Every finding on record at Cedar Pointe Health and Wellness Center

Based on 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, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified for one (Resident #1) of four residents reviewed for care plans. The facility failed to ensure Resident #1's fall interventions listed in the comprehensive care plan (fall mat at bedside) were in place on 01/23/2026 and failed to ensure Resident #1's brakes were locked when he was not in his wheelchair were added to his comprehensive care plan after his fall on 1/17/2026. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings include:Review of Resident #1's face sheet reflected a [AGE] year-old-male admitted on [DATE] , with diagnoses of schizoaffective disorder (chronic mental health condition that has symptoms of hallucinations, delusions and or disordered speech), chronic obstructive pulmonary disease (a progressive lung condition characterized by symptoms like shortness of breath, chronic cough), repeated falls, vascular dementia (changes in thinking caused by impaired supply of blood to the brain) , muscle wasting and atrophy (loss of muscle tissue or shrinking muscle mass) and anxiety disorder (group of mental health conditions characterized by excessive fear and worry that interfere with daily life). Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 14 (which indicated no cognitive impairment) . Review reflected Resident #1 required partial/moderate assistance (helper does less than half the effort) to go from sitting to lying, and lying to sitting on the edge of the bed. Review reflected Resident #1 was dependent (helper does all of the effort) for chair/bed-to-chair transfers. Review reflected Resident #1 had a history of falls with no injury. Review of Resident #1's care plan dated 01/21/2026 reflected Resident #1 had a fall on 01/20/2026 and 01/17/2026 with intervention to implement fall mat at bedside for safety dated 01/19/2026 and bed in lowest position. Review reflected Resident #1 was at risk for falls related vascular dementia and incontinence dated 03/14/2022 with interventions to maintain a clear pathway free of obstacles. Review of Resident #1's Kardex report dated 01/23/2026 reflected under the safety section implement fall mats at bedside for safety. Review of Resident #1's incident report dated 01/17/2026 reflected Resident #1 was found on floor and stated he tried to get to his wheelchair. Review reflected IDT met to discuss fall and fall mats was added and care plan updated. During an observation and interview on 01/23/2026 at 2:29 PM, Resident #1 was observed in bed. Resident stated that he had falls in the past. Resident #1 stated that now he asked for help to get in and out of bed. Resident #1's bed was observed in a low position with wheelchair placed on the left side of the bed. Observation revealed wheelchair brakes was unlocked on both sides of the wheelchair. Observation revealed that Resident #1 did not have a fall mat on either side of his bed. Observation on 01/23/2026 at 3:20 PM, revealed Resident #1 laid in bed. Resident #1's wheelchair was unlocked and had no fall mat at bedside. During an interview on 01/23/2026 at 2:49 PM, CNA A stated that fall prevention included to keep eyes on a resident, put the resident's bed in low position and to have their call light in reach. CNA A stated if the wheelchair is at bedside, the brakes should be locked. CNA A stated fall mats were usually next to the bed when the resident was in bed. If the resident was up, fall mats would be put away. CNA A stated that she was aware which residents were a fall risk based on what the nurses report or therapy reported. CNA A stated she could go into the Kardex (summary of resident's care) and it showed if residents needed assistance with transfers and if they were a fall risk. During an interview on 01/23/2026 at 2:57 PM, RN B stated that fall prevention included fall mat, frequent rounding and offering to toilet the resident. RN B stated fall mats was supposed to be positioned on the resident's dominate side of the bed, right next to the bed so the resident did not get hurt if they had a fall. RN B stated the brakes should also be locked if the wheelchair was at bedside. During an interview on 01/23/2026 at 3:09 PM, LVN C stated that fall prevention included to ensure wheelchair brakes were locked, call light was within reach, and bed in low position. LVN C stated that fall mats was placed on the floor next to the bed. LVN C stated that you can find if a resident needed a fall mat in their care plan. During an interview on 01/23/2026 at 3:21 PM, CNA D stated fall prevention included rounding on high risk fall residents. CNA D stated Resident #1 was a high fall risk. CNA D stated fall prevention included to put the bed in low position and encourage the resident to use the call button. CNA D stated Resident #1 thought he was independent. CNA D stated that Resident #1 did not have a fall mat, but that his bed was kept in low position and kept wheelchair close by. CNA D stated that wheelchair brakes was supposed to be locked. During an interview on 01/23/2026 at 4:32 PM, the DON stated Resident #1 had an increase in falls. The DON stated some interventions that was put in place for Resident #1 was increase rounding, education to use call light, medical work up and fall mats. The DON stated that staff was made aware of new fall interventions via the Kardex. The DON stated the Kardex listed if a resident needed a fall mat. The DON stated that Resident #1 should have a fall mat at bedside when he was in bed. The DON stated when the ADON added information about the fall mat on the Kardex they also informed staff. The DON stated that the Kardex was trigged by the care plan. The DON stated brakes on the wheelchair can be locked or unlocked as long as they was locked before the resident got into the wheelchair. The DON stated staff and residents was educated on locking the brakes before residents get into the wheelchair. During an interview on 01/23/2026 at 5:21 PM, with utilization of Spanish translator, CNA E stated she was assigned to work with Resident #1 on 01/23/2026 from 6:00 am to 2:00 pm. CNA E stated that she assisted Resident #1 with getting up today and helped him shower. She stated that later she helped him get into bed around 2:00 PM. CNA E stated that Resident #1 had a fall mat in his room and she put it down when she helped him to bed. CNA E stated that she was supposed to lock brakes on the wheelchair when the resident was not using it. CNA E stated that she got information on the resident from the Kardex of the POC (point of care). During an interview n 01/23/2026 at 5:26 PM, the ADM stated that falls was discussed the following day at morning meeting. The ADM stated that it is discussed what interventions needed to be implemented and this could include adding a fall mat for a resident. The ADM stated when a fall mat is added it went into the Kardex and communicated to staff verbally, but often that was not reliable. The ADM stated that anytime Resident #1 was in bed he should have a fall because it is an intervention that is in place. The ADM stated that Resident #1's orientation fluctuates, he is oriented to personal, place and generally time. Review of facility policy titled Fall Management System with revision date of 04/2025 reflected after a fall, summary of the investigation will and recommendations will be documented in the resident's clinical record and the resident's care plan will be update and provide each resident with interventions to prevent falls and to minimize complications if falls occur. Review of facility policy titled Comprehensive Person-Centered Care Planning with revision date of 04/2025 reflected the facility shall develop a person centered care plan that meets the residents medical, nursing and psychosocial need. The facility policy reflected interventions were actions, treatments, procedures or activities designed to meet an objective. Review of facility in-services reflected an in-service was conducted on 12/2/2026 with all staff over the topic fall prevention. Further review reflected no in-service specifically addressing Resident #1's increase in falls.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and hazards. The facility failed to ensure that Resident #1 had a fall mat next to his bed while he was in bed and failed to ensure Resident #1's brakes was locked on his wheelchair 01/23/2026. This failure could place residents at risk of unsafe transfers, injuries, and/or hospitalization. Findings include:Review of Resident #1 face sheet reflected a [AGE] year-old-male admitted on [DATE] with diagnoses of schizoaffective disorder (chronic mental health condition that has symptoms of hallucinations, delusions and or disordered speech), chronic obstructive pulmonary disease (a progressive lung condition characterized by symptoms like shortness of breath, chronic cough), repeated falls, vascular dementia (changes in thinking caused by impaired supply of blood to the brain) , muscle wasting and atrophy (loss of muscle tissue or shrinking muscle mass) and anxiety disorder (group of mental health conditions characterized by excessive fear and worry that interfere with daily life). Review of Resident #1 quarterly MDS dated [DATE] reflected a BIMS score of 14 (which indicated no cognitive impairment). Review reflected Resident #1 required partial/moderate assistance (helper does less than half the effort) to go from sitting to lying, and lying to sitting edge of bed. Review reflected Resident #1 was dependent (helper does all of the effort) for chair/bed-to-chair transfers. Review reflected Resident #1 had a history of falls with no injury. Review of Resident #1 care plan dated 01/21/2026 reflected Resident #1 had a fall on 01/20/2026 and 01/17/2026 with intervention to implement fall mat at bedside for safety dated 01/19/2026 and bed in lowest position. Review reflected