42pm indicated the following; Doctor notified of X-ray results Fractured Left Femur, fractured left tibia and left fibula. Gave orders to send resident to ER (emergency room ). Notified emergency room , emergency contact and EMS for transport. (EMS = Emergency Medical Services). During an interview on [DATE] at 11:42 a.m. Resident #52 said she went to a doctor's appointment on [DATE]. Resident #52 said the van driver (CNA A) had to stop suddenly and she slid off the wheelchair and landed on her butt. Resident #52 said CNA A had tried to get her up but couldn't, so the van driver called 911 and Emergency Medical Technicians (EMTs) came and helped put her back in the wheelchair. Resident #52 said the EMTs asked her if she was buckled up good and she told she did not know. Resident #52 said the EMTs made sure she was secured to the wheelchair. Resident #52 said they then came back to the nursing home and the CNA A took her to her room and she was fine. Resident #52 said she was blind and could only see light and shadows. Resident #52 said she could not tell if the CNA A had secured her correctly because she was blind and assumed the CNA A had put on the seat belts correctly. Resident #52 said the next day she felt pain between her knee and ankle. Resident #52 said the facility took her to the hospital, was x-rayed and she was told she had a fracture to her knee and ankle. Resident #52 said they did surgery on her leg. During a telephone interview on [DATE] at 6:16 p.m. CNA A said she and Resident #52 we were coming back from an out of town doctor's visit and she was driving the van on [DATE]. CNA A said it had rained that day. CNA A said it was just her and Resident #52 in the van. CNA A said she had to turn quickly due to a puddle of water on the road and the next thing she knew Resident #52 was on the floor of the van. CNA A said she pulled over and tried to put the Resident #52 back in her wheelchair, but she was unable to. CNA A said she called 911 and EMTs came and placed the resident back in her wheelchair. CNA A said the EMTs asked the resident if she was fine and the resident told them she was fine. CNA A said all the seatbelts were strapped correctly so she did not know how the resident fell out of her wheelchair. CNA A said she called the facility and told them that the resident had fallen out of the wheelchair but that the resident had stated she was fine. CNA A said when she got back to the facility they asked her what happened, so she explained it to them and then left for the day. CNA A said she continued to be the van driver, then on [DATE], the facility did their investigation of the incident on [DATE] and then they suspended her. CNA A said later the facility called her and told her that she had not done the procedures correctly and had not secured resident correctly. CNA A said she told them that they should have done an incident report then done their investigation when the incident occurred, but they waited till later. CNA A said the facility then terminated her because they said it was her fault the resident fell . CNA A said she had not been trained on securing the residents on the van. CNA A said she just made sure all 4 wheels were secured and the breaks on the wheelchair were on and the seatbelt was secured to the resident. Record review of CNA A's Facility offer letter dated [DATE] indicated part: Reason for hire - new hire. Position title - CNA + transportation. Immediate supervisor - ADON. During an interview on [DATE] at 10:12 a.m. the Human Resources director said she had only conducted the hiring process for CNA A but did not have documentation regarding any training for securing wheelchairs to the van. The HR director said nursing might have some of the training documentation. During an interview on [DATE] at 10:16 a.m. the ADON said she did not know if they had any documentation regarding securing wheelchairs to the van for CNA [NAME] The ADON said she thought someone had trained CNA A on securing the wheelchairs to the van. The facility was unable to provide any documentation indicating CNA A had been trained on securing wheelchairs on the van that included CNA A's acknowledgement or signature. During a telephone interview on [DATE] at 10:28 a.m. CNA B said she was the current van driver. CNA B said she had been trained on how to secure the wheelchair to the van by the previous Administrator; however, it had been approximately 4 years ago. CNA B said she had not been trained recently just from when the other Administrator trained them. During an interview on [DATE] at 10:48 a.m. the Administrator said she had been the Administrator at the facility since [DATE]. The Administrator said on [DATE] Resident #52 was taken to a doctor's appointment and she slid out of her wheelchair. The Administrator said CNA A called the facility and told them the resident had fallen out of her wheelchair and she called 911 and they helped put the resident back on the wheelchair. The Administrator said Resident #52 was sitting on the Hoyer sling which might have caused the resident to slide out. The Administrator said Resident #52 did not complain of any pain until the next day on [DATE], she said x-rays were done and revealed the resident had fractures. The Administrator said she had started training staff on securing the wheelchair correctly to the van on [DATE]. The Administrator said the training had all been verbal so far and there had been no actual demonstration on securing a wheelchair the van. The Administrator said she had been trained on how to secure wheelchairs to the van by CNA B. The Administrator said they had not reported the fall to the State initially due to determining the fall had been witnessed by CNA [NAME] The Administrator said they decided to report it later on [DATE] because Resident #52 had alleged that she had not been secured properly and that was the reason she had fallen. The Administrator said she was not working at the facility at the time CNA A had been hired so she did not know who had trained CNA A on securing wheelchairs on the van. Review of the undated Facility Van Instructions on Securing a Wheelchair indicated the following; ---Place Wheelchair facing forward in securement area; apply wheel locks or turn power off. ---Attach tie-downs into floor anchorages and ensure they are locked in. ---Attach the four tie-down hooks to solid frame members or weldments, near seat level. Ensure tie-downs are fixed at approximately 45 degrees and are within angles shown. Do not attach hooks to wheel, plastic, or removable parts of wheelchair. ---Ensure all tie-downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knobs (if present) to take up additional webbing slack. ---WARNING: Do not allow webbing to twist inside retractors. Wheelchair accessories and equipment should be properly secured or removed from wheelchair and secured in the vehicle transportation. Whenever possible, items attached to wheelchair in front of the passenger should be removed and secured separately during transportation. Review of the undated Facility Van Instructions on Securing Passenger indicated the following: ---Attach lap belts-Use integrated stiffeners to feed belts through opening between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant. ---On the aisle side, attach belt with female buckle to rear tie-down pin connector ensuring buckle rests on passengers' hip. ---On window-side, attach belt with male tongue to rear tie-down pin connector and insert into female buckle. --Attach Shoulder Belt- Extend shoulder belt over passenger's shoulder and across upper torso and fasten pin connector onto lap belt. Note: Combination lap/shoulder belts serve both window-side lap belt and shoulder belt. ---Ensure belts are adjusted as firmly as possible, but consistent with user comfort. ---WARNING: Lap and shoulder belt should not be held away from passenger's body by wheelchair components or parts such as the wheelchair's wheels, armrest, panels or frames,. Never rely on wheelchairs lap belt or postural support belt unless properly approved and crash tested . Ensure belt webbing is not twisted while being worn by passenger. Occupant belts should always bear upon the bony structure of passenger's body and be worn low across the front of the pelvis, with junction between lap and shoulder belts located near passenger's hip. The Administrator and the DON (Director of Nurses) were informed of the identification of an immediate jeopardy situation on [DATE] at 4:32 p.m. and the need for a plan of removal. The Administrator was provided the IJ template. Review of the facility's Plan of Removal received on [DATE] documented: Resident #52 was being transported to an appointment in the community van when she suffered a fall while in the van. Certified Nurse Aide (CNA) A, the aide that was transporting Resident #52 in the van at the time immediately called 911. Emergency Medical Services (EMS) arrived on scene and assessed Resident #52 with no negative findings. Resident #52 offered no complaints of pain or discomfort while being assessed by the EMS personnel. Upon arrival to the community, Resident #52 was assessed by Licensed Vocational Nurse (LVN) F and denied any pain. Vital Signs during the assessment were: Temperature: 98.1, Pulse: 80, Respirations: 20, Blood Pressure: ,[DATE]. A head to toe assessment was done and small dark purple bruises noted to the left lower extremity measuring 3.5cm X 1.4cm. along with a fading bruise to the left lower extremity measuring 11.4cm X 9.8cm was found. The day after the incident, on [DATE] the resident complained of pain to left leg. Resident #52's physician was notified, and an x-ray was ordered. X-ray results revealed left tibia, fibula and femur fracture. Resident #52 received appropriate treatment for [REDACTED]. Investigation revealed that CNA A change her initial statement from the point of incident, from the resident lipping from under seatbelt to being on left side head facing the front of the vehicle. Due to her change of story, CNA A wasn't trustworthy to continue care for residents. After the incident took place facility implemented a 2-person intervention to transport on facility van on all times. CNA A transported 3 times after incident but was only the designated driver. Once CNA A story change, she was terminated. After incident facility assigned CNA/CMA B, experienced trained transport personnel as secondary transport. Facility will follow investigation guidelines and policies for reporting timely and thoroughly. On [DATE] Admin and ADON inspected facility van and check seatbelts, anchoring ports, the lift. Seatbelts were intact and had no missing hooks and had no broken or faulty parts. In addition, van was inspected by regional VP, ADMIN, DCO (Director clinical services), regarding seat belt and