Every finding on record at Brentwood Place Four

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 (Residents #1) of 4 reviewed for oxygen. The facility failed to ensure Residents #1 had a written orders for oxygen administration when Resident#1 was receiving oxygen therapy on 05/27/26. This failure placed residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment. Record review of Resident #1's quarterly MDS assessment, dated 04/02/26, revealed Resident #1 was [AGE] years old male admitted to facility on 12/29/25 and readmitted [DATE]. Resident#1 active diagnosis included: Stroke, Heart Failure, High Blood Pressure, High Blood Sugar, respiratory failure, and Chronic Obstructive Pulmonary Disease (a progressive, irreversible lung disease that makes it hard to breathe.).Resident#1 had a BIMS score of 11/15 indicating moderate cognitive impairment. Section O-C1 reflected resident did require oxygen while residing at the facility. Record review on 05/27/26 of Resident#1's care plan dated 05/05/26 revealed no indication of oxygen therapy. Record review on 05/27/26 of Resident #1's physician's orders revealed: no order for oxygen therapy. Observation on 05/27/26 at 09:13 AM revealed Resident #1 was lying in bed with use of oxygen at 4.5 liters per minute nasal cannula. Resident#1 was unable to answer interview r/t his mental status. The oxygen tubing was dated 05/25/26. There was Oxygen in Use sign placed on the door frame of Resident#1's room. Observation and interview on 05/27/26 at 11:32 LVN A reviewed Resident #1's orders and confirmed there was no order for oxygen therapy in the system and went and physically checked Resident#1 and confirmed he was on oxygen at 4.5 liter/minutes. She stated she was familiar with Resident#1 and he was on oxygen all the time, and she did not check to make sure there was an order for the oxygen therapy. She stated she would contact the physician and get the order for oxygen therapy for Resident#1. She stated it was the responsibility of the nurses to physically assess residents every shift and confirm all the residents were receiving care according to the doctor's orders. LVN A stated the nursing staff was responsible to monitor Resident #1's oxygen each shift daily, and report all the changes to physician. LVN A stated not following physician orders could cause a risk to the resident breathing patterns. Interview with the DON on 05/27/26 at 11:37 AM, the DON stated Resident #1 was on oxygen. The DON stated nursing staff should be checking Resident #1's water, tubing, and level of oxygen flow on each shift daily, and confirm the therapy with the physician order. The DON stated it was the nursing staff's responsibility to check the oxygen level daily and every shift, enter new orders from the physician and document Resident #1's need for oxygen therapy. The DON stated not having Doctor order for resident's oxygen therapy could place the resident at risk of not receiving proper dose, and breathing issues. Record review of facility's policy titled Oxygen Administration revised June 2020, reflected: Purpose: To prevent or reverse hypoxemia and provide oxygen to the tissues. Policy I. Initiation of Oxygen A. A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include i. Oxygen flow rate ii. Method of administration (e.g., nasal cannula)iii. Usage of therapy (continuous or prn) iv. Titration instructions (if indicated) v. Indication for use B. In an emergency situation or when a physician's order cannot be immediately obtained, oxygen may be initiated by a Licensed Nurse in the presence of acute chest pain or anyother acute situation in which hypoxia is suspected. C. A physician is to be contacted as soon as possible after initiation of oxygen therapy inemergency situations, for verification and documentation of the order for oxygen therapy consultation, and further orders.II. Oxygen saturations will be measured and documented at a minimum of daily for resident's receiving oxygen therapy .

Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #16, Resident #62, Resident #194 and Resident#29) of 18 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #16 had her thumb nail cleaned and trimmed on 06/09/25. 2- Resident #62 had his fingernails cleaned and trimmed on 06/08/25. 3- Resident #194 had his fingernails cleaned and trimmed on 06/08/25. 4- Resident #29 had his fingernails cleaned and trimmed on 6/8/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: 1-Record review of Resident #16's Annual MDS assessment dated [DATE] reflected Resident #16 was a [AGE] year-old female admitted to the facility with initial admission date of 08/01/2022. Her relevant diagnoses included Cerebrovascular accident (disruption to blood flow to brain), hemiplegia (paralysis of one side of the body), Diabetes mellitus (high blood glucose ), hyperlipidemia (high blood lipid levels) ,End Stage renal disease (kidney functioning at severely reduced capacity requiring medical intervention), Hypertension (high blood pressure). Resident #16's BIMS score was 07, which indicated Resident #16's cognition was severely impaired. The MDS assessment indicated Resident #16 required substantial assistance with personal hygiene. Record review of Resident #16's Comprehensive Care Plan revised on 08/16/2022, reflected Focus: [Resident #16] has an ADL Self Care Performance Deficit related to Hemiplegia. Goal: Will maintain current level off unction in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. Intervention: Personal Hygiene: Substantial(extensive) assist x 1-2 staff. An observation and interview on 6/9/25 at 10:47 AM of Resident #16's left thumb nail revealed it was almost 1.5-2 inches long, thickened, jagged, bended outward, separated from the nail bed and discolored. Resident #12 stated that she would like the nail to be trimmed, and the nail did not hurt, but was long and looked dirty. Resident #12 added that she did not remember when she was last asked about trimming her thumb nail. Resident #16's right hand was contractures. In an interview on 06/09/25 03:59 PM with CNA C, she stated she worked in the facility for about a year and was familiar with Resident #16's care. She stated CNAs and Nurses were responsible for nail care. She said Resident #16 refused nail care at times. She stated that Resident #12's thumb nail looked discolored, long, and thickened, and ideally should have been cut. She also added that not trimming or cleaning fingernails could lead to infections. In an interview and observation on 06/09/25 04:02 PM with ADON D, she asked Resident #16 if she would like her left thumb nail to be cut. Resident #16 responded she would like it to be trimmed since it looked bad and was too long. ADON D added she would ask the physician and put in podiatry consult since the thumb nail was too thick to be trimmed by the facility staff. She added Nurses or CNAs perform nail care, and her expectation was nail care to be performed during shower times or as needed. She added She expected nursing staff to offer nail care to all residents. She added risk of long, dirty fingernails was loss of quality of life and potential infections. An interview on 06/09/25 04:10 PM with LVN E revealed she was a new nurse in the facility and started working about three weeks ago. She added she was not very familiar with Resident #16's care. She stated CNAs and Nurses were responsible for nail care. She added Resident #16 had history of refusals. However, nail care should be offered to all residents. She stated the risk of not cutting and cleaning nails was lapses in infection control and loss of quality of life. 2- Record review of Resident #62's Comprehensive MDS assessment dated [DATE] reflected Resident #62 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included hemiplegia and hemiparesis following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), cognitive communication deficit, and contracture of muscle, multiple sites. He had a BIMS score of 06/15, indicating sever cognitive impairment. The MDS assessment indicated Resident #62 required maximal assistance of 2 persons with personal hygiene. Record review of Resident #62's Care Plan dated 04/08/25, reflected the following: Focus: [Resident #62] has an ADL self-care performance deficit related to cerebral infarction. Goal: [Resident #62] will maintain current level of function in ADLs through the next review date. Interventions: . Personal hygiene: the resident requires total assistance with personal hygiene care . An observation on 06/08/25 at 11:12 AM revealed Resident #62 was laying in his bed. The nails on both hands were approximately 0.4 cm in length extending from the tip of his fingers. The nails were discolored tan, and had dark brown colored residue underside. Resident #62 stated he would like his fingernails cleaned and trimmed. In an interview on 06/09/25 at 08:46 AM, CNA/SC F stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA/SC F stated she did not see Resident #62's nails that morning. She stated she would do it right then. 3-Record review of Resident #194 's Comprehensive MDS assessment dated [DATE] reflected Resident #194 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, schizophrenia, hypertension, and need for assistance with personal care. He had a BIMS score of 06 out of 15, indicating severe cognitive impairment. The MDS assessment indicated Resident #194 required substantial/maximal assistance with personal hygiene. Record review of Resident #194's Care Plan dated 05/31/25, reflected the following: Focus: [Resident #194] has an ADL self-care performance deficit related to activity intolerance, fatigue, limited mobility. Goal: [Resident #194] will maintain current level of function in ADLs through the next review date. Interventions: . Personal hygiene: the resident requires supervision to limited (Partial/moderate) x 1 staff participation with personal hygiene care . An observation on 06/08/25 at 09:38 AM revealed Resident #194 was laying in his bed. The nails on both hands were approximately 0.9 cm in length extending from the tip of his fingers. The nails were discolored tan and had dark brown colored residue underneath. Resident #194 stated he would like his fingernails cleaned and trimmed. In an interview on 06/09/25 at 09:05 AM, CNA G looked at Resident #194's fingernails and stated they needed to be trimmed and cleaned. CNA G stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA G stated since Resident #194 was diabetic, she was going to clean his fingernails and notify the charge nurse to trim his fingernails. 4-Record review of Resident #29's Quarterly MDS assessment dated [DATE] reflected Resident #29 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included contracture of muscle of left hand, cognitive communication deficit, and cerebral infarction (a condition that occurs when blood flow to the brain is blocked. The blockage can lead to brain tissue death). Resident #29's BIMS score was not determined because Resident #29 was unable to complete the interview. The MDS assessment indicated Resident #29's cognitive skills for daily decision making were severely impaired. The MDS assessment indicated Resident #29 required maximal assistance with personal hygiene. Record review of Resident #29's Care Plan revised 02/20/25, reflected the following: Focus: [Resident#29] has an ADL self-care performance deficit related to cerebral infarction . Goal: [Resident #29] will maintain current level of function in ADLs through the next review date . Interventions: . Personal hygiene . Resident requires total assistance with personal hygiene care . An observation on 06/08/25 at 11:55 AM revealed Resident #29 was laying in his bed. The nails on both hands were approximately 0.5 cm in length extending from the tip of his fingers. The left hand was contracted, and the nails were pressing on the palm of the left hand. Observation reflected no skin breakdown. Resident #29 was unable to answer questions. In an interview on 06/09/25 at 9:13 AM, CNA J stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA J stated she did not see Resident #29's nails when she did her rounds. She stated she would do it right then. She stated the risk would be infection and injury. In an interview on 06/10/25 at 8:56 AM, the DON stated nail care should be completed as needed and every time aides washed the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated he expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated the ADONs would do the routine rounds to monitor. The DON stated residents having long and dirty nails could be an infection control issue. Record review of the facility's policy titled, Grooming Care of the Fingernails and Toenails undated reflected, Purpose: Nail care is given to clean and keep the nails trimmed .

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 (100/200 hall) of 3 nurse medication carts reviewed for pharmacy services. The facility failed to ensure LVN O, LVN P, and LVN R responsible for the 100/200 hall nurse cart , counted controlled drugs every shift change. This failure could place residents at risk of not having the medication available due to possible drug diversion. Findings Included: Record review and observation on 06/08/25 at 09:53 AM, of the 100/200 hall nurse cart , with LVN K revealed missing signatures for Off duty and On duty nurses for 06/06/2025 (6:00 AM to 2:00 PM shift), 06/06/25 (2:00 PM to 10:00 PM shift), and 06/07/2025 (10:00 PM to 6:00 AM shift) of the narcotic count sheet. Interview on 06/10/2025 at 12:04 PM, LVN O stated she should have signed the narcotic sheet after counting the narcotics, on 6/6/25 at the beginning and at the end of the shift 6 AM to 2 PM. She stated she got busy with a resident asking for ice and did not go back to sign the count sheet. She stated she knows that she supposed to signed immediately after the count was done. She stated the risk would be potential for drug diversion. Interview on 06/10/25 at 2:35 PM, LVN R stated he should have signed the narcotic sheet after counting the narcotics on 6/6/25 at the beginning and at the end of the shift 2 PM to 10 PM. LVN R stated, I counted the narcotics, but I got busy with a new admission. LVN R stated this failure could potentially cause a drug diversion. He stated he was trained and learned that he supposed to sign the narcotic count sheet immediately after counting with the other nurse. Interview on 06/10/25 at 4:28 PM, LVN P stated she should have signed the narcotic sheet after counting the narcotics on 6/7/25 at the beginning and at the end of the shift 10 PM to 6 AM. LVN P stated, she counted with the other nurse but forgot to go back and sign the count sheet. She stated she knows that she should sign the count sheet immediately after the count but sometime time you get interrupted LVN P stated this failure could potentially cause a drug diversion. Interview on 06/10/25 at 8:56 AM, the DON stated he expected nurses to sign the narcotic count sheet at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated if the staff was not signing the narcotic count sheets, he was unable to prove they were counting. The DON stated it was important to ensure a drug diversion did not occur. The DON stated the ADONs would daily check the cart on the weekdays and the weekend supervisor during the weekends for monitoring. Review of the facility's policy Receiving Controlled Substances dated September 2018, did not address the concerns.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to ensure food items were properly stored in the facility kitchen on 06/08/25. 2. The facility failed to ensure [NAME] A performed adequate hand hygiene while preparing lunch meal on 06/09/25. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 6/8/25 at 9:30 AM revealed a scoop in the bulk oatmeal bin in the dry storage area. Observation on 6/8/25 at 9:33 AM in the facility refrigerator revealed a zip top bag had about 6-7 cut strawberries, 1 lemon, and about 10-12 grapes in it without a date and label. Observation on 6/9/25 at 11:34 AM in the kitchen prep area revealed [NAME] A was making pureed food. [NAME] A did not wear any gloves. [NAME] A took out the pureed food from the blender in a serving container. She silenced a cell phone that was placed near the prep area. She then went to the sink area, rinsed the blender jar. She did not perform hand hygiene after returning back from the dish washing area to the food prep area. At the prep area, she added some of the cooked sweet potato casserole in the same blender jar and continued to make pureed casserole. After the pureed casserole was made, she got a dirty dish cloth from the side of the counter and proceeded to wipe off the counter with the dirty dish cloth. [NAME] A then proceeded to don gloves without washing her hands. After donning the gloves, she emptied the pureed casserole into a near-by serving container. She removed her gloves, did not wash hands, made a ball of the gloves, held it in the palm of her hands and proceeded to move some of the clean and sanitized plate covers to the serving area. In an interview on 06/09/25 01:19 PM, Dietary Aide B revealed all food items in the kitchen should be covered, labeled, and dated. She stated that all food items should have had use by date on them. She stated scoops should not be placed in bulk containers. She stated that everyone in the kitchen including dietary aides, cooks, and managers were responsible for appropriate food storage. She added that the risk to residents of not appropriately dating and labeling food items was residents could get sick. In an interview on 06/09/25 at 01:28 PM, [NAME] A revealed everyone in the kitchen, including cooks, dietary aides, and the Dietary Manager, was responsible for labeling and dating food items in the kitchen. She added that she was not aware who kept the fruit in the refrigerator. However, all items in the refrigerator should have been labeled and have use by date on them. She added that a dietary aide had used the oats for dessert and may have forgotten to put the scoop back in its place. She stated the scoop should not be placed in bulk containers for risk of food contamination. She added she was aware that hand hygiene was very important after moving from one task to other in the kitchen. She added she knew to wash hands with soap and water after moving from the prep area to the dishwasher area and back. She stated she was a little flustered in the kitchen since a surveyor was in the kitchen to observe meal service on 6/9/25. She stated risk of improper food storage or improper hand hygiene in the kitchen could lead to food spoilage and increased risk of residents being sick. An interview on 06/09/25 at 02:40 PM with the Regional Dietitian revealed that the facility's Dietary Manager was on leave and was not available for an interview. She added that she had been the Regional Dietitian for 6 months in the facility. She stated her expectation was that all food items should be covered, labeled, and dated. She also stated the scoop should not be stored in bulk container food. She stated she expected all kitchen staff to follow adequate hand hygiene which included washing hands with soap and water before and after changing kitchen tasks, and especially after moving from food prep to dishwashing area. She added the risk of improper food storage and inadequate hand hygiene could lead to cross contamination and the possible risk of food borne illness in residents. Review of the facility's policy titled Food Labelling and Dating revised 01/25/2025 reflected, .Food items will be labeled, dated, stored, thawed in accordance with good sanitary practice .VII. Any food items prepared for a meal that were not served may be retained to use later and are leftovers. Leftovers are placed in an airtight container or Ziplock bag and will be labeled with the leftover product name, date prepared, and discard date. Leftovers must be used by or discarded within 3 days of the preparation date. Review of the facility's policy titled Hand Hygiene revised 06/2020 reflected, Purpose: To ensure that all individuals use appropriate hand hygiene while at the Facility. Policy: The Facility considers hand hygiene the primary means to prevent the spread of infections Facility Staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited too . A. Wash hands with soap and water .vi. Before and after food preparation. Review of the Food and Drug Administration Food Code, dated 2022, reflected, . Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in Food preparation or dispensing, Food preparation and dispensing utensils shall be stored: (A) Except as specified under (B) of this section, in the food with their handles above the top of the food and the container; (B) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon .2-301.11 Clean Condition. The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code . 2-301.12 Cleaning Procedure. Handwashing is a critical factor in reducing fecal-oral pathogens that can be transmitted from hands to food as well as other pathogens that can be transmitted from environmental sources.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for 1 (Resident #63) of 6 residents reviewed for tracheostomy care. LVN I failed to maintain sterile technique during tracheostomy (a surgical opening in the neck providing a direct airway through the trachea) care, and change gloves with hands hygiene going from dirty to clean task. These failures could place residents at risk for respiratory infections. Findings included: Review of Resident #63's quarterly MDS assessment, dated 05/07/25, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 15/15 indicating cognitively intact. Her active diagnoses included acute and chronic respiratory failure, presence of artificial larynx, hypertension. In Section O-Special Treatments, Procedures, and Programs it revealed she required oxygen therapy, and tracheostomy (trach) care. Review of Resident #63's care plan dated 03/27/25 reflected, [Resident63] has Tracheostomy related to impaired breathing mechanics .Interventions .Ensure that trach ties are secured at all times .Monitor/document respiratory rate, depth and quality. Check and document every shift/as ordered . Review of Resident #63's Physician's orders with start/active dated 03/16/25, reflected, Change and date trach ties, mask, .weekly Fridays and as needed. In an observation on 06/10/29 at 11:22 AM, revealed LVN I inside of Resident #63's room. She donned a gown, gloves, and mask. LVN I had an unopened trach kit, T-drain sponge, tracheostomy tube holder, Q tips cotton swap, a bottle of normal saline, and a sterile glove on draped bedside table. LVN I assessed Resident #63's oxygen saturation, and lungs. LVN I removed her gloves, sanitized hands, opened the trach kit, the sterile gloves package, there was one glove only. LVN I got another sterile glove from a basket on the residents breathing supplies table. LVN I opened the sterile gloves package, and without performing any form of hands hygiene, she put on the sterile gloves. LVN I opened the bottle of normal saline with the sterile gloves and poured it into the reservoir in the trach kit. LVN I removed the old T-drain sponge dressing from the Resident #63 trach site and disposed of it. LVN I cleaned the site with normal saline using the Q tip cotton swap. LVN I placed the clean T-drain sponge dressing under the trach collar wearing the same gloves. LVN I removed her gloves and gown, washed her hands. LVN I gathered the trash disposed of them in the trash can and left the room. In an interview on 06/10/25 at 11:44 AM, LVN I stated the trach care was supposed to be a sterile procedure and she stated she did not do a sterile procedure. She stated she thought there was supposed to be 2 sterile gloves in the package, and it threw her when there was only one. She stated the reason it was supposed to be a sterile procedure was to reduce the risk of introducing infection into the lungs. She stated she should had performed hand hygiene after opening the sterile gloves package and pour the normal saline before putting on the sterile gloves. She stated she was supposed to change gloves with hand hygiene after removing the old T-sponge dressing, and before applying the clean one. In an interview with the DON on 06/11/25 at 11:31 AM, he stated the trach care was supposed to be a sterile procedure. The DON stated the reason it was supposed to be a sterile procedure was to reduce the risk of infection and pneumonia. The DON stated LVN I should perform hand hygiene before putting on the sterile gloves. The DON stated LVN I should change gloves with hand hygiene before handling the clean sponge. Record review of the facility's policy, Tracheostomy Care' dated June 2020, reflected, .In addition to routine care, stoma dressing, and trach ties will be changed when wet or soiled .Gather supplies .Wash hands .don gloves .Inspect skin and stoma site for sing or symptoms of infection, skin irritation, or open areas. If there is a tracheostomy dressing, remove the old dressing from around the tracheostomy tube and discard .Clean around the tracheostomy site .with a cotton swab or gauze pad moistened in normal saline .Repeat the cleaning process until wet and dried mucus is removed. Use a clean cotton swab or gauze pad each time .Pat the area dry with a gauze pad .Apply a precut ( non-[NAME] dressing) around the insertion site .Suction resident as needed .