Resident #1 was at risk for falls related to vascular dementia and incontinence dated 03/14/2022 with interventions to maintain a clear pathway free of obstacles. Review of Resident #1 incident report dated 01/17/2026 reflected Resident #1 was found on floor and stated he tried to get to his wheelchair. Review reflected IDT met to discuss fall and fall mats was added and care plan updated. Review of Resident #1's Kardex report dated 01/23/2026 reflected under the safety section implement fall mats at bedside for safety. During an observation and interview on 01/23/2026 at 2:29 PM, Resident #1 was observed in bed, he stated that he had falls in the past. Resident #1 stated that now he asked for help to get in and out of bed. Resident #1's bed was observed in a low position with wheelchair placed on the left side of the bed. Observation revealed wheelchair brakes was unlocked on both sides of the wheelchair. Observation revealed that Resident #1 did not have a fall mat on either side of his bed. Observation on 01/23/2026 at 3:20 PM, revealed Resident #1 laid in bed, the wheelchair was unlocked and no fall mat at bedside. During an interview on 01/23/2026 at 2:49 PM, CNA A stated that fall prevention included to keep eyes on a resident, put the resident's bed in low position and to have their call light in reach. CNA A stated if the wheelchair is at bedside, the brakes should be locked. CNA A stated it was important for the brakes to be locked in case the resident went to sit in the chair it could roll out from under them. CNA A stated fall mats was usually next to the bed when the resident was in bed. If the resident was up, fall mats would be put away. CNA A stated that she was aware which residents was a fall risk based on what the nurses report or therapy reported. CNA A stated she could go into the Kardex (summary of resident's care) and it showed if residents needed assistance with transfers and if they were a fall risk. During an interview on 01/23/2026 at 2:57 PM, RN B stated that fall prevention included fall mat, frequent rounding and offering to toilet the resident. RN B stated fall mats was supposed to be positioned on the resident's dominate side of the bed, right next to the bed so the resident did not get hurt if they had a fall. RN B stated the brakes should also be locked if the wheelchair was at the bedside because it could move and slide away from them and cause the resident to fall. During an interview on 01/23/2026 at 3:09 PM, LVN C stated that fall prevention included to ensure wheelchair brakes was locked, call light was within reach, and bed in low position. LVN C stated that fall mats was placed on the floor next to the bed. LVN C stated it was important that the fall mat be at the bedside in case they fall. LVN C stated that if wheelchair was at bedside, it was supposed to have the brakes locked in case the resident tried to get out because the wheelchair could move and cause the resident to fall. LVN C stated that you can find if a resident needed a fall mat in their care plan. During an interview on 01/23/2026 at 3:21 PM, CNA D stated fall prevention included rounding on high risk fall residents. CNA D stated Resident #1 was a high fall risk. CNA D stated fall prevention included to put the bed in low position and encourage the resident to use the call button. CNA D stated Resident #1 thought he was independent. CNA D stated that Resident #1 did not have a fall mat, but that his bed was kept in low position and kept wheelchair close by. CNA D stated that wheelchair brakes were supposed to be locked. CNA D stated it was important that the brakes were locked in case the resident tried to climb on it. CNA D stated if the wheelchair brakes were locked the wheelchair would not slip out from under the resident. CNA D stated if the brakes were unlocked it could cause the resident to fall during the transfer. During an interview on 01/23/2026 at 4:32 PM, the DON stated Resident #1 had an increase in falls. The DON stated some interventions that were put in place for Resident #1 was increased rounding, education to use call light, medical work up and fall mats. The DON stated that staff were made aware of new fall interventions via the Kardex. The DON stated the Kardex listed if a resident needed a fall mat. The DON stated that Resident #1 should have a fall mat at bedside when he was in bed and was important to have the fall mat there in cause Resident #1 tried to get up. The DON stated when the ADON added information about the fall mat on the Kardex they also informed staff. The DON stated that the Kardex was triggered by the care plan. The DON stated brakes on the wheelchair can be locked or unlocked as long as they were locked before the resident got into the wheelchair. The DON stated staff and residents were educated on locking the brakes before residents get into the wheelchair. During an interview on 01/23/2026 at 5:05 PM, ADON stated that she tried to work with Resident #1 on 01/23/2026, but he needed to be changed and toileted and this was around 11:00 AM. The ADON stated that the safest way to leave brakes on the wheelchair was locked in cause the resident tried to transfer. The ADON stated locked brakes prevented the wheelchair to slide away. During an interview on 01/23/2026 at 5:21 PM, with utilization of Spanish translator, CNA E stated she was assigned to work with Resident #1 on 01/23/2026 from 6:00 am to 2:00 pm. CNA E stated that she assisted Resident #1 with getting up today and helped him shower. She stated that later she helped him get into bed around 2:00 PM. CNA E stated that Resident #1 had a fall mat in his room and she put it down when she helped him to bed. CNA E stated that she was supposed to lock brakes on the wheelchair when the resident was not using it. CNA E stated that she got information on the resident from the Kardex of the POC (point of care). During an interview on 01/23/2026 at 5:26 PM, the ADM stated that falls was discussed the following day at morning meeting. The ADM stated that it is discussed what interventions needed to be implemented and this could include adding a fall mat for a resident. The ADM stated when a fall mat is added it went into the Kardex and communicated to staff verbally, but often that was not reliable. The ADM stated that anytime Resident #1 was in bed he should have a fall because it is an intervention that is in place. The ADOM stated that a fall mat should be used when a resident was in bed. The ADM stated that if staff noticed the fall mat was out of place it should be returned as some residents could move the fall mat. The ADM stated brakes should be locked on the wheelchair so it did not slide out when the resident attempted to self transfer into it. The ADM stated that Resident #1's orientation fluctuates, he is oriented to personal, place and generally time. The ADM stated Resident #1 was strong willed and does not always ask for help. Review of facility policy titled Fall Management System with revision date of 04/2025 reflected the facility would provide an environment that remains as free of accidents and hazards as possible and provide each resident with interventions to prevent falls and to minimize complications if falls occur. Review of facility in-services reflected an in-service was conducted on 12/2/2026 with all staff over the topic fall prevention. Further review reflected no in-service specifically addressing Resident #1's increase in falls.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services timely to maintain good grooming and personal hygiene for 5 of 10 residents (Resident #35, and Resident #48, Resident #107, Resident #114, and Resident #117) reviewed for ADLs. The facility failed to ensure Resident #35, Resident #48, Resident #107, Resident #114, and Resident #117 briefs were changed timely. This failure could place residents at risk of not receiving care services, diminished quality of life, and decreased self-esteem.Findings included: Record review of Resident #35's Face Sheet, dated 01/07/2026, reflected an [AGE] year-old female, admitted [DATE] with diagnoses that included need for assistance with personal care, cognitive communication deficit (a condition that affects how individuals think and communicate), lack of Coordination (refers to difficulty in executing controlled, purposeful movements), muscle wasting and atrophy (wasting or thinning of muscle mass), and paroxysmal atrial fibrillation (a type of irregular heartbeat).Record review of Resident #35's quarterly MDS dated [DATE], reflected a BIMS Score of 12, which indicated cognitively intact.Record review of Resident #35's Care Plan, dated 09/12/2025, reflected Resident #35 required supervision and modified independence with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #35 to maintain current level of function with assistance in his daily living care needs.Record review of Resident #48's Face Sheet, dated 01/07/2026, reflected an [AGE] year-old female, admitted [DATE] with diagnoses that included need for assistance with personal care, muscle wasting and atrophy (wasting or thinning of muscle mass),atrial fibrillation (a type of irregular heartbeat), and glaucoma (many diseases involving eye pressure increases that lead to permanent vision loss and blindness).Record review of Resident #48's quarterly MDS dated [DATE], reflected a BIMS Score of 15, which indicated cognitively intact.Record review of Resident #48's Care Plan, dated 01/07/2026, reflected Resident #48 required modified independence with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #48 to maintain current level of function with assistance in his daily living care needs.Record review of Resident #107's Face Sheet, dated 01/07/2026, reflected an [AGE] year-old male, admitted [DATE] with diagnoses that included need for assistance with personal care, cognitive communication deficit (a condition that affects how individuals think and communicate), lack