supporting parts, van had no faulty maintenance. (VP= vice president. ADMIN = administrator. ) After the incident, an in-service was provided on (MONTH) 10.2020 on the safe techniques for transporting residents in the van. All residents who are transported via the facility's van and are wheelchair bound have the potential to be affected by this alleged deficient practice. All licensed nursing staff and Certified Nurse Aides are trained and checked off for the proper safety technique for residents being transported in the facility's van. Training will occur upon hire during orientation and at least annually. The facility van was inspected for maintenance on (MONTH) 17, 2019 by local mechanic shop. No problems were detected. The van will continue to be inspected on a routine basis every 6 months or upon 5000 miles or as needed. CNA B - Medication Aide/CNA was trained on [DATE] on properly securing residents and transporting residents. CNA B was designated as the transportation CNA on [DATE]. CNA B performed a return demonstration on [DATE] to show that she was competent to perform safe transporting for resident in the facility' van. The community will designate CNA B as the lead transportation personnel to train and educate new hires to prevent future incidents from taking place. All Licensed Nurses and Certified Nurse Aides will be asked to perform a return demonstration on loading residents who use wheelchairs, boarding standees on the lift, securing residents in wheelchairs, and securing ambulatory riders. This training will be completed no later than 01 15 2020. The facility will address corrective action by training and Inservice all license nurse and nurse aide medication aide on check list specific to the focused care van, on the skill check off form 31, including loading riders who use wheelchairs, power chair vs. wheelchair, Boarding standees on the lift, procedures for securing wheelchair checklist, procedures on securing riders. DCO will monitor lead transportation personnel to ensure that quarterly check list for the van in additional to the quarterly skill care and the checklist entails details specifically to the community van. (Please see attached the community van checklist) is being implemented the facility will train and educated all staff by 1 15 2020 and all Direct care staff 1 15 2020 by 12 noon. DCO will monitor lead transportation personnel to ensure that quarterly check list for the van is being implemented. Quarterly Skill Care check off for Direct care staff. Staff interview with Maintenance Director stated that he checks the van lift every 6 months for operational use. The facility will conduct biweekly maintenance checks on seatbelts, anchors, lift, and all internal operational parts to ensure that community van is in compliance. All transportation training will be reviewed and monitored by the EDO (Executive Director Operations) and DCO in the facility's monthly QAPI meeting. The EDO or DCO will watch at least one resident transport weekly for the next 4 weeks to ensure proper procedures are being performed. (QAPI = quality assurance performance improvement). The facility has performed 24 return demonstrations out of the 26 required full time staff members that need the training on [DATE] and signed by the administrator. Review of an undated document titled DDS Recommended Safe Procedures for Transporting People who use Wheelchairs indicated the following; The safe transportation of all of the individuals who we support happens every day. But even if we succeed 99% of the time in providing safe transportation, we have not really succeeded at all. This is especially crucial in transporting people who use wheelchairs. They are especially vulnerable in accidents. With a bit of planning and preparation, we can make this process much safer. ---Safe Vehicles: Providers are encouraged to schedule regular inspections of the vehicles which are used to transport people who use wheelchairs. In addition to standard vehicle inspections which might include testing the brakes, the lights, and other components of the vehicle, the inspection should also include those features which are specific to accommodating wheelchairs. They would include the following: There are sufficient wheelchair tie downs to accommodate the maximum number of people who use wheelchairs who would be transported at one time. All of the tie downs are in good working order. The floor area of the vehicle where the tie downs are affixed is clean and clear of obstructions. There are sufficient shoulder harnesses to accommodate all the people who are being transported All the shoulder harnesses are in good working order. The wheelchair lift mechanism is in good working order. The safety gate on the lift platform automatically deploys when the lift is engaged. The safety gate retracts when the lift is level to the ground. The vehicle emits a warning sound when the lift is engaged. The parking brake works. The manual back up system for the lift is in good working order. ---Safe wheelchairs: It is important that the wheelchairs that people are using when being transported are in good repair. Parts to check: The frame of the wheelchair is intact, has no cracks or missing screws, bolts, or other hardware. The brakes are in good working order. For power chairs, the mechanism to power up and power down the chair works correctly. The controls are adapted so that the individual and/or staff cannot be accidently power up the wheelchair. Safety belts are in good working order. Make certain that the safety gate on the end of the lift platform is engaged. Engage the lift platform safety strap. Go to the outside of the van and use the control to lower the lift. Assist the person to move their wheelchair safely off the lift platform. Make certain that they are in safe place or assist them to move their wheelchair to a safe place. ---Safe Planning: Have a plan for how many staff will be needed for safe transportation for each outing and what they are expected to do. The safe procedures for loading and unloading passengers can be time consuming and it requires the full attention of the staff. If you plan to transport more than one person who uses a wheelchair at a time, you be mindful of how many staff will be needed to insure the safety of all passengers. When transporting more than one individual who uses a wheelchair it is a good idea to plan the logistics of the procedure beforehand. This will enable staff to focus their attention on supporting the individuals instead of trying to decide which staff will do which step of the process. This will depend on who is being transported, what their support needs are, and where they are going to be embarking and disembarking from the vehicle. ---Emergency Safety Procedures: Despite all of our best efforts to insure safety, accidents can and will happen. In the event of an accident, staff may become upset, anxious, and may not be able to be calm, and think clearly. It is important that staff know how to proceed if this should occur. Staff should have access to a cell phone. They should immediately call 911 in a person in a wheelchair is impacted by an accident, if they fall out of a wheelchair, or if there is any question of an injury. People in wheelchairs may be vulnerable to head or spinal injuries in the event of a fall. After calling 911, providers may have other protocols for staff to follow; calling a supervisor or others at their agency for notification and back up, etc. ---The Department of Developmental Services and the Center for Developmental Disabilities Evaluation and Research have developed a comprehensive training on the safe transfer for individuals to and from a wheelchair van. This can be accessed via the following link: http://shriver.umassmed.edu/programs/cdder/webinars/dds-safetransportation-people-who-use-wheelchairs POR Verification Review of an undated Policy and Procedure titled Van Policies received [DATE] indicated the van driver; must be a Certified Nursing Assistant, must be CPR certified, and must have a cell phone. It is the policy of all Focused Post-Acute Care that any resident transported in the facility van is secure. Review of an Invoice dated [DATE] from local body works Inc. indicated: On this date we checked the occupant restraints on the facility van operated by Focused Care. We found all restraints in the vehicle, including the drivers to be working properly. The criteria used to determine this was a check to make sure the seatbelts were fully operational in the following areas: The adjustment of the belt lengths worked correctly, the seatbelts buckled and unbuckled correctly, and the seatbelts were firmly attached to the mounting points. We found one seat (a single foldable one) in the back-left hand side of the van has no seatbelt. One seatbelt in the right front of the van has a missing cover. (it does not affect the operation of the belt) We found no defects or safety concerns in the operation of the occupant restraints. Review of a document dated [DATE] indicated the following; On (MONTH) 15, 2020 I attest That I CNA B have instructed and demonstrated to CNA A how to strap and secure a residen

Based on observation, interview and record review the facility failed to ensure that residents remained as free of accidents as possible for 1 of 5 residents (#52) reviewed for accidents, hazards and devices. The facility failed to prevent a fall due to not properly securing Resident #52's wheelchair in the facility van. On [DATE] Resident #52 fell out of her wheelchair and sustained a fracture to her left leg while being transported, by CNA A, in the facility van. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm at a scope of isolated due to the facility needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for serious injury or death if not secured properly in the van. Findings included: Record review of Resident #52's admission record dated [DATE] indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #52's order summary report for (MONTH) 2020 indicated in part: ADL - Mobility: up in w/c or rolling recliner, as tolerated, may use Hoyer lift prn, assist x2/transfer x2. Fall precautions at all times. Every shift. (PRN = as needed. ADL = activities of daily living). Record review of Resident #52's Minimum Data Set ((MDS) dated [DATE] indicated in part: Brief Interview Mental Status (BIMS) = 14 indicating the resident was cognitively intact. Functional status: Resident was total dependence for transfers. Resident was a 2 plus persons for physical assist. Mobility devices = resident used wheelchair for mobility. Record Review of a facility Incident and Accident Report dated [DATE] at 7:00pm and revised on [DATE] at 7:36pm indicated the following; Resident #52 had been out of the facility /during a transport. Nursing Description: Resident slid out of her wheelchair while in the facility van returning from a doctor appointment. Resident Description: Per resident, slid off of wheelchair due to netting from lift. Landed on her bottom directly in front of her wheelchair. Immediate Action Taken: Upon return to facility, the resident was assessed. Resident denies pain at this time. V/S 98.1, 80, 20, ,[DATE]. Small dark purple bruise noted to left lower extremity 3.5cm X 1.4cm fading purple bruise noted to left lower extremity. Resident was not taken to the hospital. Injuries Observed at Time of Incident: Bruise to Left lower leg. Level of Pain: 5 (On scale of ,[DATE]). Level of consciousness: Alert, Oriented to person, place, time and situation. Denies pain at this time. Record review of the facility's Provider Investigation Report (PIR) regarding Resident #52 indicated there was no PIR for the incident that occurred on [DATE]. Record review of the facility's PIR dated [DATE] indicated in part: Who made this allegation? Individual/Patient. When? [DATE]. Name: Resident #52. Alleged Perpetrator: CNA [NAME] Description of the allegation: On [DATE]. 