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 8 %, based on 2 errors of 25 opportunities, which involved one of five residents (Residents #74) and one of four staff (MA L) reviewed for medication errors, in that: The facility failed to ensure: MA L instructed Resident #74 to chew Aspirin low dose chewable and to place the sublingual (a pharmacological route where medication were placed under the tongue to dissolve and be absorbed directly into the bloodstream) buprenorphine under her tongue when administering medications. These failures could place residents at risk for not receiving therapeutic effects of their medications. The findings include: A record review of Resident #74's Quarterly MDS assessment, dated 05/07/25, reflected a [AGE] year-old female with an admission date of 11/15/24. She had a BIMS score of 10, which indicated her cognition was moderately impaired. Diagnoses included chronic embolism (long-term presence of blood clots), chronic kidney disease, and muscle weakness. A record review of Resident #74's medication administration records dated 05/09/25 reflected Resident #74 was to receive the following medications: Aspirin Low Dose Oral Tablet Chewable 81 MG (Aspirin) Give 1 tablet by mouth one time a day for pain -Order Date05/06/2025 Buprenorphine HCl-Naloxone HCl Sublingual Film 8-2 MG (Buprenorphine HCl-Naloxone HCl Dihydrate) Give 1 tablet sublingually one time a day for narcotic dependence. -Order Date05/06/2025 During a medication pass observation on 06/09/25 at 07:47 a.m., MA L administered the following medications to Resident #74: - Vitamin C 500 mg x 1 tablet - Aspirin 81 mg x 1 tablet- chewable - Eliquis 5 mg x 1 tablet - Methocarbamol 500 mg x 2 tablets - Multi-vitamin x 1 tablet - Zinc 50 mg x 1 tablet - Vitamin B1 x 1 tablet - Bupren-Naloxone 8mg - 2mg sl (sublingual) x 1 tablet - Pregabalin 75 mg cap x 1 tablet. In an interview with MA L on 06/09/25 11:06 AM, verified what medications was administered to Resident # 74 on 06/09/25 and stated she missed read that the Aspirin was chewable, and the Buprenorphine was sublingu al. She stated the medication must be given as ordered by the physician. In an interview with the DON on 06/10/25 at 08:56 AM, he stated he expected the staff to follow the 5 rights of medication administration which are right drug, right dose, right route, right patient, and right time. He stated failing to follow these rights put residents at risk of not receiving all their medications or could lead to drug interactions if the correct medication or dosage was not given. He stated the MAs should always go to the Charge nurse, the ADON or himself if there were any question about a medication and they should clarify with the physician any order for the chewable medication to change it to regular medication if resident can swallow medications. Record review of the facility policy titled Medications-Administration, not dated, reflected, .Nursing staff will keep in mind the seven rights of medication when administering medication: A. the right medication, B. the right amount, C. the right resident, D. the right time, E. the right route, F. right indication, G. right outcome .The Rule of 3 - the licensed nurse administering medication will perform 3 checks comparing the physician's order, pharmacy label, and medication administration record .

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (100/200 hall nurses cart) of 3 medication nurse cart reviewed for pharmacy services in that: The facility failed to ensure: 1. LVN K responsible for the 100/200 hall nurses cart , removed medications in unsecure containers from the Nurses Cart. 2. The 100/200 hall nurses cart did not have 1 insulin pen for Resident #19 with no open date. Observation of the pen reflected it was used. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications, and place residents at risk of not having the medication available due to possible drug diversion. The findings included: Record review and observation on 06/08/25 at 09:53 AM, of Nurses Cart Hall 100/200, with LVN K revealed: - The blister pack for Resident #3's tramadol 50 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister. - The pen of insulin lantus 100 unit/ml for Resident #19 with no open date. Observation of the pen reflected it was used. Interview on 06/08/25 at 1:19 PM, LVN K stated the count was done at shift change and the count was correct. She stated she did not check the blister packs during the count. She stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blister. She stated the risk would be a potential for drug diversion. She stated the nurses and med aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated when a broken seal was observed, she would waist the pill with another nurse. LVN K stated she gave insulin to Resident #19 in the morning at 7:00 AM and she did not check the pen for the open date. LVN K stated the purpose of putting an open date was for expiration purposes because the insulin was only good for 28 days. She stated after 28 days the insulin would be ineffective. Interview on 06/10/25 at 8:56 AM, the DON stated he expected if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be potential for drug diversion and infection control issue. He stated nurses was responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADONs were supposed to check the carts daily. The DON stated the insulin flex pens and vial, once opened, needed to be dated because each insulin pen and vial had a specific day's shelf life and if not thrown out by that time the insulin could lose its effectiveness. The DON stated the pharmacy consultant checked the carts monthly and he stated ADONs were supposed to do random checks of the medication carts for monitoring. Record review of the facility's policy titled Storage of Medications, dated September 2018, revealed in part . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy . Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency . The nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening .

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident # 63) reviewed for resident rights. The facility failed to ensure Resident # 63 was assisted with eating in a dignified manner on 06/08/25, CNA H stood while feeding the resident. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem. Findings included: Review of Resident #63's quarterly MDS assessment, dated 05/07/25, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 15/15 indicating cognitively intact. Her active diagnoses included acute and chronic respiratory failure, presence of artificial larynx, hypertension. In Section GG-Functional Abilities-A. Eating: Dependent. Review of Resident #63's care plan dated 03/27/25 reflected, [Resident63] has Self Care Performance Deficit r/t Respiratory failure, trach .muscle weakness. Goal. [Resident#63] needs will be met per staff through the next review date. Interventions . EATING: The Resident requires total assistance to eat. During an observation on 06/08/25 at 1:21 PM, Resident #63 was in bed with the head of the bed elevated, and CNA H was standing while assisting Resident #63 with her meal. Resident #63 was unable to interview on how she felt about staff standing during her meal. During an interview on 06/08/25 at 1:30 PM, CNA H stated she supposed to sit next to Resident #63 while assisting with her meal today. She said she should have gotten a chair and sat while assisting because standing could make a resident uncomfortable. During an interview on 06/11/25 at 11:31 AM, the DON said that all staff was responsible for ensuring resident's dignity was maintained and all staff was trained on resident rights. He said when a resident required assistance with meals, the staff should be seated to prevent the resident from being uncomfortable. Record review of a facility policy titled Resident Rights with revised date August 2020 indicated, . The Facility must 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, recognizing each resident's individuality .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for each resident that included measurable objective and timeframes to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #58) of 6 residents reviewed for comprehensive care plans. The facility failed to implement the care plan for Resident #58 by not applying the splint daily to his right arm and hand contraction. This failure could place residents at risk for not having individualized care and services to meet their needs. Findings included: Review of Resident #58's Face Sheet dated 06/10/25 reflected he was admitted to the facility on [DATE] with a diagnosis of hemiplegia affecting right dominant side. Review of Resident #58's care plan dated 04/22/25, revealed [Resident #58] has an Alteration in musculoskeletal status r/t Right hand CONTRACTURES. Goal. [Resident #58] will remain free of complications related to fracture, such as contracture formation, embolism and immobility through review date. Intervention. ASSIST APPLYING Right RESTING HAND SPLINT DAILY. Further review of the care plan revealed no document of Resident#58 refusing the application of splint to his right arm. Observation on 06/08/25 at 11:17 AM revealed the Resident #58 lying in bed wearing daytime attire, no splint was on his right arm and hand. Resident#58 was unable to respond to interview. Observation and interview on 06/09/25 at 09:17 AM revealed the Resident #58 was up in wheelchair in the TV room, and there was no splint on his right arm. CNA J looked at the Resident#58 not having the splint on his right arm, and stated, the therapy staff put the splint on the resident. Interview with the Physical Therapy Manager revealed there should be an order for a splint. The Physical Therapy Manager stated she would check the physician orders for a splint for Resident #58. The Physical Therapy Manager ignored the question for who was responsible for the resident's contracted arm care. The Physical Therapy Manager checked her laptop and stated restorative care worked with him and he refused the splint . She further stated Resident #58's refusal was care planned . Interview on 06/10/25 at 12:27 PM the MDS Coordinator stated care plan updates depended on what was happening. She stated she reviewed the care plan every 92 days. She stated if the care plan was not updated, the residents would not get the care they were supposed to get. She stated care plans instructed direct resident care staff to know the residents' needs. She further stated the care plan was the blueprint to take care of the residents. In interview on 06/11/25 at 11:31 AM, the DON stated the nurses, the ADONs, and DON were responsible for updating the care plan. He stated the implications for the residents if the care plan was not updated was it could affect the plan of care for the Resident; meeting Resident #58's needs and his contraction could get worst. The facility's current, undated Care Plans, Comprehensive Person-Centered policy reflected: .include measurable objective and timeframe; Describe the services that are to be finished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wee-being .include the residents stated goals upon admission and desired outcome; changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the residents stay.

Based on interview and record review, the facility failed to ensure a discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for one (Resident #32) of one resident reviewed for discharge assessments. The facility failed to complete and transmit Resident #32's discharge MDS assessment within 14 days of completion. This failure could place the residents at risk of having incomplete records. Findings include: Review of Resident #32's face sheet, dated 06/09/25, reflected Resident #32 was a [AGE] year-old female with initial admission date to the facility of 09/10/2024 and discharged from the facility on 01/17/2025. Review of Resident #32's MDS assessments on 06/09/25 revealed Resident #32 did not have a discharge MDS assessment completed. This MDS record was identified as greater than 120 days late on the resident assessment facility task. An interview on 06/09/25 09:56 AM with the MDS Nurse revealed all residents who were discharged from the facility and not anticipated to come back should have a discharge MDS completed. She stated that she was responsible for completing all MDS assessments. She stated the timeframe for completing and transmitting discharge assessments was within 14 days of discharge or death. She reviewed Resident #32's MDS assessments and stated she had started the assessment but failed to complete and transmit it to CMS within the stipulated time frame of 14 days. She stated that failure to do so would lead to CMS not being aware if the resident was still residing in the facility and may show up as a current resident in the facility. An interview on 06/11/25 at 09:47 AM with the DON revealed his expectation was for all MDS assessments to be completed in a timely manner. He stated that MDS Nurse was responsible for completing all assessments, and he provided oversight as needed. He stated that the failure to do so would lead to possible interference with resident care after discharge and not reflect accurately on census with CMS. An interview on 06/11/25 01:16 PM with the Administrator revealed that the Facility MDS Nurse was responsible for completing all MDS assessments in a timely manner, and it was his expectation that all the MDS assessments were completed and transmitted to CMS within the stipulated time frame. He stated that failure to do so will lead to CMS not being aware if the resident was still residing in the facility. The Administrator stated the facility did not have a policy on MDS assessments referred to CMS RAI manual. (RAI- Resident Assessment Instrument is a comprehensive nurse assessment and care planning process used by the long-term care facilities as a requirement for reimbursement under Medicare and Medicaid). Record review of CMS Long term care facility resident assessment Instrument 3.0 user's manual dated October 2024 reflected, . 09. Discharge Assessment-Return Not Anticipated . Must be completed within 14 days after the discharge date .Must be submitted within 14 days after the MDS completion date.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two (Resident #12 and Resident #64) of three residents reviewed for incontinence care. The facility failed to ensure: 1. Resident #64's foley catheter was secured prior to transferring Resident #64 from the toilet to his wheelchair on 06/09/25. 2. The facility failed to ensure CNA G provided appropriate perineal care for Resident #12 when she failed to separate the labia when cleaning the resident on 06/09/25. These failures placed residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter. Findings included: 1. Record review of Resident #64's quarterly MDS assessment, dated 04/29/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 5 indicating his cognitive was severely impaired. His diagnoses included pyelonephritis (kidney infection), neuromuscular dysfunction (condition where the nerves connection the bladder to the brain and spinal cord are damaged, leading to problems with bladder control and emptying), and need for assistance with personal care. The resident required maximal assist for toileting and personal hygiene. The resident had an indwelling catheter. Record review of Resident #64's care plans, dated 04/22/25 reflected: The resident had an indwelling foley catheter. Facility interventions included monitor/document for pain/discomfort due to catheter. An observation on 06/09/25 at 1:30 PM revealed Resident #64 was sitting on the toilet. The catheter tubing was not strapped to the resident's leg to prevent it from pulling out. CNA F was in the room, and wearing gloves and a gown. CNA M was standing by the toilet door and wearing gloves and gown. CNA F entered the toilet to assist resident with cleaning and transfer to the wheelchair. CNA F unhooked the catheter bag from the wheelchair side and handed it to CNA M. Resident #64 complained of pain to the penial area. CNA F removed her gloves and gown, and left the room to notify the nurse. CNA F came back to the room with RN N; both put on gowns and gloves. RN N assisted the resident while sitting on the toilet . RN N instructed CNA F and CNA M to transfer the resident to his bed. CNA F proceeded to clean the resident's buttocks. With the assistance of CNA M, CNA F transferred the resident from the toilet to his wheelchair and from his wheelchair to his bed. In an interview with CNA F on 06/09/25 at 02:15 PM, CNA F stated the resident should have had his catheter secured. She stated she informed the nurse. CNA F stated they had not had any recent training on foley catheter care, but knew they were supposed to always keep the foley catheter tubing secured to the resident leg to prevent pulling and injury. In an interview with RN N on 06/09/25 at 02:25 PM, she stated the catheter should have secured before they transferred the resident, but they just got nervous with someone watching them. She stated failing to secure the catheter could cause trauma to the bladder if the catheter got pulled. In an interview with the DON 06/10/25 at 08:56 AM, he stated any resident with a foley catheter should have it secured, to ensure the resident's catheter did not get pulled out causing trauma or injury. The DON stated he would do skills check on catheter care for all CNAs. 2. Record review of Resident #12's quarterly MDS assessment, dated 05/05/25, reflected a [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on 10/14 24. She had a BIMS score of 12 out of 15 indicating moderate cognitive impairment. She required substantial/maximal assistance for toileting care. Her active diagnoses included hypertension, diabetes mellitus, septicemia ( a serious condition where bacteria enters the blood stead and spreads throughout the body, and schizophrenia. Record review of Resident #12's care plan, dated on 05/05/25, reflected, Focus. [Resident#12] has an ADL Self Care Performance Deficit r/t Confusion, Impaired balance, Musculoskeletal impairment. Goal. [Resident#12] will maintain current level of function in through the next review date. Interventions/Tasks. toileting: incontinent of bowel and bladder, x2 person assist An observation on 06/09/25 at 2:05 PM revealed CNA G and CNA K entered Resident #12's room. Both staff washed their hands and put on gloves. CNA G unfasted the resident's brief. CNA G pushed the brief down between Resident#12's legs. CNA G wiped down each side of her groin area, revealing the resident had a bowel movement that had pushed up between her legs. CNA G wiped to remove the bowel movement from the resident's inner thighs, then wiped across the pubic mound but did not spread her labia and wipe down the middle. Both staff rolled the resident onto her side, revealing a large soft bowel movement. CNA G continued to clean from front to back until all bowel movement was removed. CNA G then removed her gloves, performed hand hygiene, and re-gloved before placing a clean brief under the resident. Both CNAs turned Resident#12 side to side and to her back, finished putting the brief on her, and fastened it. Both CNAs pulled the cover on the Resident#12. Both CNAs gathered the trash, removed their gloves, performed hand hygiene, and left the room. In an interview on 06/09/25 at 2:21 PM. CNA G stated, she cleaned the Resident#12's labia will pushing the brief down between the Resident's leg. When asked if that how it supposed to be done, she replied she was supposed to open the resident's labia and clean it with wipes, and not the diaper. She stated she would go back and re-perform Resident #12's incontinent care to make sure Resident#12 private area did not have any more feces. She stated the risk to the resident was a UTI, or infection if feces was still left in her vagina. She stated she received training during orientation. In an interview with the DON on 06/11/25 at 11:31 AM, he stated the CNAs were supposed to follow the proper procedure for incontinence care which included spreading the labia and wiping down the middle using wipes, not the brief, to ensure the residents were clean and to help reduce infection risk. Review of the facility policy , Catheter Care, revised June 2020, reflected: . Anchor the catheter with a leg strap to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter .

