Every finding on record at Caraday of Lampasas

Based on observation, interview, and record review, the facility failed to ensure each resident had a right to a dignified existence and to treat each resident with respect and dignity for 1 of 6 residents (Resident #1) reviewed for resident rights. The facility failed to ensure, on 07/07/2026, CNA A did not yell sit down now to Resident #1 when CNA A was walking outside Resident #1's room. This failure could lead to residents at risk of experiencing feelings of disrespect, a profound loss of dignity, triggering heightened anxiety, confusion, and a desire to withdraw socially.Findings included:Record review of Resident #1's face sheet, 07/07/2026, revealed a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnoses that included displaced fracture of greater trochanter of left femur (a break on the outer, bony prominence of the left hip where major gluteal muscles attach), acute kidney failure (a sudden loss of kidney function that happens within hours or days), and unspecified protein-calorie malnutrition (individuals lacking adequate protein and calories, without a specifically documented severity).Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 05/03/2026, Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 3 indicating severe cognitive issues.Record review of Resident #1's undated care plan revealed a focus Resident #1 had a behavior problem related to schizophrenia (a chronic, severe brain disorder where individuals struggle to distinguish reality from imagination) dated 01/20/2023 with an intervention - in a calm manner, divert attention, remove from situation and take to alternate location as needed dated 01/19/2023.Observation on 07/07/2026 at 11:20 AM of CNA A walking outside of Resident #1's room revealed CNA A yelled at Resident #1, Sit down now. Sit down now. CNA A did not enter Resident #1's room. Resident #1 was observed to be seated in her wheelchair. Attempted interview on 07/07/2026 at 11:20 AM with Resident #1 revealed she was not interviewable. During an interview on 07/07/2026 at 11:59 AM with the Administrator she said the definition of verbal abuse was speaking to a resident in a derogatory manner or disrespecting the resident. The Administrator said it was not okay to speak down to residents and make them feel bad about themselves. The Administrator said staff should not raise their voice to a resident. She said to talk to a resident in a loud voice, sit down now, was no being respectful to the resident. She said it was not kind and could be interpreted as being verbally aggressive. The Administrator said that Resident #1 had just had a hip fracture, and CNA A might have been telling her to sit down so Resident #1 would not hurt herself. The Administrator said staff should not be telling residents to sit down for staff convenience and CNA A should have entered Resident #1's room and provided her assistance. During an interview on 07/07/2026 at 2:48 PM with the SW, she said her definition of verbal abuse was speaking to a resident in any way that could be considered belittling or treating residents without respect. She said yelling at a resident to sit down now was not respectful to the resident. The SW said if they were going to communicate with a resident it was best to go to the resident and speak with them. The SW said residents should not be spoken to as if they were children and residents should be told to do something with dignity and respect, During an interview on 07/07/2026 at 4:59 PM with the Administrator ,she said that she told CNA A that she was suspending her employment pending an investigation and CNA A self-terminated her employment with the facility. On 07/07/2026 at 6:01 PM surveyor attempted to speak with CNA A by telephone. A text message was sent to CNA A and no phone call was received from CNA A. During an interview on 07/07/2026 at 6:10 PM with the RN, she said she had worked at skilled nursing facilities for about 26 years. She said she was trained in resident rights and dignity. The RN said it was not okay for a staff member to yell at resident to sit down now because they were telling the resident what to do. She said if they were yelling at the resident, they were not keeping resident information confidential and they were degrading the resident. The RN said a staff member should go in the resident's room, shut the door, and talk to the resident. The RN said the possible negative effect of yelling at a resident sit down now could be that the resident could get angry, become defensive, become confused and scared. The RN said it was better to talk to residents softly. During an interview on 07/07/2026 at 6:22 PM with CNA B, she said she had worked at the facility for about 3 years. CNA B said she was trained in resident rights and dignity. CNA B said it was not alright to tell a resident in a loud voice to sit down now. CNA B said that even if they were not yelling at the resident, it was an undignified way to speak to a resident. She said the possible negative effect of yelling at a resident to sit down now would be that a resident might give them a bad attitude right back. CNA B said she could not blame the resident if they responded to a staff member with a bad attitude if they were told to sit down now. CNA B said a better approach would be to go to the resident, talk to them and get their minds busy on something else rather than standing up. She said she felt that telling a resident in a loud voice to sit down now was a resident rights and dignity issue. Record review of CNA A's Employee Acknowledgement of Resident/Patients Rights policy consent date 10/28/2025. Record review of the facility in-service training roster dated 01/28/2026 in-service topic Resident Rights reflected CNA A's name and signature.Record review oof the facility in-service training roster dated 03/25/2026 in-service topic Resident Rights reflected CNA A's name and signature.Record review of the facility in-service training roster dated 04/03/2026 in-service topic Resident Rights reflected CNA A's name and signature.Record review of the facility in-service training roster dated 05/29/2026 in-service topic Resident Rights reflected CNA A's name and signature.Record review of the facility in-service training roster dated 05/30/2026 in-service topic Resident Rights reflected CNA A's name and signature.Record review on 07/07/2026 of facility Resident Rights policy, undated, reflected Residents in long-term care have the right to be treated with dignity, respect, and fairness at all times.

Based on interview and record review the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 DON reviewed for DON coverage and failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. The facility failed to have a full-time Director of Nursing on 2/14/2026 and 2/15/2026 as of 02/26/2026. This failure could place residents at risk of lack or nursing oversight and a higher level of care.Findings included: Record review of the facility RN Dayforce Data report indicated on 2/15/2026 there was no RN coverage. Interview on 02/26/26 at 1:50 PM with the Business Office Manager revealed the facility last DON resigned as of 2/17/2026. She stated if there are any nursing questions that can't be handled by the ADON, they were instructed to contact the regional nurse. BOM stated there was an offer that has been made and accepted by a DON but will not be able to start until 3/30/2026 to give proper notice to her current job. Interview on 02/26/26 at 2:10 PM with the Area Regional Manager revealed they currently do not have a DON but there had been an offer extended to someone that will start at the end of March. He stated there was an ADON, but she was an LVN. He stated the negative outcome was there isn't an RN to oversee the daily nursing and clinical responsibilities. He stated the regional nurse has been in the building and there was an interim that will start on 3/11/2026 that will split the coverage with the regional nurse. He stated they do not have a nurse waiver Interview on 02/26/26 at 2:30 PM with the Administrator revealed the previous DON resigned as of 2/17/2026. ADM stated there are no nursing waivers in place. She stated there was an ADON, but she was an LVN. ADM stated here will be a DON that will be starting on 3/31/2026 and she will not start until then because she had to give her current employer notice. ADM stated the negative outcome that can happen without having a DON is they would not have clinical management. She stated there are other personal and other nursing personnel that are trained to cover. MDS and ADON can review clinical dashboards, referrals, orders and they can go over that in clinical meetings during the lapse. Also, the regional nurse sits in the building, and she has been here daily. She started 1/19/2026. She was at the other facility assisting them with questions, but she is here Monday through Friday. Interview on 02/26/26 at 2:30 PM with the Regional Nurse revealed she had been covering as a DON since mid-December to currently. She works Monday through Friday and sometimes she goes to another building and comes back. She stated the ADON was a LVN, but if she was not in the building the ADON covers. She stated there was a DON in the building in the first week of December and she went back to work on the floor 2/6/2026 as a nurse and then a couple of weeks later she resigned. The negative outcome of not having a DON in the building will depend how long they have been without a DON and what systems they have in place and backup system they have. They have systems in place, if there is no DON there is RN on the floor working the floor, The LVN/RN has been trained to keep that system running and in place. She stated she came in and sat in the building and kept all the systems, risk management, weights, etc. up to par. She stated she does not feel there is any harm that had been done since they have systems set in place. Regional nurse stated according to the RN Dayforce Data report reflected on 2/14/2026 she was working and she denied working on that day. On 2/26/2026 a policy regarding DON coverage was requested and the Area Regional Manager provided the following information by email: He stated they do not have a policy; they just follow regs and it does not specify that we cannot be without a DON. See below: (2) Registered nurse.(A) The facility must use the services of a registered nurse for at least eight consecutive hours a day, sevendays a week, except when waived under paragraph (3) or (4) of this subsection.(B) The facility must designate a registered nurse to serve as the director of nursing on a full-time basis, 40hours per week, except when waived under paragraph (4) of this subsection.(C) The director of nursing may serve as a charge nurse only when the facility has an average dailyoccupancy of 60 or fewer residents.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to have expiration dates on foods in the freezer. The facility failed to have expiration dates on dry food in the kitchen. The facility failed to keep the ice machine clean. These failures could place residents who received meals from the main kitchen at risk for foodborne illnesses. Findings included: Observation on 2/24/2026 at 8:35 AM of the freezer reflected the following:- Burgers in a zip-lock bag, not in the original package, were dated 2-21-2026 with no expiration date on the package. - Biscuits in a zip-lock bag not in the original package dated 1-31-2026 with no expiration date on the package. - Garlic Bread in a zip-lock bag not in the original package dated 2-22-2026 with no expiration date on the package. Observation on 2/24/2026 at 8:47 AM of the kitchen reflected the following:- Pinto Beans in a Plastic container dated 12-10-2025 with no expiration date on the package. - Spiral Pasta in a Plastic container dated 10-29-2025 with no expiration date on the package. - Orzo Pasta in a Plastic container dated 12-20-2025 with no expiration date on the package. - The tray with serving bowls had food debris on it. - The tray with cups serving on it had coffee grounds on it. - A plastic container with kitchen utensils in it had food and debris at the bottom of the container. Observation on 2/24/2026 at 10:53 am of the dining reflected the following:Cereal in a plastic dispensing container was not labeled with the date it was put in the container or an expiration date. The ice machine had a black substance on some of the plastic inside the ice machine. An interview on 2/26/2026 at 10:53 AM, the CK stated that it is everyone's responsibility to label food. The CK stated that all food items should be labeled with the date they were placed in a zip-lock bag. The CK stated that they follow a first-in, first-out policy, with older food in front of newer food. The CK stated that residents could get sick if they are served out-of-date food. The CK stated that the kitchen is cleaned throughout the day. The CK stated that the containers with kitchen utensils are supposed to be cleaned daily. The CK stated that there was a book that lists what should be cleaned daily. The CK stated that residents could get sick from cross-contamination caused by using unclean kitchen items. The CK stated that he gets in-service training on dating and cleaning every payday, which was every other week. An interview on 2/26/2026 at 11:00 AM, the DM stated that all kitchen staff are responsible for labeling food in the kitchen with the correct date. The DM stated that all food in the kitchen should be labeled with an expiration date. The DM stated that everyone was responsible for cleaning the kitchen, and there was a log that should be checked off when the kitchen was cleaned. The DM stated that the ice machine is professionally cleaned every 3 months, and the last cleaning was on 1/26/2026. The DM stated that she did not check after it was cleaned to make sure it was done. The DM stated that she had a group text with the kitchen staff to remind them to check dates and clean the kitchen. The DM stated that if residents are served out-of-date food, food from dirty dishes, and ice from a dirty ice machine, they could get sick. An interview on 2/26/2026 at 11:16 AM, the DA stated that it was everyone's responsibility to check and label food items in the kitchen. The DA stated that all food items in the kitchen should be labeled with an expiration date. The DA stated that it was everyone's responsibility to clean the kitchen. The DA stated that the container containing the utensils should be cleaned daily. The DA stated that if residents are served out-of-date food or food cooked with dirty dishes and utensils, they could get sick. The DA stated that she has in-service training on dating and cleaning every two weeks. An interview on 2/26/2026 at 2:20 PM, the ADM stated that it was her expectation that all food items be dated with an expiration date. The ADM stated that the kitchen should be cleaned daily. ADM stated that the ice machine should be checked in between professional cleanings to ensure it was not dirty. The ADM stated that residents could get sick from out-of-date food, unclean dishes and utensils, and ice served from a dirty ice machine. Record Review of The Food Storage and Supplies policy dated 2012 stated the following: These non-perishable foods are still dated when received if they do not have an expiration date and once, they are opened, but do not need to be discarded within 7 days after opening. Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or best by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality has deteriorated. Manual Cleaning and Sanitizing of Utensils and Portable Equipment Policy not dated: The facility will follow the cleaning and sanitizing requirements of the state and United States Food Codes for manual cleaning to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #3 and Resident #4) of 5 residents reviewed for infection control practices, in that: The facility failed to ensure LVN B sanitized blood pressure monitor in between Resident #3 and Resident #4 while obtaining blood pressure.This failure could place residents at risk for cross-contamination and infections.Findings included:Resident #3Review of Resident #3's face sheet dated 12/22/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis of hypertension.Review of Resident #3's initial MDS assessment, dated 10/03/25 reflected a BIMS score of 15, indicating his cognition was intact.Review of Resident #3's care plan dated 09/27/25 had not reflected his diagnosis of hypertension.Review of Resident #3' s medication order reflected: Lisinopril Oral Tablet 30 MG (Lisinopril): Give 1 tablet by mouth one time a day for hypertension Hold forSBP<110 OR DBP<60 OR HR<60.-Start date: 09/27/25.Resident #4Review of Resident #4's face sheet dated 12/22/25 reflected a [AGE] year-old male initially admitted to the facility on [DATE] and re admitted on [DATE] with the diagnosis of hypertension.Review of Resident #4's quarterly MDS assessment, dated 11/28/25, reflected a BIMS score of 15, indicating his cognition was intact.Review of Resident #4's care plan dated 08/4/15 had not reflected his diagnosis of hypertension.Review of Resident #4's physician's order reflected: Lisinopril Oral Tablet 10 MG (Lisinopril): Give 1 tablet by mouth one time a day for HTN: Start date 07/18/25.During an observation on 12/22/25 at 10:15 a.m., LVN B measured the blood pressure of Resident #3 using a blood pressure monitor without sanitizing the device. After administering medications to Resident #3, she proceeded to Resident #4 and used the same blood pressure monitor without sanitizing it between residents. LVN B did not sanitize the monitor after using it on Resident #4 until the investigator brought it to her attention.During an interview on 12/22/25 at 10:35 a.m., LVN B stated that sanitizing blood pressure cuffs between residents was important, but she forgot to do so because she was in a rush. LVN B stated that following infection control protocols was essential to minimize the spread of disease among residents. She reported receiving infection control training the previous month but stated there had been no in-service training specifically addressing the sanitization of medical equipment.During an interview on 12/22/25 at 11:35 a.m., the ADM stated that, in accordance with the facility's infection control protocol, all medical equipment in use, including blood pressure cuffs, must be sanitized immediately after use on residents. He explained that this practice was one of the facility's measures to minimize the spread of infectious diseases and that staff are trained in these procedures. The ADM further stated he did not know the exact date staff last received in-service training on infection control, as he was new to the facility.Review of the in-service records from 10/01/25 to 12/22/25 revealed there were no in services specifically on sanitizing medical equipment in between the residents.Review of facility's undated policy Fundamentals of Infection Control Precautions reflected: . Resident care equipment and articles:Non-invasive resident care equipment is cleaned daily or as needed between use by the nursing assistant.