2020 Resident #52 alleged that she wasn't strapped in the van during transportation and that she was going to sue the facility because that's how she fell . Description of injury: On [DATE]. 2019 the community received phone call from CNA [NAME] Stated that she was driving facility vehicle after leaving orthotics appointment and came to a stop light. Stated when she came to a complete stop, resident slid out of the wheelchair. Per CNA A wheelchair remained in place as it was secured to the vehicle with straps. CNA A stated she was unable to solely transfer resident back to wheelchair, so she called EMS for assistance, Per CNA A EMS staff examined resident and found everything to be ok. With the assistance of EMS resident was transferred back to wheelchair, secured they made their way back to the community. Upon arrival to the community Resident #52 was assessed by charge nurse LVN F, resident denies any pain or showed any signs or symptoms of emotional distress. Date [DATE] Time 7:00pm. Investigation summary: On [DATE]. 2019 the community received phone call from CNA [NAME] Stated that she was driving facility vehicle after leaving orthotics appointment and came to a stop light. Stated when she came to a complete stop, resident slid out of the wheelchair. Per CNA A wheelchair remained in place as it was secured to the vehicle with straps. CNA A stated she was unable to solely transfer resident back to wheelchair, so she called EMS for assistance, Per CNA A EMS staff examined esident and found everything to be ok. With the assistance of EMS resident was transferred back to wheelchair, secured they made their way back to the community. Upon arrival to the community Resident #52 was assessed by charge nurse LVN F, resident denies any pain or showed any signs or symptoms of emotional distress. Per LVN F resident stated that she slides out the wheelchair because of her sling. The following day resident complained of pain to left lower leg. Per resident stated that she was strapped in and that CNA A always strapped her in. Per resident she stated that slide out right in front of the chair on her butt. On [DATE] Administrator and Assistant Director of Nurses (ADON) interviewed CNA A who was transporting Resident #52. Per CNA A I always strapped the residents in before I leave and I did the two finger check, then I asked her if it was tight and she said no the seatbelt was not tight When CNA A was asked how did the resident fall stated that she slide put her wheelchair and was laying in front of the wheelchair. Investigation findings: Confirmed. Signed by Administrator on [DATE]. Review of Resident #52's Nursing Progress Notes dated [DATE] at 6:02pm indicated the following; Received phone call at this time from CNA [NAME] Stated she was driving facility vehicle after leaving orthotics appointment and came to a stop light. Stated when she came to a complete stop, resident slid out the wheelchair. Per CNA A wheelchair remained in place as it was secured to the vehicle with straps. CNA A stated she was unable to solely transfer resident back to wheelchair, so she called EMS for assistance. Record review of Resident #52's nurses notes dated [DATE]. 10:30am indicated in part: CNA C reported resident complain of pain to left leg. Upon assessment, resident with [MEDICAL CONDITION]/bruise to left leg below knee. Per resident has pain with movement of left leg. MD aware, ordered x-ray to left leg. Mobile imaging contacted for x-ray. Review of a Mobile Medical X-Ray Services report dated [DATE] indicated the following significant findings; ---IMPRESSION: Acute appearing proximal tibial fracture, as described. Suspicion of extension of the fracture 10 the proximal tibial articular surface. Joint effusion, Clinical correlation recommended. I strongly recommend consideration of further assessment of this fracture with CT. Pretibial soft tissue swelling hematoma, as above. Remote-appearing distal femoral fracture with medial plate and multiple screw fixation. The findings at the fracture site are worrisome for partial non-union. Clinical correlation recommended. ---IMPRESSION: Please see report of left knee radiographs for findings at the distal femur, knee, and proximal tibia and fibula. Nondisplaced acute appearing distal fibular shaft fracture, Soft tissue swelling, I recommend further assessment with CT. Review of Resident #52's Nursing Progress Notes dated [DATE] at 10:42pm indicated the following; Doctor notified of X-ray results Fractured Left Femur, fractured left tibia and left fibula. Gave orders to send resident to ER (emergency room ). Notified emergency room , emergency contact and EMS for transport. (EMS = Emergency Medical Services). During an interview on [DATE] at 11:42 a.m. Resident #52 said she went to a doctor's appointment on [DATE]. Resident #52 said the van driver (CNA A) had to stop suddenly and she slid off the wheelchair and landed on her butt. Resident #52 said the van driver and she tried to get her up but couldn't so the van driver called 911 and they came and helped put her back in the wheelchair. Resident #52 said the 911 people asked her if she was buckled up good and she told she did not know. Resident #52 said the 911 people made sure she was secured to the wheelchair. Resident #52 said they then came back to the nursing home and the van driver took her to her room and she was fine. Resident #52 said she was blind and could only see light and shadows. Resident #52 said she could not tell if the van driver had secured her correctly because she was blind and assumed the van driver had put on the seat belts correctly. Resident #52 said the next day she felt pain between her knee and ankle. Resident #52 said the facility took her to the hospital, was x-rayed and she was told she had a fracture to her knee and ankle. Resident #52 said they did surgery on her leg. During a telephone interview on [DATE] at 6:16 p.m. CNA A said she and Resident #52 we were coming back from an out of town doctor's visit and she was driving the van on [DATE]. CNA A said it had rained that day and it was just her and Resident #52 in the van. CNA A said she had to turn quickly due to a puddle of water on the road and the next thing she knew Resident #52 was on the floor of the van. CNA A said she pulled over and tried to put the resident back in her wheelchair but she was unable to. CNA A said she called 911 and they came and placed the resident back in her wheelchair. CNA A said the Emergency Medical Technicians (EMTs) asked the resident if she was fine and the resident told them she was fine. CNA A said all the seatbelts were strapped correctly so she did not know how the resident fell out of her wheelchair. CNA A said she called the facility and told them that the resident had fallen out of the wheelchair but that the resident had stated she was fine. CNA A said when she got back to the facility they asked her what happened so she explained it to them and then left for the day. CNA A said she continued to be the van driver after that, then on [DATE] was when the facility did their investigation and then they suspended her. CNA A said later the facility called her and told her that she had not done the procedures correctly and had not secured resident correctly. CNA A said she told them that they should have done an incident report then done their investigation when the incident occurred, but they waited till later. CNA A said the facility then terminated her because they said it was her fault the resident fell . CNA A said she had not been trained on securing the residents on the van. CNA A said she just made sure all 4 wheels were secured and the breaks on the wheelchair were on and the seatbelt was secured to the resident. Record review of CNA A's Facility offer letter dated [DATE] indicated part: Reason for hire - new hire. Position title - CNA + transportation. Immediate supervisor - ADON. During an interview on [DATE] at 10:12 a.m. the Human Resources director said she had only conducted the hiring process for CNA A but did not have documentation regarding any training for securing wheelchairs to the van. The HR director said nursing might have some of the training documentation. During an interview on [DATE] at 10:16 a.m. the ADON said she did not know if they had any documentation regarding securing wheelchairs to the van for CNA [NAME] The ADON said she thought someone had trained CNA A on securing the wheelchairs to the van. The facility was unable to provide any documentation indicating CNA A had been trained on securing wheelchairs on the van that included CNA A's acknowledgement or signature. During a telephone interview on [DATE] at 10:28 a.m. CNA B said she was the current van driver. CNA B said she had been trained on how to secure the wheelchair to the van by the previous Administrator which was approximately 4 years ago. CNA B said she had not been trained recently just from when the other Administrator trained them. During an interview on [DATE] at 10:48 a.m. the Administrator said she had been the Administrator at the facility since [DATE]. The Administrator said on [DATE] Resident #52 was taken to a doctor's appointment and she slid out of her wheelchair. The Administrator said CNA A called the facility and told them the resident had fallen out of her wheelchair and she called 911 and they helped put the resident back on the wheelchair. The Administrator said Resident #52 was sitting on the Hoyer sling which might have caused the resident to slide out. The Administrator said Resident #52 did not complain of any pain until the next day on [DATE], she said x-rays were done and revealed the resident had a fracture. The