of coordination (refers to difficulty in executing controlled, purposeful movements), muscle weakness (a lack of muscle strength), muscle wasting and atrophy (wasting or thinning of muscle mass), paroxysmal atrial fibrillation (a type of irregular heartbeat), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and retention of urine (inability to empty the bladder when urinating).Record review of Resident #107's quarterly MDS, dated [DATE], reflected a BIMS Score of 15, which indicated cognitively intact.Record review of Resident #107's Care Plan, dated 09/29/2025, reflected Resident #107 required supervision and modified independence with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #107 to maintain current level of function with assistance in his daily living care needs.Record review of Resident #114's Face Sheet, dated 01/07/2026, reflected an [AGE] year-old female, admitted [DATE] with diagnoses that included need for assistance with personal care, muscle weakness (a lack of muscle strength), lack of coordination (refers to difficulty in executing controlled, purposeful movements), cognitive communication deficit (a condition that affects how individuals think and communicate), muscle wasting and atrophy (wasting or thinning of muscle mass), alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), and urinary tract infections (an infection in any part of the urinary system. The urinary system includes kidneys, ureters, bladder and urethra).Record review of Resident #114's quarterly MDS, dated [DATE], reflected a BIMS Score of 14, which indicated cognitively intact.Record review of Resident #114's Care Plan, dated 07/23/2025, reflected Resident #114 required modified independence with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #114 to maintain current level of function with assistance in his daily living care needs.Record review of Resident #117's Face Sheet, dated 01/07/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included lack of coordination (refers to difficulty in executing controlled, purposeful movements), muscle weakness (a lack of muscle strength), muscle wasting and atrophy (wasting or thinning of muscle mass), cerebrovascular disease (disease includes a variety of medical conditions that affect the blood vessels of the brain and the cerebral circulation), and peripheral vascular disease (a disorder of the blood vessels outside the heart that affects blood flow to the limbs).Record review of Resident #117's quarterly MDS, dated [DATE], reflected a BIMS Score of 15, which indicated cognitively intact.Record review of Resident #117's Care Plan, dated 10/13/2025, reflected Resident #117 required modified independence with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #117 to maintain current level of function with assistance in his daily living care needs.In an interview on 01/06/2026 at 10:26 a.m., Resident #114 stated she had not addressed the facility about this, but there have been times the staff took too long to check her to change her brief. Resident #114 stated if staff checked her brief, sometimes she had not wet the brief yet and a few minutes later she ended up going in the brief and had to wait for the next round in 2 hours to be checked by staff. Resident #114 stated she wanted it addressed to the facility. During an observation on 01/06/2026 at 10:26 a.m., Resident #114 appeared to be well groomed and clean. In an interview on 01/06/2026 at 10:30 a.m. Resident #35 stated sometimes staff had a lot to do with other residents requiring more assistance, but there were times staff took longer than every two hours to check briefs. Resident #35 stated to let the facility know.During an observation on 01/06/2026 at 10:30 a.m., Resident #35 appeared to be well groomed and clean. In an interview on 01/06/2026 at 11:18 a.m., Resident #48 stated the staff could do better by changing briefs on time. Resident #48 stated sometimes it was over three hours before her brief was changed. Resident #48 stated it did not make her feel good when her brief was not changed timely.During an observation on 01/06/2026 at 11:18 a.m., Resident #48 appeared to be well groomed and clean. In an interview on 01/07/2026 at 9:44 a.m., Resident #107 stated sometimes it could be within five minutes or over one hour he waited to have his brief changed and it was not consistent. Resident #107 stated he did not like wearing soiled brief. Resident #107 stated he wanted the facility to be notified of the delay in care. During an observation on 01/07/2026 at 9:44 a.m., Resident #107 appeared to be well groomed and clean. In an interview on 01/07/2026 at 11:00 a.m., Resident #117 stated sometimes he needs his brief change during shift changes, and the staff leave instead of changing him. Resident #117 stated it sometimes takes the oncoming shift a long time to make their rounds and change his brief. Resident #117 stated he felt staff waited for the next shift to change his brief. During an observation on 01/08/2026 at 11:13 a.m., CNA G and CNA H performed resident care for Resident #48. CNAs changed gloves and cleaned hands in between changing gloves. Resident #48's brief was moderately wet, peri (a hygiene practice involving the cleaning and maintenance of the genital and anal regions, known collectively as the perineum.) area appeared clean, and no urine like smell was noticed. There was redness at the top epidermal layer excoriation (refers to as skin picking or dermatillomania, is characterized by the repetitive picking, scratching, or rubbing of the skin. This behavior removes the skin's outer layers, resulting in abrasions, erosions, or open wounds) was observed on Resident #48's right buttock. In an interview and observation on 01/08/2026 at 11:15 a.m., Resident #48 stated his right buttock hurt where the redness was located when she laid on it. CNA G and CNA H jointly stated that they did not have barrier cream (ointment cream) with them in which they are trained to apply cream on residents during changes, but they would apply the cream next time and continued to change Resident #48's brief. In an interview on 01/08/2026 at 1:28 p.m., the DON stated the facility does not have a specific ADL care policy on brief changes. In an interview on 01/08/2026 at 3:45 p.m., CNA A stated she worked at the facility for seven years. CNA A stated she received training a month ago on ADL care and changing resident briefs timely. CNA A stated ADL care and changing resident briefs timely training went over making sure residents were changed every 45 minutes to an hour to prevent skin breakdowns. CNA A stated rounds should be done every hour, including checking residents' briefs. CNA A stated ADL care and changing resident briefs timely was monitored by all nursing staff. CNA A stated it was the responsibility of nursing staff to ensure ADL care and changing resident briefs timely was taking place. CNA A stated if ADL care and timely brief changing were not taking place, it could affect and diminish the resident's quality of life by potentially making residents feel staff did not care about them, skin breakdowns, and urinary tract infections. CNA A stated it was ultimately the overall responsibility of the DON to ensure ADL care and timely changing resident briefs were conducted.In an interview on 01/08/2026 at 4:05 p.m., LVN B stated she worked at this facility for eight years. LVN B stated she received ADL care and changing resident briefs timely training a month ago and nursing staff were reminded daily. LVN B stated ADL care and changing residents briefs timely training goes over to prevent skin damage, kept residents comfortable with having to dry as well as clean briefs, and not putting briefs on too tight. LVN B stated ADL care and changing resident briefs timely are monitored by all nursing staff, and staff were in-serviced about it. LVN B stated she has not received complaints from residents that staff were taking a long time to change their briefs. LVN B stated it's the responsibility of nursing staff to ensure ADL care and changing resident briefs timely is taking place. LVN B stated if ADL care and changing resident briefs timely aren't taking place, it can affect and diminish the resident's quality of life by potentially making them feel uncomfortable wearing a soiled brief, affect the resident's dignity, and cause issues to the residents' skin. LVN B stated it's ultimately the overall responsibility of the nurses and management to ensure ADL care and changing resident briefs were conducted timely for all residents. In an interview on 01/08/2026 at 5:19 p.m., the DON stated she had worked at the facility for three years and 11 months. The DON stated ADL care and changing resident briefs timely training went over peri care, and how to put on and take off briefs. DON stated she received ADL care and changing resident briefs timely training in October 2025. DON stated ADL care and changing resident briefs timely is monitored by charge nurses. DON stated it's the responsibility of nursing staff to ensure ADL care and changing resident briefs timely is taking place. DON stated if ADL care and changing resident briefs timely aren't taking place, it can affect and diminish the resident's quality of life by potentially getting skin breakdowns. DON stated it's ultimately the overall responsibility of the DON to ensure ADL and changing resident briefs are conducted timely. In an interview on 01/08/2026 at 5:40 p.m., the ADM stated he worked at the facility since August 2021. The ADM stated received ADL care and changing resident briefs timely training to prevent skin breakdown. ADM stated he is not certified to conduct brief changes. ADM stated ADL care and changing resident briefs timely training goes over making sure residents are changed every two hours and if they aren't dirty, they won't be changed as well as some residents did not want to be woken up. ADM stated ADL care and changing resident