Based on observation, interview, and record review, the facility failed to ensure residents were free from Misappropriation of property for 1 (Resident # 1) of 8 residents reviewed for misappropriation of property. The facility failed to protect Resident #1 from misappropriation of property from CNA A. CNA A used Resident #1's Debit card for unauthorized transactions. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 08/24/2024 and ended on 09/03/2024. The facility had corrected the noncompliance before the Incident investigation began on 02/04/2025. This failure could place residents at risk of Exploitation/Misappropriation of Property and loss of lifelong earnings. Findings included: Record review of Resident #1's face sheet dated 02/05/2025 revealed he was a [AGE] year-old male with an admitted [DATE]. His diagnoses included mild cognitive impairment of uncertain or unknown etiology (exact cause of the memory/cognitive decline cannot be determined) Primary Open Angle Glaucoma, (Increased pressure inside eye which may cause gradual damage to the optic nerve), Hypertension (blood pressure in the arteries is consistently elevated). Record review of Resident #1's MDS assessment dated [DATE] revealed he had a BIMS score of 14, which indicated he had an intact cognition. Resident #1 needed extensive assistance with ADLs for toileting and personal hygiene. Record review of Resident #1's progress note dated 08/24/2024 at 04:24 PM created by RN supervisor reflected Resident #1 reported to RN supervisor about missing credit card and RN supervisor reported it immediately to the administrator. Resident's [family member] was in the room with the resident, they searched for the card but could not find it. On further noted the credit card has been used to make several purchases including Greyhound ticket to Los Angeles California. Police was called, awaiting dispatch to the facility. Review of the PIR dated 09/03/2024 for incident report # 527680 reflected the date this incident was reported to HHSC was on 08/26/2024 and the date the PIR submitted to the state was on 09/03/2024. Record review of PIR (Form 3613-A of Texas Health and Human Services) dated 09/03/2024 reflected the incident date as 08/26/2024. The PIR summary reflected the Resident #1 reported to the facility staff that his debit card went missing after he last used it at the facility front desk. Upon further investigation by the facility, [department store] surveillance camera captured one of the facility employees making unauthorized purchases, totaling $161.60 with Resident #1's debit card. [Department store] was unable to release the video footage without police involvement. [Local] police was notified, online report was created with a report dated 08/27/2024 at 01:42 PM. The resident #1's family, MD, Ombudsman were also notified. Based on the facility investigation findings, it was determined that the incident involving the theft and unauthorized use of Resident #1's debit card was the result of actions taken by an individual staff member. An initial interview with the facility administrator on 02/04/2025 at 12:41 PM revealed she learned that Resident #1's debit card was missing on 08/26/2024. She stated Resident #1 was a new admission. On the next day, Resident #1's family member came and reported to her that Resident #1's debit card was missing, the last time Resident #1 used it was at the front desk. Resident #1's family member told her that she noticed several charges on the card transaction history, and transactions took place on [NAME] Avenue, the same street where the facility was located. The Administrator stated she went over to the gas station where the card was used but they refused to provide any information. Intereview revealed she then went to department store where the card was used for unauthorized transaction The Administrator stated the store let her see the video footage of the person , who was using the card. Interview revealed the Adminstrator recognized the facility employee, CNA A as the person who was making the unauthorized transaction. The department store refused to provide her a copy of the video footage without police involvement. The Administrator stated she called the police and reported the incident. The Administrator stated she tried calling CNA A on her cell phone, but CNA A never answered or returned her call, CNA A never came back to the facility to collect her remaining check for the time she worked and so she was not able to talk to the CNA A about the alleged incident. She stated she did not know how CNA A got hold of Resident #1's debit card. The Administrator stated she immediately acted, called a staff meeting and provided in service on elder justice act, abuse/ neglect, resident rights, misappropriation of resident property, a QAPI meeting with department heads and discussed how to prevent such incidents, held a resident council meeting notifying them of not sharing card or card info with any staff, Educated on misappropriation, if a resident had to buy something from the vending machine inside the facility, a staff will assist the resident to the vending machine and resident did transaction themselves . She stated those residents who received trust fund money had a shopping day and they used cash only for transactions. Those residents who wanted to buy something from outside, most of them used the family assistance, the facility had a facility credit card for resident purchases and used that for some residents, the residents never gave their card to the employees. CNA A was terminated on 09/03/24. The Administrator stated Resident lost a total of $161.60. The facility gave the lost money back to the resident, completed audit on debit credit card holders among residents, sent letter out to those residents who had debit /credit card asking them to check for unauthorized transactions and to notify facility if they noticed any, completed a survey among residents who managed own money and there were no other concerns. The Administrator stated she was the abuse coordinator; she expected all the employees to not take any of resident belongings and she expected all employees to notify her of any suspicion of abuse/neglect/misappropriation immediately. An interview with CNA B on 02/04/2025 at 02:15 PM revealed misappropriation was, taking the resident's valuable things without their permission. She stated she received in service on abuse/neglect/misappropriation within the past month. She stated she was not aware of any resident who lost their bank debit/credit card. She stated she would immediately report to the administrator of any such abuse/neglect/misappropriation concerns. CNA B stated she never accepted cash or bank card from a resident, she stated if a resident wanted to purchase anything from outside, they had to get permission from the administrator and work with the activity director. An interview with CNA C on 02/04/2025 at 02:52 PM revealed misappropriation was taking the resident's belongings, he stated he was not supposed to accept any cash, credit/debit card from residents and he would direct the resident to the nurse if they wanted to purchase something. He stated he would not go through resident's belongings unless resident wanted him to search for something missing. He stated he was not aware of any resident who lost their bank card at the facility. He stated none of the staff were supposed to misappropriate a resident's cash or valuable things and he would notify the administrator/abuse coordinator about misappropriation immediately. He stated he received in service training on misappropriation within the past one month. An interview with the Corporate Business Office Consultant on 02/04/2025 at 03:11 PM revealed the facility's business manager was on medical leave and she came to the facility a few days to complete the work. She stated she was aware of the incident involving Resident #1 and CNA A. She stated Resident #1 managed his own money, bank cards and he reported to the administrator that his bank card got stolen. She stated the police was notified, the resident's card was cancelled, and he received a new debit card. She stated none of the employees were expected to accept cash/bank cards from residents, only the Activity Director was responsible to assist residents in purchasing outside goods with cash payment and the administrator was involved in the process. She stated she was not aware of any other incidents of missing bank cards; she stated the employee/CNA A stole the debit card and then used it for unauthorized transactions. An interview with the Dietary Manager on 02/05/2025 at 09:35 AM revealed Misappropriation was taking resident's clothes, belongings without their permission. She stated she received in service on Misappropriation within the past few weeks. She stated she heard about the alleged misappropriation incident from other employees, she stated she would not accept debit/credit cards/cash from the residents, she would direct them to the activity department for any purchases. She stated she would notify the administrator of any misappropriation concerns immediately. She stated she was not aware of any resident lost their card or money. She stated CNA A no longer worked at the facility. An interview with the MA on 02/05/2025 at 09:43 AM revealed she was working at the facility for 2 years. The MA stated misappropriation was taking a resident's belongings such as money, clothes, valuables without their permission. The MA stated she received in services on misappropriation within the past one month. The MA stated she was not aware of any misappropriation of credit/debit cards. She stated she would never accept any bank card or cash from a resident, she would direct the resident to the activity director for any purchases. She stated she was not aware of the alleged misappropriation incident. She stated she would immediately report the administrator of any suspicion of abuse/neglect/misappropriation. An interview with Dietary Aide on 02/05/2025 at 09:52 AM revealed misappropriation was taking resident's belongings without their permission, and she received in service on Misappropriation within the past month. She stated she would not accept cash/bank cads from the residents, the activity director was responsible to assist residents with purchases. She stated she would immediately report of any misappropriation concerns to the administrator. An interview with Resident #1 over the phone on 02/05/2025 at 11:06 AM revealed he was currently staying at his residence. He stated he stayed for few weeks at the facility for rehab and at that time his debit card went missing from the facility front desk. Resident stated he left the card at the front desk and returned to his room to pick up something, by the time he came back to the front desk, the card went missing. Resident stated he could not remember the exact date, but he immediately reported this to the facility staff, and he called the police and reported the incident. Resident stated he noticed on the online bank transaction history that his card was used at some stores close by the facility, he stated the transactions included a department store, restaurants, and a bus ticket to California. Resident stated he learned from the police that one of the facility employees stole his card and used it initially, later the police caught a man from California using his card. He stated he lost a total of $800, and the facility did not pay him anything so far. He stated he did not have a copy of his bank statement ready to send to the investigator at that time. Resident stated he filed fraud charges with the bank, he received new debit card, and his finances were safe now. Resident stated he did not go without any of his immediate needs due to the theft. An attempt for a telephone interview with CNA A was made on 02/05/2025 at 11:19 AM on her cell. A man answered and stated that was a wrong number for CNA A and that he did not know CNA A. An attempted telephone interview with RN supervisor was made on 02/05/2025 at 12:16 PM on her cell phone, but received no answer, left voice mail requesting a call back. An interview with the Activity Director on 02/05/2025 at 01:40 PM revealed she was working at the facility for 4 years. She stated misappropriation was taking/using resident's valuables for unauthorized use. She stated administrator informed her about the alleged incident and she was not involved in it. She stated none of the residents gave credit/debit card to the employees. She went to the store to purchase things for residents on every second Thursdays and those residents who wanted to purchase something would give her the list. Residents who had trust fund account collected money from the business office and gave the money to the activity director. The activity director verified each resident transaction with the facility administrator before and after the purchase, showed receipts, returned balance amount and items to the residents. The Activity director stated she never accepted debit/credit card from residents, and she was not aware of card theft/misappropriation other than the one involving Resident #1. She stated she would immediately report to the administrator of any suspicion of abuse/neglect/misappropriation. An interview with LVN D on 02/05/2025 at 03:30 PM revealed misappropriation was a type of abuse, taking resident's valuables without their permission was misappropriation. She stated she received in service on misappropriation within one week. She stated she would immediately report to the abuse coordinator/administrator of any concerns of misappropriation. She stated she was not aware of any resident missing their cash or bank debit/credit cards. She stated none of the employees were supposed to accept cash or debit/credit cards from residents and she would direct them to the activity director for any purchases. An interview with the administrator on 02/05/2025 at 04:51 PM revealed she was working at the facility as the administrator for a year and she was the abuse coordinator. She stated, once she learned about misappropriation, she had 24 hours to report it to the state, she had 5 days to submit the report of her investigation to the state and that was the policy of their facility. The investigator observed the administrator referring the PIR regarding this incident, and she stated this misappropriation incident was reported to her on 08/26/2024 and she reported this incident to the state on the same day. She stated as soon as she learned about the allegation, she suspended CNA A, removed her from the schedule, CNA A was working 6 AM 2 PM shift that week. The Administrator stated CNA A did not work at the facility or answer her call after the alleged incident of Resident #1's missing debit card. During the interview, the administrator was observed reading Resident #1's progress note dated 08/24/2024 at 04:24 PM, entered by RN supervisor, that the incident was reported to the RN supervisor by the resident and that she had immediately reported this to the abuse coordinator/administrator. The administrator initially stated the resident's family member told her that the debit card was missing, and administrator did not consider it as misappropriation until 08/26/2024, since she wanted to give the family enough time to search for the missing card. The Administrator later stated learned about this misappropriation on 08/24/2024 and she was responsible to report this to the state within 24 hours, which could have been by 08/25/2024 at 04:24 PM. The Administrator stated she was responsible to submit her investigation report to the state within 5 days per policy, she stated even if the incident was reported to her on 08/26/2024, she was supposed to submit the investigation report by 08/30/2024, but per the PIR the investigation report was submitted to the state on 09/03/2024. The Administrator stated she did not follow policy on reporting the misappropriation incident to the state within 24 hours and did not follow policy on submitting the investigation report to the state within 5 days from the date of reporting. An interview with the corporate administrator on 02/05/2025 at 05:36 PM revealed the facility administrator was the abuse coordinator, Resident #1 reported this incident to the facility staff on 08/24/2024 and the administrator was responsible to report the misappropriation incident to the state within 24 hours. The corporate administrator sated the facility administrator was responsible to submit the PIR to the state within 5 days and the facility administrator failed to follow and implement policy since it took longer than 5 days. An interview with the DON on 02/05/25 at 06:10 PM revealed he was working at the facility for 3 months. The DON stated misappropriation was recognized as abuse, needed to be reported immediately to the administrator by him or any employee who had the knowledge of that incident. He stated the facility staff received in service on misappropriation regularly, he could not remember the most recent Inservice date. He stated if a resident reported missing item such as a debit card, he would immediately assist the resident in searching the room and ask family members about it. If it was not found, then he would immediately notify the administrator. He stated he did not want any employees to take resident's belongings, he stated it was important to report misappropriation incidents immediately and take precautionary action to prevent further occurrence of the incident. Record review of CNA A's personal file revealed her date of hire was 02/15/2024. Last day at work was on 08/25/2024, involuntary termination date was on 09/03/2024, for violation of policy and procedure. Record review of in-service attendance record dated 08/30/2024 revealed employees received in service on topic: resident rights, elder justice act, abuse/ neglect, misappropriation. Record review of the facility policy titled, Abuse Prevention and Prohibition Program revised October 24,2022 reflected, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures regarding allegations of abuse/neglect for 1(Resident#1) of 8 residents reviewed for abuse/neglect. The facility failed to report a suspicion of misappropriation of property within 24 hours to the state agency as required by their policy. This failure could place all residents at risk of misappropriation of property. Findings included: Record review of Resident #1's face sheet dated 02/05/2025 revealed he was a [AGE] year-old male with an admitted [DATE]. His diagnoses included mild cognitive impairment of uncertain or unknown etiology (exact cause of the memory/cognitive decline cannot be determined) Primary Open Angle Glaucoma, (Increased pressure inside eye which may cause gradual damage to the optic nerve), Hypertension (blood pressure in the arteries is consistently elevated). Record review of Resident #1's MDS assessment dated [DATE] revealed he had a BIMS score of 14, which indicated he had an intact cognition. Resident #1 needed extensive assistance with ADLs for toileting and personal hygiene. Record review of Resident #1's progress note dated 08/24/2024 at 04:24 PM created by RN supervisor reflected Resident #1 reported to RN supervisor about missing credit card and RN supervisor reported it immediately to the administrator. Resident's [family member] was in the room with the resident, they searched for the card but could not find it. On further noted the credit card has been used to make several purchases including Greyhound ticket to Los Angels California. Police was called, awaiting dispatch to the facility. Review of the PIR dated 09/03/2024 for incident report # 527680 reflected the date this incident was reported to HHSC was on 08/26/2024, date the PIR submitted to the state was on 09/03/2024. Record review of PIR (Form 3613-A of Texas Health and Human Services) dated 09/03/2024 reflected the incident date as 08/26/2024. The PIR summary reflected the Resident #1 reported to the facility staff that his debit card went missing after he last used it at the facility front desk. Upon further investigation by the facility, [department store] surveillance camera captured one of the facility employees making unauthorized purchases, totaling $161.60 with Resident #1's debit card. [Department store] was unable to release the video footage without police involvement. [Local] police was notified, online report was created with a report dated 08/27/2024 at 01:42 PM. The resident #1's family, MD, Ombudsman were also notified. Based on the facility investigation findings, it was determined that the incident involving the theft and unauthorized use of Resident #1's debit card was the result of actions taken by an individual staff member. An initial interview with the facility administrator on 02/04/2025 at 12:41 PM revealed she learned that Resident #1's debit card was missing on 08/26/2024. She stated Resident #1 was a new admission, the next day Resident #1's family member came and reported to her that Resident #1's debit card was missing, the last time Resident #1 used it was at the front desk. Resident #1's family member told her that she noticed several charges on the card transaction history, and transactions took place on [NAME], the same street where the facility was located. The Administrator stated she went over to the gas station where the card was used but they refused to provide any information, she then went to department store where the card was used for unauthorized transaction, they let her see the video footage of the person who was using the card and she recognized the facility employee, CNA A as the person who was making the unauthorized transaction. The department store refused to provide her a copy of the video footage without police involvement. The Administrator stated she called the police and reported the incident. The Administrator stated she tried calling CNA A on her cell phone, but CNA A never answered or returned her call, CNA A never came back to the facility to collect her remaining check for the time she worked and so she was not able to talk to the CNA A about the alleged incident. She stated she did not know how CNA A got hold of Resident #1's debit card. The Administrator stated she immediately acted, called a staff meeting and provided in service on elder justice act, abuse/ neglect, resident rights, misappropriation of resident property, a QAPI meeting with department heads and discussed how to prevent such incidents, held a resident council meeting notifying them of not sharing card or card info with any staff, Educated on misappropriation, if a resident had to buy something from the vending machine inside the facility, a staff will assist the resident to the vending machine and resident did transaction themselves . She stated those residents who received trust fund money had a shopping day and they used cash only for transactions. Those residents who wanted to buy something from outside, most of them used the family assistance, the facility had a facility credit card for resident purchases and used that for some residents, the residents never gave their card to the employees. CNA A was terminated on 09/03/24. The Administrator stated Resident lost a total of $161.60. The facility gave the lost money back to the resident, completed audit on debit credit card holders among residents, sent letter out to those residents who had debit /credit card asking them to check for unauthorized transactions and to notify facility if they noticed any, completed a survey among residents who managed own money and there were no other concerns. The Administrator stated she was the abuse coordinator; she expected all the employees to not take any of resident belongings and she expected all employees to notify her of any suspicion of abuse/neglect/misappropriation immediately. An interview with CNA B on 02/04/2025 at 02:15 PM revealed misappropriation was, taking the resident's valuable things without their permission. She stated she received in service on abuse/neglect/misappropriation within the past month. She stated she was not aware of any resident who lost their bank debit/credit card. She stated she would immediately report to the administrator of any such abuse/neglect/misappropriation concerns. CNA B stated she never accepted cash or bank card from a resident, she stated if a resident wanted to purchase anything from outside, they had to get permission from the administrator and work with the activity director. An interview with CNA C on 02/04/2025 at 02:52 PM revealed misappropriation was taking the resident's belongings, he stated he was not supposed to accept any cash, credit/debit card from residents and he would direct the resident to the nurse if they wanted to purchase something. He stated he would not go through resident's belongings unless resident wanted him to search for something missing. He stated he was not aware of any resident who lost their bank card at the facility. He stated none of the staff were supposed to misappropriate a resident's cash or valuable things and he would notify the administrator/abuse coordinator about misappropriation immediately. He stated he received in service training on misappropriation within the past one month. An interview with the Corporate Business Office Consultant on 02/04/2025 at 03:11 PM revealed the facility's business manager was on medical leave and she came to the facility a few days to complete the work. She stated she was aware of the incident involving Resident #1 and CNA A. She stated Resident #1 managed his own money, bank cards and he reported to the administrator that his bank card got stolen. She stated the police was notified, the resident's card was cancelled, and he received a new debit card. She stated none of the employees were expected to accept cash/bank cards from residents, only the Activity Director was responsible to assist residents in purchasing outside goods with cash payment and the administrator was involved in the process. She stated she was not aware of any other incidents of missing bank cards; she stated the employee/CNA A stole the debit card and then used it for unauthorized transactions. An interview with the Dietary Manager on 02/05/2025 at 09:35 AM revealed Misappropriation was taking resident's clothes, belongings without their permission. She stated she received in service on Misappropriation within the past few weeks. She stated she heard about the alleged misappropriation incident from other employees, she stated she would not accept debit/credit cards/cash from the residents, she would direct them to the activity department for any purchases. She stated she would notify the administrator of any misappropriation concerns immediately. She stated she was not aware of any resident lost their card or money. She stated CNA A no longer worked at the facility. An interview with the MA on 02/05/2025 at 09:43 AM revealed she was working at the facility for 2 years. The MA stated misappropriation was taking a resident's belongings such as money, clothes, valuables without their permission. The MA stated she received in services on misappropriation within the past one month. The MA stated she was not aware of any misappropriation of credit/debit cards. She stated she would never accept any bank card or cash from a resident, she would direct the resident to the activity director for any purchases. She stated she was not aware of the alleged misappropriation incident. She stated she would immediately report the administrator of any suspicion of abuse/neglect/misappropriation. An interview with Dietary Aide on 02/05/2025 at 09:52 AM revealed misappropriation was taking resident's belongings without their permission, and she received in service on Misappropriation within the past month. She stated she would not accept cash/bank cads from the residents, the activity director was responsible to assist residents with purchases. She stated she would immediately report of any misappropriation concerns to the administrator. An interview with Resident #1 over the phone on 02/05/2025 at 11:06 AM revealed he was currently staying at his residence. He stated he stayed for few weeks at the facility for rehab and at that time his Debit card went missing from the facility front desk. Resident stated he left the card at the front desk and returned to his room to pick up something, by the time he came back to the front desk, the card went missing. Resident stated he could not remember the exact date, but he immediately reported this to the facility staff, and he called the police and reported the incident. Resident stated he noticed on the online bank transaction history that his card was used at some stores close by the facility, he stated the transactions included a department store, restaurants, and a bus ticket to California. Resident stated he learned from the police that one of the facility employees stole his card and used it initially, later the police caught a man from California using his card. He stated he lost a total of $800, and the facility did not pay him anything so far. He stated he did not have a copy of his bank statement ready to send to the investigator at that time. Resident stated he filed fraud charges with the bank, he received new debit card, and his finances were safe now. Resident stated he did not go without any of his immediate needs due to the theft. An attempt for a telephone interview with CNA A was made on 02/05/2025 at 11:19 AM on her cell. A man answered and stated that was a wrong number for CNA A and that he did not know CNA A. An attempted telephone interview with RN supervisor was made on 02/05/2025 at 12:16 PM on her cell phone, but received no answer, left voice mail requesting a call back. Record review of CNA A's personal file revealed her date of hire was 02/15/2024. Last day at work was on 08/25/2024, involuntary termination date was on 09/03/2024, for violation of policy and procedure. Record review of in-service attendance record dated 08/30/2024 revealed employees received in service on topic: resident rights, elder justice act, abuse/ neglect, misappropriation. An interview with the Activity Director on 02/05/2025 at 01:40 PM revealed she was working at the facility for 4 years. She stated misappropriation was taking/using resident's valuables for unauthorized use. She stated administrator informed her about the alleged incident and she was not involved in it. She stated none of the residents gave credit/debit card to the employees. She went to the store to purchase things for residents on every second Thursdays and those residents who wanted to purchase something would give her the list. Residents who had trust fund account collected money from the business office and gave the money to the activity director. The activity director verified each resident transaction with the facility administrator before and after the purchase, showed receipts, returned balance amount and items to the residents. The Activity director stated she never accepted debit/credit card from residents, and she was not aware of card theft/misappropriation other than the one involving Resident #1. She stated she would immediately report to the administrator of any suspicion of abuse/neglect/misappropriation. An interview with LVN D on 02/05/2025 at 03:30 PM revealed misappropriation was a type of abuse, taking resident's valuables without their permission was misappropriation. She stated she received in service on misappropriation within one week. She stated she would immediately report to the abuse coordinator/administrator of any concerns of misappropriation. She stated she was not aware of any resident missing their cash or bank debit/credit cards. She stated none of the employees were supposed to accept cash or debit/credit cards from residents and she would direct them to the activity director for any purchases. An interview with the administrator on 02/05/2025 at 04:51 PM revealed she was working at the facility as the administrator for a year and she was the abuse coordinator. She stated, once she learned about misappropriation, she had 24 hours to report it to the state, she had 5 days to submit the report of her investigation to the state and that was the policy of their facility. The investigator observed the administrator referring the PIR regarding this incident, and she stated this misappropriation incident was reported to her on 08/26/2024 and she reported this incident to the state on the same day. She stated as soon as she learned about the allegation, she suspended CNA A, removed her from the schedule, CNA A was working 6 AM 2 PM shift that week. The Administrator stated CNA A did not work at the facility or answer her call after the alleged incident of Resident #1's missing debit card. During the interview, the administrator was observed reading Resident #1's progress note dated 08/24/2024 at 04:24 PM, entered by RN supervisor, that the incident was reported to the RN supervisor by the resident and that she had immediately reported this to the abuse coordinator/administrator. The administrator initially stated the resident's family member told her that the debit card was missing, and administrator did not consider it as misappropriation until 08/26/2024, since she wanted to give the family enough time to search for the missing card. The Administrator later stated learned about this misappropriation on 08/24/2024 and she was responsible to report this to the state within 24 hours, which could have been by 08/25/2024 at 04:24 PM. The Administrator stated she was responsible to submit her investigation report to the state within 5 days per policy, she stated even if the incident was reported to her on 08/26/2024, she was supposed to submit the investigation report by 08/30/2024, but per the PIR the investigation report was submitted to the state on 09/03/2024. The Administrator stated she did not follow policy on reporting the misappropriation incident to the state within 24 hours and did not follow policy on submitting the investigation report to the state within 5 days from the date of reporting. An interview with the corporate administrator on 02/05/2025 at 05:36 PM revealed the facility administrator was the abuse coordinator, Resident #1 reported this incident to the facility staff on 08/24/2024 and the administrator was responsible to report the misappropriation incident to the state within 24 hours. The corporate administrator sated the facility administrator was responsible to submit the PIR to the state within 5 days and the facility administrator failed to follow and implement policy since it took longer than 5 days. An interview with the DON on 02/05/25 at 06:10 PM revealed he was working at the facility for 3 months. The DON stated misappropriation was recognized as abuse, needed to be reported immediately to the administrator by him or any employee who had the knowledge of that incident. He stated the facility staff received in service on misappropriation regularly, he could not remember the most recent Inservice date. He stated if a resident reported missing item such as a debit card, he would immediately assist the resident in searching the room and ask family members about it. If it was not found, then he would immediately notify the administrator. He stated he did not want any employees to take resident's belongings, he stated it was important to report misappropriation incidents immediately and take precautionary action to prevent further occurrence of the incident. Record review of the facility policy titled, Abuse Prevention and Prohibition Program revised October 24,2022 reflected, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. D. The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime. See AN - 01 - Form E - Initial Report - Facility Reported Incidents. ii. No later than 24 hours after forming the suspicion - if the alleged violation (e.g., misappropriation of property, neglect) does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation).