Administrator said she had started training staff on securing the wheelchair correctly to the van on [DATE]. The Administrator said the training had all been verbal so far and not actual demonstration on the van. The Administrator said she had been trained on how to secure wheelchairs to the van by CNA B. The Administrator said they had not reported the fall to the State at first because they determined the fall had been witnessed by CNA [NAME] The Administrator said they decided to report it later on [DATE] because Resident #52 later alleged that she was not secured properly and reason she had fallen. The Administrator said she was not working at the facility at the time CNA A had been hired so she did not know who had trained CNA A on securing wheelchairs on the van. Review of the undated Facility Van Instructions on Securing a Wheelchair indicated the following; ---Place Wheelchair facing forward in securement area; apply wheel locks or turn power off. ---Attach tie-downs into floor anchorages and ensure they are locked in. ---Attach the four tie-down hooks to solid frame members or weldments, near seat level. Ensure tie-downs are fixed at approximately 45 degrees and are within angles shown. Do not attach hooks to wheel, plastic, or removable parts of wheelchair. ---Ensure all tie-downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knobs (if present) to take up additional webbing slack. ---WARNING: Do not allow webbing to twist inside retractors. Wheelchair accessories and equipment should be properly secured or removed from wheelchair and secured in the vehicle transportation. Whenever possible, items attached to wheelchair in front of the passenger should be removed and secured separately during transportation. Review of the undated Facility Van Instructions on Securing Passenger indicated the following: ---Attach lap belts-Use integrated stiffeners to feed belts through opening between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant. ---On the aisle side, attach belt with female buckle to rear tie-down pin connector ensuring buckle rests on passengers' hip. ---On window-side, attach belt with male tongue to rear tie-down pin connector and insert into female buckle. --Attach Shoulder Belt- Extend shoulder belt over passenger's shoulder and across upper torso and fasten pin connector onto lap belt. Note: Combination lap/shoulder belts serve both window-side lap belt and shoulder belt. ---Ensure belts are adjusted as firmly as possible, but consistent with user comfort. ---WARNING: Lap and shoulder belt should not be held away from passenger's body by wheelchair components or parts such as the wheelchair's wheels, armrest, panels or frames,. Never rely on wheelchairs lap belt or postural support belt unless properly approved and crash tested . Ensure belt webbing is not twisted while being worn by passenger. Occupant belts should always bear upon the bony structure of passenger's body and be worn low across the front of the pelvis, with junction between lap and shoulder belts located near passenger's hip. The Administrator and the DON (Director of Nurses) were informed of the identification of an immediate jeopardy situation on [DATE] at 4:32 p.m. and the need for a plan of removal. The Administrator was provided the IJ template. Review of the facility's Plan of Removal received on [DATE] documented: Resident #52 was being transported to an appointment in the community van when she suffered a fall while in the van. Certified Nurse Aide (CNA) A, the aide that was transporting Resident #52 in the van at the time immediately called 911. Emergency Medical Services (EMS) arrived on scene and assessed Resident #52 with no negative findings. Resident #52 offered no complaints of pain or discomfort while being assessed by the EMS personnel. Upon arrival to the community, Resident #52 was assessed by Licensed Vocational Nurse (LVN) F and denied any pain. Vital Signs during the assessment were: Temperature: 98.1, Pulse: 80, Respirations: 20, Blood Pressure: ,[DATE]. A head to toe assessment was done and small dark purple bruises noted to the left lower extremity measuring 3.5cm X 1.4cm. along with a fading bruise to the left lower extremity measuring 11.4cm X 9.8cm was found. The day after the incident, on [DATE] the resident complained of pain to left leg. Resident #52's physician was notified, and an x-ray was ordered. X-ray results revealed left tibia, fibula and femur fracture. Resident #52 received appropriate treatment for [REDACTED]. Investigation revealed that CNA A change her initial statement from the point of incident, from the resident lipping from under seatbelt to being on left side head facing the front of the vehicle. Due to her change of story, CNA A wasn't trustworthy to continue care for residents. After the incident took place facility implemented a 2-person intervention to transport on facility van on all times. CNA A transported 3 times after incident but was only the designated driver. Once CNA A story change, she was terminated. After incident facility assigned CNA/CMA B, experienced trained transport personnel as secondary transport. Facility will follow investigation guidelines and policies for reporting timely and thoroughly. On [DATE] Admin and ADON inspected facility van and check seatbelts, anchoring ports, the lift. Seatbelts were intact and had no missing hooks and had no broken or faulty parts. In addition, van was inspected by regional VP, ADMIN, DCO (Director clinical services), regarding seat belt and supporting parts, van had no faulty maintenance. (VP= vice president. ADMIN = administrator). After the incident, an in-service was provided on (MONTH) 10.2020 on the safe techniques for transporting residents in the van. All residents who are transported via the facility's van and are wheelchair bound have the potential to be affected by this alleged deficient practice. All licensed nursing staff and Certified Nurse Aides are trained and checked off for the proper safety technique for residents being transported in the facility's van. Training will occur upon hire during orientation and at least annually. The facility van was inspected for maintenance on (MONTH) 17, 2019 by local mechanic shop. No problems were detected. The van will continue to be inspected on a routine basis every 6 months or upon 5000 miles or as needed. CNA B - Medication Aide/CNA was trained on [DATE] on properly securing residents and transporting residents. CNA B was designated as the transportation CNA on [DATE]. CNA B performed a return demonstration on [DATE] to show that she was competent to perform safe transporting for resident in the facility' van. The community will designate CNA B as the lead transportation personnel to train and educate new hires to prevent future incidents from taking place. All Licensed Nurses and Certified Nurse Aides will be asked to perform a return demonstration on loading residents who use wheelchairs, boarding standees on the lift, securing residents in wheelchairs, and securing ambulatory riders. This training will be completed no later than 01 15 2020. The facility will address corrective action by training and Inservice all license nurse and nurse aide medication aide on check list specific to the focused care van, on the skill check off form 31, including loading riders who use wheelchairs, power chair vs. wheelchair, Boarding standees on the lift, procedures for securing wheelchair checklist, procedures on securing riders. DCO will monitor lead transportation personnel to ensure that quarterly check list for the van in additional to the quarterly skill care and the checklist entails details specifically to the community van. (Please see attached the community van checklist) is being implemented the facility will train and educated all staff by 1 15 2020 and all Direct care staff 1 15 2020 by 12 noon. DCO will monitor lead transportation personnel to ensure that quarterly check list for the van is being implemented. Quarterly Skill Care check off for Direct care staff. Staff interview with Maintenance Director stated that he checks the van lift every 6 months for operational use. The facility will conduct biweekly maintenance checks on seatbelts, anchors, lift, and all internal operational parts to ensure that community van is in compliance. All transportation training will be reviewed and monitored by the EDO (Executive Director Operations) and DCO in the facility's monthly QAPI meeting. The EDO or DCO will watch at least one resident transport weekly for the next 4 weeks to ensure proper procedures are being performed. (QAPI = quality assurance performance improvement). The facility has performed 24 return demonstrations out of the 26 required full time staff members that need the training on [DATE] and signed by the administrator. Review of an undated document titled DDS Recommended Safe Procedures for Transporting People who use Wheelchairs indicated the following; The safe transportation of all of the individuals who we support happens every day. But even if we succeed 99% of the time in providing safe transportation, we have not really succeeded at all. This is especially crucial in transporting people who use wheelchairs. They are especially vulnerable in accidents. With a bit of planning and preparation, we can make this process much safer. ---Safe Vehicles: Providers are encouraged to schedule regular inspections of the vehicles which are used to transport people who use wheelchairs. In addition to standard vehicle inspections which might include testing the brakes, the lights, and other components of the vehicle, the inspection should also include those features which are specific to accommodating wheelchairs. They would include the following: There are sufficient wheelchair tie downs to accommodate the maximum number of people who use wheelchairs who would be transported at one time. All of the tie downs are in good working order. The floor area of the vehicle where the tie downs are affixed is clean and clear of obstructions. There are sufficient shoulder harnesses to accommodate all the people who are being transported All the shoulder harnesses are in good working order. The wheelchair lift mechanism is in good working order. The safety gate on the lift platform automatically deploys when the lift is engaged. The safety gate retracts when the lift is level to the ground. The vehicle emits a warning sound when the lift is engaged. The parking brake works. The manual back up system for the lift is in good working order. ---Safe wheelchairs: It is important that the wheelchairs that people are using when being transported are in good repair. Parts to check: The frame of the wheelchair is intact, has no cracks or missing screws, bolts, or other hardware. The brakes are in good working order. For