briefs is more for the nursing staff. The ADM stated ADL care and changing resident briefs timely is monitored by all nursing staff going from DON down to the CNA level. ADM stated it's the responsibility of DON to ensure ADL care and changing resident briefs timely is taking place by all nursing staff at the facility. The ADM stated if ADL care and changing resident briefs timely aren't taking place, it can affect and diminish the resident's quality of life by potentially causing physiological issues, skin breakdowns, and urinary tract infections. ADM stated it's ultimately the overall responsibility of the ADM to ensure ADL care and changing resident briefs are conducted timely by the facility staff. ADM stated it's his expectation that all staff are changing residents' briefs and ensuring they are helping residents' wellbeingRecord review of Resident #48's facility orders, dated 4/10/2025, reflected apply barrier cream with each brief change on every shift.Record review of facility in-service education for peri care with ADL's, dated 08/29/2025, reflected to have been provided and completed by all staff, including CNA A, CNA G, CNA H, LVN B. Record review of Nursing Services ADLs policy, dated 05/2007, reflected: Nursing service staff cares for its residents in manner and in an environment that promotes maintenance or enhancement of each residents' quality of life and promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Residents receive assistance as needed to manage their physical needs which includes personal hygiene grooming, dressing, toileting, transferring, ambulating and eating. Each Resident is assessed for their ability to perform ADLs and the assistance needed, and a plan of care is developed, and interventions are implemented based on their needs, goals of care and preferences.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for nutrition services. 1.The facility failed to ensure sanitation practices (cleaning the ice machine).2. The facility failed to label and date all food items in the kitchen. These failures could place residents at risk of foodborne illness. Findings included: Observation on 1/6/26 at 9:09 am of the facility kitchen revealed the ice machine had black and brown mold appearing substance growing on the inside of the ice machine. Further observation revealed the ice machine maintenance log's last recorded maintenance was dated 12/25.Observation on 1/6/26 at 9:11 am of the facility kitchen revealed a tray with 13 bowls containing cream of wheat or grits next to the steam table serving line undated and unlabeled.Observation on 1/6/26 at 9:12 am of the facility kitchen revealed a saucepan with melted butter on stove with ladle in pan uncovered, undated, and unlabeled.Observation on 1/6/26 at 9:14 am of the facility kitchen's reach in refrigerator revealed:-tray of bowls of oatmeal with label dated 1/2/26 as prep date no discard date recorded -container of chicken salad dated 12/26/25; receipt date, open date, or discard date not indicated.-To Go container dated 1/6/26 with a name marked on it.-container of Pico de Gallo dated 1/4/26 receipt date, preparation/open date, or discard date not indicated. Observation on 1/6/26 at 9:19 a.m. of the facility kitchen walk-in cooler revealed:-Ziploc bag of waffles dated 1/3/26 preparation date or discard date not indicated.-Container of cheesy potatoes dated 1/5/26 preparation date or discard date not indicated.-Container of vegetable blend dated 1/2/26 preparation date or discard date not indicated.-Container of BBQ sauce dated 1/5/26 preparation date or discard date not indicated.-Container of beans dated 1/1/26 preparation date or discard date not indicated.Observation on 1/6/26 at 9:21 a.m. of facility kitchen walk-in freezer revealed - Ziploc bag of chicken tenders dated 1/2/26 preparation date or discard date not indicated.Observation on 1/6/26 at 9:30 a.m. of facility nourishment room on the long-term care side of the facility revealed signage on refrigerator door stating all food must be labeled and dated. Expired and unlabeled food will be disposed of. Opened food can only be stored in refrigerator for three days. Further observation revealed: -container of blue bell ice cream undated and unlabeled.-bag of popsicles and ice cream cones, undated and unlabeled, with one ice cream cone, packaging open. Observation on 1/6/26 at 12:30 p.m. of the facility nourishment room on the skilled side of the facility revealed: - To go glass with frozen liquid in freezer unlabeled and undated.Observation on 1/7/26 at 11:37 a.m. of kitchen reach in refrigerator revealed: -container of tuna salad dated 1/3/26 preparation date or discard date not indicated.-container of grits dated 1/3/26 preparation date or discard date not indicated.Observation on 1/7/26 at 11:47 a.m. of skilled side of facility nourishment room revealed: -Reusable shopping bag with to go container and plastic containers of food items unlabeled and undated.-Disposable shopping bag with one 20 oz bottle of soda and to go container of food unlabeled and undated.Interview on 1/8/26 at 4:30 p.m,, DA E stated they were in their position for three months and received dietary aide training (basic job duties, meal types, kitchen cleaning, food preparation, basic kitchen maintenance, ANE, and Resident rights). DA E stated the process for labeling and dating food items was to use the FIFO method, food items were dated upon receipt, dated upon opening or preparation, dated with expiration or discard date. DA E stated the truck was received and items put away by the DM and the dietary staff are responsible for dating food items with the opening/preparation date and the discard/expiration date. DA E stated the ice machine was cleaned nightly by the dietary aides and it must be shut off, emptied, wiped clean with sanitizer, let it dry, then plugged in and it refilled. DA E stated there were daily and weekly cleaning lists completed. When asked if food items were not properly labeled and dated, how it could negatively affect a resident, DA E stated it could make residents sick. When asked if the ice machine was not properly cleaned how it could negatively affect a resident DA E stated it could be because of salmonella.Interview on 1/8/26 at 4:53 p.m., [NAME] F stated that she was in this position for five years. [NAME] F stated at this facility she received three days of training because she had prior experience cooking at a different facility. [NAME] F stated her training was to get familiar with this facility and their way of doing things. [NAME] F stated that all food items were labeled and dated and that it was the cook's responsibility to label and date all food items when they were prepared. [NAME] F stated for cleaning the ice machine that all the inside was cleaned and then cleaned all of the outside. [NAME] F stated that the dietary aides were responsible for cleaning the ice machine every day because the corners developed mold in them. [NAME] F stated the maintenance director cleaned the ice machine once a week. [NAME] F stated if food items were not properly labeled and dated and if the ice machine was not cleaned it could be a big problem for residents and they could have stomach issues.Interview on 1/8/26 at 3:37 p.m., CNA A stated she worked at the facility for seven years. CNA A stated she received ANE training roughly two weeks ago and Resident Rights training about two months ago. CNA A stated all food items should be labeled and dated daily for anything in the resident nourishment room refrigerator. CNA A stated it depended on if the food item comes from the kitchen, then the kitchen was responsible for labeling and dating but if the item was something the family brought in then the nursing staff was responsible for labeling and dating those items. CNA A stated it could negatively affect a resident if food items were not properly labeled and dated by the residents getting food poisoning. CNA A stated she thought the DM was responsible for assigning kitchen staff to clean the ice machine. CNA A stated it could negatively affect a resident if the ice machine was not properly cleaned by giving them diarrhea or vomiting if the ice was contaminated.Interview on 1/8/26 at 5:03 p.m., the DM stated he was in the position for 4 years and 3 months. DM stated food items must be labeled upon receipt and then again upon preparation and they are good for 72-96 hours depending on the food item. DM stated if foods were prepared or opened, then a discard or expiration date was needed. DM stated all kitchen staff were responsible for labeling and dating. DM stated his expectation from staff was that staff would date upon receipt, date as soon as prepared with preparation date and discard date. DM stated the kitchen staff clean the inside, outside, and filters of the ice machine daily and the MD does a deep clean monthly on the ice machine. DM stated the DAs are responsible for the daily cleaning of the machine and the MD is responsible for the monthly deep clean of the machine. DM stated it was his expectation that the ice machine needs to be spotless when the ice machine is cleaned and that he wants the machine to shine when the staff are done. DM stated if foods are not properly labeled and dated that it could absolutely affect the residents with foodborne illness. DM stated it could negatively affect the residents if the ice machine was not cleaned properly by causing the residents to become sick. Interview on 1/8/26 at 5:12 p.m., the DON stated she was employed with the facility for three years and 11 months. The DON stated food items were dated upon receipt. The DON stated the kitchen staff date the items from the kitchen and nursing staff date items the residents bring in. Items are good for only 3 days and ADON's check the refrigerators in the morning. DON stated staff should not be putting their items in the refrigerator as they have a break room. DON stated it was her expectation