Based on observation, interview and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and 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, and the alleged violation is verified appropriate corrective action was taken for 1 of 8 residents (Residents #1) reviewed for Misappropriation of property. The facility failed to investigate and submit the results of their investigation within 5 days as per their policy, after Resident #1 reported his debit card was missing on 08/24/2024. This failure could place residents at risk of Misappropriation of property. Findings included: Record review of Resident #1's face sheet dated 02/05/2025 revealed he was a [AGE] year-old male with an admitted [DATE]. His diagnoses included mild cognitive impairment of uncertain or unknown etiology (exact cause of the memory/cognitive decline cannot be determined) Primary Open Angle Glaucoma, (Increased pressure inside eye which may cause gradual damage to the optic nerve), Hypertension (blood pressure in the arteries is consistently elevated). Record review of Resident #1's MDS assessment dated [DATE] revealed he had a BIMS score of 14, which indicated he had an intact cognition. Resident #1 needed extensive assistance with ADLs for toileting and personal hygiene. Record review of Resident #1's progress note dated 08/24/2024 at 04:24 PM created by RN supervisor reflected Resident #1 reported to RN supervisor about missing credit card and RN supervisor reported it immediately to the administrator. Resident's [family member] was in the room with the resident, they searched for the card but could not find it. On further noted the credit card has been used to make several purchases including Greyhound ticket to Los Angels California. Police was called, awaiting dispatch to the facility. Review of the PIR dated 09/03/2024 for incident report # 527680 reflected the date this incident was reported to HHSC was on 08/26/2024, date the PIR submitted to the state was on 09/03/2024. Record review of PIR (Form 3613-A of Texas Health and Human Services) dated 09/03/2024 reflected the incident date as 08/26/2024. The PIR summary reflected the Resident #1 reported to the facility staff that his debit card went missing after he last used it at the facility front desk. Upon further investigation by the facility, [department store] surveillance camera captured one of the facility employees making unauthorized purchases, totaling $161.60 with Resident #1's debit card. [Department store] was unable to release the video footage without police involvement. [Local] police was notified, online report was created with a report dated 08/27/2024 at 01:42 PM. The resident #1's family, MD, Ombudsman were also notified. Based on the facility investigation findings, it was determined that the incident involving the theft and unauthorized use of Resident #1's debit card was the result of actions taken by an individual staff member. An initial interview with the facility administrator on 02/04/2025 at 12:41 PM revealed she learned that Resident #1's debit card was missing on 08/26/2024. She stated Resident #1 was a new admission, the next day Resident #1's family member came and reported to her that Resident #1's debit card was missing, the last time Resident #1 used it was at the front desk. Resident #1's family member told her that she noticed several charges on the card transaction history, and transactions took place on [NAME], the same street where the facility was located. The Administrator stated she went over to the gas station where the card was used but they refused to provide any information, she then went to department store where the card was used for unauthorized transaction, they let her see the video footage of the person who was using the card and she recognized the facility employee, CNA A as the person who was making the unauthorized transaction. The department store refused to provide her a copy of the video footage without police involvement. The Administrator stated she called the police and reported the incident. The Administrator stated she tried calling CNA A on her cell phone, but CNA A never answered or returned her call, CNA A never came back to the facility to collect her remaining check for the time she worked and so she was not able to talk to the CNA A about the alleged incident. She stated she did not know how CNA A got hold of Resident #1's debit card. The Administrator stated she immediately acted, called a staff meeting and provided in service on elder justice act, abuse/ neglect, resident rights, misappropriation of resident property, a QAPI meeting with department heads and discussed how to prevent such incidents, held a resident council meeting notifying them of not sharing card or card info with any staff, Educated on misappropriation, if a resident had to buy something from the vending machine inside the facility, a staff will assist the resident to the vending machine and resident did transaction themselves . She stated those residents who received trust fund money had a shopping day and they used cash only for transactions. Those residents who wanted to buy something from outside, most of them used the family assistance, the facility had a facility credit card for resident purchases and used that for some residents, the residents never gave their card to the employees. CNA A was terminated on 09/03/24. The Administrator stated Resident lost a total of $161.60. The facility gave the lost money back to the resident, completed audit on debit credit card holders among residents, sent letter out to those residents who had debit /credit card asking them to check for unauthorized transactions and to notify facility if they noticed any, completed a survey among residents who managed own money and there were no other concerns. The Administrator stated she was the abuse coordinator; she expected all the employees to not take any of resident belongings and she expected all employees to notify her of any suspicion of abuse/neglect/misappropriation immediately. An interview with CNA B on 02/04/2025 at 02:15 PM revealed misappropriation was, taking the resident's valuable things without their permission. She stated she received in service on abuse/neglect/misappropriation within the past month. She stated she was not aware of any resident who lost their bank debit/credit card. She stated she would immediately report to the administrator of any such abuse/neglect/misappropriation concerns. CNA B stated she never accepted cash or bank card from a resident, she stated if a resident wanted to purchase anything from outside, they had to get permission from the administrator and work with the activity director. An interview with CNA C on 02/04/2025 at 02:52 PM revealed misappropriation was taking the resident's belongings, he stated he was not supposed to accept any cash, credit/debit card from residents and he would direct the resident to the nurse if they wanted to purchase something. He stated he would not go through resident's belongings unless resident wanted him to search for something missing. He stated he was not aware of any resident who lost their bank card at the facility. He stated none of the staff were supposed to misappropriate a resident's cash or valuable things and he would notify the administrator/abuse coordinator about misappropriation immediately. He stated he received in service training on misappropriation within the past one month. An interview with the Corporate Business Office Consultant on 02/04/2025 at 03:11 PM revealed the facility's business manager was on medical leave and she came to the facility a few days to complete the work. She stated she was aware of the incident involving Resident #1 and CNA A. She stated Resident #1 managed his own money, bank cards and he reported to the administrator that his bank card got stolen. She stated the police was notified, the resident's card was cancelled, and he received a new debit card. She stated none of the employees were expected to accept cash/bank cards from residents, only the Activity Director was responsible to assist residents in purchasing outside goods with cash payment and the administrator was involved in the process. She stated she was not aware of any other incidents of missing bank cards; she stated the employee/CNA A stole the debit card and then used it for unauthorized transactions. An interview with the Dietary Manager on 02/05/2025 at 09:35 AM revealed Misappropriation was taking resident's clothes, belongings without their permission. She stated she received in service on Misappropriation within the past few weeks. She stated she heard about the alleged misappropriation incident from other employees, she stated she would not accept debit/credit cards/cash from the residents, she would direct them to the activity department for any purchases. She stated she would notify the administrator of any misappropriation concerns immediately. She stated she was not aware of any resident lost their card or money. She stated CNA A no longer worked at the facility. An interview with the MA on 02/05/2025 at 09:43 AM revealed she was working at the facility for 2 years. The MA stated misappropriation was taking a resident's belongings such as money, clothes, valuables without their permission. The MA stated she received in services on misappropriation within the past one month. The MA stated she was not aware of any misappropriation of credit/debit cards. She stated she would never accept any bank card or cash from a resident, she would direct the resident to the activity director for any purchases. She stated she was not aware of the alleged misappropriation incident. She stated she would immediately report the administrator of any suspicion of abuse/neglect/misappropriation. An interview with Dietary Aide on 02/05/2025 at 09:52 AM revealed misappropriation was taking resident's belongings without their permission, and she received in service on Misappropriation within the past month. She stated she would not accept cash/bank cads from the residents, the activity director was responsible to assist residents with purchases. She stated she would immediately report of any misappropriation concerns to the administrator. An interview with Resident #1 over the phone on 02/05/2025 at 11:06 AM revealed he was currently staying at his residence. He stated he stayed for few weeks at the facility for rehab and at that time his Debit card went missing from the facility front desk. Resident stated he left the card at the front desk and returned to his room to pick up something, by the time he came back to the front desk, the card went missing. Resident stated he could not remember the exact date, but he immediately reported this to the facility staff, and he called the police and reported the incident. Resident stated he noticed on the online bank transaction history that his card was used at some stores close by the facility, he stated the transactions included a department store, restaurants, and a bus ticket to California. Resident stated he learned from the police that one of the facility employees stole his card and used it initially, later the police caught a man from California using his card. He stated he lost a total of $800, and the facility did not pay him anything so far. He stated he did not have a copy of his bank statement ready to send to the investigator at that time. Resident stated he filed fraud charges with the bank, he received new debit card, and his finances were safe now. Resident stated he did not go without any of his immediate needs due to the theft. An attempt for a telephone interview with CNA A was made on 02/05/2025 at 11:19 AM on her cell. A man answered and stated that was a wrong number for CNA A and that he did not know CNA A. An attempted telephone interview with RN supervisor was made on 02/05/2025 at 12:16 PM on her cell phone, but received no answer, left voice mail requesting a call back. Record review of CNA A's personal file revealed her date of hire was 02/15/2024. Last day at work was on 08/25/2024, involuntary termination date was on 09/03/2024, for violation of policy and procedure. Record review of in-service attendance record dated 08/30/2024 revealed employees received in service on topic: resident rights, elder justice act, abuse/ neglect, misappropriation. Record review of An interview with the Activity Director on 02/05/2025 at 01:40 PM revealed she was working at the facility for 4 years. She stated misappropriation was taking/using resident's valuables for unauthorized use. She stated administrator informed her about the alleged incident and she was not involved in it. She stated none of the residents gave credit/debit card to the employees. She went to the store to purchase things for residents on every second Thursdays and those residents who wanted to purchase something would give her the list. Residents who had trust fund account collected money from the business office and gave the money to the activity director. The activity director verified each resident transaction with the facility administrator before and after the purchase, showed receipts, returned balance amount and items to the residents. The Activity director stated she never accepted debit/credit card from residents, and she was not aware of card theft/misappropriation other than the one involving Resident #1. She stated she would immediately report to the administrator of any suspicion of abuse/neglect/misappropriation. An interview with LVN D on 02/05/2025 at 03:30 PM revealed misappropriation was a type of abuse, taking resident's valuables without their permission was misappropriation. She stated she received in service on misappropriation within one week. She stated she would immediately report to the abuse coordinator/administrator of any concerns of misappropriation. She stated she was not aware of any resident missing their cash or bank debit/credit cards. She stated none of the employees were supposed to accept cash or debit/credit cards from residents and she would direct them to the activity director for any purchases. An interview with the administrator on 02/05/2025 at 04:51 PM revealed she was working at the facility as the administrator for a year and she was the abuse coordinator. She stated, once she learned about misappropriation, she had 24 hours to report it to the state, she had 5 days to submit the report of her investigation to the state and that was the policy of their facility. The investigator observed the administrator referring the PIR regarding this incident, and she stated this misappropriation incident was reported to her on 08/26/2024 and she reported this incident to the state on the same day. She stated as soon as she learned about the allegation, she suspended CNA A, removed her from the schedule, CNA A was working 6 AM 2 PM shift that week. The Administrator stated CNA A did not work at the facility or answer her call after the alleged incident of Resident #1's missing debit card. During the interview, the administrator was observed reading Resident #1's progress note dated 08/24/2024 at 04:24 PM, entered by RN supervisor, that the incident was reported to the RN supervisor by the resident and that she had immediately reported this to the abuse coordinator/administrator. The administrator initially stated the resident's family member told her that the debit card was missing, and administrator did not consider it as misappropriation until 08/26/2024, since she wanted to give the family enough time to search for the missing card. The Administrator later stated learned about this misappropriation on 08/24/2024 and she was responsible to report this to the state within 24 hours, which could have been by 08/25/2024 at 04:24 PM. The Administrator stated she was responsible to submit her investigation report to the state within 5 days per policy, she stated even if the incident was reported to her on 08/26/2024, she was supposed to submit the investigation report by 08/30/2024, but per the PIR the investigation report was submitted to the state on 09/03/2024. The Administrator stated she did not follow policy on reporting the misappropriation incident to the state within 24 hours and did not follow policy on submitting the investigation report to the state within 5 days from the date of reporting. An interview with the corporate administrator on 02/05/2025 at 05:36 PM revealed the facility administrator was the abuse coordinator, Resident #1 reported this incident to the facility staff on 08/24/2024 and the administrator was responsible to report the misappropriation incident to the state within 24 hours. The corporate administrator sated the facility administrator was responsible to submit the PIR to the state within 5 days and the facility administrator failed to follow and implement policy since it took longer than 5 days. An interview with the DON on 02/05/25 at 06:10 PM revealed he was working at the facility for 3 months. The DON stated misappropriation was recognized as abuse, needed to be reported immediately to the administrator by him or any employee who had the knowledge of that incident. He stated the facility staff received in service on misappropriation regularly, he could not remember the most recent Inservice date. He stated if a resident reported missing item such as a debit card, he would immediately assist the resident in searching the room and ask family members about it. If it was not found, then he would immediately notify the administrator. He stated he did not want any employees to take resident's belongings, he stated it was important to report misappropriation incidents immediately and take precautionary action to prevent further occurrence of the incident. Record review of the facility policy titled, Abuse Prevention and Prohibition Program revised October 24,2022 reflected, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. D. iv. The Administrator will provide the state survey agency, law enforcement and the Ombudsman (if applicable per state regulation) with a copy of the investigative report within 5 days of the incident.