power chairs, the mechanism to power up and power down the chair works correctly. The controls are adapted so that the individual and/or staff cannot be accidently power up the wheelchair. Safety belts are in good working order. Make certain that the safety gate on the end of the lift platform is engaged. Engage the lift platform safety strap. Go to the outside of the van and use the control to lower the lift. Assist the person to move their wheelchair safely off the lift platform. Make certain that they are in safe place or assist them to move their wheelchair to a safe place. ---Safe Planning: Have a plan for how many staff will be needed for safe transportation for each outing and what they are expected to do. The safe procedures for loading and unloading passengers can be time consuming and it requires the full attention of the staff. If you plan to transport more than one person who uses a wheelchair at a time, you be mindful of how many staff will be needed to insure the safety of all passengers. When transporting more than one individual who uses a wheelchair it is a good idea to plan the logistics of the procedure beforehand. This will enable staff to focus their attention on supporting the individuals instead of trying to decide which staff will do which step of the process. This will depend on who is being transported, what their support needs are, and where they are going to be embarking and disembarking from the vehicle. ---Emergency Safety Procedures: Despite all of our best efforts to insure safety, accidents can and will happen. In the event of an accident, staff may become upset, anxious, and may not be able to be calm, and think clearly. It is important that staff know how to proceed if this should occur. Staff should have access to a cell phone. They should immediately call 911 in a person in a wheelchair is impacted by an accident, if they fall out of a wheelchair, or if there is any question of an injury. People in wheelchairs may be vulnerable to head or spinal injuries in the event of a fall. After calling 911, providers may have other protocols for staff to follow; calling a supervisor or others at their agency for notification and back up, etc. ---The Department of Developmental Services and the Center for Developmental Disabilities Evaluation and Research have developed a comprehensive training on the safe transfer for individuals to and from a wheelchair van. This can be accessed via the following link: http://shriver.umassmed.edu/programs/cdder/webinars/dds-safetransportation-people-who-use-wheelchairs Plan of Removal Verification: Review of an undated Policy and Procedure titled Van Policies received [DATE] indicated the van driver; must be a Certified Nursing Assistant, must be CPR certified, and must have a cell phone. It is the policy of all Focused Post-Acute Care that any resident transported in the facility van is secure. Review of an Invoice dated [DATE] from local body works Inc. indicated: On this date we checked the occupant restraints on the facility van operated by Focused Care. We found all restraints in the vehicle, including the drivers to be working properly. The criteria used to determine this was a check to make sure the seatbelts were fully operational in the following areas: The adjustment of the belt lengths worked correctly, the seatbelts buckled and unbuckled correctly, and the seatbelts were firmly attached to the mounting points. We found one seat (a single foldable one) in the back-left hand side of the van has no seatbelt. One seatbelt in the right front of the van has a missing cover. (it does not affect the operation of the belt) We found no defects or safety concerns in the operation of the occupant restraints. Review of a document dated [DATE] indicated the following; On (MONTH) 15, 2020 I attest That I CNA B have instructed and demonstrated to CNA A how to strap and secure a resident into the community van within the last year. Signed by CNA B. Review of a facility in-service dated [DATE]-[DATE] titled Transportation and Safety Precautions indicated; 13 staff had participated in the in-service. The staff consisted of CNAs and charge nurses. Review of a facility in-service dated [DATE]-[DATE] titled Transportation. How to correctly load and unload a resident and how to safely secure while in the van indicated; 14 staff had participated in the in-service. The staff consisted of CNAs and charge nurses. Review of a facility in-service dated [DATE] titled Lift operations, wheelchair and rider securement. Van operations for transportation to and from community indicated; 35 staff had participated in the in-service. The staff consisted of CNAs, charge nurses, ADON and DON. Review of an undated document titled Wheelchair and Rider Securement Procedures and Checklist indicated the following: General Information; Proper securement of the wheelchair and the rider are the two most important duties a volunteer van driver has when transporting a person who uses wheelchair or scooter. Wheelchairs must be forward-facing if possible, or rear-facing if necessary, but never sideways. The securement system is designed to be used with the wheelchair facing forward or backward. Wheelchair securement positions are inherently safer, and wheelchairs and the human body are better capable of surviving a frontal crash when facing forward. Sled tests show that side facing wheelchairs are unstable and often collapse. Lap and shoulder belt restraint systems are designed to be most effective in the frontal impact position wheelchairs are stronger in frontal loading conditions as opposed to side loading. During an observation on [DATE] at 2:38 p.m. CNA B demonstrated how to secure a wheelchair in the facility's van. The CNA correctly secured the wheelchair in the van as indicated on the instructions. During an observation on [DATE] at 2:45 p.m. LVN G demonstrated how to secure a wheelchair in the facility's van. The LVN correctly secured the wheelchair in the van as indicated on the instructions. During an observation on [DATE] at 2:50 p.m. LVN H demonstrated how to secure a wheelchair in the facility's van. The LVN correctly secured the wheelchair in the van as indicated on the instructions. During an observation on [DATE] at 3:02 p.m. CNA D demonstrated how to secure a wheelchair in the facility's van. The CNA correctly secured the wheelchair in the van as indicated on the instructions. During an interview on [DATE] at 3:38 p.m. LVN [NAME] explained the procedures on how to secure a wheelchair in the facility's van. The LVN correctly explained how to secure the wheelchair in the van as indicated on the instructions. During an interview on [DATE] at 3:42 p.m. CNA I explained the procedures on how to secure a wheelchair in the facility's van. The CNA correctly explained how to secure the wheelchair in the van as indicated on the instructions. During an interview on [DATE] at 3:48 p.m. CNA J explained the procedures on how to secure a wheelchair in the facility's van. The CNA correctly explained how to secure the wheelchair in the van as indicated on the instructions. Plan of removal verification completed [DATE]: regarding the training they had received regarding securing the wheelchairs in the van. The staff was able to explain the new way to secure the wheelchairs and also observed them secure a wheelchair as indicated in the [DATE] in-service. During an interview on [DATE] at 5:15 p.m. the Administrator was informed that the IJ was removed but the facility remained out of compliance at a scope of isolated for more than minimal harm due to the facility's need to monitor its corrective action for effectiveness.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance necessary to prevent accidents for 1 of 1 residents (Resident #24) reviewed for accidents. On 02/24/19 Certified Nurse Aide (CNA) C failed to ensure adequate assistance and training while transferring Resident #24 from a sliding board to Resident #34's bed, causing Resident #24 to fall, fracturing her left femur. This failure could put residents at risk of accidents, exposure to hazards and serious injuries which could result in a reduced quality of life. Findings include: Review of Resident #24's undated Face Sheet reveals she was a [AGE] year-old-female admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #24's quarterly MDS (minimum data set) dated 12/19/18 revealed Resident #24's BIMS (brief interview for mental status) of 15 indicates resident can make her needs known. Resident #24's functional status documented in the MDS revealed Resident #24 required 2 people transfer from wheelchair to bed. Review of Resident #24's undated Care Plan revealed: Transfer: Resident #24 is totally dependent on staff times 2 as needed for transferring. Record review of Incident Report dated 02/25/19 revealed the following: Indicant description: This writer (RN F) was sums (sic) to room [ROOM NUMBER] (Resident #24) The CNA (CNA C) was helping the resident into her wheelchair with a slider board at the time per CNA (CNA C). Resident #24 slide off the board and CNA (CNA C) guided her to the floor at that time and requested this writer (RN F) assess-Noted Resident was on the floor with her back against the bed-Resident #24 is dead weight- it took 3 staff members to assist her to the wheelchair VS (vital signs) at 11:50 AM blood pressure 157/73, heart rate 98. No apparent bruising or skin tears, stated or noted . Record review of Nurses Notes dated 02/27/19 per physician order [REDACTED]. Fracture to left femur. Record review of Resident #24's X-rays dated 02/27/19 revealed the following: Impression: .Fracture involving the medial left femoral condyle is not well visualized. During an interview on 02/27/19 at 2:00 PM with the Assistant Director of Nurses (ADON) she said Resident #24 fell on [DATE] and was complaining of pain and was sent to the emergency room and not expected to return today. She said technically Resident #24 did not fall she slid to the floor with (Certified Nurses Assistant ) CNA C and did not fall when she was transferred from a sliding board to her bed. During an interview on 02/27/19 at 4:10 PM with CNA C she said I was transferring Resident #24 from the wheelchair to her bed with the sliding board. She was leaning forward and I told her not to but she wanted to go to bed and she was sliding off the board and we slipped down to the floor, she did not fall. When we were on the floor I called for help and it took 3 people to help, the charge nurse and one of the housekeeping aids and myself to get her back to bed. She said Resident #24 has only one leg and it folded under her when we went to the floor. CNA C said she has not received any training using the sliding board, but felt comfortable using the sliding board. During an interview on 02/27/19 at 4:53 PM with