that all food items are labeled and dated when they are placed in the nourishment room refrigerators. DON stated if food items are not bad it will not hurt a resident but that all items should have a date on them. DON stated she was unsure of the process for cleaning the ice machine as that is something the DM and MS take care of. DON stated the MS, and the kitchen staff are responsible for cleaning the ice machine. The DON stated it could probably negatively affect a resident if the ice machine was not properly cleaned but she was unsure as to how besides that it would be gross. Interview on 1/8/26 at 5:41 p.m., the ADM stated all items should be labeled and dated upon receipt ASAP, when prepared. Unsure if a discard date is needed. The kitchen staff and the individual placing the items in the fridge for the nourishment rooms are responsible for labeling and dating food items. It is my expectation that food labeling and dating is done appropriately by policy. The ice machine is cleaned daily by kitchen staff and monthly by MS staff. The responsibility of the ice machine cleaning is the kitchen staff and MS. ADM stated it is their expectation for the ice machine cleaning that it gets done according to policy. The ADM stated it could negatively affect a resident if the food items were not properly labeled and dated and if the ice machine was not properly cleaned.Record review of facility Labeling and dating for safe storage of food policy, dated with a revision date of 2/2025, reflected under heading policy:Labeling and dating are critical to promoting food safety. The use of use-by-date is also reviewed below.-All products should be dated within 30 minutes of receipt.-Use Use-by-dates on all food once opened and stored under refrigeration.-If commercially processed foods come marked with an expiration or use by date there is no need to mark a use by date on the products.-When food is taken out of an original container write the name of the food being stored on the container and the use by date. Record review of the facility Trayline refrigerated leftover storage policy with a revision date of 3/2025 reflected under heading policy:Appropriate storage, rotation, and disposal of leftover food is essential to ensure appropriate food safety.-Leftovers must have a legible date in a visible location, with the date reflecting the day that the food was prepared.-Any stored leftovers must be used within 72-96 hours of the prepat=red date. If they are not used in that timeframe, they must be disposed of.Record review of facility Kitchen sanitation and food safety policy, dated with a revision date of 10/2024, reflected under heading Overview: Foodborne illness in compromised older adults may result in serious complications such as severe illness, need for hospitalization, or even death. Therefore, sanitary conditions must be present in the facility's kitchen to promote safe food handling and to prevent foodborne illness. Kitchen equipment: Key elements-The ice machine is clean inside and out.-The ice machine cleaning schedule is posted and maintained.Food storage: Key elements-Food items in the refrigerators are covered/sealed, labeled, dated, and shelved to allow air circulation.-Food items in the freezers are covered/sealed, labeled, dated, and shelved to allow air circulation.-Dry food storage is clean, covered/sealed, and dated.Record review of Cleaning Schedule undated reflected Saturday-Walk in freezer & Cooler, Ice MakerRecord review of (PM) Dietary Aide Closing Checklist /Responsibilities undated-Ice Maker (Inside & Outside) & Filters Cleaned with Yes and No and spaces for a check to be completed next to the response further review reflected cleaning checklist with a signature line and date line. Further record review reflected checklists reviewed for dates 12/31/25-1/6/26 with all being checked Yes that the ice machine was cleaned.Record review of kitchen in-services reflected: -In-service dated 9/15/25 titled Following cleaning lists with 9 staff signatures.-In-service dated 11/30/25 titled Proper labeling & dating food items with 8 staff signatures.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodations to meet the needs and preferences for 1 of 4 residents (Resident #16) reviewed for accommodations. The facility failed to ensure Resident #16 had the call light button in reach while lying in bed.This failure could place residents at risk of injury, not receiving timely care or receiving nursing interventions to meet the resident's needs, and/or it could make the resident feel neglected affecting their mental health. Findings included: Record review of Resident #16's Face Sheet, dated 01/07/2026, reflected a [AGE] year-old male, admitted [DATE] with diagnoses that included need for assistance with personal care, cognitive communication deficit (a condition that affects how individuals think and communicate), lack of coordination (refers to difficulty in executing controlled, purposeful movements), abnormalities of gait and mobility (referred to the way an individual moved and walked), muscle weakness (a lack of muscle strength), and traumatic brain injury ( a brain injury that was caused by an outside force).Record review of Resident #16's quarterly MDS, dated [DATE], reflected a BIMS score of 13, which indicated cognitively intact.Record review of Resident #16's Care Plan, dated 08/18/2025, reflected Resident #16 required supervision and modified independence with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goal was for Resident #16 to maintain current level of functioning with assistance in his daily living care needs. Record review of Resident #16 Care Plan for call light, initiated on 08/18/2025, reflected for all facility staff to be sure the call light was within reach and encouraged Resident #16 to use it to call for assistance as needed. Record review of facility in-service education for call lights conducted on 09/26/2025 and 12/05/2025 reflected to have been provided and completed by all facility staff. During an observation on 01/06/2026 at 12:15 p.m., Resident #16's call light was on the floor out of his reach. Resident #16 was not able to reach it. Resident #16 appeared to struggle with getting the call light and was not able to get out of bed to grab the call light off the floor. Resident #16 appeared to be well taken care groomed and clean. In an interview on 01/06/2026 at 12:15 p.m. Resident #16 stated staff have not put the call light near him since moving to this new room. Resident #16 stated not having the call light button next to him would stop him from getting assistance with things he may need and did not want that to happen. Resident #16 stated he did not want to feel isolated by not having the call light button near him. In an interview on 01/08/2026 at 3:45 p.m., CNA A stated she worked at the facility for seven years. CNA A stated she received call light training a week ago. CNA A stated call light training went over response times and 20 minutes was too long. CNA A stated call light response times should be within three to five minutes but staff needed to respond as soon as possible, in case of an emergency. CNA A stated the positioning of call lights should be within easy reach of the residents such as, on their lap or on the bedside table. CNA A stated call light placements were monitored by all nursing staff members. CNA A stated rounds should be done every hour with checking on residents. CNA A stated it is the responsibility of nursing staff to ensure call lights were in resident's reach. CNA A stated if call lights were not placed near residents, it could affect the resident's quality of life by not receiving assistance when needed and potentially not helping them in an emergency situation, putting residents in danger if they were on the floor. CNA A stated it was ultimately the overall responsibility of the DON and ADM to make sure residents had access to call lights.In an interview on 01/08/2026 at 4:05 p.m., LVN B stated she worked at this facility for eight years. LVN B stated she received call light training. LVN B stated call light training went over not leaving the call lights unanswered for more than 15 minutes, and for staff to respond to call lights as soon as possible. LVN B stated call lights should be positioned on the side residents were able to reach with their hands. LVN B stated she did not remember the last time she received call light training, but it was talked about daily. LVN B stated call light placements were monitored by all nursing staff. LVN B stated it was the responsibility of nursing staff to ensure call lights were in resident's reach. LVN B stated the nursing station had a call light board which notified them when call lights were turned on. LVN B stated if call lights were not placed near residents, or on the floor, it could affect the resident's quality of life by not receiving assistance when needed, the resident may not be feeling good, or potentially not help them in an emergency situation that could be fatal. LVN B stated call lights needed to be within reach to call for assistance other than the staff doing rounds every two hours. LVN B stated it was ultimately the overall responsibility of the DON to make sure residents had access to call lights. In an interview on 01/08/2026 at 5:19 p.m. the DON stated she had worked at the facility for three years and 11 months. The DON stated she received call light training last month. DON stated call light training went over call light responses, not to just turn off the call light, and make sure the call light was within reach for the residents. The DON stated call light placements were monitored by all nursing staff such as CNAs, nurses, and the DON. The DON stated it was the responsibility of nursing staff to ensure that call lights were in resident's reach, and she was responsible overall as the DON. The DON stated if call lights were not placed near residents, it could affect