Based on interview and record review, the facility failed to immediately consult with the resident 's physician when there was a significant change in the resident 's physical status and a need to alter treatment significantly for two (Residents #17 and #55 ) of ten residents reviewed for notification of changes. 1. ADON C failed to notify the physician and responsible party of Resident #17's change of condition of significant weight loss on 04/28/24. Resident #17's physician was not informed of significant weight loss until 05/06/24. The responsible party for Resident #17 was not notified until 05/07/24. 2. ADON C failed to notify the physician and responsible party of Resident #55's change of condition of significant weight loss on 05/04/24. These failures could place residents at risk for a delay in treatment and diagnosis of new symptoms resulting in serious illness, hospitalization , further decline in the resident's condition, and death. Findings included: 1. Review of Resident #17's quarterly MDS assessment dated [DATE] reflected Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke, heart failure, hypertension, kidney failure, diabetes, dementia, metabolic encephalopathy (brain dysfunction caused by problems with your metabolism), dysphagia (difficulty swallowing that can be caused by various conditions affecting the throat or esophagus), cognitive communication deficit and gastrostomy status. Resident #17 had a BIMS of 11 indicating he was moderately cognitively impaired. Resident #17 had a substantial/maximal assistance to dependent with ADLs. Resident #17 had a feeding tube with 51% or more proportion of total calories received through tube feeding while in the facility. Review of Resident #17's face sheet dated 05/08/24 reflected Resident #17 responsible party and POA was a resident's family member. Review of Resident #17's weights from March to May 2024 reflected the following: - Dated 05/03/24 178 lbs recorded by ADON C - Dated 04/28/24 179.2 lbs recorded by ADON C - Dated 04/05/24 224 lbs recorded by previous DON - Dated 03/07/24 226.9 lbs recorded by previous DON Review of Resident #17's progress/nutrition notes and assessments from 04/01/24 to 05/06/24 reflected there was no notification to physician or responsible party for change of condition. Interview on 05/09/24 at 11:41 AM with Resident #17's Responsible Party revealed she was notified on 05/07/24 about Resident #17's weight loss but the facility did not go into detail about how much weight. She stated she was told they would put some interventions in place but did not tell her what was put in place. She would like to know what interventions the facility put in place to address the weight loss. She was concerned about Resident #17's significant weight loss and would have liked more information from the facility when she was notified about it. 2. Review of Resident #55's quarterly MDS assessment dated [DATE] reflected Resident #55 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses of chronic respiratory failure with hypoxia (occurs when you do not have enough oxygen in your blood), seizures, adult failure to thrive, tracheostomy status and gastrostomy status. Resident #55 had moderately impaired cognitive skills for daily decision making with no BIMS score completed for Resident #55 since he was rarely/never understood per the assessment. Resident #55 was dependent with all ADLs. Resident #55 has a feeding tube with 51% or more proportion of total calories the resident received through tube feeding. Review of Resident #55's weights from 11/6/23 to 05/04/24 reflected the following: - Dated 11/06/23 203 lbs recorded by previous DON - Dated 12/06/23 204 lbs recorded by previous DON - Dated 01/07/24 202.4 lbs recorded by previous DON - Dated 02/04/24 197.9 lbs recorded by previous DON - Dated 03/07/24 197.6 lbs recorded by previous DON - Dated 04/05/24 198.5 lbs recorded by previous DON - Dated 05/04/24 164.4 lbs recorded by previous DON Review of Resident #55's progress/ nutrition notes from 04/01/24 to 05/07/24 reflected there was no notification to physician or responsible party for change of condition. Interview on 05/07/24 at 4:48 PM with ADON C revealed she had not notified Resident #17 or Resident #55's responsible party about the weight loss. Interview revealed she did not inform the physician about the weight loss for Resident #55. Interview on 05/08/24 at 10:38 AM with Regional Nurse Consultant A revealed the QAPI put ADON C as the one responsible for ensuring weights completed and for notifying the physician and the responsible party for any weight loss for residents. She stated ADON C should have notified the physician and responsible party. Interview on 05/08/24 at 1:53 PM with Resident #17's Physician revealed he expected to be notified when residents have weight loss . He stated he was not notified until Monday (05/06/24) for Resident #17's weight loss. He was not notified or aware of Resident #55's weight loss. Review of facility's policy Assessment and Management of Resident Weights last revised December 2023 reflected under procedure V. Significant Weight Change Management A. Significant weight changes will be reviewed by the DON or designated licensed nurse. Significant weight changes are: i. 5% in one (1) month ii. 7.5% in three (3) months iii. 10% in six (6) months B. The DON or licensed nurse will: i. Report weight change in the medical record and on the 24-Hour Report. ii. Notify the physician, resident/RP/family/healthcare decision maker of significant weight changes. iii. Document the notification. iv. Complete a change of condition on residents with significant 1 month 5% or greater weight changes .D. The licensed nurse will notify the physician and resident/RP/family/healthcare decision maker of the dietitian's recommendations as indicated. Review of facility's policy Change of Condition Notification revised June 2020 reflected to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner .The Facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition cause by, but not limited to: .A significant change in the resident's physical, cognitive, behavioral or functional status . The Licensed Nurse will notify the resident's Attending Physician when there is an .A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status .III. Notifying the Attending Physician A. The Attending Physician will be notified timely with a resident's change in condition. B. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vitals signs and review system focusing on the condition and/or signs and symptoms for which the notification is required .A licensed nurse will document the following: Date, time and pertinent details of the incident and subsequent assessment in the nursing notes. ii. The time the Attending Physician was contacted, the method by which he was contacted, the response time and whether or not orders were received. iii. The time the family/responsible party was contacted.

42971 Based on observation, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene to a resident who is unable to carry out activities of daily living for three of six residents (Resident #536, Resident #4, and Resident #32) reviewed for quality of life. 1. The facility failed to provide Resident #536, who required extensive assistance, with timely incontinence care on 05/7/24 from 6:00 a.m. to 2:20 p.m. 2. The facility failed to provide Resident #4, who required extensive assistance, with timely incontinence care on 05/07/24 from 6:00 a.m. to 2:50 p.m. and failed to consistently shampoo resident's hair. 3. The facility failed to ensure Resident #32 had his fingernails cleaned and trimmed. These failures could place residents at risk of skin breakdown, urinary tract infections, and loss of dignity. Findings included: 1. Record review of Resident #536's Face sheet dated 05/09/24 reflected a [AGE] year-old male with an admitted [DATE]. Resident was listed as his own responsible party. Diagnoses included cauda equina syndrome (compression of nerve roots in the lumber spine), malignant neoplasm of the prostate and bone (cancer), neuromuscular dysfunction of the bladder(lack bladder control due to nerve problems) and need for assistance with personal care. Record review of Resident #546's base line care plan completed on 05/07/24 reflected, The resident has an ADL Self Care performance deficit related to impaired balance, cauda equina syndrome, weakness .Interventions .toileting .dependent assist of 2 persons, incontinent care, foley care . In an interview with Resident #536 on 05/07/24 at 10:50 a.m., he stated he admitted to the facility yesterday (05/06/27). Resident had a foley catheter and he stated he had a wound on his bottom. During a medication pass observation on 05/07/24 at 01:15 p.m. while standing in hallway outside of Resident #536's room, an unknown staff member entered Resident #536's room with his lunch tray. Resident #536 told unknown staff member he needed to be changed. Unknown staff member stated she would let his CNA know and left the room. In an interview with Resident #536 on 05/07/24 at 2:05 p.m. he stated no one had come and changed him. He stated he was concerned about his catheter since he had a history of drainage from his catheter and stated he had a bowel movement and needed to be changed. In an interview with the Regional Director of Operations on 05/07/24 at 02:10 p.m. he was informed Resident #536 had requested to be changed at 01:15 p.m. and no one had come and changed him. Regional Director of Operations stated he would send someone right away. In an observation on 05/07/24 at 05/07/24 at 2:20 p.m., CNA K and CNA G donned gowns and entered Resident #536's room to provide incontinence care. Resident stated this was the first time anyone had been in to change him this shift. CNA K stated it was the first time she had been in to provide incontinent care to the resident and stated no one had informed her he needed to be changed. 2. Record review of Resident #4's annual MDS assessment, dated 03/16/24, reflected a [AGE] year-old female with an admitted d of 05/18/21. She had a BIMS score of 12, indicating her cognition was moderately impaired. She had no behaviors documented and had not resisted care. Resident #4 required extensive assistance with toileting and personal hygiene and was always incontinent of bowel and frequently incontinent of urine. Resident #4 was at risk of pressure ulcers with no current skin issues. Her active diagnoses included diabetes, cerebral vascular accident (stroke) and dementia. Record review of Resident #4's Comprehensive Care Plan with a revision date of 03/18/24, reflected, .[Resident #4] has mixed bladder and bowel incontinence related to confusion, dementia, impaired mobility, inability to communicate needs, physical limitations. She is at increased risk for alterations in skin integrity and/pressure ulcer development Has an ADL Self-Care performance deficit .Interventions .Uses disposable briefs .Toilet use .Personal Hygiene .requires extensive assistance (2x) staff participation . In an Interview and observation with Resident #4 on 05/07/24 at 11:20 a.m. Resident was observed lying in bed with a hospital gown on. Hair was noted to be oily, and resident had a musty smell. Resident #4 stated her hair had not been washed in over a month. She stated she wanted it washed. She stated she did not get into the shower because it hurts too much to be lifted with the lift. She stated she gets a bed bath instead of going to the shower. In an Interview with CNA K on 05/07/24 at 1:00 p.m. she stated she was the aide assigned to Resident #4. She stated Resident #4 probably had not had her hair washed in over a month, because the shower bed was too short for the resident. She stated she did not always work the hall Resident #4 was on, and stated she had never washed the resident's hair. In an interview with CNA K on 05/07/24 at 2:45 p.m., she stated she had not provided incontinence care to Resident # 536 or Resident #4. She stated she was headed to Resident #4's room next. She stated she had worked the hall by herself and some of the residents had some behaviors which placed her behind. She stated she had not gotten to Resident #4. She stated the hall trays did not get to the hall until 1:00 p.m. so she had not gotten to do her final rounds before she should have been clocking out. She stated she stayed over to provide care to these two residents and had gotten CNA G to help her since it took 2 people. An observation on 05/07/24 at 2:50 p.m. revealed CNA K and CNA G entered Resident #4's room. Both staff sanitized their hands and put on gloves. Resident #4 stated this was the first time she had been changed this shift but stated that was not typical. She stated CNA K was good about taking care of her. Staff provided incontinence care without issue. In an interview on 05/08/24 at 09:30 a.m. with LVN M she stated she was not aware Resident #536 and Resident #4 were not provided with incontinence care on the 06:00 to 02:00 p.m. shift on 05/07/24. She stated had the aide asked her for help, she would have helped her. In an interview on 05/10/24 at 11:00 a.m. with CNA O she stated she was assigned to the hall where Resident #4 resided. She stated Resident #4 did not get in the shower and took bed baths instead. She stated residents who were bed bound, she just used towels and soap to wash their hair. She stated she had only washed Resident #4's hair once or twice in the times she had taken care of her. She stated she was not sure how often they were supposed to wash residents' hair. She stated she just waited for them to tell her when they wanted it washed. In an interview on 05/10/24 at 11:15 a.m. with the Regional Nurse Consultant A, she stated any resident who was incontinent was to be checked every 2 hours and changed as needed. She stated residents could have a bath or shower anytime they wanted it, but at a minimal, baths and showers were offered three times a week according to the bath schedule. She stated staff should be washing residents' hair during their shower or bed bath days. She stated failing to provide hair care and timely incontinent care could lead to skin breakdown, poor hygiene, and a loss of dignity. She stated the Charge Nurse should be aware of which resident were scheduled for showers or baths and should ensure the care was provided. 3. Record review of Resident #32's Comprehensive MDS assessment dated [DATE] reflected Resident #32 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), cognitive communication deficit, and contracture of muscle on the left hand. Staff assessed his cognitive status as severely cognitively impaired. The MDS assessment indicated Resident #32 required maximal assistance of 2 persons with toileting and personal hygiene. Record review of Resident #32's Care Plan dated 03/12/24, reflected the following: Focus: [Resident #32} has an ADL self-care performance deficit related to cerebral infarction. Goal: [Resident #32] will maintain current level of function in ADLs through the next review date. Interventions: . Personal hygiene: the resident requires total assistance with personal hygiene care . An observation on 05/07/24 at 09:58 AM revealed Resident #32 was laying in his bed. The nails on both hands were approximately 0.4cm in length extending from the tip of his fingers. The nails were discolored tan and had dark brown colored residue underside. Resident #32 did not answer questions. In an interview on 05/07/24 at 10:59 AM, CNA U stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA U stated did not see Resident #32's nails this morning. She stated she would do it right then . In an Interview on 05/09/24 at 04:06 PM, ADON D stated nail care should be completed as needed and every time aides wash the residents' hands. The ADON D stated nails should be observed daily. The ADON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The ADON D stated he expected CNAs to offer to cut and clean nails if they were long and dirty. The ADON D stated he would do the routine rounds to monitor. The ADON D stated residents having long, and dirty nails could be an infection control issue. Review of the facility's policy titled, Care and Services, dated June 2020, reflected, Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhance self-esteem and self-worth .The facility will have sufficient staff to provide services to resident with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing as determined by individualized resident assessments and plans of care