Based on observations, interviews, and record reviews, the facility failed to provide nutrition and hydration care and services for two of three residents (Resident # 24 and Resident #18), consistent with the resident's comprehensive care plan. The facility failed to provide sufficient fluids for two of three residents to prevent dehydration and infections. This deficient practice placed the residents at risk for increased confusion, lethargy, increased urinary tract infections, kidney issues, excessive thirst, dry skin, decline in status, pain, illness, hospitalization and affects their psychosocial wellbeing. Findings included: Review of the undated face sheet and undated care plan for Resident #24 reflected a [AGE] year-old male admitted on [DATE]. His diagnoses include Huntington's Disease (a brain disorder that causes the nerve cells in the brain to breakdown and die), adjustment disorder with Mixed Anxiety and Depressed Mood (a person experiences mixed symptoms of adjustment disorder with Anxiety and Adjustment Disorder with Depressed Mood), Other Lack of Coordination (the brains inability to coordinate muscle movements), Dysphagia (difficulty swallowing), Unspecified Protein-Calorie Malnutrition (inadequate intake of food). Observation on 11/06/2024 at 11:25 AM, Resident #24 was sitting in wheelchair in dining area prior to lunch. No fluids were offered to resident before he was assisted with feeding. The resident was unable to speak. The resident was observed with dry lips and dry skin on his face. Observation on 11/07/2024 at 8:50 AM, Resident #24 was sitting in wheelchair in lobby. The resident was observed with dry, cracked lips, a dried, crusty fluid around both eyes, dry skin on his face. There were no fluids observed near the resident. Observations on 11/07/2024 at 10:15 AM, 10:53 AM, 11:10 AM, 2:24 PM and 3:40 PM revealed that Resident #24 was sitting in wheelchair in the lobby. Resident #24's face remained dry and appeared that his face was not washed since he woke up or after breakfast. There were no fluids observed near the resident, no cups with the resident's name, nor was staff observed offering fluids to the resident. Review of Resident #24's undated care plan reflected the following: Problem: The resident has a potential for fluid deficit related to poor intake. Goal: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. The resident will be offered and encouraged to drink adequate fluids through the next review date. Interventions: 1) Educate the resident/family/caregivers on importance of fluid intake. 2) Encourage the resident to drink fluids of choice. 3)Ensure The resident has access to fluids whenever possible. 4) Invite the resident to activities that promote additional fluid intake. Offer drinks during one-to-one visits. Ensure that all beverages offered comply with diet/fluid restrictions and consistency requirements. 5) Monitor/document/report PRN any signs and symptoms of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. 6)The resident needs assistance/encouragement/supervision to meet the daily requirements for fluid intake. Review of the face sheet for Resident #18 reflected a [AGE] year-old-male readmitted on [DATE]. His diagnoses include Down Syndrome (a genetic disorder when there is an extra copy of chromosome 21), anxiety disorder (excessive fear and anxiety that interferes with daily life), Restlessness and Agitation (feeling of intense distress or irritability), Major Depressive Disorder (affects how a person feels, thinks and acts), Shortness of Breath (not being able to breathe normally or deeply enough). Observation on 11/06/2024 at 8:43 AM, revealed the resident in his room, sitting in wheelchair watching television. There were no cups or water bottles in the resident's room. Resident is unable to communicate. Observations on 11/07/2024 at 10:15 AM, 10:53 AM, 11:10 AM, 2:24 PM and 3:40 PM revealed that Resident #18 was sitting in wheelchair in the lobby. There were no fluids observed near the resident, no cups with the resident's name, nor was staff observed offering fluids to the resident. Review of Resident #18's progress note 11/4/2024 at 10:00 PM revealed, When administering evening mediations writer noticed resident was lethargic and very pale. Resident was only alert to painful stimuli at this time. Vitals were 99/65, 110, 22 resp. 94% on RA, 97.4. Call placed to on call. Order given to start IV and administer bolus of NS. 22G to Right hand was established and IV fluids started. On-call also stated to order stat CBC, CMP, BNP. Family was notified and decided they would like resident sent to ER for evaluation. Resident returned to facility at 1:00 AM with DX of hypotension, bladder infection, dehydration with new order for Benzonatate 100 MG capsule by mouth three times a day as needed for cough. Vitals at return were 110/75, 90, 19, 99%RA, 98.0. Review of Resident #18's undated care plan reflected the following: Problem: The resident has a potential for fluid deficit. Goal: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Interventions: 1) Administer medications as ordered. Monitor/document for side effects and effectiveness. 2) Educate the resident/family/caregivers on importance of fluid intake. 3) Invite the resident to activities that promote additional fluid intake. Offer drinks during one-to-one visits. Ensure that all beverages offered comply with diet/fluid restrictions and consistency requirements. 4) Monitor and document intake and output as per facility policy. 5) Monitor/document/report PRN any signs or symptoms of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. 6) Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow-up as indicated. Record Review of Resident #18's physicians orders, progress notes, assessments, and miscellaneous documents in Point Click Care (electronic health record) revealed that fluid intake was not tracked prior to and after Resident #18's trip to the emergency roiagnom on [DATE]. Observations on 11/5/2024, 11/6/2024 and 11/7/2024 between 8:30 AM and 3:00 PM revealed that Resident #24 and Resident #18 did not have fluids readily available, nor were staff observed offering them fluids. Interview on 11/7/2024 at 10:18 AM with CNA-A, who stated hydration was being passed at that time and pointed down the hallway towards the cart. She could not identify signs and symptoms of dehydration. She was not able to provide example of how Resident #24 and Resident #18, who are both non-communicative, would demonstrate thirst or ask for fluids. Interview on 11/7/2024 at 3:49 PM with AD, who stated Hydration was on the activities calendar. She said she was informed by her predecessor that Hydration should have been on the calendar, although she disagreed. She stated she and her assistant take the hydration cart around to residents. She stated hydration was supposed to be offered to residents once on each shift 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM. Interview on 11/7/2024 at 3:49 PM with CNA-B, who stated she had witnessed hydration being passed out on the night shift. Interview on 11/7/2024 at 3:57 PM with CNA-C, who stated, We have a hydration cart. The residents had their own water bottles/cups in their rooms, and we tried to fill them up. She identified signs and symptoms of dehydration as mouth looks dry, skin looks flushed, they might have trouble communicating or they might have a facial expression. Interview on 11/7/2024 at 4:12 PM with the DON, who stated that the AD and CNA-B passed water and ice to the residents at 10:00 AM and 2:00 PM. She stated they, generally in-service monthly on Hydration. She checked the in-service book, and the last Hydration in-service was conducted on 9/23/2024. She stated her expectation was that non-communicative residents receive the same level of hydration as other residents. She identified signs, symptoms and consequences of dehydration include dry mouth, making mouth gestures or smacking their lips, lack of tear production, incontinence, and skin issues. She stated Resident #24 was also on a medication that has a noted side effect of dehydration. Review of the facility policy titled, Hydration - Clinical Protocol, MED-PASS, revision date September 2017, reflected the following: Assessment and Recognition: 1. The physician and staff will help define the individual's current hydration status (fluid and electrolyte balance or imbalances) a. The physician will distinguish various types of fluid and electrolyte imbalance (for example, hyponatremia, hypernatremia, pre-renal azotemia, etc.) from true dehydration (clinically significant loss of total body water). 2. The staff, with the physician's input, will identify and report to the physician individuals with signs and symptoms (for example, delirium, lethargy, increased thirst, etc.) or lab test results (for example, hypernatremia, azotemia, etc.) that might reflect existing fluid and electrolyte imbalance. 3. The physician and staff will identify significant risk for subsequent fluid and electrolyte imbalance; for example, individuals with prolonged vomiting, diarrhea, or fever, or who are taking diuretics and/or ACE inhibitors and who are not eating or drinking well. Cause Identification: 1. The physician will help identify the cause(s) of any existing fluid and electrolyte imbalance or help the staff document why the individual should not be tested or evaluated. a. A limited review for causes (for example, based on the clinical situation and a basic metabolic profile [BMP]) may be appropriate even if an extensive work-up is not. Treatment/Management: 1. The physician will manage significant fluid and electrolyte imbalance, and associated risks, appropriately and in a timely manner. a. Timeliness depends on the severity, nature, and causes of the fluid and electrolyte imbalance. b. For minor, uncomplicated fluid and electrolyte imbalance, oral rehydration may suffice. For more severe or complicated fluid and electrolyte imbalance, subcutaneous (hypodermoclysis) or intravenous hydration may be needed. c. Any medications that are contributing to fluid and electrolyte imbalance should be tapered or stopped (at least temporarily), or the physician should provide clinically valid documentation as to why they cannot or should not be changed, even temporarily. 2. The staff will provide supportive measures such as supplemental fluids and adjusting environmental temperature, where indicated. Monitoring and Follow-Up: 1. The physician and staff will monitor for the subsequent development, progression, or resolution of fluid and electrolyte imbalance in at-risk individuals. a. For example, replacement may be adequate if the resident is clinically stable, not having delirium, aiding at least every 3-4 hours, and the urine specific gravity (where attainable) is less than 1.015. 2. The physician will adjust treatments based on specific information (lab results, level of consciousness, etc.) relevant to that individual. a. Oral replacement may be adequate if the patient is clinically stable, not having delirium, voiding at least every 3-4 hours, and the urine specific gravity (where attainable) is less than 1.015. b. Repeating the basic metabolic profile and/or serum osmolality can help track progress in correcting abnormalities.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. The facility failed to ensure the green beans in the refrigerator were discarded after the handwritten discard date and that food temperatures were tested in a manner that prevented food contamination. This failure places the residents at risk for being served food past the expiration date and foodborne illness from eating contaminated food. Findings included: Observation on 11/5/2024 at 9:01AM revealed an opened, white, plastic container with a label that read, [NAME] Beans 10/29 - 11/1. Interview on 11/5/2024 at 9:03AM with the DM, who stated the green beans should have been discarded 4 days ago. She said her expectation was that all items should have been clearly labeled with an opened on and discard by date. She stated she had routinely trained and reminded staff regarding the importance of having foods properly labeled and discarded by the discard date. Interview on 11/7/2024 at 4:30PM with the ADM, who stated his expectation was that the kitchen staff should have followed the policy regarding proper labeling and storage. Observation on 11/5/2024 at 11:58AM revealed while testing the food temperatures, DC allowed the thermometer to lay on top of the chicken strips. Observation on 11/5/2024 at 12:02PM revealed while testing the food temperatures, DC allowed the thermometer to lay on top of the broccoli pieces. Observation on 11/5/2024 at 12:06PM revealed while testing the food temperatures, DC allowed the bottom of the thermometer to touch the gravy. Interview on 11/5/2024 at 12:06PM with DC, who stated the food thermometer should not have touched the food when testing food temperature. Interview on 11/6/2024 at 11:09PM with the DM, who stated her expectation was that the food thermometers should not have touched the food when the food temperatures were tested , as it could have contaminated the food. Interview on 11/6/2024 at 11:25PM with the RD, who stated his expectation was that the thermometers should not have touched the food as it could have contaminated the food. Interview on 11/7/2024 at 4:30pm with the ADM, who stated his expectation was that the kitchen staff should have tested the food temperature in a safe manner and avoided potential contamination of the food. Review of the facility policy titled Food Storage, revision date June 1, 2019, stated the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food stored according to the state, federal and US Food Codes and HACCP guidelines: 2. Refrigerators e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Review of the facility policy titled Taking Temperatures, revision date June 1, 2019, does not address how food temperatures should have been tested without contaminating the food. The policy only what temperatures were acceptable, when reheating was required and when food should have been discarded. .

Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 (Resident #20) of 5 residents reviewed for comprehensive care plans. Record Review of Resident #20's comprehensive care plan did not reflect that Resident #20 had a blister-like lesion to the mid portion of her bottom lip that was purplish-blue in color of unknown origin date per medical record review . The wound was approximately two centimeters in size. This deficient practice could place residents at risk for receiving improper care and services due to inaccurate care plans. Findings included: Observation of Resident #20 first occurred 11/05/2024 at 9:00 am upon entrance to the facility. She was sitting in the lobby. Resident #20 had a blister-like lesion to the mid portion of her bottom lip that was purplish-blue in color. The wound was approximately two centimeters in size. The second observation took place in the Dining Room at 12:30 PM on 11/06/2024 Resident #20 was observed being assisted to eat by the facility staff. The lesion did not appear to affect her nutritional or fluid intake. A record review of Resident #20's face sheet for admitted [DATE] reflected an [AGE] year-old female. Resident #20's diagnosis Unspecified Dementia (a general term for a decline in mental abilities that affects a person's daily life), Unspecified Severity, without Behavioral Disturbance, Mood Disturbance, and Anxiety. A record review of Resident #20's Initial MDS assessment, dated 08/31/2024, reflected the resident had a BIMS score of 0, which indicated severe cognitive impairment. Resident #20's Initial MDS reflected Resident #20's current diagnosis of Diabetes Mellitus (a chronic disease that occurs when the body cannot properly regulate blood sugar levels). Documentation of the lesion to the bottom lip was not recorded on the MDS. A record review of Resident #20's care plan, dated 10/04/2024, did not reflect or address Resident #20's lesion to the middle portion of the lower lip. A record review of Resident #20's Nursing Notes dated 10/24/2024 and 10/25/2024 reflected that Resident #20 was on an antibiotic for a bacterial infection of the lip lesion. Also, the medical record contain ed an Infection Control Surveillance Form dated 10/18/2024. There was documentation on the form of a skin/soft tissue infection that contained pus at wound, skin, or tissue site, redness at affected site, swelling at affected site, and tenderness or pain at affected site with no location documented. Review of skin assessments of last 3 months reveal no documentation of the lesion. There were no wound care records to review. During an interview with the Social Worker on 11/05/2024 at 3:20pm, who stated that the resident had had this lesion since admission, and it was caused by a protruding front tooth. According to the Social Worker, early in the Resident's stay, the resident's responsible party was not supportive of having the tooth removed. Later, he did give consent and the Social Worker planned with the dentist to have one of the front teeth removed; however, the dentist declined to remove the other front tooth because it was a healthy tooth. In another interview on 11/06/2024 at 9:20 am, the Social Worker stated the wound had gotten better and had gotten worse over time. She reported that it was a result of an assault the resident suffered at another facility prior to her admission to the facility She reported noting that the resident had been observed to nibble at the site from time to time. the Social Worker confirm ed that she had not entered any documentation in the medical record regarding her conversations with the dentist. During an interview with the DON on 11/06/2024 at 9:05 am, she reported the wound care team stated there was nothing to treat. She confirmed the lesion had been present since admission. Additionally, she stated the lesion had not hindered the resident's ability to take in nourishments and fluids and there were no non-verbal signs of pain at the sight unless direct pressure was exerted upon the lesion. An interview was conducted with the DON on 11/07/2024 at approximately 2:00pm. The DON reported she was shocked that the lesion did not appear on the Care Plan and that the IDT was responsible for making sure all Care Plans are accurate. She stated not having the lesion on the care plan would put the resident at risk for not receiving appropriate care and treatment. Interview at 2:00pm on 11/07/2024, the ADM stated he was not aware that the lesion was not addressed on the Care Plan. It was his expectation that it should be to ensure the resident received appropriate care. A record review of the facility's Care Plans, Comprehensive Person-Centered policy, dated revised March 2022, reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on Interview and Record Review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled (a system of recordkeeping that ensures an accurate inventory of medication by accounting for controlled medications that have been received, dispensed, administered, and/or, including the process of disposition ). The documentation was incomplete on the controlled medications (narcotics) count logs for one of four medication carts reviewed. The facility failed to ensure all controlled medications (narcotics) were accurately reconciled at the start and end of each shift on 11/01/2024. This failure could place residents at risk of misappropriation by drug diversion and could result in diminished health and well-being. The findings included: A Record Review On 11/06/2024 at 2:20pm, of the facility change of shift narcotic counts revealed missing documentation for 11/1/2024 for the 6am-2pm shift, the 2pm-10pm shift, and the 10pm-6am shifts. The missing documentation was observed on the Med Cart labeled Hall B/C Medication cart. During an Interview with LVN D on 11/05/2024 at approximately 8:30am, she affirmed that controlled medications (narcotics) were to be counted at every shift change. During an Interview with MDS Nurse on 11/07/2024 at 2:36pm who stated she did assist with giving medications at times. MDS Nurse confirm ed there was to be a narcotic count at the change of each shift. When asked how she knew she was to count narcotics with the off-going and on-coming nurse at shift change, she replied, it's a given. During an interview with the DON and the Corporate Nurse on 11/07/2024, they affirmed that there was no policy that specifically require d and define d the parameters for change of shift narcotic count. There was also no printed material regarding the change of shift count in new employee orientation; however, they did share the Drug Discrepancies, Loss, or Diversion document from the contracted Pharmacy provider. The document stated: The facility will comply with all federal, state, and local laws as it pertains to dangerous drugs and controlled substances. The facility must have a system that records receipt, usage, and disposition of all controlled substances in sufficient detail that permits an accurate reconciliation.

Based on observation, interviews and record review the facility failed to ensure residents had the right to be free from abuse for 10 (Resident's # 1-10) of 16 residents on the memory care unit. The facility failed to ensure a safe environment free from verbal abuse for residents on the memory care unit when LVN C was yelling at Residents # 1-10 in the common room on 2/28/2024. This failure could affect all residents in the memory care unit by placing them at risk for physical, mental, and emotional decline, psychosocial harm, and can lead to isolation and withdrawal from activities of enjoyment. This was determined to be a Past Noncompliance (2/28/2024-2/29/2024) due to the facility having to implemented actions that corrected the noncompliance prior to the investigation. Findings included: Review of Resident #1's electronic admission record, undated, revealed they were a [AGE] year-old female admitted [DATE]. Resident #2' electronic admission record, undated, revealed they were a [AGE] year-old female admitted [DATE]. Resident # 3's electronic admission record, undated, revealed they were a [AGE] year-old male admitted [DATE]. Resident #4's electronic admission record, undated, revealed they were a [AGE] year-old female admitted [DATE]. Resident #5's electronic admission record, undated, revealed they were a [AGE] year-old female admitted [DATE]. Resident # 6's electronic admission record, undated, revealed they were a [AGE] year-old female admitted [DATE]. Resident # 7's electronic admission record, undated, revealed they were a [AGE] year-old male admitted [DATE]. Resident # 8's electronic admission record, undated, revealed they were a [AGE] year-old female admitted [DATE]. Resident # 9's electronic admission record, undated, revealed they were a [AGE] year-old female admitted [DATE]. Resident # 10's electronic admission record, undated, revealed they were a [AGE] year-old female admitted [DATE]. Observation on 3/6/2024 at 11:55 am of lunch on the memory care unit, residents clean, dry, and appropriately dressed, no odor or clutter noted. Staff interacting with residents and assisting with meal set-up. Two residents being assisted to eat. All residents appear calm and staff member is calm and appropriately redirects behaviors. Interview with DON on 3/6/2024 at 1:00 pm she stated that LVN B reported to her and the administrator the events of 2/28/2024 during her shift on 2/29/24, an investigation was started, and the ADM contacted LVN C and placed her on administrative leave. The residents on the memory care unit had a safe assessment and none reported memory of the event. Facility wide Abuse and neglect in service was completed by all staff on duty and Inservice was available at change of shift for staff review and acknowledgement prior to reporting for duty. She stated that usually on days the staff on the Memory care unit was an LVN and a CNA. She stated that her expectations are that residents are treated with respect and verbal abuse was not acceptable. She stated that verbal abuse could be harmful to the resident for decline and withdrawal and fear. Interview with LVN C on 3/6/2024 3:15 pm attempted by phone, no answer, message left with request for return call, as of exit on 3/6/2024 at 5:00 pm no call back received. Interview with LVN B on 3/6/24 3:30 pm by phone, stated that LVN C was yelling in the common room on the secured unit, she was not yelling at one resident but in general stating for them to leave her alone and go away. She stated that this agitated the residents. Interview with CNA A on 3/6/24 3:45 pm by phone, she stated that LVN C was agitated and yelling at the residents all day on 2/28/2024. She stated this was not the first time she raised her voice at the residents in the memory care unit. When asked why she did not report this, she stated that she was usually back there with only LVN C and she was afraid of retaliation. Interview with ADM on 3/6/24 at 4:00 pm He stated when he called LVN C to inquire about the events of 2/28/24 she replied okay and made no other comment, when he stated she would be placed on administrative lead pending an investigation her reply was okay, thank you and she ended the phone call. He stated that after interviewing both LVN B and CNA A, and the observations he had made of LVN C since she has been working here, that the incident actually happened. He stated his plan was to terminate LVN C. Abuse of any kind was not tolerated. He stated his expectation was that all employees follow policy and procedure and ask in a professional manner. Record review 3/6/24 at 1: 30 pm Policy Abuse, neglect, exploitation and misappropriation prevention program revised April 2021 revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, and physical abuse ., further is revealed protect residents from abuse, neglect exploitation or misappropriation of resources by anyone including a. Facility, staff. Record Review 3/6/2024 at 1:45 pm of LVN C employee record revealed documentation of phone call on 2/29/2024 placing on administrative leave pending outcome of investigation. Record review 3/6/2024 at 1:50 pm of Written witness statement of LVN B, revealed that LVN C was yelling at the residents in the common room on 2/28/2024, no a particular resident just in general and that the resident were agitated the rest of the day. Record Review 3/6/2024 at 1:50pm of written witness statement of CNA A revealed that LVN C was yelling at the residents in the common room This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 2/28/2024 and ended on 2/29/24. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance: 1. 2/29/24 Administrator immediately notified LVN C, that she was on administrative leave. 2. 2/29/24 DON has been in-serviced on abuse and neglect by the ADM. 3. 2/29/24 The Facility self-reported the incident to Health and Human Services 4. 2/29/24 The facility notified the families of the residents. 5. 02/29/24 The facility notified the facility's medical director. 6. 2/29/24 The facility in-serviced staff on Preventing Abuse, reporting and Abuse Coordinator. Verification of facility steps by Surveyor 1. Interviews were conducted with staff across multiple shifts on 3/6/24 from 10:54 AM through 4:00PM, including Maintenance Director, Culinary Director, Lead Housekeeper revealed they had all been in-serviced by the Facility of staff. Staff stated they were educated on abuse, neglect, and exploitation, who to report abuse to, types of abuse, residents' rights and where to find the resident rights posted in the facility. 2. Interviews were conducted with staff across all shifts on 03/0624 from 10:22 PM including 2 CNAs, 2 LVN revealed they had all been in-serviced by the facility staff. Staff stated they were educated on abuse, neglect, and exploitation, who to report abuse to, types of abuse, residents' rights and where to find the resident rights posted in the facility. 10. Per interview on 3/6/24 at 4:00 pm with ADM, plans to terminate LVN C.