CNA F said he worked on the day Resident #24 fell , (02/24/19) he said CNA C, the Charge Nurse and some skinny housekeeping aide assisted in getting Resident #24 back into her wheelchair. I was told she fell . During an interview on 02/28/19 at 9:30 AM with the ADON she said Resident #24 was sent to another acute care facility due to a fractured femur. During an interview on 02/28/19 at 10:50 AM with Therapy Director G she said we do not train staff to use sliding boards unless we are asked to. We did not do any training regarding the sliding board with Resident #24. I was told to do training with the gait belt but not the sliding board. During an interview on 02/28/19 at 11:45 AM with the ADON revealed staff are trained with videos and check off from the nursing staff. Therapy checks them off for any special training like sliding boards. ADON said if the staff are not trained we need to start. She said my expectations are the staff should be trained and use proper mechanics. During an interview on 02/28/19 at 2:15 PM the Charge Nurse (RN F) revealed Resident #24 was dead weight, she slid off the sliding board and CNA C helped her to the floor. It took myself, housekeeping aide and CNA C to pick Resident #24 up and put her back into the wheelchair. Resident #24 complained of pain and I gave her some Tylenol and it seem to work because she did not complain anymore. Resident #24 has frequent phantom pain from her amputate leg and takes pain medication. She said she called the primary care physician regarding the fall and monitored the resident. During an interview on 03/01/19 at 10:16 AM the Therapy Director G revealed Resident #24 had a prosthesis on her leg and while in therapy she would stand and walk. She said when she went to her room she wanted the aides to use the sliding board so we did not do any training on using the sliding board. She said Resident #24 has been using the sliding board since she has been admitted . During an interview on 03/01/19 at 10:20 AM with CNA C she said she knew she was supposed to use 2 people to transfer with Resident #24 but I had no choice she wanted to go to bed and there was no one to help me. During an interview on 03/01/19 at 2:30 PM with the ADON she said the only CNA Care Plan she could find is the one on 02/22/19 (2 days prior to the fall) all of the Care Plans should be the same in regards to Resident #24 needing 2 person transfer from her wheelchair to her bed. Record review of CNA Care Plan regarding care for residents revealed on 02/22/19 Resident #24 was supposed to have 2 people to transfer her.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the potential development and transmission of disease and infection for seven of eight residents (Residents #1 #4, #5, #6, #8, #9 and #18) observed for infection control. The facility failed to ensure: a) nurse aides and housekeeping staff practiced good hand-hygiene (hand washing), wear or change gloves and wear Personal Protective Equipment (PPE) when they provided direct care to residents with known contagious infections (C-Diff) (Resident #6); These failures resulted in an Immediate Jeopardy (IJ) situation on 7/11/13. While the IJ was removed on 07/12/13, the facility remained out of compliance at a scope of "widespread" and at a level of no actual harm with a potential for more than minimal harm because all staff had not been in-serviced and the facility had not yet monitored their plan of action for effectiveness. Non- IJ b) certified nurse aides (CNA) wash/sanitized their hands and/ or changed gloves during incontinent care (Resident #4, #5); c) nursing staff wash/sanitized their hands and changed gloves during wound care (Resident #4) ; These facility failures to follow transmission based isolation precautions resulted in the contamination of the facility's environment and placed all 69 residents, facility staff, and visitors at risk of contracting serious infections, illness and even death. Findings included: RESIDENT #6 Review of Resident #6's admission and discharge summary dated 6/27/13 documented she was an [AGE] year old female admitted on [DATE] with her most recent readmission on 3/29/13. Her [DIAGNOSES REDACTED]. Review of Resident #6's July 2013 monthly physician orders [REDACTED]." The date this order was originated was 6/25/13. Review of physician telephone orders documented: 4/22/13--[MEDICATION NAME] (antibiotic) 500 milligrams (mg) 1 by mouth three times a day for 10 days for[DIAGNOSES REDACTED]. 5/05/13--[MEDICATION NAME] (antibiotic) 250mg/5ml orally four times a day for 10 days for[DIAGNOSES REDACTED]. 5/15/13--[MEDICATION NAME] 250mg orally four times a day for 14 days for[DIAGNOSES REDACTED]. 6/20/13--[MEDICATION NAME] 250mg orally four times a day for 2 weeks; then [MEDICATION NAME] 250mg orally three times a day for 2 weeks; then [MEDICATION NAME] 250mg orally two times a day for 2 weeks; then [MEDICATION NAME] 250mg orally once daily for 2 weeks for[DIAGNOSES REDACTED]. Review of an article on the CDC website at http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html#9 documented the following, in part: [DIAGNOSES REDACTED]icile is a bacterium that causes diarrhea and more serious intestinal conditions such as colitis. Symptoms include: watery diarrhea, Fever, loss of appetite; nausea; and abdominal pain/tenderness. Healthcare workers can spread the bacteria tothe patients or contaminate surfaces through hand contact. Review of Resident #6's Minimum Data Set (MDS) assessment dated [DATE] documented she was incontinent of bowel and bladder and required maximum assistance of two people for transfers. Observations on 07/08/13 at 7:05 p.m., during initial tour revealed Resident #6's room had a bedside cabinet by the door and a hanger type appliance over the door with gloves and gowns in it. There was no isolation notice sign on the door (to alert all the room was under strict infection control measures). At that time, RN O said Resident #6 was "in isolation with C- Diff." Resident #6 was observed to receive incontinent care on 7/10/13 at 3:25 p.m. by CNA C and NA P. Both staff entered the isolation room without wearing any protective wear and went to the residents restroom to wash their hands. There were no paper towels in the holder. Both staff exited the room and went to the next door resident's restroom and washed their hands. Both staff then re-entered Resident #6's room and put on gloves and a protective gown. CNA C pulled down the resident's pants, removed the urine soiled brief and placed it in a plastic bag. CNA C cleaned Resident #6 then put a new brief on her. NA P placed the soiled items in a red biohazard barrel that was at the end of the resident's bed. Both staff removed one set of gloves (double gloved) and proceeded to transfer the resident to her recliner. CNA C and NA P removed their gloves and protective gown while still in the resident's room, discarded the items in the red biohazard barrel then walked across the room (unprotected) and left the room to go, once again, next door to wash their hands (cross contaminating the other room). Observations further revealed on 7/10/13 at 3:40 p.m., housekeeping staff X put a protective gown and gloves on, entered the isolation room (Resident #6) and cleaned the overbed table with a Clorox type spray solution. Staff X exited the room to retrieve a red biohazard bag from her cleaning cart, contaminating items on the cleaning cart. Staff X touched all over her cleaning cart with the dirty gloves. She then used a master key to refill the paper towel dispenser in the resident's restroom. After Staff X mopped the room, she removed her gown and gloves, disposed of them in the room. Staff X did not wash her hands in Resident #6's restroom; instead she walked next door to the other resident's restroom and used the sink. A bottle of drinking water was on top of the cleaning cart. An interview on 7/10/13 at 3:40 p.m. Staff X said she had worked at the facility about six months. She said the only training she was taught (about isolation rooms) was to use the red mop head, put her wiping rags in a red bag and to wear a gown and gloves. Staff X did not know what infection Resident #6 had or the rationale for the strict clothing and cleaning measures. Staff X acknowledged she went in and out of Resident #6's room wearing the contaminated gown and gloves and without washing or sanitizing her hands. Observation on 7/11/13 at 10:30 a.m. revealed housekeeping Staff Y began to clean Resident #6's room. Staff Y put her gown and gloves on. She was observed to go in and out of the room while wearing the dirty gown and gloves, retrieving items from her cleaning cart. Staff Y then took a dry dust mop and cleaned the resident's room. She placed the dry dust mop back on the cart when she finished and began to mop with a red mop. Note: the dry dust mop was not intended for resident to resident room usage as this could potentially spread the[DIAGNOSES REDACTED] infection. An interview on 7/11/13 at 10:30 a.m. Staff Y said she worked at the facility for one month. She said "her boss" taught her to "look for a sign of sorts on the room to warn her of infections, a red barrel or something outside the room. This means wear a gown and glove to clean the room." Staff Y acknowledged she did not know what infection Resident #6 had or what the different infections were that would require isolation or extra precautionary measures. Staff Y acknowledged she used the same dust mop and cleaning rags for each room saying she was not aware you could not use a dry dust mop. Staff Y added, "there is usually a sign on the door that says stop or something but I saw the dresser out in the hall and the gloves hanging on the door so I knew to put a gown on." During an interview on 7/11/13 at 1:05 p.m., the Administrator and DON were informed the above failures constituted an Immediate Jeopardy situation. During this interview, the Administrator said staff watched a video from the Health Department that allowed for double gloving. She acknowledged that was generally for practices like taking out the trash. The Administrator acknowledged the staff were to use one specific mop (only the red wet mop and not the dry dust mop) for Resident #6's room. The Administrator said there was a sign on the door when Resident #6 was in another room (before being moved to a private room). She said the sign was put in the night stand when Resident #6 changed rooms. She said from now on, the facility would tape the isolation sign to the glove hanger outside the door. According to Lippincott's Manual of Nursing Practice, Ninth Edition: Pages 181 through 183 documented in part, hand hygiene is the single most important measure to reduce the risk of transmitting micro-organisms. When[DIAGNOSES REDACTED] is suspected or confirmed hand hygiene with