Based on observation, interview, and record review the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise when the facility failed to implement significant weight loss interventions for two (Residents #17 and #55) of seven residents reviewed for significant weight loss, in that: 1. The facility failed to communicate and follow-up on Resident #17's significant weight loss of 44.8 pounds (20%) from 04/05/24 to 04/28/24 to the facility. Resident #17 was weighed on 05/03/24 revealing Resident #17 had lost 46 pounds (21%) for 1 month period from 04/05/24 to 05/03/24. The facility did not notify physician until 05/06/24 and failed to follow physician guidance to notify Dietitian on 05/06/24. The Dietitian was notified by ADON C after surveyor intervention on 05/07/24. The Dietitian failed to observe Resident #17 when she became aware of Resident #17's significant weight loss of 20% for 1 month on 05/07/24 and to follow-up to ensure Resident #17 was receiving enteral feeding as ordered by the physician. The facility failed to monitor Resident # 17 after a feeding change and them he experienced a weight loss. 2. The facility failed to notify the Physician, Dietitian and responsible party regarding resident 55's significant weight loss of 34.1 lbs (17%) from 04/05/24 to 05/04/24. Facility failed to ensure Resident #55 was weighed weekly as per policy for residents dependent on enteral feeding. These failures could place residents who are completely dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown and overall decline in quality of care, and death. Findings include: 1. Review of Resident #17's quarterly MDS assessment dated [DATE] reflected Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke, heart failure, hypertension, kidney failure, diabetes, dementia, metabolic encephalopathy (brain dysfunction caused by problems with your metabolism), dysphagia (difficulty swallowing that can be caused by various conditions affecting the throat or esophagus), cognitive communication deficit and gastrostomy status. Resident #17 had a BIMS of 11 indicating he was moderately cognitively impaired. Resident #17 had a substantial/maximal assistance to dependent with ADLs. Resident #17 had a feeding tube with 51% or more proportion of total calories received through tube feeding while in the facility. Review of Resident #17's comprehensive care plan last revised on 01/24/24 reflected Resident #17 requires tube feeding r/t dysphagia and aspiration Resident is NPO at this time . Interventions included to Monitor/document/report to MD PRN . and The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Review of Resident #17's current physician orders dated 04/09/24 reflected Enteral Feed Order every shift Begin Jevity 1.5 @ 52mls Q/hr times 22/hrs QD to provide 1716 kcals, 73 gm protein and 869 mls free water. Review of Resident #17's Nurse Administration Record for April and May 2024 reflected Resident #17 received Enteral Feed Order every shift Begin Jevity 1.5 @ 52mls Q/hr times 22/hrs QD to provide 1716 kcals, 73 gm protein and 869mls free water. The MAR had a check mark from April 10th to May 6th on the day, evening, and night shift . There was a check mark on May 7th for the Day shift. It did not reflect how much feeding Resident #17 received via tube feeding. Review of Resident #17's Nutrition assessment dated [DATE] by previous Dietitian reflected Resident #17 was npo and received tube feedings with weight history stable with most recent weight on 04/05/24 of 224 lbs via mechanical lift. It reflected to discontinue Jevity1.5 bolus 1 can via 5 times daily and to Begin Jevity 1.5 @ 52mls Q/hr times 22/hrs QD to provide 1716 kcals, 73 gm protein and 869mls free water. Provide additional 45mls water, via PEG, times 22/hrs QD to provide 990mls water. It reflected Resident #17 had nutritional risk related to diagnosis, history, incontinency, enteral feeding dependency and age Review of Resident #17's weights reflected the following: - Dated 05/03/24 178 lbs recorded by ADON C - Dated 04/28/24 179.2 lbs recorded by ADON C - Dated 04/05/24 224 lbs recorded by previous DON - Dated 03/07/24 226.9 lbs recorded by previous DON Weight loss calculations for Resident #17 reflected the following: From 4/5/24 to 4/28/24 = 224-179.2 = 44.8 lbs = 20 % weight loss x 1 month From 4/5/24 to 5/3/24 = 224-178 = 46 = 21% weight loss x 1 month From 4/5/24 to 5/7/24 = 224-174.6 = 49.4 = 22% weight loss x 1 month Review of Resident #17's progress/nutrition notes and assessments from 04/01/24 to 05/06/24 reflected there was no notification to physician or responsible party for change of condition. Review of Resident #17's clinical record from 04/01/24 to 05/06/24 reflected no nutrition assessment or progress note by Dietitian since 04/09/24. Observation on 05/07/24 at 2:14 PM revealed Restorative Aide and CNA S weighed Resident #17 via mechanical lift reflecting Resident #17 weighed 174.6 lbs. Interview on 05/07/24 at 2:18 PM with Restorative Aide revealed Resident #17 had his own hoyer sling for use with him only and weighed Resident #17 via mechanical lift each time. She stated she was responsible to weigh all residents including weekly and monthly. She was not aware of any weight loss for Resident #17 but after she weighed the residents she gave her weight documentation to ADON C currently who put in the resident weights in the PCC electronic record. She stated she did not have access to input resident weights herself. She stated she did not have her weight book with her today and left it at home. Interview on 05/07/24 at 2:51 PM with RN W revealed Resident #17 was tube feeding only for nutrition. She stated she did not really look at resident weights but ADON C and Dietitian were responsible for looking at resident weights. 2. Review of Resident #55's quarterly MDS assessment dated [DATE] reflected Resident #55 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses of chronic respiratory failure with hypoxia (occurs when you do not have enough oxygen in your blood), seizures, adult failure to thrive, tracheostomy status and gastrostomy status. Resident #55 had moderately impaired cognitive skills for daily decision making with no BIMS score completed for Resident #55 since he was rarely/never understood per the assessment. Resident #55 was dependent with all ADLs. Resident #55 has a feeding tube with 51% or more proportion of total calories the resident received through tube feeding. Review of Resident #55's comprehensive care plan last reviewed on 04/05/24 reflected the following: -Date initiated on 12/26/23 - Resident #55 has Tracheostomy r/t Impaired breathing mechanics, Injury. -Date initiated on 12/26/23 and revised on 01/10/24 - Resident #55 requires tube feeding r/t Dysphagia, semi- Coma state, nonverbal, no responsive to stimuli. Interventions included RD to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. - Dated initiated on 12/26/23 - Resident #55 has potential nutritional problem related to GTUBE, anoxic brain injury. Interventions included Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Provide G-Tube feedings as ordered. Review of Resident #55's current physician orders dated 02/04/24 reflected Enteral Feed Order every shift Continuous Enteral Feeding: Formula: Jevity 1.5; Rate: 60cc/hr times 22/hrs QD. Review of Resident #55's weights from 11/6/23 to 05/04/24 reflected the following: - Dated 11/06/23 203 lbs recorded by previous DON - Dated 12/06/23 204 lbs recorded by previous DON - Dated 01/07/24 202.4 lbs recorded by previous DON - Dated 02/04/24 197.9 lbs recorded by previous DON - Dated 03/07/24 197.6 lbs recorded by previous DON - Dated 04/05/24 198.5 lbs recorded by previous DON - Dated 05/04/24 164.4 lbs recorded by previous DON Weight loss calculations from 4/05/24 to 5/04/24 = 198.5-164.4= 34.1 = 17.2% x 1 month. From 02/04/24 to 05/04/24 = 197.9-164.4=33.5=16.9% x 3 months From 11/03/23 to 05/04/24 = 203-164.4=38.6=19.2% x 6 months Review of Resident #55's Nutrition admission assessment dated [DATE] reflected Resident #55 was npo with weight of 204 lbs via mechanical lift on 12/06/23. Resident #55 has wounds on sacrum deep tissue injury. Resident #55 was on Jevity 1.5 @ 60/hr x 22 hours. Review of Resident #55's progress notes from 04/01/24 to 05/07/24 including nutrition notes reflected no nutrition progress notes for Resident #55. There were no progress notes about significant weight loss or notification to physician or responsible party for change of condition. Interview on 05/07/24 at 3:10 PM with LVN L stated Resident #55 had a history of weight loss in the past, but she was not aware of Resident #55 currently losing weight. She stated that ADON C and Dietitian were mostly responsible for checking and monitoring resident weights. Interview 05/07/24 at 2:35 PM with ADON C revealed on 03/07/24 she started at facility and on 04/24/24 she took over the weights after previous DON left. She stated on 04/28/24 weights were the first time she was responsible for inputting weights. She stated Restorative Aide was responsible for doing weekly and monthly weights for all residents at the facility. She stated at end of the month she printed off weight list and highlight weekly weights giving it to Restorative Aide. She stated once restorative aide is done with getting all weights she turns them into her, she reviews weights and puts resident weights in electronic record system manually. She stated she contacted Regional Nurse Consultant A at this time telling her there were fluctuations in the weights but did not go into detail about the specific residents and weight. She stated she did not know who was the Consultant Dietitian at time since she was just given the responsibility for weights on 04/25/24 so she did not notify Consultant Dietitian about the specific significant weight loss for residents. She stated the facility had a QAPI meeting at end of April 2024 to discuss about questioning weight calculations. She stated she found residents not getting weighed monthly and started weekly weights for Resident #55 since prior to her taking over the weights Resident #55 was not getting weekly weights. She stated residents who were weekly weights should have included g-tube residents and did not know why Resident #55 was not weighed weekly. Follow-up interview on 05/07/24 at 4:48 PM with ADON C revealed they discussed in an IDT meeting about the resident weights having discrepancies but did not specifically mention which residents and the significant weigh loss calculations for the residents. She did not have re-weighs for residents to be completed to verify the accuracy of the resident weights. ADON C stated she notified Dietitian after surveyor intervention earlier in the afternoon today but did not mention specific weight loss percentage asking her to review Resident #17's weights. She stated based on the weights in the PCC system it reflected Resident #55 did have a significant weight loss. She stated she did not document about Resident #17 and #55's significant weight loss or any notification of significant weight loss Interview on 05/07/24 at 5:20 PM with Consultant Dietitian revealed she had been recently hired 2 weeks ago started working at the facility. She stated this was her first day in the facility and she was now starting to work on monthly weights which were supposed to be in the PCC system by the 5th of the month and by the 10th of the month she would have reviewed all the weights for all residents. She stated residents who were weekly weighed included residents with g-tube feedings. She stated the ADON or DON should notify me of resident's significant weight loss when became aware of it. She was notified today of Resident #17's significant weight loss and reviewed his weights. She did not go observe Resident #17 or look at Resident #17's enteral feeding pump she only reviewed his weights in the PCC and it looked like Resident #17 was not weighed the same way. She stated she would ask the charge nurse about their enteral feeding to determine if resident getting physician ordered enteral feeding and She stated she reviewed resident weights to monitor weight trends and important to ensure residents getting correct tube feeding as ordered by the physician for residents dependent on enteral feeding. She stated residents dependent on enteral feeding with significant weight loss were at a higher risk for malnutrition and higher risk for skin conditions. She was not aware or notified of Resident #55's significant weight loss. She will review his weights. She looked at his weights in the PCC system showing Resident #55 had a 34.1 lb weight loss for 1 month which was a 17.2 % weight loss. Follow-up Interview on 05/08/24 at 10:15 AM with Restorative Aide revealed she had been weekly weighing Resident #17 and would provide the weights to the previous DON and now the ADON C inputted the weights. She stated when she did her weekly and monthly resident weights she would turn them in within the same day she completed them. She stated Resident #55 was not on her weekly weight list until this week when she did the weekly weights on 05/06/24. She stated she had been doing the resident weights at the facility since beginning of January 2024. She stated Residents #17 and #55 were both weighed via mechanical lift. She was not aware Resident #17's weekly weights were not inputted into PCC but she turned them into the previous DON. She stated on 05/06/24 Resident #17 was weighed via mechanical lift with weight of 172 lbs. Interview on 05/08/24 at 10:38 AM with Regional Nurse Consultant A revealed they did have a QAPI meeting on 04/25/24 about missing weights for residents and were going to weigh all residents weekly for 4 weeks to identify weight trends getting a better idea of resident baseline. She stated the previous DON was responsible for weight management and significant weight loss issues. She stated at the QAPI the facility put ADON C as the one responsible for ensuring weights completed and for notifying the physician and Dietitian about any significant weight loss for residents. She stated they had not been able to find any other resident weights documented to clarify the weights. She stated Restorative Aide was responsible for doing all weights monthly and weekly for residents. She stated ADON C would give the Restorative A a list of residents to be weighed each week. She stated ADON C should have notified the physician and Dietitian on 04/28/24 of any significant weight loss for Resident #17 so interventions could be put in place. She stated ADON C should have documented the significant weight loss notification for residents. She stated she expected g-tube residents to receive the physician ordered enteral feedings. She stated the Dietitian was responsible to calculate nutritional intake including calories to ensure enteral feedings were meeting resident nutritional needs. She stated nurses should make sure setting is correct on enteral feeding and match physician orders along with bags dated and time of started. She stated looking at the history of the feeding g-tube pump would allow the nurse to see what amount of feeding was given since last reset to ensure residents receiving enteral feeding. She stated residents with significant weight loss were at a greater risk for malnutrition and can place residents at risk for skin breakdown. Interview on 05/08/24 at 1:53 PM with Resident #17's Physician revealed he expected to be notified when residents trigger for a significant weight loss with a day and for the Dietitian to be notified so she can evaluate the weight loss and put nutritional interventions in place for the residents. He stated he was not notified until Monday (05/06/24) for Resident #17's significant weight loss and stated to consult with Dietitian about the significant weight loss to assess Resident #17's weight loss and put Dietitian's nutritional recommendations in place for Resident #17. He stated he expected residents to receive their physician ordered enteral feedings. He stated he expected residents with significant weight loss who are dependent on enteral feedings should be consulted with Dietitian. He was not notified or aware of Resident #55's significant weight loss. Review of facility's policy Assessment and Management of Resident Weights last revised December 2023 reflected To ensure that each resident maintains acceptable parameters of weight and nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible based on the resident's comprehensive assessment. Under procedure I. A facility designee will obtain weight on residents: A. Admissions and re-admissions will be weighed. B. Hospital weight will not serve as admission or re-admission weight. C. Adaptive or assistive equipment used during measurement will be documented. II. If the weight is less than or greater than 5 pounds from the previous weight, immediately re-weigh and have a licensed nurse verify the accuracy of the weight. III. Weights will be entered into the clinical record in a timely manner. V. Significant Weight Change Management A. Significant weight changes will be reviewed by the DON or designated licensed nurse. Significant weight changes are: i. 5% in one (1) month ii. 7.5% in three (3) months iii. 10% in six (6) months B. The DON or licensed nurse will: i. Report weight change in the medical record and on the 24-Hour Report. ii. Notify the physician, resident/RP/family/healthcare decision maker of significant weight changes. iii. Document the notification. iv. Complete a change of condition on residents with significant 1 month 5% or greater weight changes. C. The Registered Dietitian will: i. Complete a nutritional assessment on all residents with a significant weight change; and ii. Document the nutritional assessment and weight management recommendations in the medical record. iii. Notify the facility's IDT team of the nutritional recommendation. D. The licensed nurse will notify the physician and resident/RP/family/healthcare decision maker of the dietitian's recommendations as indicated.