the residents' quality of life without receiving assistance when needed. The DON stated it was ultimately the overall responsibility of the DON to make sure residents had access to call lights. In an interview on 01/08/2026 at 5:40 p.m., the ADM stated he has worked at the facility since August 2021. The ADM stated he received call light training two to three months ago. ADM stated call light training went over placing call lights in proximity near the residents, and for staff to not turn off call lights when needs were not met. The ADM stated call light placements were monitored by all staff in the facility. The ADM stated it is the responsibility of all facility staff to ensure call lights were in resident's reach or if it was moved to make sure it was put in reach. ADM stated if call lights were not placed near residents, it could affect the residents' quality of life by not receiving assistance when needed and potentially not helping residents with their needs in an emergency situation. The ADM stated if call lights were on the floor, the residents would not be able to signal for help. The ADM stated it was ultimately the responsibility of the ADM to make sure residents had access to call lights and that facility staff were ensuring residents had access to call lights. The ADM stated it was his expectation that if staff noticed the call lights were not near residents, to make sure to put them back, and if call lights had fallen on the floor, staff needed to put it back in reach of the residents.Record review of Call Light policy, dated 05/2007, reflected: It is the policy of this facility to provide the residents with a means of communication with nursing staff. Place the call device within resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor.

Based on observation, interview, and record review, the facility failed to ensure residents remained free of any significant medication errors for 1 of 6 residents (Resident #63) reviewed for medication errors. The facility failed to ensure Resident #63 received unexpired insulin glargine (long-acting insulin) required for treating Type 1 Diabetes. This failure could place residents at risk of complications such as increased blood sugar and decline in health.Findings included:Record review of Resident #63's face sheet, dated 01/07/2026, revealed, an 85- years-old female admitted on [DATE] and readmitted on [DATE]. Resident #63's diagnoses included acute diastolic (congestive) heart failure (a sudden worsening of the chronic condition where the stiff left ventricle can't relax enough to fill properly, causing fluid backup (congestion) into the lungs/body, leading to severe shortness of breath, swelling, and fatigue), anxiety disorder (mental health conditions marked by intense, persistent, and excessive worry or fear about everyday situations, leading to significant distress and impairment in daily life), chronic obstructive pulmonary disease (a progressive lung condition making breathing difficult), and type 1 diabetes mellitus (a chronic autoimmune disease where the body mistakenly destroys insulin-producing cells in the pancreas, leading to insulin deficiency and high blood sugar). During an observation of the medication pass on 1/7/2026 at 8:12 a.m., LVN C checked the blood sugar of Resident #63 with results of 203 mg/dL (normal blood sugar range: 70-99 mg/dL) and administered insulin Glargine 10 units through subcutaneous injection (the injection was given in the fatty tissue, just under the skin) to Resident #63 without checking the expiration date of the medication. Per observation of the medication vial with insulin Glargine Solution 100 U/ML revealed the marked open date, 12/7/2025, which exceeded 28 days storage instructions for this medication on the nursing cart after opening. Per MAR review Resident #63 received 4 doses of expired medication. During an interview with LVN C on 1/7/2026 at 8:25 a.m., revealed she was trained in the last six months on the medication administration policy and was aware of checking an expiration date for each medication and each resident before administering medications. She stated she thought this insulin would expire after 30 days of opening and kept it unrefrigerated on the nursing cart. She stated that she was responsible for checking the expiration date of medication on her cart. She stated the potential risk for administering expired medication would be ineffectiveness of this medication to treat the residents' medical condition and could negatively affect their health. She stated Resident #63 was dependent on receiving insulin to control her blood sugar and this medication was very important for treating her health condition and it is essential to keep insulin potent.During observation of Resident #63 on 1/7/2026 at 8:35 a.m. she appeared well kept and without any signs of physical distress. Per interview of Resident #63 on 1/7/2026 at 8:37 a.m., she stated that she felt fine without any concerns to report.During an interview on 1/08/2026 at 3:05 p.m., the DON stated that nursing staff was responsible for checking expiration dates on medication carts every day and before administering medication. She stated the DON and ADONs spot checked the med carts for the expiration dates. She stated the pharmacist checked med carts monthly for expired meds and any other issues with medications. She stated all nurses had access to the medication expiration reference chart available on each nursing cart and nursing station to refer to in case they had questions regarding medication expiration times. She stated she provided in-services on medication errors (yesterday) and on as needed basis when they changed the pharmacy, and through computer training modules on an annual basis. She stated that the potential risk for residents if they received expired insulin would be uncontrolled blood sugar levels which could affect their BP, circulation and overall health due to ineffectiveness of the medication. She stated that med errors were documented, in-service was provided, and notifications were sent to the Medical Director, Administrator, and family of the residents.During an interview on 1/08/2026 at 3:45 p.m., the ADM revealed that nursing staff who administer medications were responsible for proper medication administration, and he relied on the DON to oversee in-services and to follow proper medication administration policy and procedure to avoid medication errors. He stated potential risk of administering expired medications, including insulin, would be ineffectiveness of those medications and worsening of residents' health. Record review of storage and expiration insulin policy, dated 5/2021, revealed that insulin vials of Lantus (insulin glargine) had 28 expiration days period after opening. Record review of medication orders for Resident #63, dated 08/09/2025, revealed the order for Insulin Glargine 100 unit/ml to inject 10 unit subcutaneously in the morning. Discard 28 days after 1st use. Record review of Resident #63's care plan, dated 09/28/2025, revealed Resident #67 was on insulin to manage her blood sugars, and she was at risk of impaired circulation related to Diabetes. Resident # 63 was at risk for hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) with ordered treatment through diabetes medication with interventions in place: monitor/document for side effects and effectiveness. Record review of Resident #63's MDS, dated [DATE], revealed Resident's BIMS score was 13 indicating intact cognitive status. Record review of Medication error report, dated 1/7/2026, revealed that insulin glargine given to Resident #63 on 1/7/2026 and dated 12/07/2025 (open date) should be discarded after 28 days of being opened. Record review of an in-service, dated 01/07/2026 and provided by the DON, revealed an in-service on insulin: please ensure before giving insulin that you check the dates on bottle to ensure open day is still within range of how long insulin can remain out and open from refrigerator. If not within date, throw away, get new insulin, and order new from pharmacy signed by 13 nurses including LVN C. Per record review of in-services for last six months, no other in-services on Medication Administration signed by LVN C was available. Record review of undated Medication administration policy (9.3 on page 16), revealed that facility staff should take all measures required by Facility Policy, Applicable Law, and the State Operation Manual when administering medications. Medications are administered as prescribed in accordance with good nursing principles and practices. Record review of undated Med Pass Policy revealed one of the required steps during med pass was, Check drug dose and expiration on all medications.