Based on observation, record review, and interview, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one of four residents (Resident #39) reviewed for pain management. The facility failed to ensure Resident #39 was assessed, monitored, and received pain medication prior to wound care provided for a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) his right lateral heel. This failure could place residents at risk for unnecessary pain and discomfort. Findings included: Review of Resident #39's Face Sheet dated 09/13/2023 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This was a gradually progressive condition.), Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache) and Hemiplegia and Hemiparesis following a Cerebral infarction (Hemiparesis is weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing. Cerebral infarction is the pathologic process that results in an area of necrotic tissue in the brain (cerebral infarct). It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia), most commonly due to thromboembolism, and manifests clinically as ischemic stroke. In response to ischemia, the brain degenerates by the process of liquefactive necrosis.) Review of Resident #39's annual MDS dated [DATE] reflected Resident #39 was assessed to have a BIMS score of one indicating severe cognitive impairment. Resident #39 was assessed to require extensive to dependent assist with ADLs. Resident #39 was assessed to have a Stage III pressure ulcer. Resident #39 was further assessed to have pressure ulcer/ injury/ care, applications of nonsurgical dressings and applications of dressings to feet. Resident #39 was assessed to not have pain and assessed to not have opioid therapy. Review of Resident #39's Comprehensive Care Plan reflected a problem dated 12/20/2023 and revised on 08/28/2023 The resident has potential for pressure ulcers development related to impaired mobility and incontinence. Interventions included administer treatments as ordered and monitor effectiveness .follow facility policies/ protocols for the preventions/ treatment of skin breakdown; Heel protectors at all times; Treat pain as per orders prior to treatment; turning etc. to ensure the resident's comfort . Further review of Resident #39's care plan reflected a problem dated 07/18/2023 The resident has pressure ulcer Stage III to right outer heel from callous. Resident #39 care plan also reflected a problem dated 02/27/2023 Resident is on services of hospice due to terminal illness. Review of Resident #39's Weekly Wound Progress note dated 09/12/2023 reflected Resident #39 had one pressure ulcer wound and was not on a pain management program. Resident #39's pressure ulcer was assessed to be a stage 3. Review of Resident #39's Consolidated Physician's orders reflected an order with the start date of 09/13/2023 for Acetaminophen tablet 325 mg give two by mouth every 6 hours as needed for fever/ pain. Review of Resident #39's MAR reflected an entry for Acetaminophen 325 mg two tabs with a start date of 09/13/2023. Further review of Resident #39's MAR reflected the medication was only documented administered once at 9:30 AM on 09/13/2023. Observation and interview on 09/12/2023 at 10:00 AM revealed Resident #39 in his room in bed. Resident #39 was observed to have his right heel in a heel protector with his left heel out of his heel protector. His heels were not floated (using a pillow to suspend the heels to alleviate pressure). Resident #39 did not respond to questions. Observation and interview on 09/13/2023 at 9:42 AM, revealed LVN A prepared wound care supplies for Resident #39's pressure ulcer treatment. LVN A stated the hospice aide just gave Resident #39 his bath and the dressing came off and Resident #39 was bleeding. LVN A gathered supplies and entered room. LVN started by spraying wound cleanser on Resident #39's open stage III pressure ulcer on his right heel. LVN A then using 4x4 gauze started cleaning the pressure ulcer and Resident #39 was moaning and pulling his leg away from LVN A. LVN A then applied the calcium alginate dressing and applied it to Resident #39's right heel. Resident #39 moaned and yelled out that hurts. LVN A then asked Resident #39 if he was hurting and he stated yes. LVN A told Resident #39 she was almost done and then she would get him some more Tylenol. LVN A continued with the application of the kerlix wrap around Resident #39's foot. Resident #39 continued to moan as she applied the kerlix wrap. In an interview on 09/13/2023 at 10:40 AM Resident #39 was asked how to describe his pain during his wound care. Resident #39 stated it was pretty bad. When asked on a scale from 1 to 10 (very little to the worse he has ever felt) how bad was it and he stated 7. In an interview on 09/13/2023 at 11:10 AM, LVN A stated Resident #39 had winced during wound care and yes he was in pain. LVN A stated she did not think the Tylenol she gave him at 9:30 AM was effective at all for this pain because it needed more time to take effect. LVN A stated she felt like Resident #39 was in pain during his treatment, but his pain is a constant thing. When asked if Resident #39 had a stronger pain medication to be used during his treatments, LVN A stated she was not sure if he had a stronger pain medication. In an interview on 09/13/2023 at 1:51 PM CNA D stated Resident #39 did complain of pain when he had any pressure applied to his heel or when he got his treatment. She stated she would report his complaints to the nurses. When asked if the nurses would medicate him, she stated she recalled hearing them say Tylenol, but she was not sure if he was medicated. In an interview on 09/13/2023 at 02:00 PM, the DON stated prior to wound care Resident #39 should have been pre-medicated, or the nurse should have stopped the procedure and called the Doctor to get him something stronger for pain. She stated the nurse should be observant for signs of pain. She stated not pre-medicating for pain could cause the resident an increased pain level, emotional distress, and an increased stress level. In an interview on 09/13/2023 at 2:31 PM LVN A stated today was the first time Resident #39 had pain medication ordered PRN for pain. She stated he had not reported pain but did complain of pain when his wound was touched. LVN A stated she should have stopped the treatment when he stated he was in pain. She stated it was facility policy to stop and that was how she was trained. When asked what the consequences of her not following the policy was, she stated that the resident would have endure pain during treatment. LVN A stated she called the physician at 11:15 AM and received an order for Tramadol HCL 50mg to be administered one hour prior to wound care. In an interview on 09/13/2023 at 2:00 PM the DON stated she expected nurses to follow doctor orders when doing treatments and if a resident was showing signs of pain during treatment for the staff to stop the treatment and get them something for pain. The DON further stated she expected nurses to assess if what was administered for pain was effective. Review of the facility's policy Pressure Ulcers/Skin Breakdown- Clinical Protocol dated 04/2018 reflected The nursing team member and practitioner will assess and document an individual's significant risk fac-tors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following: a) Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. b.) Pain assessment .The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure the [NAME] (one cook) wore a beard net during food service. 2. The facility failed to properly label food in two of four open front refrigerators located in the kitchen and one of one vegetable freezers located in the dry storage room. Findings included: 1. Observation on [DATE] at 8:45 AM revealed the cook was standing in the kitchen between the dietary manager office and the steam table. He did not have on a beard guard. Observed from the kitchen door approximately 10 - 15 feet from the [NAME] there was not a beard guard over approximately two-four inches of hair growth on the cook's face of the hair growth on the cook's face. The cook had hair growth from his left ear , on chin, slightly under the chin to the right ear. Observation on [DATE] at 12:06 PM revealed the [NAME] was standing at the steam table placing food on plates for resident's lunch meal. The cook did not have a beard guard on his face and was wearing a N95 mask. His hair growth was not completed covered. There was approximately four inches from both of his ears to part of his mouth of hair exposed. The cook was serving food without wearing a bear guard. 2. Observation of the kitchen on [DATE] between 8:45 AM-9:30 AM revealed two leftover boiled eggs not in the original package not labeled or dated. The leftover eggs were in a clear plastic bag. Observation of the kitchen on [DATE] between 8:45 AM - 9:30 AM revealed deli slice ham was stored in the open front refrigerator in the dietary manager office. The deli slice ham was not in the original package the clear package was opened and was not labeled or dated. Observation of the kitchen on [DATE] between 8:45 AM- 9:30 AM revealed a package of Italian green bean was stored in the open front vegetable freezer in the dry storage room. The Italian green beans were not in the original package and was not labeled or dated. The Italian green beans had approximately one inch of ice on the beans. In an interview on [DATE] at 7:50 AM the Administrator stated he expected all food to be labeled and dated including leftover food. He stated if any food was not in the original package the food was expected to be sealed. He also stated a resident had potential to become physically ill with bacterial infection if a resident ate spoiled boiled eggs. He stated he would never have a leftover boiled egg in the refrigerator. The Administrator stated he would expect the boiled eggs not used to be discarded and not kept in refrigerator to be used later. He also stated all males enter the kitchen with hair growth on their face was expected to wear a beard guard. He stated it did not matter how long the hair was on the face it was expected to be properly covered with beard guard. He stated there was a possibility any hair not covered may fall onto food especially if the cook was preparing food and serving food without wearing a beard guard. He stated a resident had a possibility of becoming physically ill with some type of stomach issues from bacteria from the hair. He stated it was the dietary managers responsibility to monitor the kitchen. In an interview on [DATE] at 09:58 AM the [NAME] stated he did have hair Growth on his face on [DATE]. He stated he did not wear a beard guard all day on [DATE]. He stated if he had any hair on his face it was expected to wear a beard guard. He stated he had been in serviced on wearing beard guard when he does not shave prior to coming to work. He stated he did have on a N95 mask when he was serving lunch, however, the N95 mask did not replace the beard guard. He stated the N95 did not cover both sides of his face where hair was exposed. He also stated if a resident swallowed hair and the hair had germs on it there was a possibility a resident could become sick. He stated a resident may have stomach issues such as vomiting and diarrhea and may need to see a doctor. He stated all left-over food was expected to be labeled and dated. If the boiled eggs or ham was over 3 months old and was served to the residents there was a possibility a resident may develop food poisoning and other illnesses from expired food. In an interview on [DATE] at 11:00 AM the Dietary Manager stated all foods were expected to be labeled and dated. She stated if any food was left over and did not have a date when the food was placed in the refrigerator especially boiled eggs there was a potential if served to a resident as a snack or for meal the resident had potential of becoming very ill with food poisoning or any type of digestive issues. She stated there was a possibility a resident may need to be hospitalized according to the extent of the illness if the food was spoiled. She also stated any food in the freezer was expected to be labeled and dated. The Dietary Manager stated if any food had ice covering the food it was to be discarded in the garbage. She stated if the frozen food were cooked there was a potential the food would not have any flavor due to being covered with ice. She also stated if a male staff has any facial hair on his face, he was to wear a beard guard. She also stated if hair fell on the food and a resident ingested the hair there was a possibility a resident would become ill such as vomiting , diarrhea, and any type of stomach issues. She stated hair is considered cross contamination. She also stated there was a possibility a resident may need to be hospitalized . She stated she had in serviced staff on label, dating food, and wearing a beard guard. The Dietary Manager also stated it was her responsibility to monitor the dietary staff. Record Review of Kitchen Orientation- Personal Hygiene and Health Reporting signed by the [NAME] and dated on [DATE] reflected beards and mustaches should be closely cropped and neatly trimmed. When around exposed foods must be restrained using beard guards. Record Review of the Facilities Policy of Food Storage dated 2018 reflected , To ensure that all food served by the facility is of excellent quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes. Date , label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.

Based on observation, record review, and interview the facility failed to ensure a PASRR screening was completed for residents with a mental disorder or an intellectual disability for one of three residents (Resident #26) reviewed for PASRR [NAME] I (PASRR 1) screenings The facility failed to ensure an accurate PASRR Level I screening (a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) was completed for Resident #26. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services accordance with individually assessed needs. Findings included: Record review of Resident #26's face sheet, dated 09/13/2023, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bipolar disorder, unspecified ( mental health condition that causes shifts in mood), and anxiety disorder ( a type of mental health condition, a person may respond to certain things and situations with fear or dread. Heart can beat fast and experience sweating). Record review of Resident #26's Quarterly MDS assessment, dated 07/04/2023, reflected Resident# 26 had a BIMS score of 15 which indicated residents' cognition was intact. Resident #26 had mood symptom presence during the assessment period such as: 1. Little interest or pleasure of doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about herself 7. Trouble concentrating on things such as reading or watching television Resident #26 was assessed of not rejecting care. She had a diagnosis of anxiety disorder (a type of mental health condition, a person may respond to certain things and situations with fear or dread. Heart can beat fast and experience sweating), and bipolar disorder (mental health condition that causes shifts in mood). Record review of Resident #26's Comprehensive Care plan, dated 07/25/2023, reflected Resident had been assessed for actual trauma symptoms as manifested by: upsetting thoughts or memories against their will; upsetting dreams, bodily reactions such as : fast heartbeat/stomach churning; difficulty falling asleep or staying asleep; irritability anger or depression or staying asleep; difficulty concentrating. Being jumpy or started at something unexpected; inability to cope with normal stresses of daily living; inability to trust; cognitive difficulties. Interventions: Psych Eval as ordered/ PRN. Psychotherapy referral to encourage verbalization of feelings and coping strategies. Encourage resident to verbalize feelings and specific triggers that may manifest symptoms. Resident had anxiety disorder and depression. Record review of Resident #26's PASRR Level 1 Screening, dated 01/05/2023, reflected, Is there evidence of an indicator this is an individual had a Mental Illness? Response was no. Is there evidence or an indicator this was an individual that had an intellectual disability? Response was No. the form was filled out the date of admission (01/05/2023) by hospice medical social worker. Record review of Resident #26's Mental Illness/ Dementia Resident Review, dated 04/26/2023, reflected Completed this form only for nursing home facility residents with a current Negative PASRR Level 1 Screening for Mental Illness to determine whether to submit a new positive PASRR Level 1 screening from on the Long-Term Care Portal because further evaluation was needed. Resident #26 did not have diagnosis of dementia. PASRR Level 1 Date of Assessment was 01/05/2023. Resident #26 did not have a new positive PASRR Level 1 completed on 04/26/2023 to indicate she had a mental illness. The form was completed by MDS Coordinator. In an interview and observation on 09/12/2023 at 4:08 PM Resident #26 was in her room lying in bed watching television. She stated she had seen psychiatrist few times, but it was not the same services she was receiving at home. She stated she had more extensive therapy from services which the state had set up. She stated she did not recall the name of all the services, but she understood the facility would process papers for her to continue the services at the facility. Resident #26 stated these services did benefit her at home and she stated she did not benefit from the psychologist visits at the facility. She stated she did refuse the psychologist visits. Resident #26 also stated she was receiving better psychiatric services at home. Resident #26 stated she did speak with nurse and the social worker about the more intense psychiatric visits she received at home. She stated she did not recall the nurses name but there was only one social worker. In an interview on 09/14/2023 at 07:39 AM, the Director of Nurses stated every resident admitted to the facility required a PASRR Level 1. She stated if the PASRR was completed by another agency day of admission, the social worker and the MDS Coordinator was expected to review the PASRR the day a resident was admitted to ensure it was correct. She stated if a resident was admitted with a mental illness such as Bipolar and Anxiety disorder, the PASRR should indicate the resident had a mental illness. If the PASRR was incorrect the MDS Coordinator or the Social Worker was expected to complete a new PASRR on the day the resident was admitted . She stated if the MDS Coordinator and the MDS Corporate Consultant reviewed the PASRR in April 2023. The Director of Nurses also stated the MDS Coordinator and The MDS Corporate Consultant did not take the necessary measures to make the corrections on the PASRR 1 (a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability). She stated Resident #26 had a possibility of receiving various types of programs to enhance her mood and decrease her anxiety that the facility psychologist may not provide to the residents. The Director of Nurses stated Psychologist was seeing Resident #26 sometimes. She stated any resident assessed after the facility submits PASRR positive, may receive specialized services according to the resident's needs. She stated there was a possibility Resident #26 could have benefited in receiving specialized services since her admission on 01/05/2023. She stated it was the Social Worker and the MDS Coordinator's responsibility to monitor to ensure the PASRR were correct. In an interview on 09/14/2023 at 7:50 AM, the Administrator stated if Resident #26 was admitted with a diagnosis of bipolar and anxiety disorders, the PASRR 1 should have been marked yes reflecting the mental illness diagnosis. He stated the Social Worker and the MDS Coordinator Nurse was expected to review the new admissions PASRRs. He stated if the PASRR 1 was incorrect he expected a new PASRR 1 be completed with the correct information and submitted to the appropriate agency. The Administrator also stated Resident #26 would not receive the necessary services she may need to enhance her quality of life. If the MDS Coordinator and the MDS Corporate Consultant reviewed Resident #26 PASRR on 04/2023, residents' diagnosis was required to be assessed correctly and a new PASRR 1 be completed in 04/2023 and submitted a new PASRR with correct information. He also stated there needed to be a new monitoring system to ensure the PASRR's were completed correctly. The Administrator also stated the PASRR 1 was the Social Workers and MDS Coordinator responsibility to ensure all PASRRs for new admits are correct when the resident was admitted to the facility. In an interview on 09/14/2023 at 8:30 AM, MDS Coordinator stated when a resident was admitted to the facility it was the Social Workers and her responsibility to ensure the PASRRs were correct. She stated Resident #26's PASSR was not coded correctly by the hospice staff on 01/05/2023. She also stated 01/05/2023 was the date Resident #26 was admitted to the facility . MDS Coordinator also stated Resident #26 had a diagnosis of Bipolar and Anxiety Disorders on her admission records. She stated the incorrect PASRR was missed by the Social Worker and by herself on Resident #26 admission. She also stated there was a review of residents with a negative PASRR on 04/26/2023 by her and the MDS Corporate Consultant. She stated according to the Mental Illness/ Dementia resident Review Assessment it was determined Resident #26 did not have dementia (the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). She also stated we complete reviews of PASRRs to ensure they are correct. Resident #26's PASRR was missed during the review upon admission and on 04/26/2023. She stated a new PASRR 1 (a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) was required to reflect Resident #26 had a mental illness. MDS Coordinator stated Resident #26 had a potential of not receiving the services she needed to enhance her Quality of Life. She stated Resident #26 did receive psych services, but she refused at times. She stated Resident #26 had a potential of receiving services if her PASRR 1 was completed correctly and submitted for services. She stated if Resident #26 were receiving services at home there was a possibility Resident #26 would have benefited to continue these services at the facility. The MDS Coordinator stated Resident #26 may prefer certain type of psychiatric services. She stated there needed to be a better monitoring system between her and the Social Worker to ensure the PASRR were correct upon residents' admission to the facility. In an interview on 09/14/23, 09:32 AM, the Social Worker stated when the residents were admitted to the facility if the PASRR was completed by another agency she reviewed the PASRR to ensure the PASRR was coded correctly. She stated she assumed Resident #26's was correct and did not review Resident #26's PASRR. The Social Worker stated when a resident was admitted to the facility the protocol was the MDS Coordinator and herself was expected to review the PASRR 1 and the diagnosis record to ensure the PASRR 1 was correct. She also stated she did not know Resident #26 had a mental diagnosis until few weeks after Resident #26 was admitted to the facility. The Social Worker stated she forgot to focus on Resident #26's mental illness and did not contact the PASRR Representative. What is potential negative outcome whatever potential any benefits that could help her mental services she would not get them. She also stated Resident #26 was receiving specialized services when she was living at home prior to being admitted to the facility. She stated she preferred the psychiatric services she received at home that the one at the facility. She also stated she did not ask Resident #26 if she wanted to continue the services she was receiving at home when she was admitted to the facility. The Social Worker stated Resident #26 had a potential to have a decline in her quality of life, increase her anxiety and may affect her mood if she was not receiving the specialized services she needed at the facility. She stated in her opinion she believed Resident #26 would have benefited from specialized services if the PASRR 1 had been completed correctly. She also stated she felt the system the facility had in place to ensure PASRRs was completed accurately needed to be changed to a different system. She stated this was something a committee needed to discuss and change the current monitoring system. She also stated she had spoken with Resident #26 about her specialized treatment she received at home, however, did not recall the entire conversation or the exact specialized treatment Resident #26 received at home. In an interview on 09/14/2023 at 11:53 AM, attempted to call the MDS Corporate Consultant and left voice message with the agency, surveyors name, and the surveyors phone number. The MDS Corporate Consultant did not return call prior to this surveyors exit. Record review of the facilities Pre-Admission Screening and Resident Review (PASRR) dated, 05/10/2021, reflected It is the intent of this company to meet and abide by all State and Federal regulations that pertain to resident Preadmission and Screening Resident Review (PASRR) Rules. The intent of this guideline is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions, and to ensure they are properly placed, whether in community or in a Nursing Facility and to ensure they receive the services they require for their MI, or ID/DD.