Based on observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for two (Residents #17 and #55) of six residents reviewed for enteral tube feeding, in that: 1. The facility failed to verify adequate nutrition was provided via enteral tube feeding or PEG tube (surgical placement of feeding tube in the stomach to provide nutrition, hydration and/or medicines) for Resident #17. 2. The facility failed to notify Consultant Dietitian of Residents #17 and #55's significant weight loss to ensure nutritional interventions were in place. 3. The facility failed to administer enteral feedings for Resident #17 as ordered by the physician. 4. The facility failed to administer enteral feedings to Resident #55 as ordered by the physician. These failures could place residents who are completely dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown and overall decline in quality of care. Findings include: 1. Review of Resident #17's quarterly MDS assessment dated [DATE] reflected Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke, heart failure, hypertension, kidney failure, diabetes, dementia, metabolic encephalopathy (brain dysfunction caused by problems with your metabolism), dysphagia (difficulty swallowing that can be caused by various conditions affecting the throat or esophagus), cognitive communication deficit and gastrostomy status. Resident #17 had a BIMS of 11 indicating he was moderately cognitively impaired. Resident #17 had a substantial/maximal assistance to dependent with ADLs. Resident #17 had a feeding tube with 51% or more proportion of total calories received through tube feeding while in the facility. Review of Resident #17's face sheet dated 05/08/24 reflected Resident #17 responsible party and POA was resident's family member. Review of Resident #17's comprehensive care plan last revised on 01/24/24 reflected Resident #17 requires tube feeding r/t dysphagia and aspiration Resident is NPO at this time . Interventions included to Monitor/document/report to MD PRN . and The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Review of Resident #17's current physician orders dated 04/09/24 reflected Enteral Feed Order every shift Begin Jevity 1.5 @ 52mls Q/hr times 22/hrs QD to provide 1716 kcals, 73 gm protein and 869 mls free water. Review of Resident #17's Nurse Administration Record for April and May 2024 reflected Resident #17 received Enteral Feed Order every shift Begin Jevity 1.5 @ 52mls Q/hr times 22/hrs QD to provide 1716 kcals, 73 gm protein and 869mls free water. The MAR had a check mark from April 10th to May 6th on the day, evening, and night shift . There was a check mark on May 7th for the Day shift. It did not reflect how much feeding Resident #17 received via tube feeding. Review of Resident #17's Nutrition assessment dated [DATE] by previous Dietitian reflected Resident #17 was npo and received tube feedings with weight history stable with most recent weight on 04/05/24 of 224 lbs via mechanical lift. It reflected to discontinue Jevity1.5 bolus 1 can via 5 times daily and to Begin Jevity 1.5 @ 52mls Q/hr times 22/hrs QD to provide 1716 kcals, 73 gm protein and 869mls free water. Provide additional 45mls water, via PEG, times 22/hrs QD to provide 990mls water. It reflected Resident #17 had nutritional risk related to diagnosis, history, incontinency, enteral feeding dependency and age Review of Resident #17's clinical record from 04/01/24 to 05/06/24 reflected no nutrition assessment or progress note by Dietitian since 04/09/24. Observation on 05/07/24 at 2:14 PM revealed Restorative Aide and CNA S weighed Resident #17 via mechanical lift reflecting Resident #17 weighed 174.6 lbs. Observation on 05/07/24 at 2:49 PM revealed Resident #17 was lying with head of bed elevated with Jevity 1.5 at 52 ml/hr with tube feeding revealed dated 05/07/24 at 5:30 AM. Interview with RN W revealed she did not know how to look at Resident #17's history of clock time on the enteral feeding pump. Observation at 2:50 PM with RN W of Resident #17's Enteral pump history with surveyor guidance revealed the following about the last 71 hours of clock time for feed rate set at 52ml/hr with flush 45ml every 1 hour for Resident #17: - Pump history of last 11 hours - 396 ml feed, 315 ml water flush - Pump history of last 21 hours - 733 ml feed, 675 ml flush - Pump history of last 31 hours - 1217 ml feed, 1105 ml flush - Pump history of last 41 hours - 1717 ml feed, 1555 ml flush - Pump history of last 51 hours - 2179 ml feed, 1940 ml flush - Pump history of last 61 hours - 2682 ml feed, 2390 ml flush - Pump history of last 71 hours - 3092 ml feed, 2730 ml flush Resident #17's Pump history reviewed for last 71 hours of clock time reflected 3092 ml of formula delivered to Resident #17. However, 52ml/hr x 71 hour = 3692 ml feed. Resident #17 received 600 ml formula deficit -> 900 kcals delivered less in last 71 hours. Resident #17 had a protein deficit for the last 71 hours of 38.2 grams. Interview on 05/07/24 at 2:51 PM with RN W revealed Resident #17 was tube feeding only for nutrition. She stated her responsibility as a charge nurse was to ensure resident's tube feeding orders match with the pump rate. She did not know if the tube feeding pump needed to be reprogrammed every 24 hours. She did not usually start the tube feeding or take it out on her shift. She stated according to tube feeding it was hung at 5:30 am today for Resident #17. 2. Review of Resident #55's quarterly MDS assessment dated [DATE] reflected Resident #55 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses of chronic respiratory failure with hypoxia (occurs when you do not have enough oxygen in your blood), seizures, adult failure to thrive, tracheostomy status and gastrostomy status. Resident #55 had moderately impaired cognitive skills for daily decision making with no BIMS score completed for Resident #55 since he was rarely/never understood per the assessment. Resident #55 was dependent with all ADLs. Resident #55 has a feeding tube with 51% or more proportion of total calories the resident received through tube feeding. Review of Resident #55's comprehensive care plan last reviewed on 04/05/24 reflected the following: -Date initiated on 12/26/23 - Resident #55 has Tracheostomy r/t Impaired breathing mechanics, Injury. -Date initiated on 12/26/23 and revised on 01/10/24 - Resident #55 requires tube feeding r/t Dysphagia, semi- Coma state, nonverbal, no responsive to stimuli. Interventions included RD to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. - Dated initiated on 12/26/23 - Resident #55 has potential nutritional problem related to GTUBE, anoxic brain injury. Interventions included Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Provide G-Tube feedings as ordered. Review of Resident #55's current physician orders dated 02/04/24 reflected Enteral Feed Order every shift Continuous Enteral Feeding: Formula: Jevity 1.5; Rate: 60cc/hr times 22/hrs QD. Observation on 05/07/24 at 3:07 PM revealed Resident #55 was lying in bed with head of bed elevated. Resident #55's enteral feeding pump history of clock time with LVN L revealed the following: -Feed rate: Jevity 1.5 60 ml/hr and feed rate 1540 ml, 662 ml flush. - pump history of last 12 hours - 538 ml feed rate, ml flush - pump history of last 22 hours - 1203 ml feed rate, 1321 ml flush - Pump history of 32 hours - 1745 ml feed, 1981 ml flush - Pump history of 42 hours - 2224 ml feed, 2461 ml flush - Pump history of 52 hours - 2594 ml feed, 2761 ml flush - Pump history of 62 hours - 3164 ml feed, 3361 ml flush - Pump history of 72 hours - 3705 ml feed, 4021 ml flush Resident #55's Pump history reviewed for last 72 hours of clock time revealed 3750 ml of formula delivered for Resident #55. However, 60ml/hr x 72 hour = 4320 ml of formula. Resident #55 had a 570 ml formula deficit -> 855 kcals delivered less in last 72 hours. Resident #55 had a protein deficit of 36.3 grams in the 72 hour period. Review of Resident #55's Nutrition admission assessment dated [DATE] reflected Resident #55 was npo with weight of 204 lbs via mechanical lift on 12/06/23. Resident #55 was on Jevity 1.5 @ 60/hr x 22 hours. Review of Resident #55's progress notes from 04/01/24 to 05/07/24 including nutrition notes reflected no nutrition progress notes for Resident #55. Interview on 05/07/24 at 3:10 PM with LVN L revealed charge nurse need to clear the pump every 24 hours and before starting new tube feeding each day. She stated the risk for not clearing the enteral feeding pump was unaware of how much feed has been given to the resident and whether it is accurate. Interview on 05/07/24 at 5:20 PM with Consultant Dietitian revealed she had been recently hired 2 weeks ago started working at the facility. She stated this was her first day in the facility. She stated she would ask the charge nurse about their enteral feeding to determine if a resident was getting physician ordered enteral feeding. The Consultant Dietitian stated she needed to ensure residents were getting correct tube feeding as ordered by the physician. Interview on 05/08/24 at 10:38 AM with Regional Nurse Consultant A revealed they did have a QAPI meeting on 04/25/24 about missing weights for residents. She stated she expected g-tube residents to receive the physician ordered enteral feedings. She stated the Dietitian was responsible to calculate nutritional intake including calories to ensure enteral feedings were meeting resident nutritional needs. She stated nurses should make sure setting is correct on enteral feeding and match physician orders along with bags dated and time of started. She stated looking at the history of the feeding g-tube pump would allow the nurse to see what amount of feeding was given since last reset to ensure residents receiving enteral feeding. She stated residents with significant weight loss were at a greater risk for malnutrition and can place residents at risk for skin breakdown. Interview on 05/08/24 at 1:53 PM with Resident #17's Physician revealed he expected residents to receive their physician ordered enteral feedings. Review of facility's policy Tube Feeding/TPN (Total Parenteral Nutrition) revised December 2020 reflected To ensure that the Facility meets the nutritional guidelines and resident's nutritional requirements per physician orders . A physician order is required to administer tube feedings/total parenteral nutrition (TPN). I. The physician's order for tube feedings and TPN are considered diet orders .The physician order and information communicated to the Nutrition Services Department should include: A. Type of formula; B. Amount of formula and fluid; and C. Frequency and amount of feeding. The Dietitian should periodically review residents receiving tube feeding and TPN to ensure nutritional adequacy. 42971

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for two of two (Resident #20 and Resident # 76) residents reviewed for tracheostomy care. 1. The facility failed to ensure the RT performed hand hygiene during tracheostomy (a surgical opening in the neck providing a direct airway through the trachea) care. 2. The RT failed to maintain sterile technique during the suctioning of Resident #20's trach. 3. The facility failed to ensure LVN L performed hand hygiene during tracheostomy care for Resident #76 and changed her gloves and performed hand hygiene before applying a clean trach drainage sponge around Resident #76's trach stoma. These failures could place residents at risk for respiratory infections. Findings included: 1. Review of Resident #20's Admission MDS assessment, dated 05/01/24, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Staff assessed his cognitive status as severely cognitively impaired. His active diagnoses included acute respiratory failure, cerebrovascular accident (stroke), pneumonia (lung inflammation caused by bacterial or viral infection), and seizure disorder. In Section O-Special Treatments, Procedures, and Programs it revealed he required oxygen therapy, suctioning, and tracheostomy (trach) care during the 14-day look back period. Review of Resident #20's care plan initiated on 05/02/24 reflected, The Resident has Tracheostomy related to impaired breathing mechanics .Interventions .Ensure that trach ties are secured at all times .Monitor/document respiratory rate, depth and quality. Check and document q shift/as ordered .Suction as necessary . Review of Resident #20's Physician's orders summary report dated 05/09/24, reflected, .Trach care daily and PRN . with a start date of 04/27/24. In an observation on 05/08/24 at 9:40 a.m. revealed the Respiratory Therapist (RT) outside of Resident #20's room. He donned a gown and an N95 mask and gathered an unopened trach kit and entered the resident's room. The RT cleaned the bedside table with a germicidal wipe and placed a box of procedure gloves and the unopened trach kit on top of the bedside table. The RT removed his gloves and put on another pair of gloves without performing hand hygiene and opened the trach kit and removed the sterile drape and placed it on the bedside table for his clean field. He reached into the kit and removed the bottle of saline. The RT removed his gloves and re-gloved with no hand hygiene. The RT reached under his gown to retrieve a pulse oximeter (device used to check O2 saturation) and his stethoscope. The RT placed the pulse oximeter on the resident's finger and listened to his lungs with the stethoscope. The RT removed the pulse oximeter and placed his stethoscope back around his neck. The RT, wearing the same gloves, opened the bottle of normal saline and poured it into the reservoir in the trach kit. The RT removed his gloves and re-gloved with no hand hygiene. The RT stated he needed to suction the resident. The RT reached into the top drawer of the chest of drawers next to the resident's bed and pulled out a tracheal suctioning kit and placed the kit on the clean field. He opened the package and attempted to put on the sterile glove on his right hand. At one point he used his ungloved left hand and tried to get sterile glove on. He then used the hand with the sterile glove (which was half on) and searched the kit. After a few minutes he disposed of the kit and removed the sterile glove and reached into the drawer and retrieved another tracheal suctioning kit. He opened the kit and put on the sterile glove on his right hand and then reached into the box of utility gloves (unsterile) with the hand that had the sterile glove on it and retrieved a utility glove and placed it on his left hand with the hand with the sterile glove, thus making it non-sterile. The RT then picked up the tracheal suctioning catheter by the end that connects to the suctioning machine with his sterile hand (right) and held up the catheter which was dangling and connected it to the suctioning machine. He grabbed the end of the suction catheter with his left hand (un-sterile) and removed the oxygen from the trach and inserted the catheter into the trach and suctioned the resident, which elicited coughing from the resident. He then disposed of the suction catheter, removed his gloves, and re-gloved with utility gloves with no hand hygiene and reached into the trach kit and removed the gauze and the trach dressing. He removed the old trach dressing which had phlegm and placed it on the clean field, next to the clean gauze and trach sponge. The RT then picked up a gauze with the same gloves used to remove the old trach sponge and dipped it in the normal saline and wiped around the trach stoma and repeated the same process twice. He then placed the clean trach sponge under the trach collar wearing the same gloves. The RT then removed his glove and gown and washed his hands. In an interview with the Respiratory Therapist on 05/08/24 at 10:15 a.m. he stated the tracheal suctioning was supposed to be a sterile procedure and he stated he did not do a sterile procedure. He stated he thought there were supposed to be 2 sterile gloves in the tracheal suctioning kit, and it threw him when there was only one. He stated the reason it was supposed to be a sterile procedure was to reduce the risk of introducing infection into the lungs. He stated he should had performed hand hygiene between gloves changes. In an interview with the VP of clinical services on 05/08/24 at 11:00 a.m. she stated tracheal suctioning was considered a sterile procedure and anytime gloves were changed they should be doing hand hygiene. She stated the Regional Director of Respiratory therapy was responsible for skills checking the Respiratory therapist as well as the nursing staff and the DON would be responsible for ongoing oversight of any respiratory therapy care in the facility. She stated the RT would be immediately re-trained. In an interview on 05/8/24 at 11:05 a.m. with the Regional Director of Respiratory Therapy she stated she was responsible for performing the skills checks on the RTs and the nurses for tracheostomy care. She stated she had skills checked the RT and was surprised he had performed so poorly. She stated he must had been very nervous. She stated she was doing re-training and skills check before he resumed care on any of the residents. She stated tracheal suctioning was a sterile procedure and staff should always perform hand hygiene between glove changes. She stated failure to follow proper procedures could lead to lung infections. Record Review of the Respiratory Therapist competency validation dated 04/05/24 reflected he was competent in Tracheostomy suctioning and Tracheostomy care. 2. Review of Resident #76's Comprehensive MDS assessment, dated 04/21/24, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Staff assessed his cognitive status as moderately impaired. His active diagnoses included acute and chronic respiratory failure, pneumonitis (lung inflammation caused by bacterial or viral infection), and tracheostomy status. In Section O-Special Treatments, Procedures, and Programs it revealed he required oxygen therapy, suctioning, and tracheostomy (trach) care during the 14-day look back period. Review of Resident #76's care plan initiated on 04/23/24 reflected, The Resident has Tracheostomy related to chronic respiratory failure .Interventions .Ensure that trach ties are secured at all times .Monitor/document respiratory rate, depth and quality. Check and document q shift/as ordered . Review of Resident #76's Physician's orders summary report dated 05/10/24, reflected, .Trach care daily and PRN . with a start date of 05/07/24. In an observation on 05/09/24 at 12:25 PM revealed LVN L outside of Resident #76's room. She donned a gown and gloves and gathered an unopened trach kit and entered the resident's room. LVN L cleaned the bedside table with a germicidal wipe. LVN L removed her gloves and put on another pair of gloves without performing hand hygiene and opened the trach kit and removed the sterile drape and placed it on the bedside table for her clean field. She removed and discarded the gloves, and she donned sterile gloves without performing hand hygiene. She opened the bottle of normal saline and poured it into the reservoir in the trach kit. LVN L disconnected the trach tube, and removed and discarded the inner cannula using the left hand. She inserted the sterile cannula using the right hand. She removed the old trach dressing which had phlegm and discarded it, she then picked up a gauze with the same gloves used to remove the old trach sponge and dipped it in the normal saline and wiped around the trach stoma and repeated the same process twice. She then placed the clean trach sponge under the trach collar wearing the same gloves. The LVN L then removed her gloves and gown and washed her hands. In an interview with LVN L on 05/09/24 at 1:14 PM she stated the trach care was supposed to be a sterile procedure. She stated the reason it was supposed to be a sterile procedure was to reduce the risk of infection and pneumonia. She stated she should had performed hand hygiene between gloves changes, and she stated she should had changed gloves before handling the clean sponge. She stated she was nervous. In an interview on 05/9/24 at 12:05 PM with the Regional Director of Respiratory Therapy she stated she was responsible for performing the skills checks on the nurses for tracheostomy care. She stated she had skills checked the LVN L. She stated tracheal care was a sterile procedure and staff should always perform hand hygiene between glove changes. She stated failure to follow proper procedures could lead to lung infections. Record Review of LVN L competency validation dated 05/08/24 reflected she was competent in Tracheostomy care. Record review of the facility's policy, Tracheostomy Care' dated June 2020, reflected, .In addition to routine care, stoma dressing, and trach ties will be changed when wet or soiled .Gather supplies .Wash hands .don gloves .Inspect skin and stoma site for sing or symptoms of infection, skin irritation, or open areas. If there is a tracheostomy dressing, remove the old dressing from around the tracheostomy tube and discard .Clean around the tracheostomy site .with a cotton swab or gauze pad moistened in normal saline .Repeat the cleaning process until wet and dried mucus is removed. Use a clen cotton swab or gauze pad each time .Pat the area dry with a gauze pad .Apply a precut ( non-[NAME] dressing) around the insertion site .Suction resident as needed . Record review of the Facility's undated Clinical Competency Validation Tracheostomy Suctioning check list reflected: .2. Gathers supplies, puts on PPE; including gloves. 5. Cleanses hands 6. Apply gloves and clean work surface with disinfectant. 7. Remove gloves and dispose in plastic bag 8. Wash hands and apply clean gloves 10. Attached connecting tubing to suction machine 11. Turns on suction machine and checks equipment for proper working order 12. Removes gloves and cleanses hands 13. Places suction kit on bedside table. Opens wrapper and uses as sterile filed. Opens sterile water. 14 Establishes one sterile and one non-sterile hand. Designates dominant hand as the sterile field. 15. Puts on sterile gloves 16. Leaves sterile catheter in wrapper. With non-sterile hand, attaches connecting tubing to end of catheter. 17. Places thumb of non-sterile hand over aspiration port and suctions up a small amount of water to test effectiveness of suction pressure. 18.With Sterile hand and without applying suction, inserts catheter into tracheostomy stoma/trach tube until resistance is felt then pulls back 1 cm. 19. With non-sterile hand, applies suction and gently withdraw catheter, slowing rotating catheter with fingertips . 22. With sterile hand, rinses catheter in sterile water and repats procedure until breath sounds are clean no more mucous returns. 23. Detaches suction catheter from connecting tube and discards 25. Removes PPE and cleansed hands 42971