soap, warm water, and friction for 15 seconds is recommended as the spores C-Dif forms are resistant to alcohol hand gel. Gloves are worn to provide a protective barrier and prevent gross contamination of the hands of healthcare workers. Wearing gloves does not replace the need for hand hygiene because gloves may have small defects, or may be torn during use and can become contaminated. Gloves also must be changed between procedures on the same patient Examination gloves must not be worn outside the patient's room. Review of the July 2013 Infection Control Log documented there were no other active cases of C-Dif in the facility. Review of the undated policy, Examples of Safe Donning and Removal of Personal Protective Equipment (PPE) documented, in part: Safe work Practices: -work from clean to dirty -limit surfaces touched -change when torn or heavily contaminated -Perform hand hygiene Removing PPE: Remove PPE at doorway before leaving patient room or in another room. Hand Hygiene: -Perform hand hygiene immediately after removing all PPE! Review of the policy, Cleaning and disinfection of Environmental Surfaces, dated revised 10/2009, documented, in part: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in resident's environment: c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical environmental surfaces include bed rails, some food utensils, bedside tables, furniture and floors. (2) Most non-critical items can be decontaminated where they are used (as opposed to being transported to a central processing location) 18. Protective gloves and other PPE appropriate for this task will be used. Review of an article on the CDC website at http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html#9 documented the following, in part: C. Difficile is shed in feces, any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for [DIAGNOSES REDACTED]icile spores.[DIAGNOSES REDACTED]icile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. Review of an article on CDC website at http://www.cdc.gov/hicpac/pdf/isolation2007.pdf documented the following, in part: The Guideline for Hand Hygiene in Health-Care Settings suggests that the contaminated hands of healthcare personnel are important contributors to indirect contact transmission. Hands of healthcare personnel may transmit pathogens after touching an infected colonized body site on one patient or a contaminated inanimate object, if hand hygiene is not performed before touching another patient. Clothing, uniforms, laboratory coats, or isolation gowns used as personal protective equipment (PPE), may become contaminated with potential pathogens after care of patient colonized or infected with an infectious agent, (e.g., MRSA (Resistant Staphylococcus Aureus, VRE([MEDICATION NAME] Resistant [MEDICATION NAME]), and [DIAGNOSES REDACTED]icile). The facility submitted the 2nd revised plan of removal with an additional addendum which included: PLAN OF REMOVAL -7/11/13 at 2:00 p.m. staff identified as having participated in deficient practice were immediately removed. Identified nursing staff were in-services regarding identified deficient practice and proper facility protocol. -7/11/13 2:00 p.m. Certified nurse ' s assistants identified as having participated in deficient practice were immediately removed from performing additional perineal care for residents and providing care and providing care to residents on isolation precautions. Identified Certified Nurse Assistants were in-services regarding the identified deficient practices and proper facility protocol. - 7/11/13 2:00 p.m. Upon notification of deficient practice, housekeeping staff identified as having participated in deficient practice were immediately removed from performing additional housekeeping duties. Identified housekeeping staff were in-services regarding the identified deficient practice and proper facility protocol. -7/11/13 1:30 p.m. Director of Nursing and Housekeeping supervisor obtained additional biohazard containers to place in current facility isolation room. Biohazard containers were rearranged within isolation room to promote compliance with infection control procedures and disposal of personal protective equipment prior to leaving isolation room. -7/12/13 9:30 a.m. Prior to completing additional facility treatments, the identified Licensed Nursing staff will receive skill proficiency testing from Director of Nursing. Staff will be restricted from completing additional wound care treatments until proficiency has been established and documented by Director of Nursing. -7/12/13 9:30 a.m. Following in-servicing, all on-duty Certified Nurse assistants will receive skill proficiency testing from Director of Nursing and/or Infection Preventionist regarding proper infection control procedures and perineal care. Staff will be restricted from completing additional resident care until proficiency has been established and documented by Director of nursing. -7/12/13 9:30 a.m. Following in-servicing, housekeeping staff identified as having participated in deficient practice will receive skill proficiency testing from Housekeeping supervisor and Infection Preventionist regarding proper infection control procedures disinfection of surfaces. Staff will be restricted from completing additional housekeeping duties and until proficiency has been established and documented by Housekeeping supervisor. -7/11/13 1:50 p.m. Infection Preventionist instructed by Administrator to review all current infections and identify and document causative organism(s) on infection control log for tracking and trending purposes --7/11/13 2:30 p.m. (on duty staff ) 6:30 p.m. (off duty staff) All staff were in-serviced regarding facility infection control procedures regarding hand hygiene (hand washing); review of cross-contamination using transmission-based precautions in addition to standard precautions; proper procedure for disinfection of surfaces and cleaning of designated isolation areas. -7/11/13 7:30 p.m. All Nursing staff were in-serviced regarding proper wound care procedures and review of cross contamination using transmission based precautions in addition to standard precautions during wound care procedures. -7/12/13 12:20 p.m. (& ongoing) Administrator, Director of Nursing and Infection Preventionist will meet with Medical Director to discuss management of existing facility infections, implementing any suggested strategies. Implemented strategies will be monitored weekly for three months by Director of Nurses and Infection Preventionist and findings will be reported to Administrator and Medical Director weekly. If strategies are determined successful, Director of Nursing and Infection Preventionist will continue monitoring monthly for three months, reporting to the Administrator and Medical Director monthly regarding findings. If determined successful monthly monitoring of system will continue. All findings will be discussed quarterly with the Quality Assurance Committee with revisions being made as necessary to ensure continued compliance. -7/12/13 Director of Nursing and Infection Preventionist will complete quarterly skills assessments for Certified nurse Assistants. Skills assessments will include hand hygiene, proper perineal care and proper infection control procedures. Implemented strategies will be monitored weekly for three months by Director of Nursing and Infection Preventionist and findings will be reported to Administrator and Medical Director weekly. If strategies are determined successful, Director of Nursing and Infection Preventionist will continue monitoring monthly for three months, reporting to Administrator and Medical Director monthly regarding findings. If determined successful, monthly monitoring of system will continue. All findings will be discussed quarterly with the Quality Assurance committee with revisions being made as necessary to ensure continued compliance. - 7/12/13 (ongoing) Director of Nursing and Infection Preventionist will complete quarterly skills proficiency assessments for Licensed Nursing staff. Skills assessments will include hand hygiene, wound care, and proper infection control procedures. Proficiency assessments will continue daily until proficiency assessments have been completed for all Nursing Staff. Following initial proficiency assessments, random Licensed Nursing staff will receive weekly proficiency assessments for three months by Director of Nursing and Infection Preventionist and findings will be reported to Administrator and Medical Director weekly. If strategies are determined successful, Director of Nursing and Infection Preventionist will continue monitoring monthly for three months, reporting to Administrator and Medical Director monthly regarding findings. If determined successful, monthly monitoring of system will continue. If unsuccessful, revisions will be made until correction is achieved. All findings will be discussed quarterly with the Quality Assurance committee with revisions being made as necessary to ensure continued compliance. - 7/11/13 ending by 7/12/13 10:30 a.m. All facility Nursing staff (Nurses and Certified Nurse Assistants) were in-serviced regarding proper procedures for perineal care for male residents and proper perineal care for female residents. - 7/11/13 beginning at 7:30 p.m. and finishing 7/11/13 at 8:30 p.m. all Nursing staff were in-serviced regarding proper wound care procedures and review of cross contamination using transmission based precautions in addition to standard precautions during wound care. -7/12/13 noon ending at 12:20 p.m. Administrator, Director of Nursing and Infection Preventionist will meet with Medical Director to discuss management of existing facility infections, implementing any suggested strategies. Implemented strategies will be monitored weekly for three months by Director of Nursing and Infection Preventionist and finding will be reported to Administrator and Medical Director weekly. If strategies are determined successful, Director of Nursing and Infection Preventionist will continue monitoring monthly for three months, reporting to Administrator and Medical Director monthly regarding findings. If determined successful, monthly monitoring of system will continue. All findings will be discussed quarterly with the Quality Assurance committee, with revisions being made as necessary to ensure continued compliance. -7/11/13 beginning at 1:30 p.m. and ending 7/12/13 Infection Preventionist will monitor and document all facility infections, tracking causative organisms, analyzing outbreaks and implementing actions to resolve identified problems with the assistance of Director of Nursing, Administrator, and Medical Director. Implemented strategies will be monitored weekly for three months by Director of Nurses and Infection Preventionist. And findings will