Based on observations, interviews and record reviews, the facility failed to ensure 1 (Resident #1) of 5 residents received necessary treatment and services, consistent with professional standards of practice reviewed for pressure ulcers. A facility staff failed to ensure Resident #1's orders for a low air loss mattress (LAL) to treat an unavoidable pressure ulcer was placed in the resident's electronic health records, and for the mattress to be ordered. Resident #1's pressure ulcers increased in size. This failure could place residents at risk of improper pressure ulcer management, deterioration of existing pressure injuries, infection, and pain. Findings included: Review of Resident #1's face sheet, dated 02/29/2024, revealed an [AGE] year-old-female who was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses of dementia (a medical term used to describe a group of symptoms affecting memory, thinking, and social abilities in people), Parkinson's Disease ( a chronic condition and progressive movement disorder that initially causes tremors, stiffness, or slow movement in affected parts of the body.), chronic venous insufficiency (malfunction of venous walls and/or valves in systemic circulation that result in peripheral pooling of blood known as stasis.), anxiety, and lack of coordination. Review of Resident #1's quarterly MDS assessment, dated 02/15/2024, revealed a BIMS of 06 indicating a severe cognitive impairment. Resident #1's MDS revealed that the resident is at risk of developing pressure ulcer/injuries. Further review of Resident #1's MDS revealed skin conditions, other ulcers, wounds, and skin problems: moisture associated skin damage (MASD). Additional review of Resident #1's MDS revealed skin and ulcer/injury treatments as application of non-surgical dressing (with or without topical medications) other than feet and application of ointment/medications other than to feet. Review of Resident #1's care plan, no date, revealed a focus of a potential for pressure ulcer development r/t (related to) decreased ADL ability, a goal of having intact skin, free of redness, blisters, or discoloration; and interventions/tasks to monitor nutritional status, monitor changes in skin status, notify nurse immediately for any new areas of skin breakdown, and weekly head to toe assessment. Additional review revealed Resident #1 has a focus of potential nutritional problems related to mechanical soft diet and dementia, with a goal to maintain adequate nutritional status; and with interventions to honor resident rights to make personal dietary choices and provide education as needed, monitor and report to MD as needed for any s/s (signs and symptoms) of decreased appetite, unexpected weight loss, stomach pain, and serve diet as ordered. Review of Resident #1's progress note, dated 02/29/2024, revealed on 02/28/2024 a nursing note text: At 0200 (02:00 a.m.) pt (Resident #1) had a T (temperature) 101.3, BP (blood pressure) 139/80, HR (heart rate) 136, O2 (oxygen) 95%, lung sounds clear, all quadrants. On call was notified and NP (nurse practitioner) said to call EMS (emergency medical services). NP notified family. Review of Resident #1's Hospital Records, date 02/29/2024, revealed Resident #1 admitted to the hospital on 02/28/2024 and arrived on 03:30 a.m., ED (emergency department) course revealed patient (Resident #1) arrived with tachycardia (heart rhythm disorder), hypertension (high pressure in the arteries) , and afebrile (often used to describe a fever that is not associated with an infection.) T 98.7 F (not feverish), CMP (comprehensive metabolic panel) unremarkable. CBC with mild anemia (11.6 Hb), right ischial (lower and back part of right hip bone) decubitus (bed sore) with osteomyelitis (infection in bone). Additional review revealed hospital physical exam temperature of 98.7 F, CBC with WBC (white blood cell count) at 10.4 (reference range of 4.4 to 10.8). Review of Resident # 1's physician progress note from wound care specialist, no date, revealed effective 02/21/2024 and created 02/27/2024, [AGE] year old female with Parkinson's disease and dementia who has developed pressure injuries over the coccyx and right buttock. Resident #1's wound exam revealed there are stage 2 sacral pressure injuries measuring 2.1 x 3.0 x 0.1 and 1.5 x 1.1 x 0.2 centimeters with minimal surroundings erythema (redness of the skin). There is an unstageable right ischial pressure injury measuring 2.2 x 1.5 centimeters with slough (dead skin tissue) present to the level of skin. There is minimal surrounding erythema. Plan: -Collagen with foam cover over sacral wounds three times a week. Medihoney with foam cover right ischial wound three times a week. -LAL mattress -Frequent Turning -Consider protein supplement Review of Resident #1's Skin Pressure ulcer Weekly, no date, revealed pressure ulcer 1 onset date 02/21/2024 in the Coccyx, stage 3, serous exudate type, moderate exudate amount, no odor, undefined edges. Further review revealed, pressure ulcer 2 onset date 02/21/2024 in the right gluteal fold, size 2.2 x 1.5, UTD (underdetermined) depth, serous exudate type, moderate exudate amount, no odor, wound bed normal for skin, undefined wound edges, erythema surrounding tissue. Additional documentation revealed: Resident (Resident #1) is now being followed by Wound Care Doctor, initial visit 2.21.24. no new orders noted. Stage III, previously noted as MASD, noted to Sacrum: 2.1 x 3 x 0.1, 1.5 x 1.1 x 0.2 (wound has progress to 2 adjacent areas. Periwound intact, friable. Edges diffuse, irregular. Wound bed 80 % pink tissue, 20 % epithelium. Moderate serous exudate noted. Unstageable P.U. (pressure ulcer), previously noted as MASD noted to Right Ischium: 2.2 x 1.5 x UTD. Periwound intact, friable. Edges diffuse, friable. Wound bed 40% pink tissue, 60 % yellow, moist, moderately adhered slough noted. Moderate serous exudate noted. Will treat as ordered. signed by LVN A on 02/26/2024. Review of Resident #1's orders, date 02/29/2024, revealed orders: -Magic Cup two times a day for supplement. Order status active. Order date 12/20/2023, start date 12/20/2023. -R gluteal fold; cleanse with ns (normal saline), pat dry, apply calcium alginate and cover with a bordered gauze dressing as needed for as needed if soiled, order status discontinued, order date 02/02/2024, start date 02/09/2024. - R gluteal fold; cleanse with ns (normal saline), pat dry, apply calcium alginate and cover with a bordered gauze dressing one time a day for wound care. Order status discontinued, order date 02/02/2024, start date 02/09/2024. -Sacrum opening: cleanse with ns, pat dry, apply calcium alginate and cover with bordered gauze dressing qd (every day) until resolved one time a day for wound care. Order status discontinued, order date 02/09/2024, start date 02/10/2024. -Sacrum: Cleanse with DWC, apply collagen sheet, cover with silicone border foam, every day shift for MASD. Order status discontinued. Order date 02/10/2024, start date 02/11/2024. -Right Ischium: Cleanse with DWC (Dakin's solution or sodium hypochlorite). Apply Medihoney. Cover with adaptic/oil emulsion dressing and silicone border foam. As needed for as needed if soiled. Order status discontinued, order date 02/10/2024, start date 02/10/2024. -Right Ischium: Cleanse with DWC (Dakin's solution or sodium hypochlorite). Apply Medihoney. Cover with adaptic/oil emulsion dressing and silicone border foam. As needed for as needed if soiled. Order status discontinued, order date 02/10/2024, start date 02/11/2024. -Arginaid Oral Packet (Nutritional Supplements) give 1 packet by mouth tow times a day for Wound Healing. Order status active. Order date 02/23/2024, start date 02/23/2024. -Right Ischium: Cleanse with DWC (Dakin's solution or sodium hypochlorite). Apply Medihoney. Cover with adaptic/oil emulsion dressing and silicone border foam. As needed for as needed if soiled. Order status active, order date 02/26/2024, start date 02/26/2024. -Right Ischium: Cleanse with DWC (Dakin's solution or sodium hypochlorite). Apply Medihoney. Cover with adaptic/oil emulsion dressing and silicone border foam. Every day shift for pressure ulcer. Order status active, order date 02/26/2024, start date 02/27/2024. -Sacrum: Cleanse with DWC, apply collagen sheet, cover with silicone border foam, every day shift for pressure ulcer. Order status active, Order date 02/26/2024, start date 02/27/2024. -P.T. Clarification order: POC (point of care) to include low frequency non thermal ultrasound mist wound care to sacrum and R ischium, 2x/week as indicated. Order status active. Order date 02/27/2024. -No order for LAL mattress as per wound care specialist plan on 02/21/2024. Review of Resident #1's skin/wound note, no date, revealed a note created on 02/26/2024, LVN A documented the following: Resident (Resident #1) is now being followed by Wound Care Doctor. Initial visit 2.21.24, no new orders noted. Stage III, previously noted as MASD, noted to sacrum: 2.1 x 3 x 0.1, 1.5 x 1.1 x 0.2 (wound has progressed to 2 adjacent areas. Periwound intact, friable. Edges diffuse, irregular. Wound bed 8- % pink tissue, 20 % epithelium. Moderate serous exudate noted. Unstageable P.U., previously noted as MASD noted to Right Ischium: 2.2 x 1.5 x UTD. Periwound intact, friable. Edges diffuse, friable. Wound bed 40% pink tissue, 60 % yellow, moist, moderately adhered slough noted. Moderate serous exudate noted. Will treat as ordered. Review of NP progress note, no date, appointment date and time 02/27/2024 at 10:18 p.m. revealed NP HPI (history of present illness), seen today per nurse request due to constipation. F/u (follow up) wounds on buttock and right thigh. She (Resident #1) is noted to have weight loss as well as wounds recently. Sacral wounds are noted to be worse than prior. She is sitting up in chair as usual. No fever or pain. No change of behavior or mood. Physical Exam, skin: -right ischium about 3.5 cm in diameter with 100% thick grayish slough, no surrounding erythema, no edema, or warmth. -right buttock about 3.3.5 cm dark red wound, small serious drainage, no surrounding erythema, edema. Further review revealed NP assessment/plan: -Pressure injury of sacral region of back-unstageable, seems bigger and worsened this is unavoidable given her age, severe malnutrition/FTT (failure to thrive) and progressive dementia probably not a healable wound, appropriate for palliative care/hospice care f/u wound care MD continue PT to assist wound cleaning with pressure NS wash 2x/week continue wound care daily continue measure to keep pressure off this region-Pressure ulcer of sacral region, unspecific stage. -Pressure injury of ischial tuberosity region of right buttock-Right Ischium, appears worsened, this unavoidable given her age, severe malnutrition/FTT (failure to thrive) and progressive dementia probably not a healable wound, appropriate for palliative care/hospice care f/u wound care MD continue PT to assist wound cleaning with pressure NS wash 2x/week continue wound care daily continue measure to keep pressure off this region-Pressure ulcer of sacral region, unspecific stage.