Based on observations, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to ensure Dietary Aide ZB wore effective hair restraints to cover his hair and facial hair on 05/07/24 while cleaning dishes and using the dish machine. 2. The facility failed to ensure 1 of 3 freezers were free of ice accumulation on the bottom of freezer. These failures could place residents at risk for food-borne illness and food contamination. Findings included: Observation on 05/07/24 at 10:35 AM with Dietary Aide ZB revealed he did not wear a hair restraint to cover the 2.5 inches of back of hair along with 1/2 inch near his ear not covered with cap. Dietary Aide ZB had facial hair not covered with no facial hair restraint while doing dishes. Interview on 05/07/24 at 10:50 AM with Dietary Aide ZB stated he knew he should have been wearing a hair restraint while doing dishes to cover his facial hair along with covering hair restraint to cover the areas where his cap did not cover. Observation on 05/07/24 at 10:31 AM revealed 1 of 3 freezers had ice accumulation of about 1 inch of inside bottom of freezer. Interview on 05/10/24 at 3:35 PM with the Dietary Supervisor revealed they cleaned up the ice on the bottom of the freezer after it was brought to her attention on 05/07/24 from surveyor. She stated the hose slipped off in the top back of the freezer which allowed water to drip down the back and bottom of the freezer and it froze over. She stated, routinely, kitchen freezers were cleaned weekly and as needed. She stated Dietary Aide ZB had been in-serviced prior about hair restraints. He should wear hair restraint to cover facial hair and restraints. Asked for in-service for dietary aide. She stated she had on-going in-service about hair restraints when entering kitchen. Iinterview on 05/10/24 at 5:20 PM with the Maintenance Supervisor revealed the freezers had gotten ice accumulation before and it had to be emptied out and clean it when it does. He stated he replaced the hose in the back before especially when dietary staff were stacking items in freezer too high on top shelf. Review of facility's dietary staff in-service dated 02/28/24 by Dietary Supervisor reflected about hair nets and beard guards. The in-service included Dietary Aide ZB. Review of facility's policy Nutrition Services Personnel Guidelines revised January 2024 reflected important personnel guidelines followed by Food and Nutrition Services .Dress code .4 .Hair must be fully covered with hairnet or hair bonnet always within the department. The facility did not have a specific policy about freezer maintenance.

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for one (Resident #1) of five residents reviewed for abuse. CNA B failed to provide Resident #1, who was in a vegetative state and ventilator dependent, the necessary level of assistance with ADLs. On 04/20/20, CNA B provided Resident #1 incontinent care with no assistance, resulting in the resident rolling off the bed onto the floor and sustaining facial injuries. Resident #1 was transferred to the emergency roiagnom on [DATE], where he was diagnosed with [REDACTED]. It was determined a past non-compliance Immediate Jeopardy (IJ) existed from 04/20/20 to 04/22/20. The IJ was determined to have been removed on 04/22/20 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation on 04/23/20. This failure placed residents at risk for serious injuries, a decline in the resident's condition, hospitalization or death. Findings included: Review of Resident #1's MDS Annual Assessment, dated 04/01/20, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His active [DIAGNOSES REDACTED]. According to the assessment he was in a persistent vegetative state/no discernible consciousness and was on a ventilator. He was totally dependent and required assistance of two staff for bed mobility and toileting, was frequently incontinent of bowel and bladder, and had upper and lower extremity impairment on both sides. Review of Resident #1's comprehensive care plan reflected the following: -He was incontinent of bowel and bladder; he was totally dependent on staff x 2 with incontinence needs. Initiated on 10/15/19 and last revised 05/06/20 - Resident #1 was high risk for falls related to paralysis and vegetative state. The interventions included: to anticipate and meet the resident's needs and to review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Initiated on 01/27/20 and last revised 05/06/20 - Resident #1 had a [MEDICAL CONDITION] and oxygen therapy related to [MEDICAL CONDITION]. Resident #1 to wear 28% humidity with 5 LPM (liters per minute) O2 (oxygen) bleed-in in [MEDICAL CONDITION]-bar continuous q (every) shift. Initiated on 01/27/20 and last revised on 05/06/20, -Resident #1 had impaired cognitive function and nonverbal related to [MEDICAL CONDITION]. Initiated on 05/10/19 and last revised on 05/06/20 Review of the facility's Provider Investigation Report involving Resident #1 dated 04/24/20 reflected, .Incident date 04/20/20 at 6:30 AM revealed Agency Staff member (CNA B) was providing care to (Resident #1) and rolled out of bed. Head to toe assessment revealed Resident #1 had an abrasion to the head and his nose was bleeding. Resident #1 was transported to the hospital for further evaluation. Provider response included in-service on abuse/neglect completed, in-service on ensuring the Agency knew how to find ADL care information, notified Physician, family. Safe surveys were completed with other residents. The report revealed CNA B was terminated from further service with the facility and the staffing agency was notified of the neglect. The Investigation Summary revealed after reviewing the findings, it is summarized that the facility has confirmed that neglect occurred. Review of the facility's Fall with injury report completed by LVN A and dated 04/20/20 reflected, . Incident description .At approx. 0450 (4:50 AM) this nurse was in another patients (pt) room when the CNA notified that pt had fell on the floor during changing. Upon entry pt was found on his left lateral side and bleeding from his nose. After transferring pt to bed via hoyer lift, this nurse assessed patient. VS (vital signs) 107/74 (blood pressure) 96% (oxygen saturation), 99.9 F (temperature) HR (heart rate) 107, Eyes PERRLA, CNA used towel to clean blood from his face. Left message with DR (doctor) and DON. Called (company name) transport for pick up. Injuries observed at time of incident including abrasion to face and bruise to face. The report reflected Resident #1 had mobility of bedridden. Review of Resident #1's emergency room hospital discharge records, dated 04/20/20, reflected the following: Pt coming from (facility). Pt was dropped while staff was changing him. Facial bruising noted. Blood from trach, mouth and scalp. Patient Diagnosis: [REDACTED].Injury resulting from fall from height. Review of the Resident #1's hospital records dated 04/20/20 reflected the following: - Maxillofacial CT revealed small amount of fluid in the left maxillary sinus. No fractures or dislocations. - Chest CT revealed remote appearing rib fractures. No acute rib fractures identified. - An interview with CNA B on 05/14/20 at 3:22 PM revealed RN A was in another resident's room doing a code. CNA B stated she went to Resident #1's room to provide incontinent care and she knew he was a two-person assistance. She stated when she went into the room to provide incontinence care to Resident #1 he was on his left side. She instructed Resident #1 to stay still and not to continuing rolling. She stated Resident #1 was non-compliant and continued rolling. She could not hold him by herself and stop him from rolling out of the bed, so he fell out of the bed. She stated he was bleeding from his nose and face. She stated the facility was short staffed with only one other nurse and CNA in the whole facility. She stated she went to get a nurse immediately. She stated she knew most of her residents on the hall she was assigned were two-person assistance for ADLs but she provided assistance by herself throughout the shift. CNA B stated she did not ask anyone for assistance prior to providing care to Resident #1. She stated she had access to the electronic medical record kiosk system and charted on all her residents that night total dependence with one-person physical assistance. Review of CNA B's Witness Statement dated 04/20/20 at 6:05 AM signed by CNA B reflected, Upon performing peri-care on (Resident #1) pt was noted to the left side, and instructed to stay still and not to continue rolling. Pt was not compliant (sic), and continue to role. Pt was held on as long as possible, until pt. slipped out of hands and hit the floor. Pt incident was reported to charge nurse, and pt. was assisted x3 back to bed for further assessment. Interviews with RN A on 05/14/20 at 3:55 PM and 05/18/20 at 1:43 PM revealed on 04/20/20 on the night shift another nurse came and reported there was an emergency on the hall but she was in the middle of conducting a code on a resident. She stated once EMS had taken over the code, she went to check on Resident #1. She stated Resident #1 was on the floor next to his bed and on his left side. She stated he was bleeding from the nose and recalled a bruise on his nose and on one of his cheeks. She assessed injuries on his shoulder and chest. RN A stated Resident #1's ventilator did not get disconnected but it could have when he rolled out of bed. She stated they used a hoyer lift to transfer him back to the bed since Resident #1 was totally dependent. RN A stated they were able to stop the bleeding from his nose. She stated she called transportation to send him to the hospital for further evaluation and notified the physician, family and DON. She stated she asked CNA B what happened, and CNA B told her she was providing incontinent care to Resident #1 by herself and he rolled out of the bed. She stated she went over with CNA B at the beginning of the shift Resident #1 being a two- person assistance with all ADLs including incontinent care. She stated CNA B had access to the kiosk system and the electronic medical record to know resident care level needs and even document on the residents that shift. RN A stated she was unaware of any other time CNA B provided care to residents by herself on a two-person assistance resident. She stated CNA B did not ask her for assistance to provide care to Resident #1 prior to the incident. Review of RN A's emailed statement dated 04/20/20 at 10:41 AM reflected: I was with another patient when CNA came in and told me (Resident #1) had fallen. Upon entry into the room, I observed him laying on the floor (between the bed and the dresser) ) on his left lateral side and he was bleeding from his nose. After assessing for injuries, he was transferred from floor to bed via hoyer lift. VS (vital signs) were assessed. Eyes PERRLA (pupils equal, round, and reactive to light and accommodation). I observed an abrasion to his forehead redness on the left should/chest, bruise/abrasion on right cheek, and bruise on his nose. CNA brought a towel and cleaned blood from his face, he was no longer actively bleeding. He was suctioned by RT and inner cannula was cleaned . I informed the CNA that he is a 2 person assist and must be transferred with hoyer lift. I called (company name) for transport to ER for assessment/evaluation. I called to inform DON and DR. I called his wife who had the son translate due to her being Spanish-speaking only. They requested that the patient be sent to Hospital on (street name), used to be Doctors hospital. I resumed q 15 min neuro checks until transportation arrived. Informed transport of family request to go to specific hospital. He was then transported out. Interview on 05/18/20 at 10:15 AM with LVN C revealed on 04/20/20 in early morning CNA B, who was an agency aide, came and got her telling her she had an emergency and needed a nurse, so she went to see what was going on. She stated RN A was busy in another resident's room doing a code, so she went with CNA B. She stated she saw Resident #1 was on the ground and bleeding from his nose. She stated CNA B told her she was providing incontinent care to Resident #1 and rolled him over to one side. LVN C stated CNA B said she told Resident #1 to stop rolling but he kept rolling and fell off the bed. She stated she told CNA B Resident #1 was nonverbal, totally dependent and could not respond to what was said. She stated Resident #1's bed was not on the lowest position when she went in the room to find Resident #1 on the floor next to the bed. She stated that night, 04/20/20, there were only two CNAs instead of three CNAs but there were three nurses along with two Respiratory Therapists. She stated she did not understand why CNA B provided incontinent care to Resident #1 by herself. She stated CNA B had worked at the facility before and had access to the kiosk system to know Resident #1's ADL care needs . Interview on 05/21/20 at 3:48 PM with RT E revealed an Agency CNA (CNA B) on 500 hall came and told her Resident #1 had fallen. She stated she went into Resident #1's room and saw Resident #1 was bleeding from his nose and trach. She stated if she had not suctioned his trach, the blood could have gotten into his lungs. She stated his respirations were 20. She stated EMS was called and she suctioned him again before he went to hospital. She stated Resident #1 was nonverbal and could not follow commands. She stated the only time she had seen him move his arms was when he coughed for her and it could have been just a reflex. She stated Resident #1 was totally dependent . Review of the staff timesheet and sign-in sheets for 04/19/20 - 04/20/20 night shift reflected three nurses, two respiratory therapists and two Agency CNAs were working. Review of CNA B's timesheets reflected she worked on 04/11/20 on 300 and 400 halls from 9:45 PM to 6:15 AM, 4/12/20 on 500 hall from 10:00 PM to 6:30 PM, on 04/19/20 on 500 hall from 2:00 PM to 10:00 PM, and on 04/19/20 from 10:00 PM to 6:00 AM. In an interview on 05/15/20 at 2:08 PM the ADM revealed CNA B did not provide care to any other residents after the incident with Resident #1. He stated he informed the staffing agency of CNA B's neglect and she was not allowed to come back to the facility. He stated it was neglect because she knew the resident was a two-person assist. He stated the nurse did a head to toe assessment and sent Resident #1 to the hospital. He stated CNA B never returned to the facility. He stated there was adequate staff and CNA B should have waited to provide care to Resident #1 when she had assistance. In an interview with the DON on 05/18/20 at 1:42 PM revealed at the beginning of the shift the Charge Nurse went over care level needs including who was a two-person assistance and how to access their care needs in the kiosk system and electronic medical record with CNA B about all residents on her shift. She stated nurses were responsible for ensuring any agency staff or new staff were oriented prior to the start of their shift on resident care assistance needs, how to access kiosk system in the electronic medical record to document and see resident care level assistance needs. Review of facility's investigation of Resident #1's Incident undated by DON reflected agency staff members that did come back were in-serviced on care needs. The ADON position was responsible for making sure the agency staff were trained and the facility no longer had an ADON. The DON stated until a new ADON was hired, the DON would be responsible for making sure the training was being done. The agency staff were assigned an access code before they came to the floor so they could access the patient care record. The DON stated, .When we do have agency, we will utilize the form that the charge nurses will have them sign. Review of the facility's Abuse - Reportable Events, dated May 2017 reflected, It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/vent in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person Definition of abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. Review of facility's in-services to Charge Nurses dated 04/20/20 to 04/22/20 reflected ten nurses were in-serviced on Agency staff and new staff receiving training on kiosk in the electronic medical record and giving report to Agency staff on residents' care assistance needs. They went over being aware of all residents who required two-person assistance and hoyer lift transfers . Review of facility's in-service for Agency Staff with start date of 04/21/20 reflected, make sure you review resident care information in (electronic medical record) prior to caring for the residents. You will receive your access code to the (electronic medical record) system when you arrive to the facility and your nurse will assist you in accessing the information. Receive a report from your nurse on the residents that you will care for that day. Please make sure you are aware of whether the resident is 1 or 2 person assist. Always get another person to help in 2 person assist residents . Interviews on 05/15/20 and 05/18/20 with RN A and LVN C revealed they were able to discuss their role in providing the required orientation and verbal report about residents' assistance level needs including which residents require two person assistance to agency staff at beginning of their shift. Observation on 05/15/20 at 9:37 AM with CNAs F and G conducting incontinent care for Resident #1 revealed no concerns with staff assistance level. Observation on 05/15/20 at 10:05 AM with CNAs F and H revealed no concerns with staff assistance level. On 05/15/20 at 7:12 PM the ADM was informed an Immediate Jeopardy was determined to have existed from 04/20/20 to 04/22/20. The IJ was determined to have been removed on 04/22/20 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation on 04/23/20.