Based on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for one of eight residents (Resident # 27) reviewed for quality of life. The facility failed to ensure Resident #27 fingernails were trimmed and cleaned. These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life. Findings included: Record review of Resident #27's face sheet, dated 08/17/2023, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included needs assistance with personal care ( the support and supervision of daily personal living tasks and private hygiene), unspecified lack of coordination (uncoordinated movement due to a muscle control problem that causes and inability to coordinate movement), and type 2 diabetes mellitus with hyperglycemia (occurs when a person's blood sugar elevates to potentially dangerous levels that require medical treatment). Record review of Resident #27's Quarterly MDS assessment, dated 07/28/2023, reflected Resident # 27 had a BIMS score of 9 which indicated residents' cognition was moderately impaired. Resident #27 was assessed to require assistance with ADLs. She required extensive assistance with one person assist with personal hygiene. Resident #27 did not reject care. Record review of Resident #27's Comprehensive Care Plan, 08/23/2023 was the completion date, reflected Resident #27 had a behavior of picking at her face. Intervention: notify physician of any signs or symptoms of infection. She had an ADL self-care performance deficit. Intervention: Resident #27 required staff assistance with personal hygiene. Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Observation on 09/12/2023 at 10:21 AM, revealed Resident #27 was sitting in her wheelchair near her bed. Resident #27 was scratching the right side of her face near her eyebrow during the visit. The scratched area on her face began to bleed. Her right middle fingernail on her right hand was jagged and had a blackish/ brownish substance underneath the nail. She also had blood on the tip of the middle finger and the ring finger on her right hand. Resident #27's ring finger on her right hand also had blackish/ brownish substance underneath the nail. She was using both fingers to scratch her face when the area began to bleed. In an interview on 09/12/2023 at 10:25 AM, Resident #27 stated her face was itching and she began to scratch her face and did not know it would bleed. She stated my fingernail was a little sharp. She also stated there was bowel stuff underneath her nails. She stated she did scratch her bottom and a little black stuff from her bowels was on her fingers. Resident #27 stated she did not remember when this happened. She stated she thought it was two days ago. Resident #27 stated she did ask someone to look at her nails, however, she did not recall the person's name or the date. Resident #27 stated sometimes she prefers her nails long, but she did not prefer when they would break off and become rough around the edges. In an interview on 09/14/2023 at 7:39 AM, The Director of Nurses stated if a resident had dirty nails there was a possibility bacteria could be on their fingers and/or underneath the resident's nails. She stated there was a potential a resident could ingest bacteria from their fingernails into their mouth. She stated it depended on the type of bacteria of what type an illness a resident could receive from the bacteria. The Director of Nurses stated Resident #27 did pick at her skin. She stated Resident #27 was a diabetic and her nails were long. She stated Resident #27 preferred long nails and the care plan team documented Resident #27's preference in her care plan record located in the electronic medical records. The Director of Nurses stated if Resident #27 did scratch her face and the area on her face began to bleed there was a possibility it may become infected. She stated it was the nurse's responsibility to monitor staff to ensure residents were receiving proper nail care. Record Review on 09/14/2023 at 7:43 AM, Reviewed Resident #27's current care plan completed on 08/23/2023 reflected Resident #27 preferred long fingernails was not documented in her care plan located in the electronic medical records. In an interview on 09/14/2023 at 7:50 AM the Administrator stated the residents' nail care was the CNAs responsibility. He stated if a resident was a diabetic it was the nurse's responsibility. The Administrator stated nail care was expected to be taken care of when nails were visibly dirty or needed to be trimmed. He stated if the blackish substance was a certain type of bacterial a resident may become physically ill. He stated there was a possibility a resident may require medical care from the hospital and that depended on what type of bacteria a resident may ingest. The Administrator stated if a resident's nails was rough around the edges or was broken and had a sharp edge, he expected the nail to be filed. He stated if the nail was not filed a resident may scratch themselves and cause open area on their skin. The Administrator also stated the open area on the skin had a potential of becoming infected. He stated if Resident #27 preferred her nails to be long he would expect it to be care planned. He stated it was the nurse's responsibility to monitor residents nail care. In an interview on 9/14/2023 at 8:25 AM, LVN A stated it was the nurses and CNAs responsibility to trim, cut and clean residents' fingernails. She stated only the nurses can trim and clean residents with diagnosis of diabetes. LVN A stated if there was a blackish substance underneath a resident's nails there was a possibility the substance was feces. She stated if a resident placed their finger in their mouth the feces could transfer from their fingers to their mouth. LVN A also stated if the resident swallowed the feces or other bacteria a resident may develop a stomach infection such and the resident would require to be hospitalized . She stated the symptoms of a stomach infection may include the following: diarrhea, vomiting and/or loss of appetite. LVN A stated if a resident's nail was not smooth and the resident scratched themselves and the area was bleeding, there was a possibility a resident may develop an infection. She stated if a resident preferred long nails and did not want them to be trimmed or cut the residents preferences was expected to be care planned. She stated it would not be on CNAs Kardex (electronic medical records where all the residents care was documented for the CNAs to review to know what type of care each resident required) or any other type of documentation if it was not care planned. She stated Resident #27's nails were thin at times and would break off and the nails would be uneven. She stated it was the nurse's responsibility to monitor nail care. LVN A also stated anyone can report to the nurse if a resident with a diagnosis of diabetes needed nail care. In an interview on 9/14/2023 at 8:35 AM, CNA C stated the CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually trimmed, and cleaned nails during showers, however, the nails can be cleaned or trimmed by nurses or CNAs as needed. CNA C stated the nursing staff was expected to clean and trim residents' nails immediately if there were blackish substance underneath the residents' nails and/ or if their nails needed to be trimmed. She stated if a resident scratched their face from a broken nail or a rough nail, there was a possibility the resident may develop an infection from the skin tear. CNA C said the blackish substance possibly may be fecal matter underneath the residents' nails. She stated a resident may become physically ill with an intestinal problem and may need to be admitted to the hospital if the resident swallowed the fecal matter. She stated she had given care to Resident #27, and she did not refuse nail care or any type of care. She stated the nurse was responsible for Resident #27's nail care due to resident being a diabetic. CNA C also stated Resident #27 would pick at her fingernails when the polish was coming off and her fingernails would break very easily. She stated she was in serviced on nail care, however, did not recall the last time she received in-service. In an interview on 9/14/2023 at 8:54 AM, CNA B stated the nurses were responsible for diabetic nail care. She stated the CNAs were responsible for all other resident's nail care such as cleaning, trimming and possibly filing the nails. She stated nail care was usually completed during showers or as needed. She stated nail care was to be completed daily if a resident's nails were dirty or needed to be trimmed. She also stated if a resident had a blackish/brownish substance underneath their nails it could be any type of bacteria. CNA B stated there was a possibility a resident may eat with their hands and the blackish substance may transfer from residents' hands to the food. She also stated the resident may become physically ill with stomach problems such a vomiting or diarrhea. She stated it was a possibility a resident may need to be assessed at a hospital if it was severe. CNA B stated if a residents' nails were rough and scratched their face the open area may become infected. She also stated a resident had potential of receive a tear on their eyeball if they scratched their eyes. She stated there was a potential a resident may develop and infection in their eyes. She stated she had been in serviced to clean and trim residents' nails in the shower and/or as needed except for diabetic nails. She stated she did not recall when the last in-service on nail care was given by nurse supervisors. CNA B stated no one had informed her and she had not witnessed Resident # 27 refused nail care. She also stated she had given care to Resident #27, and she would pick at her fingernails when the fingernail polish was coming off her nails. She stated sometimes her nails would break off and they would be rough around the edges. Record Review of the Facilities Policy on Activities of Daily Living dated 03/2018 reflected, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of four (Resident #39) residents reviewed for pressure ulcers. -The facility failed to ensure Resident #39 received his physician ordered treatment to his right heel pressure ulcer. -The facility failed to ensure Resident #39 received his physician ordered pressure ulcer preventative measures routinely. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections. Findings included: Review of Resident #39's Face Sheet dated 09/13/2023 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache) and Hemiplegia and Hemiparesis following a Cerebral infarction (Hemiparesis is weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing. Cerebral infarction is the pathologic process that results in an area of necrotic tissue in the brain (cerebral infarct). It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia), most commonly due to thromboembolism, and manifests clinically as ischemic stroke. In response to ischemia, the brain degenerates by the process of liquefactive necrosis.) Review of Resident #39's annual MDS dated [DATE] reflected Resident #39 was assessed to have a BIMS score of one indicating severe cognitive impairment. Resident #39 was assessed to require extensive to dependent assist with ADLs. Resident #39 was assessed to have a Stage III pressure ulcer. Resident #39 was further assessed to have pressure ulcer/ injury/ care, applications of nonsurgical dressings and applications of dressings to feet. Review of Resident #39's Comprehensive Care Plan reflected a problem dated 12/20/2023 and revised on 08/28/2023 The resident has potential for pressure ulcers development related to impaired mobility and incontinence. Interventions included administer treatments as ordered and monitor effectiveness .follow facility policies/ protocols for the preventions/ treatment of skin breakdown; Heel protectors at all times . Further review of Resident #39's care plan reflected a problem dated 07/18/2023 The resident has pressure ulcer Stage III to right outer heel from callous. Resident #39 care plan also reflected a problem dated 02/27/2023 Resident is on services of hospice due to terminal illness. Review of Resident #39's Consolidated Physician's orders dated 09/13/2023 reflected an order dated 09/12/2023 for wound care-pressure ulcer Stage 3 Clean wound with wound cleanser spray, apply Anasept gel (a Dakin's solution is used to prevent and treat skin and tissue infections that could result from cuts, scrapes, and pressure sores. It is also used before and after surgery to prevent surgical wound infections.) followed by calcium alginate and wrap with kerlix. An order dated 08/13/2023 heel protectors to bilateral heels at all times and an order dated 07/25/2023 to off load heels while in bed. Review of Resident #39's Weekly Wound Progress note dated 09/12/2023 reflected Resident #39 had one pressure ulcer wound and was not on a pain management program. Resident #39's pressure ulcer was assessed to be a stage 3. Observation on 09/12/2023 at 10:00 AM revealed Resident #39 in his room in bed. Resident #39 was observed to have his right heel in a heel protector with his left heel out of his heel protector. His heels were not floated (using a pillow to suspend the heels to alleviate pressure). Observation on 09/13/2023 at 9:00 AM revealed Resident #39 in room in bed. Resident #39 did not have his heel floated in bed. Observation and interview on 09/13/2023 beginning 9:42 AM, revealed LVN A prepared wound care supplies for Resident #39's pressure ulcer treatment. LVN A stated the hospice aide just gave Resident #39 his bath and the dressing came off and Resident #39 was bleeding. LVN A gathered supplies; wound cleanser, 4x4, and a calcium alginate dressing and entered room. LVN A started by spraying wound cleanser on Resident #39's open stage III pressure ulcer on his right heel. LVN A then using 4x4 gauze started cleaning the pressure ulcer. LVN A then applied the calcium alginate dressing (dry) and applied it to Resident #39's right heel. LVN A then applied the kerlix wrap around Resident #39's foot. In an interview on 09/13/2023 at 12:02 PM LVN A was asked if she applied Anasept gel to Resident #39's right heel pressure ulcer when she performed his treatment. She stated it was on the Calcium alginate, right? Surveyor stated no you opened the dressing in the room and cut it with scissors and applied the dry dressing to the wound. LVN A stated she was not sure if she applied it or not. In an interview on 09/13/2023 at 2:17 PM LVN A stated she went down to Resident #39's room to check his dressing. She stated the dressing was dry, so she applied the Anasept gel. In an interview on 09/13/2023 at 2:31 PM LVN A stated by not applying the Anasept gel during wound care it could cause worsening of the pressure ulcer and make the pressure ulcer dry causing discomfort. LVN A further stated Resident #39 should have his heels floated at all times and by not having his heels floated it could cause worsening of his pressure ulcer and discomfort. In an interview on 09/13/2023 at 2:00 PM the DON stated she expected nurses to follow doctor orders when doing treatments. The DON stated Resident #39's heels should be floated at all times to ensure no other pressure ulcers develop. The DON stated by staff not floating his heels it could cause pressure ulcers or worsening of current pressure ulcers. The DON stated if nurses did not follow doctors' orders for treatment it could lead to worsening or non-healing of pressure ulcers. Review of the facility's policy Pressure Ulcers/Skin Breakdown- Clinical Protocol dated 04/2018 reflected The nursing team member and practitioner will assess and document an individual's significant risk fac-tors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following: a) Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. b.) Pain assessment .The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #27 and Resident #35) infection control, in that: LVN B observed did not follow the facility's infection control policy and procedure of sanitizing blood pressure monitor after using on Resident #27 and before using it on Resident #35. This failure could place at risk of transmission of disease and infection. Findings included: Review of Resident #27's medical record reflected a [AGE] year-old woman admitted on [DATE]. Diagnoses included Schizoaffective disorder- bipolar type, Insomnia due to medical condition, personal history of other venous thrombosis (blood clots in the deep veins) and embolism ( blockage in an artery in the lung), muscle weakness (generalized), urinary tract infection site not specified, stress incontinence (female) (male), cough, nausea, dysphagia ( difficulty in swallowing), abnormalities of gait and mobility, unspecified lack of coordination, edema (swelling), unspecified, long term (current) use of anticoagulants. Review of Resident # 27's Medication Administration Record (MAR) for June 2022, reflected an order for CloNIDine HCl Tablet 0.1 MG as follows: Give 0.05 mg by mouth two times a day for hypertension hold for SBP<110 or DBP <60, and Notify MD. An observation of taking blood pressure using a wrist blood pressure monitor on 06/13/2022 beginning at 09:00 am, on residents with blood pressure related issues revealed LVN B failed to sanitize the wrist blood pressure cuff after using it on Resident #27 and before using it on Resident #35 until the surveyor asked her about it. Without sanitizing she kept the equipment on the medication cart and opened the medication cart drawers and operated the computer without sanitizing her hands. When asked her about the facility sanitation policies and procedure for hand and equipment sanitization, LVN B stated that all the healthcare providers should sanitize their hands as well as reusable medical equipment after the use. Then she searched for sanitizing wipes in the medication cart. Since there were no wipes available on the cart, she went to the storeroom and returned with a new packet of sanitizing wipe to sanitize the blood pressure monitor. During an interview conducted on 06/13/2022 at 09:30 am with LVN B, stated that she sanitized the blood pressure wrist cuff after she used it on the resident prior to the Resident #27. However, surveyor observed that there was no sanitation supply available on the cart at that time. When asked about touching the surfaces of the medication cart and computer keypad without sanitizing her hands after touching Resident #27, LVN B kept quiet . An interview on 06/14/2022 at 2:00 pm with the DON revealed that her expectation was that the nursing staff follow facility policy/procedure for handwashing/sanitization and when using reusable medical equipment. The DON added that they have infection control training annually and in services on regular intervals related to infection control ( Eg. Hand washing). The facility identifies deficiencies in infection control practices through direct observations. In services provided to the relevant staff members when any deficiencies identified. Facility's policy Cleaning and disinfection of resident-care items and equipment dated October 2018 it was stated that Reusable items are cleaned between residents (e.g., stethoscopes, durable medical equipment) Durable medical equipment (DME)must be cleaned and disinfected before reuse by another resident Reusable resident care equipment will be decontaminated and /or sterilized between residents according to manufacturer's instructions

Based on observations and interviews, it was determined the facility failed to ensure store all drugs and biologicals in locked compartments on one of four (Hall D) halls reviewed for medication storage. Specifically, the facility failed to ensure staff did not leave medications unsupervised and medication carts unsecure on Hall D. This failure could affect residents on Hall D by placing them at risk for accidents. Findings included: 1. Observations on 09/15/2021 at 7:32 PM revealed Licensed Vocational Nurse (LVN) #2 walked away from the Hall D medication cart, leaving it unlocked. She walked down the hall into a resident's room. She returned to the cart at 7:34 PM. Several staff members and residents walked by the unlocked medication cart. Observations on 09/15/2021 at 7:36 PM revealed LVN #2 walked away from the Hall D medication cart, leaving it unlocked and a card of [MEDICATION(S)] 50 mg containing two (2) pills lying on the top of the cart. She walked down the hall into a resident's room. She returned to the cart at 7:38 PM. Several staff members and residents walked by the unlocked medication cart and unsecured medications. Observations on 09/15/2021 at 7:49 PM revealed LVN #2 walked away from the Hall D medication cart, leaving it unlocked. She walked down the hall to the nurse's station and returned to the cart at 7:51 PM. Two residents and one staff member walked by the unlocked medication cart. An interview with LVN #2 on 09/15/2021 at 7:55 PM revealed the nurse said she was very busy and did not think about locking the cart since the surveyor was standing there and .would watch it. An interview with the Director of Nursing (DON) on 09/16/2021 at 1:25 PM revealed she said the nurse was responsible for the medication cart and medications, and the medication cart should be locked with all medications always secured when the nurse was not within visual sight of the cart. She said medications should never be left on top of the medication cart. The facility's policy and procedure for medication storage was requested and not received from the facility during the survey.

Based on observations, interviews, and record review, the facility failed to prepare and serve food in accordance with professional standards for one of one kitchen. The facility failed to ensure staff did not touch ready-to-eat foods with bare hands or ensure adequate hand washing during meal service. This had the potential to affect all residents who received food from the kitchen. Findings included: 1. An observation on 09/15/2021 at 4:37 PM revealed the cook was preparing pureed food for the dinner meal service. He washed the Robot Coupe (mechanical equipment) pieces in the 3-pan sink multiple times in between making the pureed food items. No hand washing was observed in between the dirty and clean dish handling. At 4:56 PM, the cook was observed taking temperatures of the food items on the steam table. The cook placed a scoop of pasta onto a plate with some of the food off center. The cook pushed the pasta back into place with his bare left hand. The cook touched his face a couple of times. At 5:20 PM, the cook picked up a knife from the 3-pan sink. He proceeded to cut bread and picked the bread up with his bare hands before placing it onto a resident's plate. At 5:28 PM, the cook placed a scoop of green beans onto a resident's plate and touched them with his bare left hand. He touched his face and proceeded to dish food from the steam table. At 5:33 PM, the cook plated some food for a resident and then proceeded to scoop some of the casserole back into the pan on the steam table. He touched fish patties with his bare left hand to help plate the items. At 5:39 PM, the cook opened a hamburger bun with his bare hands and placed it into a toaster. He took the hamburger bun out of the toaster and placed it onto a plate with his bare hands. No hand washing by the cook was observed throughout the meal service from 4:37 PM through 5:39 PM. An interview with the DM on 09/15/2021 at 6:02 PM revealed the cook had been there about three weeks and was still in training. She said anything from hand to mouth required a tong or glove. She said he had been educated on touching food. An interview with the DM on 09/16/2021 at 10:31 AM revealed the staff should have been hand washing all the time. She said the cook considered the dish washing at the 3-pan sink equivalent to hand washing. She said he knew he should not have touched the hamburger bun. She said he continued to train. The facility's policy, Food Preparation and Handling, revised 06/01/2019, revealed prepare food with the least manual contact possible. Do not allow bare hands to touch raw food directly. The facility's policy, Employee Sanitation, dated 10/01/2018, revealed hand washing during food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks. Texas Food Establishment Rules: 288.65 (a)(2)-Except when washing fruits and vegetables as specified under section 228.66(f) of this title or as specified in paragraphs (4) and (5) of this subsection, food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use-gloves, or dispensing equipment.

Based on interviews and record reviews, the facility failed to honor the choice of a daily 4:30 AM bed bath for one of one resident (Resident #8) who was reviewed for choices. Failing to honor the wishes of the resident has the potential to impact sense of independence and self-esteem. Findings included: 1. Resident #8 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact, dependent on staff for all aspects of daily care, including a bath and had functional limitation in bilateral lower and upper extremities. Refusal of care was not identified on the MDS. The care plan for Resident #8 initiated on 05/03/2019 and revised 05/11/2021 indicated the resident received a bed bath every morning per their request. The goal was the resident would be provided a daily bed bath through the next review. The intervention was documented on the care plan to indicate Resident #8 would receive the bed bath as desired. The care plan did not indicate Resident #8 had any refusals of care. Review of the Activities of Daily Living (ADL) record for August 2021 revealed a morning bed bath for Resident #8 had been recorded as completed for three out of 31 potential days. The September 2021 ADL record indicated Resident #8 had received four out of 16 potential days. The ADL record for August and September did not have any incidents of bath refusal documented for Resident #8. Nurse's notes for August and September 2021 had no documentation of bath refusal for Resident #8. Resident #8 was interviewed on 09/13/2021 at 11:17 AM. The resident stated a bath had been requested daily, but at times a bath was not received due to short staffing. The resident gave an example of this morning, explaining the bed bath was not given. Resident #8 stated their bed bath was scheduled for 4:30 AM every day. During an interview with Resident #8 on 09/15/2021 at 8:34 AM, the resident stated the scheduled morning bath was not received. The resident added the certified nursing assistant (CNA) had worked alone and had not been able to provide the scheduled bed bath. Certified Nursing Assistant (CNA) #2 was interviewed on 09/15/2021 at 2:29 PM. The CNA stated Resident #8 had complained of not getting a bed bath as scheduled and desired. The CNA added when there was not enough staff, the resident was unable to receive the scheduled 4:30 AM bath. The CNA stated she had not reported the lack of bed baths for Resident #8 since Resident #8 was able to report independently. She stated that night shift CNAs (no names given) had reported they were unable to complete the bath for Resident #8 and there were some agency staff that refused to bathe Resident #8 because they thought Resident #8 was hard to handle. The CNA stated she had worked over the weekend on the night shift and had been unable to provide the bed bath to Resident #8 due to not enough staff. The Assistant Director of Nursing (ADON) was interviewed on 09/15/2021 at 5:06 PM. The ADON stated Resident #8 had made a special request for early morning bed baths. The ADON stated she had seen Resident #8 that morning and the resident had said nothing to her about not getting the scheduled bed baths.

Based on interviews and record reviews, the facility failed to ensure the residents were free from abuse/neglect for one of three residents (Resident #37) reviewed for abuse as evidenced by: The facility failed to ensure the safety of Resident #23 from Resident #37 in a resident-to-resident physical altercation in the dementia unit. This has the potential to affect all residents in the dementia unit. Findings included: 1. A review of Resident #37's MDS assessment dated [DATE] revealed admitted on [DATE] and discharged on [DATE] with anxiety, [CONDITION(S)], [CONDITION(S)], and post traumatic stress disorder ([CONDITION(S)]). The resident had moderately impaired cognition based on the staff assessment for mental status. Verbal behaviors and other behavioral symptoms exhibited one to three days. A review of Resident #23's MDS assessment dated [DATE] revealed an admitted on [DATE] with dementia, anxiety, and depression. The resident had severe cognitive impairment with a BIMS score of 2 out of 15. A review of the incident investigation dated 08/23/2021 revealed Resident #37 was not interviewable. On 08/23/21 [Resident #37] yelled to [Resident #23], 'You are not my boss,' and 'I am going to [NAME] you.' [LVN #1] heard [Resident #37] threatening to hit [Resident #23]. [LVN #1] yelled out for [Resident #37] to stop, as she tried to intervene. [Resident #37] hit [Resident #23] on the head with [the resident's] closed fist. [Resident #23] fell over a chair that was in the hallway. [Resident #37] was asked to back away. [Resident #23] had a skin tear to [the] right forearm. [LVN #1] assisted [Resident #23] from the floor into a chair. The interim DON and the ADON were called for assistance. The investigation summary revealed Resident #37 hit Resident #23 with the resident's fist. One-to-one aid was provided for Resident #37 until the resident was sent to a behavioral hospital. Provider action revealed an in-service was completed on Abuse and Neglect/Resident to Resident Confrontation. They continued to find placement for Resident #37. A review of the care plan for Resident #37, dated 08/23/2021, revealed a history of aggressive behavior related to dementia with behavioral tendencies and a history of [CONDITION(S)]. Interventions included Contact a behavioral unit for assessment .head-to-toe assessment completed post altercation; resident separated from other residents on the dementia unit . An interview with CNA #1 on 09/14/2021 at 2:23 PM revealed she usually worked in the dementia unit. She said Resident #23 escalated quickly and they had to keep an eye on the resident. She said the last altercation they had in the unit was between Resident #37 and Resident #23. An interview with LVN #1 on 09/15/2021 at 8:47 AM revealed Resident #37 would get agitated at times. She said the afternoon of the incident, the staff and some of the residents were dancing in the hallway. She said Resident #37 came out of the resident's room yelling. She said this resident usually had verbal outbursts but nothing physical. She said Resident #23 was sitting in a chair and she headed towards the exit. She said she heard the two residents exchanging words and she saw Resident #37 threaten Resident #23. She said they were both standing up at that point. She said she told Resident #37 to stop. She said she ran towards the two residents and Resident #37 hit Resident #23, who went to the floor. She said Resident #37 scared her and she did not feel the residents were safe with Resident #37 around. She confirmed the resident was out at a behavioral hospital. An interview with the ADON and interim DON on 09/15/2021 at 8:59 AM revealed the ADON was in the hallway talking to the nurse, and the DON was in her office during the incident. They said they were called to the incident right away. They said staff was with Resident #23, and Resident #37 was in the dining room with an aide. They said Resident #23 did have a skin tear from the incident. They said Resident #37 was shaken up and agitated. They said Resident #23 did not know what happened. The ADON said that psych was seeing Resident #37, and the resident was diagnosed with [CONDITION(S)]. The ADON said they thought something happened to the resident with the resident's brother when they were younger. They said Resident #37 received regular psych services. An interview with CNA #3 on 09/15/2021 at 3:14 PM revealed she was there during the incident. She said Resident #37 was agitated. She said Resident #37 started punching Resident #23's head. She said she ran over there, got in between them, and calmed the situation before Resident #23 went to the floor. She said Resident #23 tried to grab the chair but kept going down. She said Resident #37 had swung at Resident #23 about four times before she had gotten there. She said Resident #37 did not have any prior incidents with other residents. She said the resident was mostly aggressive towards the staff. She said this was the first incident Resident #37 hit a resident. She said she was not aware of any triggers Resident #37 might have had. An interview with the NHA on 09/16/2021 at 9:46 PM revealed Resident #23 was sitting in a chair and Resident #37 just started hitting Resident #23. She said they had both consistent staff and agency staff in the unit. She said they were trying to find alternate placement for Resident #37. She said they were going to be doing one-on-one when the resident returned to the facility. A review of the facility's policy, Abuse, dated 02/17/2020, revealed it was the policy of this center to, prohibit resident abuse or neglect .Abuse is the willful infliction of injury.