be reported to Administrator and Medical Director weekly. If strategies are determined successful, Director of Nursing and Infection Preventionist will continue monitoring monthly for three months reporting to Administrator and Medical Director monthly regarding findings. If determined successful, monthly monitoring of system will continue. All findings will be discussed quarterly with the Quality Assurance committee, with revisions being made as necessary to ensure continued compliance. - Begin 7/12/13 ending 7/12/13 Housekeeping supervisor and Infection Preventionist will complete quarterly skills assessments for housekeeping staff. Skills assessments will include hand hygiene, proper infection control procedures and proper disinfection of surfaces. Implemented strategies will be monitored for weekly for three months by Housekeeping supervisor and Infection Preventionist and findings will be reported to Administrator weekly. If strategies are determined successful, Housekeeping supervisor and Infection Preventionist will continue monitoring monthly for three months, reporting to Administrator monthly regarding findings. If determined successful, monthly monitoring of system will continue. All findings will be discussed quarterly with the Quality Assurance committee with revisions being made as necessary to ensure continued compliance. -On going: All future staff will be in-serviced regarding facility infection control procedures regarding hand hygiene (hand washing); review of cross contamination using transmission based precautions, in addition to standard precautions; proper procedure for disinfection of surfaces and cleaning of designated isolation areas. - For each resident identified as being affected by the deficient practices: (residents listed), Director of Nursing, Infection Preventionist and Housekeeping supervisor will monitor respective departmental staff to ensure that facility infection control procedures regarding the required hand hygiene (hand washing); procedures to avoid cross-contamination using transmission based precautions in addition to standard precautions; and procedures for disinfection of surfaces and cleaning of designated isolation areas are being followed per facility protocol. Monitoring of procedures for each of the identified residents will be conducted a minimum of five times per week for two weeks. With the Director of Nursing and Infection Preventionist monitoring Nursing staff for compliance with Infection control procedures (including hand hygiene, cross-contamination, perineal care, and wound care); and Housekeeping supervisor monitoring housekeeping staff for compliance with proper hand hygiene, cross-contamination avoidance, and disinfection of surfaces and cleaning of designated isolation areas. Following the random monitoring, each of the designated monitoring staff will submit to the Administrator written evidence of return demonstration for each monitored incident. The Administrator will review the information submitted to determine compliance with facility protocol. If plan is successful, each of the designated monitoring staff (Director of Nursing, Infection Preventionist, and Housekeeping supervisor) will continue random monitoring for a period of three months. Monitoring will be conducted a minimum of fifteen times per month for the three month period, then after the initial monitoring report, it will be revised until correction is achieved. Information regarding this procedure and findings will be reported to the quarterly Quality Assurance Committee for review and necessary modifications. Surveyors verified the facility had completed the above actions prior to removing the IJ through observations and interviews with staff. The IJ was removed 7/12/13 at 6:45 p.m. The facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm, widespread, because all staff had not been in-serviced and the facility had not yet monitored their plan of action for effectiveness. Non-IJ findings INCONTINENT CARE RESIDENT #4 Review of Resident #4's admission and discharge summary 6/04/13 documented she was admitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Review of Resident #4's physician's orders [REDACTED]. During an observation on 7/9/13 at 11:00 a.m. CNA D and CNA E entered Resident #4's room. CNA D put on her gloves, without washing her hands, lowered the side rails, took off the resident's pants and soiled brief. CNA D cleaned the perineal area and turned Resident #4 over on to her left side and cleaned the buttocks area. CNA D did not change gloves before putting on the clean brief. The residents sheet had urine that had soaked onto it. CNA D took a clean pad and set it on the area wet with urine. CNA D and CNA E did not change the sheet that had a urine soaked area on it. CNA D then put lotion on resident legs using the gloves she had worn while doing the incontinent care. CNA D then took off her gloves, put on clean ones on and pulled Resident #4's pants up. RESIDENT #5 Admission and discharge summary dated 6/21/13 indicated Resident #5 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. She was [AGE] years old. Observation on 07/09/13 at 9:20 a.m. CNAs J and K performed incontinent care on Resident #5. CNA K assisted CNA J by holding Resident #5 in place while CNA J did the care. Resident #5 had a bowel movement and CNA J changed her gloves as they became soiled. During the glove change CNA J did not wash or sanitize her hands in between glove changing. Both CNAs did not wash their hands after providing care. During an interview on 07/12/13 at 2:00 p.m. CNA J said she had forgotten to sanitize her hands between glove changes during incontinent care. RESIDENT #9 Review of Resident #9's admission and discharge summary dated 7/09/13 documented she was admitted on [DATE] with [DIAGNOSES REDACTED]. low end femur fracture, [DIAGNOSES REDACTED], dementia, diabetes type II, infections with microorganisms to [MEDICATION NAME]'s, onychia of toe, reflux disease, hypertension, acute respiratory failure, and Alzheimer's Disease. She was [AGE] years of age. During an observation on 7/10/13 at 9:25 a.m. CNA C and Nurse Assistant (NA) I entered Resident #9's room and prepared to do incontinent care. CNA C put on a pair of gloves, pulled the privacy curtain down the middle of the room, lowered the bed with his gloves on. CNA C took the soiled brief off Resident #9 and cleaned the perineal area, turned the Resident to her left side and cleaned the buttock area. NA I held Resident #9 in position on her side while CNA C did the incontinent care. CNA C put a clean brief on the resident, turned her onto her side and placed pillows under the resident. CNA C and NA I took off their gloves and left the room. CNA C and NA I did not change their gloves or wash their hands before beginning the incontinent care or after. During an interview on 7/11/13 at 10:35 a.m. CNA C said he was told to use gel instead of washing his hands. For residents who have isolation precautions he was told to go in and wash his hands, put on a gown and after giving care to wash his hands again. CNA C said, "I know I didn't change my gloves before I put on the new brief." He acknowledged not changing gloves caused cross-contamination. RESIDENT #20 Review of Resident #20's admission and discharge summary 4/26/13 documented she was admitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. During an observation on 7/10/13 at 9:50 a.m. CNA Z entered Resident #20's room and prepared to do incontinent care. CNA Z put on a pair of gloves, pulled the privacy curtain down the middle of the room, and lowered the bed with her gloves on. CNA Z took the soiled brief off Resident #20 and cleaned the buttocks area first by wiping the area twice, each wipe with a clean wet wipe. CNA Z then turned the resident to her back and cleaned her perineal area with one wipe only. CNA Z wiped the outer perineal area three times, from top down toward the anal area without changing positions of the wet wipe or obtaining a clean wet wipe. CNA Z did not separate the labia to fully clean the vaginal area. CNA Z then removed her soiled gloves, buttoned the resident's gown, transferred the resident to her wheelchair, sanitized her hands, gathered up the plastic bag of dirty laundry and left the room, pushing the resident in her wheelchair to the shower room. CNA Z did not wash her hands when she finished performing incontinent care to Resident #20. During an interview on 7/11/13 at 1:05 p.m. the Administrator and the DON were informed of the incontinent care observations. The DON closed her eyes and say, "oh my." INFECTION CONTROL LOG Review of the facility's infection control logs for April 2013-July 2013 revealed incomplete documentation. The areas of Symptoms, Lab results with micro-organics identified, and Date Resolved were not documented for all residents identified with infection(s). Procedures were not put in place for the quick confinement and eradication of the organism(s). During an interview on 07/11/13 at 9:59 a.m. RN O said she was in charge of the infection control program. RN O acknowledged she did not document the type of organism that caused the infection on the infection control log. RN O said she was never told she needed to determine the causitive organisms. POLICIES Review of the (undated) hand washing policy documented, in part: It is the policy of this facility that hand washing be regarded as the single most important means of preventing the spread of infections. Appropriate hand washing must be performed at the following times: -after having prolonged contact with a patient/resident (i.e., bed, bathing, changing linen, etc.) -before and after all patient/resident care activities. Patient/resident care activities. The following are examples of patient/resident care activities: -before performing dressing care or touching wounds of any kind -after contact with patients/residents in isolation -after handling used dressing care or touching wounds of any kind -after handling used dressings, urinals, bedpans, catheters, contaminated tissues, linen, etc. -after offering incontinence care/Foley care. Hand washing facilities: -hand washing facilities shall be readily accessible to patient/resident and associate-when hand washing facilities are not readily accessible, antiseptic towelettes may be used but hands shall be washed with soap and running water as soon as feasible. Use of gloves: The use of gloves does not replace hand washing. If gloves are worn, hands are to be washed before putting gloves for a procedure and after removal of the gloves with deposit of the gloves in the appropriate trash container. Review of the form CMS 672 Resident Census and Conditions of Residents completed by the MDS Coordinator on 7/08/13 documented there were 69 residents in the facility.