Based on interviews and record reviews, the facility failed to ensure notice of bed-hold policy and return was provided to the resident or representative at the time of transfer to the hospital for one (Resident #19) of one resident reviewed for hospitalization . The facility failed to provide Resident #19 or the resident's representative a copy of the bed-hold policy and return to the facility. This has the potential to affect all residents who are sent to the hospital by not having a bed available within the facility for them to return to. Findings included: 1. A review of Resident #19's MDS assessment, dated 09/12/2021, revealed admitted on [DATE] with diabetes, sleep apnea, heart failure, and muscle weakness. The resident was a modified independent cognition as identified on the staff assessment for mental status. A review of the resident's chart revealed no bed-hold notice for the time of the hospital transfer on 09/12/2021. An interview with the Nursing Home Administrator on 09/14/2021 at 12:30 PM revealed there was no bed hold provided for this hospitalization . An interview with the Director of Nurses (DON) and the Assistant Director of Nurses on 09/15/2021 at 8:59 AM revealed the Business Office Manager (BOM) and Social Service oversaw the bed holds. They said they had no control over the process. They said nursing completed the transfers, but nothing related to bed holds. An interview with the social services staff on 09/15/2021 at 10:16 AM revealed they never worried about the process because the residents were always welcomed back to the facility. She said she was not aware the resident needed the bed hold at the time of hospitalization . She said she was not aware of that process or who would have overseen providing that information. She said there needed to be a plan so that residents did not fall through the cracks. An interview with the BOM on 09/15/2021 at 10:30 AM revealed she explained the bed-hold process at the time of admission. She said this resident had been transferred to the hospital after hours. She said nursing would have done this at her previous facility. She said she did not complete the bed-hold information at the time of transfer. An interview with the DON on 09/15/2021 at 11:35 AM revealed the information on bed hold was completed on admission but the DON did not know how it should be completed during transfers. An interview with the Regional Nurse Consultant on 09/15/2021 at 11:55 AM revealed the BOM was the one responsible for completing the bed hold on transfers within 24 hours of the transfer. They said that was not getting done with the new BOM, and they would correct this for the future. A review of the facility's policy, Bed Holds, dated 01/2021, revealed signed bed hold agreements are required on all residents who discharge to the community and wish to return to the same bed when readmitted . This signed agreement should be obtained at the time of discharge.

Based on observation interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 34 of 34 residents (Residents #1 - 34) reviewed for infection control. A. The facility failed to ensure staff were properly utilizing PPE and performing hand hygiene in that: staff were in the COVID-positive isolation hall without wearing masks, face shields, or gloves; discarded PPE was seen on the ground and other facility surfaces; and staff did not perform hand hygiene according to CDC guidelines. B. The facility failed to have dedicated staff caring for COVID-positive residents in the isolation hall. C. The facility failed to provide COVID-19 in-services or training to agency staff. D. The facility failed to have a dedicated food cart and food trays for the COVID-19 unit. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/02/2020. While the IJ was removed on 08/05/2020, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place residents at risk for the transmission of COVID-19 and death. Findings included: A. Review of a document titled Resident COVID Tracking log requested on 7/31/20 reflected 13 residents positive (Resident #14, Resident #13, Resident #35, Resident #11, Resident #36, Resident #12, Resident # 31, Resident #38, Resident #32, Resident # 4, Resident #20, Resident # 37, Resident # 9) for COVID-19 from 7/14/20 to 7/27/20. Review of the facility's Resident and Staff COVID-19 report dated 8/05/2020 provided by the ADM reflected 13 COVID- positive residents and 3 residents death. Review of the facility's Resident and Staff COVID-19 report dated 8/11/2020 provided by the ADM reflected 18 COVID-positive residents and 4 residents death. Review of a document titled Resident COVID Tracking log requested on 8/11/20 reflected 13 residents positive Review of Resident #25's laboratory results with a collection date of 8/6/20, reflected resident was positive for COVID-19. Review of Resident #19's laboratory results with a collection date of 8/6/20, reflected Resident was positive for COVID-19. Observations conducted on 7/30/20 at 10:33 a.m. reflected the facility had four hall A, B, C, and D. COVID-19 unit/isolation wing was located in B hall. Regular halls were located in A, C, and D hall. Observations conducted on 7/30/20 at 10:34 a.m. reflected MT staff wearing a N95 mask with the bottom strap loose and not over the head. Observation conducted on 7/30/20 at 10:35 a.m. reflected one used N95 mask and a regular face mask on the therapy office desk and one used N95 over the therapy bench. Further observations reflected the administrator moving the masks aside but not discarding them. The regional nurse was observed moving in and out of this office while the masks were in this state. Observations conducted in wing A on 7/30/20 at 1:52 p.m. reflected CNA B putting on gloves first and then a gown before entering Resident #2's room. Observations conducted in wing D on 7/31/20 at 2:01 p.m. reflected CNA A leaving Resident #2's room holding a biohazard bag with used PPE inside and in the other hand holding a bag with dirty linen and not wearing gloves. CNA A threw the dirty biohazard bag into a container without performing hand hygiene. CNA A walked into the D hall holding the bag with the dirty linen, she stopped in front of Resident #19's room. Resident # 19 had a cart outside of her room with personal items and over the cart was the trash from lunch. CNA A took the trash and gave it to CNA B. CNA A put her hand over the cart and pushed the cart inside Resident #19's room. Observations conducted on 7/31/20 at 2:05 p.m. reflected Resident #19 touching the same cart without been sanitized Observations conducted in wing D on 7/30/20 at 2:13 p.m. reflected CNA B was donning gloves first and then an isolation gown. Observations conducted on 7/31/20 at 2:28 p.m. reflected CNA A donning an isolation gown outside of Resident #25's room. She then removed the gown and walked into the linen room, retrieved some supplies from the linen room and walked toward the resident's room again. CNA A began to don PPE and performed no hand hygiene at any point before entering Resident #25's room. Observations conducted in the isolation wing on 7/31/20 at 6:33 p.m. reflected CNA C entering a staff break room wearing full PPE after leaving a resident room. During an interview on 7/31/10 at 6:40 p.m., CNA C stated she forgot to remove PPE when entering the break room. She stated she didn't get any in-services from the facility related to COVID-19. Observations in the isolation wing on 7/31/20 at 7:00 p.m. reflected, LVN A charting without using gloves and did not sanitize the computer or med cart after using it. Observation on 7/31/20 at 7:14 p.m. revealed LVN A opening the isolation wing back/exit door for LVN B. LVN B entered the unit without wearing PPE. LVN A was observed handing a gown to LVN B without wearing gloves or performing hand hygiene. Further observations reflected LVN B donning the gown. Observations conducted outside of the isolation wing on 7/31/20 at 7:38 p.m. revealed used PPE, gown and gloves on the ground next to the biohazard container. Observation on 8/01/20 at 12:25 p.m. revealed one used N95 mask and a regular face mask on the therapy office desk, and a surgical mask on the therapy bench. Observation on 8/01/20 at 1:57 p.m. revealed when the PTD pulled the power cord of his computer, a used N95 mask fell from his desk. He did not pick up the used N95 from the floor or dispose of it in any way. During an interview on 8/01/20 at 2:17 p.m. PTD stated they had to dispose the used PPE including mask in the biohazard bags. He stated it was unacceptable to not properly dispose of a used face mask. He stated if a used face mask was not properly disposed it could increase the possibility of staff and residents getting an infection. He stated the N95 and face masks that were on the therapy desk were used by some of their staff. He stated the used masks should have been properly discarded. Observation in the isolation wing on 8/01/20 at 2:37 p.m. revealed LVN B outside of the break room without wearing mask, gowns, or face shield. Observation on 8/01/20 at 6 :50 p.m. revealed CNA D in the COVID-19 unit, not wearing face mask, gown, gloves, or face shield and handling resident's laundry. Observation on the isolation wing 8/01/20 at 6:55 p.m. revealed LVN A handing a plastic bag to LVN C. None of them were wearing gloves or sanitized their hands. During an interview on 8/01/20 at 5:15 p.m. LVN A stated she did not know if she needed to wear gloves when she was not providing care to the resident in the COVID-19 unit. She stated she was not wearing gloves because it was difficult to chart and type using gloves. She stated she did not know how often they should be cleaning the common areas. She stated they were not supposed to wear PPE in the break room. She stated they could be without PPE after passing the biohazard boxes. During an interview on 8/01/20 at 5:35 p.m. LVN B stated she was not sure if someone instructed them to be wearing full PPE before entering the COVID-19 unit. She stated they were supposed to remove the PPE before entering the break room. She stated she assumed that passing the biohazard boxes was considered the clean area. She stated that once passing the biohazard boxes she could be without PPE. During an interview on 8/02/20 at 10:42 p.m., the Regional RN stated staff should be entering the COVID-19 unit through the inside of the facility, the front door and exiting through the back door. She stated no one should be using the back door to enter the COVID-19 unit. She stated LVN A should be using the back door to enter because she was positive, asymptomatic with COVID-19. She stated staff should be wearing PPE before entering the COVID-19 unit and removing the PPE by the biohazard boxes close to the exit door. She stated they should remove the PPE before entering the break room and close the door. She stated staff working on the COVID-19 unit should be wearing full PPE, all the time. Regional RN stated staff should be doing hand hygiene before donning and doffing PPE or after touching dirty biohazard bags or trash cans. She stated if staff were not wearing full PPE before entering the unit, they were putting themselves and residents at risk to get sick. Regional RN stated staff should wear gloves before disposing of a used mask, clean the surface area where the mask was located, and disinfect their hands after these. She stated if a used mask was not disposed of properly, it could potentially expose staff and residents to infection with COVID-19. During an interview on 8/02/20 at 11:30 p.m., the ADM stated staff should be using the back door to enter and exit the COVID-19 unit. She stated there was a PPE cart available outside the entry door. She stated staff need to be wearing PPE before entering the COVID-19 unit. She stated she was not aware they had an asymptomatic positive staff member working in the isolation unit. The ADM stated staff should be disposing of used PPE in the trash cans or biohazard bags if it was soiled. She stated the PPE should not be on the ground outside of the biohazard containers. She stated staff should not leave a used mask on a desk and that they should be wearing gloves to dispose of a used mask. The ADM stated staff should be washing their hands before donning and doffing PPE or after touching used biohazard bags or trash. Review of the facility Policy titled Coronavirus Emergency Pandemic Policy Addendum dated 7/29/20 reflected Admission/Readmission Quarantine Hall: Applicable to designated staff working this hall designated should be pre-assigned. Wear full PPE (gown, gloves, mask, N95 (if possible)/KN95 and eye protection Resident to wear cloth mask or cover nose and mouth with tissue when staff enter their rooms. Change gloves and gown between every resident encounter (if used) Eye goggle/face shield will be disinfected with an approved COVID-19 disinfectant between resident encounter (as needed) PPE discarded in trash in resident room unless it is contaminated with excretions or secretions from residents. N95 will be placed in the employees assigned brown paper bag. Assigned employee can wear a face mask over the N95 to conserve N95. Hand hygiene will be performed prior to entering the isolation area/admission/readmission hall, leaving the room and isolation area/admission/readmission area/ Hand hygiene criteria will be followed Doffing will be conducted prior to exiting the room. Review of the facility Policy titled Coronavirus Emergency Pandemic Policy Addendum dated 7/29/20 reflected Confirmed Cases of COVID If a resident tests positive for COVID-19 the CDC recommendation is to place the whole hall on full isolation (i.e., N95, gown, eye protection, gloves). This is because the whole hall was presumably exposed to COVID, and even if an exposed resident test negative initially they could still become positive and infectious during the 14-day incubation period. Gowns and gloves are to discharge after care of each resident. If, the center's layout allows, confirmed positive resident will be moved to the COVID Isolation Hall (if possible) Provide separate space to don (put on) and doff (take off) PPE when possible Review of the facility Policy titled Infectious waste-storage dated 3/01/20 reflected, It is the policy of this center to assure that infectious waste generated within the center it properly dispose ; Medical wastes must be stored in such a manner that it is protected from animals and that it does not provide breeding place or food source for insects and rodents Review of the facility Policy titled Coronavirus Emergency Pandemic Policy Addendum dated 7/29/20 reflected If HCP are permitted to return to work before meeting all return to work criteria, the should still adhere to all return to work practices and work. They should be reminded that in addition to potentially exposing patients they could also exposed their co-workers. Facemasks should be worn even when they are in no-patient care areas such as break rooms. Review of the facility Policy titled Coronavirus Emergency Pandemic Policy Addendum dated 7/29/20 reflected, HCP should remove their respiratory or facemask and put on their cloth face covering when leaving the facility at the end of their shift. They also should be instructed that if they must touch or adjust their facemask or cloth face covering they should perform hand hygiene immediately before and after. B. Review of facility Daily schedule dated 7/30/20 reflected CNA A and CNA C were scheduled to work the COVID-19 unit. Review of facility Daily schedule dated 7/31/20 reflected CNA A was scheduled to work the COVID-19 unit. Review of facility Daily schedule dated 7/31/20 reflected CNA C was scheduled to work the regular halls. Review of facility Daily schedule dated 7/31/20 reflected LVN B was scheduled to work regular halls. Review of Staff COVID Tracking Log for the month of July 2020, reflected LVN A was positive on 7/27/20 and asymptomatic-working. Review of Daily Work Schedule dated 7/31/20, reflected LVN A was assigned to work the isolation hall. Review of facility Daily schedule dated 8/01/20 reflected CNA A and CNA C were scheduled to work the COVID-19 unit. During an interview conducted on 7/31/20 at 12:43 p.m., CNA A stated yesterday she was working in the COVID-19 unit. She stated staff did not know what hall they were going to work until they arrived at the facility. CNA A stated she and CNA B were assisting the residents of the A, C, and D halls. During an interview on 7/31/20 at 7:15 p.m., LVN B stated she worked the regular halls today. She stated she did not know if tomorrow she would be working the regular halls or the isolation wing. During an interview on 8/01/20 at 12:55 p.m. HR staff stated she was the weekend supervisor. She stated it was fine for the staff that worked the COVID-19 unit to work the regular halls the following day. Observation on 8/01/20 at 4 :20 p.m. revealed CNA C, who worked the COVID-19 unit yesterday, working the regular halls. She stated she looked at the schedule for today and she was assigned to work the COVID-19 unit but another CNA told her she needed to work the regular wing. She stated today she was assist the resident on the A, C, and D halls. She stated she did not have any concern working the COVID-19 hall. During an interview on 8/01/20 at 4:54 p.m. Agency RN B stated she worked on the COVID-19 unit her first day of work and since then she worked the regular halls. She stated she did not know if she was supposed to only be working the COVID-19 unit. She stated LVN B was working in the regular halls during the morning. During an interview on 8/01/20 at 5:35 p.m., LVN B stated she did not know what hall she was supposed to be working today so she went to the COVID-19 unit. She stated staff did not know what hall they were working until they get to the facility. During an interview on 8/02/20 at 10:42 p.m., Regional RN stated they tried to have dedicated staff to work the COVID-19 unit. She stated they were trying to schedule the same staff to be working the COVID-19 unit consistently. During a Phone Interview on 8/01/20 at 11:30 p.m., the ADM stated staff who worked the COVID-19 unit were basically the same nurses that worked that unit before. Review of the facility Policy titled Coronavirus Emergency Pandemic Policy Addendum dated 7/29/20 reflected Probable case(s) of COVID in the center- a probable or confirmed case of COVID is considered and outbreak in a resident or employee. The center will be utilized N95 (if possible)/ KN95, eye protection, gloves and isolation gown. Employees will be assigned to work the hall with probable/presumed or conformed only. Minimize all employees from working across units or halls C. During an interview on 7/30/20 at 12:43 p.m., agency CNA A and CNA B stated they were agency staff and they have been working since Wednesday. They stated they did not get any type of training through the agency. They stated the facility had not provided them any type of training. Observation conducted in the isolation wing on 7/31/20 at 6:30 p.m., revealed the residents' room doors open. During an interview on 7/31/20 at 7:05 p.m., LVN A stated she did not know if the doors in the isolation wing should be closed or open. LVN A stated this was her first time working in a COVID-19 wing, so she did not know the process. During an interview on 8/01/20 at 12:15 p.m. Agency RN A stated she did not receive any in-services from the facility. During an interview on 8/01/20 at 4:54 p.m. Agency RN B stated she did not receive any in-services from the facility. During an interview on 8/02/20 at 10:42 p.m., Regional RN stated all the staff should have in-services related to COVID-19. She stated the DON or the charge nurse were responsible to provide in-services to the facility and agency staff. She stated she, the ADM and HR were responsible to make sure staff were getting the training or in-services. Regional RN stated staff should be cleaning the common areas every, one to two hours. She stated the staff should know the time frames for cleaning common areas. Regional RN stated the doors to the isolation wing should be closed. During an interview on 8/02/20 at 11:30 p.m., the ADM stated nurses and the DON were responsible to provide in-services to the facility and agency staff. She stated Regional RN was conducting in-services with the facility and agency staff. The ADM stated she expected for LVN A to be wearing gloves when she was touching common areas or handed items to negative staff. Observations in the isolation wing on 8/02/20 between 12 :19 p.m. and 12:21 p.m. reflected LVN A wearing gloves touching the med cart, touching medications, crushing medications, open a pudding and transfer the crushed medication into the pudding. LVN A did not perform hand hygiene during the observations. During an interview on 8/03/20 at 9:43 p.m., DON stated the ADM, RN C and Regional Nurse were responsible for providing in-services. She stated she had been in quarantine since July 19 and she had not come back to the facility until today. Review of the facility Policy titled Coronavirus Emergency Pandemic Policy Addendum dated 7/29/20 reflected, Administrative procedures and infection control methods to prevent and reduce the generation of infectious droplet nuclei (i.e., staff training on airborne, droplet and standard precautions and cough hygiene) Employees to follow the center's procedure for PPE and eye protection. Review of the facility Policy titled Coronavirus Emergency Pandemic Policy Addendum dated 7/29/20 reflected Resident rooms on the isolation hall (COVID hall) need to be cleaned last if there is not assigned staff to the hall. Environment cleaning of highly touched areas and workstations in center with confirmed or probable COVID-19 at least every 2 hours and as needed. D. Observations on 8/02/20 at 12 :29 p.m. revealed a food cart and food trays in the isolation wing. CNA A was observed passing resident meals using regular, reusable hard plastic food trays, which were taken into the resident's room. Observations on 8/02/20 from 12:40 p.m. to 1:30 p.m. revealed DA getting the food cart with dirty food trays from the outside back door of the isolation unit to the dining room. DA was wearing a N95 mask and gloves. He didn't wear a face shield or gown. DA was observed opening the door to the dining room without removing the gloves or performing hand hygiene. Observations reflected DA spraying the food cart and food trays in the dining room on the clean side of the facility. During an interview on 8/02/20 at 1:30 p.m., DA stated the food cart and food tray from the COVID-19 units were being disinfected in the dining room on the clean side of the facility. He stated he did not wear gown or face shield during this process because it's too hot. He stated the food carts from the regular units had a binder over them. He stated he uses this process to identify the food cart from the COVID unit from the other food carts from the regular unit. During an interview on 8/02/20 at 1:30 p.m., Regional RN stated the food cart from the isolation wing should not be disinfected in the dining room to avoid cross contamination. She stated she will provide in-services to the DA. Observations on 8/02/20 at 1:32 p.m. revealed Resident #18 touching the same door handle that was touched by the DA when entering the dining area. The door handle had not been disinfected by the DA. During an interview on 8/02/20 at 1:33 p.m., Regional RN stated staff would disinfect the door and assist Resident #18 in performing hand hygiene. Review of the facility Policy titled Coronavirus Emergency Pandemic Policy Addendum dated 7/29/20 reflected The program incorporated the following components: Guidelines for cleaning, disinfecting, and sterilizing contaminated items. Review of Resident and Staff counts positive for COVID-19 dated 08/05/20, reflected 10 positive staff and 13 Residents positive for COVID-19. Review of Resident list Report dated 7/31/20 reflected 34 residents at the facility. Review of Resident COVID Tracking log requested on 7/31/20 reflected 13 residents positive for COVID-19. Review of Staff COVID tracking Log for the period of July 2020 reflected 13 positive staff. ADM was notified on 08/02/2020 at 4:16 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to ADM on 08/02/2020 at 4:36 p.m. The facility's Plan of Removal (POR) was submitted by the ADM on 8/02/2020 at 7:43 p.m. The following POR was accepted by the survey team on 08/03/2020 at 2:00 p.m. Actions Taken/Plan included: All staff including agency working the COVID hall that provide resident care. Residents are only on COVID-19 isolation. No residents are on isolation for any other disease process. All staff including agency staff are being in-serviced on entering the COVID Hall with required PPE (gown, N95, eye protection and gloves) DON/designee will monitor the appropriate process for PPE is being followed on the COVID hall. The monitoring will be completed daily by the DON/designee. The Clinical Nurse Consultant will monitor the process completed by the DON/designee. The Clinical Nurse Consultant initiated the in-service training 08/02/2020. DON/designee will verify return demonstration on 08/03/2020. The facility will provide separate spaces to don (put on) and doff (take off) PPE when possible When a single area is provided for donning and doffing PPE, these principals should be followed: Provide for hand hygiene and adequate disposal of used PPE in the donning and doffing area Only donning or doffing should occur at any given time - do not perform these activities at the same time Only two people should be in the area at any time - use the buddy system to assure that donning and doffing is done correctly Donning will occur prior to the entry of B-Hall (COVID-Hall) and doffing will occur as they leave the COVID hall via the exit door to the outside. All staff including agency staff are being in-serviced on the correct donning of PPE. The following procedure will be followed: staff will don a set of the required PPE (gown, mask, face shield and gloves). When a staff member leaves the COVID hall, they will doff their gown when coming out of the hallway, perform hand hygiene and don a clean gown if re-entry is necessary. This in-service was started on 08/02/2020 by the DON/designee. In-service was initiated by Clinical Consultant on 08/02/2020. Clinical Nurse Consultant/designee will verify competency with return demonstration starting on 08/03/2020. Asymptomatic positive staff member was in-serviced on: One asymptomatic positive staff member was in-serviced by Clinical Nurse Consultant on 08/02/2020. After returning to work, HCP should: Wear a facemask for source control at all times while in the facility. A facemask instead of a cloth face covering should be used by these HCP for source control while in the facility. Asymptomatic positive staff will enter at the end of B-hall. Donning station will be set-up prior to entering the COVID hall from outside. Doffing will occur as the asymptomatic staff leave COVID hall. One asymptomatic staff member will continue to enter and exit the COVID Hall through the exit until August 6th (10 days from test date of July 27, 2020). A facemask for source control does not replace the need to wear an N95 or higher-level respirator (or other recommended PPE) when indicated, including when caring for residents with probable or confirmed COVID-19. Of note, N95 or other respirators with an exhaust valve might not provide source control. Both the provider and the employee must take all necessary measures to ensure the safety of everyone in the facility, including adhering to all infection control procedures such as hand hygiene, respiratory hygiene, and cough etiquette. Facility will continue to have designated staff for the COVID-19 positive hallways. Staff should maintain the same designation by cohort status, in all facilities in which they work, and staff should not change designation from one facility to another, unless required in order to maintain adequate staffing for a given cohort. Regional Director provided in-service to Clinical Consultant on 08/02/2020 via phone conference regarding the following: Once staff are designated to work with a given cohort, staff should not change designation from one day to another, unless required in order to maintain adequate staffing for a cohort. All staff including agency staff working the COVID were in-serviced to encourage residents to keep door closed and face mask/cloth covering. A dedicated food cart was placed on the COVID hall and will be disinfected prior to re-use, food will be delivered by nursing staff working the COVID hall after trays are delivered to the COVID hall by dietary staff. All staff to include agency staff working the COVID Hall were in-serviced on frequent sanitization of high touch areas. Cleaning log was given to staff with areas to clean. All staff to include agency staff were in-serviced on handling linen in the COVID-19 hall, maintenance will make rounds on the outside of the facility in observation of gowns and gloves on the grounds. The survey team monitored the plan of removal from 8/03/20 through 8/05/20 as follows: Observations from 08/03/20 through 08/05/20 revealed compliance with wearing PPE appropriately. There were dedicated staff working just the isolation wing and regular staff were not allowed to go to the isolation wing. Staff were able to identify the procedures and process for COVID-19. A cleaning log was available in the COVID-19 unit. Review of in-services conducted from 08/03/20 through 8/05/20 regarding putting on and removing, wearing PPE appropriately, wearing PPE before entering Isolation wing, dedicated staff assigned to work the COVID-19-unit, food delivery process in the COVID-19 unit. In-services were appropriate and contained all necessary information for staff. During an interview conducted on 8/03/20 at 9:09 p.m., CNA E stated the DON provided her demonstrative in-services on how to don and doff PPE. She stated she received in-services about the process for the COVID-19 unit, such as, where to enter and exit the COVID-19-unit and how to don PPE before entering the COVID-19 unit. Observation in the COVID-19 unit on 8/03/20 at 10:00 p.m. revealed all the doors closed at the COVID-19 unit and a cleaning log with staff initials available. During an interview conducted on 8/03/20 at 9:09 p.m., LVN C stated she had to don before entering to the COVID-19 unit. She stated they had to remove the PPE before entering the break room. She stated they had to clean the common areas every two hours and put their initials in the cleaning log. She stated she was only allowed to work the COVID-19 unit. During an interview conducted on 8/04/20 at 4:23 p.m. CNA F stated the DON provided in-services about how to don and doff PPE. She stated the food cart had to stay outside of the COVID-19 unit, she stated the COVID-19-unit staff were responsible to disinfect the food trays and put them inside a biohazard bag. During an interview conducted on 8/04/20 at 4:41 p.m., CNA G stated she was agency staff. She stated she got in-services from the DON on how to don and doff PPE and where to dispose it. She stated it was demonstration in-services. She stated the food cart should not be brought into Isolation. Observations on the isolation wing on 8/04/20 at 5:20 p.m. revealed LVN A wearing full PPE, including gloves, when charting. During an interview conducted on 8/04/20 at 5:22 p.m., LVN A stated they had to wear full PPE in the isolation wing. She stated she had to use the back door to enter the COVID-19 unit. She stated the staff had to remove PPE before entering the break room. She stated they had to sanitize the common areas every two hours and put her initials in the cleaning log. She stated the food cart was not entering the COVID-19 unit and added they were responsible to sanitize the food trays and place them in the biohazard bags. She stated she had to use the back the door to enter the COVID-19 unit. During an interview conducted on 8/05/20 at 12:54 p.m., DA stated he got in-services from the DON and how to don and doff PPE. He stated the food cart did not enter the COVID-19 unit and added the staff from the COVID-19 unit were responsible to disinfect the food trays and place them inside of a plastic biohazard bag. He stated those trays are washed at the end and were separated from the rest of the food trays. The ADM was notified on 8/05/2020 at 4:30 p.m. the IJ had been lowered, and that the facility remained out of compliance at a severity of no actual harm with the potential for more than minimal harm and a scope identified as pattern due to a need for ongoing monitoring.