-Pressure ulcer of unspecified buttock, unspecified stage. Review of Resident #1's TAR and MAR for February, dated 02/29/2024, revealed all discontinued and active orders for treatment and supplements completed with no inconsistencies. Observation and Interview on 02/29/2024 at 08:45 a.m., at the hospital family stated they have seen wound care completed on Resident #1, as well as dressing changes, and they were aware of Resident #1's issue with weight loss and the NP has been in communication. Family did state that Resident #1's likes to stay on her recliner chair in her room. Observation of Resident #1, in bed she does not appear disheveled, no signs of physical or emotional distress. Limited interview with Resident #1, states that the facility staff takes care of her. Interview on 02/29/2024 at 02:08 p.m., Hospital Physician revealed Resident #1's WBC was within the normal range at 10.4, and she believed the fever she initially presented with probably came from the wound, although we do not have any other source as her WBC was normal. The hospital physician added that the resident's weight loss could have played a part in the wound development. Interview on 02/29/2024 at 02:08 p.m., the Wound Care Doctor stated Resident #1 has an unstageable wound in her sacrum is unstageable, and the right ischial wound, I would characterize as it as more severe. The Wound Care Doctor stated we (with LVN A), treated Resident #1's wounds and retrieved measurements, whatever I noted in my notes are the dimensions, and my plan to treat was in the note as well. The Wound Care Doctor stated that the wounds were not bad after assessments, they were the size of a thumbnail and were so shallow without debri, we treated it and I gave orders for treatment with Medihoney, the low air mattress; I ordered the mattress that day (02/21/2024), out of all the orders the most important are the LAL mattress and the repositioning, if those don't get completed then that's when a wound could get worse. The Wound Care Doctor stated he met with LVN A on the 28th (02/28/2024) and spoke on Resident #1, and he was informed the wounds were healing. Observation and Interview on 02/29/2024 at 02:45 p.m., the DON stated the resident was sent to the hospital that day (02/28/2024) due to having an increase in temperature and heat rate, procedures followed, and the NP wanted to send her to the hospital. The DON stated if a MD.NP, or wound care specialist places and order, nurses are to place the orders in POC, you place all pertinent information in the resident's EHR so it can be administered to our residents. The DON did state that she is aware of Resident #1's issue with weight loss, and we have been meeting with the resident's dietician and the NP to intervene. The DON stated that for a mattress needed for wound care, LVN A would inform us in our morning meetings, and CS A will order the item or anything that is needed. The DON stated she is unsure of when they placed the LAL mattress in residents' room. Observation of Resident #1's room revealed no LAL mattress. The DON confirmed that no items have been moved or changed. Interview on 02/29/2024 at 03:24 p.m., CS A stated and confirmed that she orders supplies and specialized mattress for residents. CS A stated that the LAL mattress for Resident #1 was ordered yesterday (02/28/2024) and it was brought to her attention by the DON during the morning meeting, and It should be ready when Resident #1 comes back to the facility. CS A stated she was not informed by LVN A on ordering a LAL mattress for Resident #1 on 02/21/2024, CS A further confirmed that the mattress in Resident #1's room is not a LAL mattress. Interview on 02/29/2024 at 03:34 p.m., LVN A stated he is the wound care nurse for the facility, and he does round with Wound Care Doctor on Wednesdays. LVN A stated that during rounds I document and take notes from the Wound Care Doctor, that is how he processes the information for resident care. LVN A stated he recalls doing rounds with Wound Care Doctor on 02/21/2024 on Resident #1. LVN A stated, we saw the wound that day and I took orders for the Medihoney and foam dressing, the resident (Resident #1) had already had those orders because we were treating her MASD, and that we were supposed to get a LAL mattress for the resident. LVN A stated that the LAL mattress order was not placed in, and further stated, there is no particular reason for me not placing in the order for the mattress, I just dropped the ball on that. LVN A stated he was aware of how important the LAL mattress was for residents, and for Resident #1, if she did not receive it the wound would have deteriorated or gotten worse. LVN A stated he performed wound care on Resident #1 before she went to the hospital and the wounds were better than before. Interview on 03/01/2024 at 08:24 a.m., NP revealed the resident had multiple factors that could have contributed to the Resident #1's wound. NP stated, she (Resident #1) has Parkinson's disease, progressive dementia, she has been losing weight in that we are intervening on as we started talking with the family the dietician on supplements to stimulate her appetite. NP further stated, I referred her to the Wound Care Doctor as her MASD gotten worse despite treatment, and there is no evidence that would support that the lack of the mattress contributed to the Resident being admitted to the hospital, the wounds were unavoidable due to her conditions, and despite our treatment, I was not seeing that Resident #1 was absorbing her ordered supplements due to her condition. NP stated, I placed on my notes that her prognosis was poor, and I had placed that the pressure ulcers were unavoidable due to her conditions. Interview on 03/04/2024 at 08:38 a.m., ADM stated that if orders are given by any doctor or NP, they must be executed. The ADM stated that Resident #1 did not spend much time on her bed, Resident #1 wanted to lay on her recliner in her room, we would assure that she would be repositioned, and have the support wedges to alleviate pressure for Resident #1. The ADM stated despite our efforts Resident #1 would be reluctant with her repositioning despite the facility efforts, we would educate her and intervene although her choice was to remain on her recliner. Record Review for sampled Resident #2, 3, 4, and 5 revealed orders, care plans and treatments occurred, with no significant findings. On 02/29/2024 Physician orders were requested from the ADM; no Physician Orders policy was supplied. Review of the facility's Care and Treatment, subject Medication orders policy, revised 05/2007, reflected 2. Documentation of Medication Order: A. Each medication orders is documented in the resident's medical record with the date and time, and signature of the persons receiving the order. The order is recorded on the physician order sheet, or telephone order sheet if it is a verbal order and the Medication Administration Record (MAR). B. Clarify the order, enter the orders on the medication order and receipt record. Review of the facility's Wound Care and treatment Guidelines, revised 05/2007, revealed a policy, it is the policy of this facility to provide wound care to promote healing.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, for 1 of 2 residents (Resident #60) reviewed for oxygen in that: 1. The facility failed to ensure Resident #60's O2 tubing was dated. 2. The facility failed to ensure Resident #60's humidifier bottle and oxygen tubing were changed as ordered. These failures placed residents receiving oxygen as needed at risk for infections. The findings were: Record review of Resident #60's Admission Record , undated, revealed the resident was admitted to the facility on [DATE] with diagnoses that included Stroke, Hemiplegia (paralysis to one side of the body), Hemiparesis (weakness to one side of the body), Hypertension, Bipolar Disorder, Dementia, Other Reduced Mobility, Chronic Obstructive Pulmonary Disease and Dysphagia (difficulty swallowing). Record review of Resident #60's MDS dated ___ did not indicate the use of oxygen therapy. Record review of Resident #60's Order Summary Report , undated, revealed an order for Oxygen at 2L/min via nasal cannula for saturation <92% on room air with an order start date of 05/10/2023. The Report also reflected, Change O2 tubing and humidifier bottle, provide clean plastic bag with label to put in o2 tubing when not being used - every night shift on Sunday. Observation on 08/28/2023 at 11:55 AM revealed Resident #60 had an oxygen concentrator next to her bed. Further observation revealed a plastic bag, dated 06/12/2023, attached to the machine that contained O2 tubing placed inside. A No Smoking; Oxygen in Use sign was posted outside of Resident #60's door. During an interview on 08/28/23 at 2:17 PM revealed Resident #60 was hooked up to the oxygen concentrator and the machine was in use by the resident. Observation of the plastic bag attached to the Oxygen concentrator revealed it was empty. During an interview on 08/28/23 at 2:17 PM, Resident #60 stated she was doing well. She stated she uses the Oxygen concentrator very close to daily or when they think she needs it. She stated she has not had any issues with the machine. She stated she has observed the staff change the bags regularly. Observation on 8/29/23 at 8:53 AM revealed the plastic bag that contained O2 tubing, attached to the Oxygen concentrator was still dated for 06/12/2023. During an interview on 08/29/2023 at 12:35 PN, LVN A stated it was the night nurse's responsibility to check on Oxygen concentrators; to include changing and labeling the O2 tubing and nebulizers. LVN A stated that when the machine equipment is changed, it should be labeled with that date. She stated some nurses will date the water concentrator bottle, the tubing, and the plastic bag and some nurses date one or the other. She stated the water concentrator and plastic bag attached to the water concentrator should be changed weekly, as well as the tubing, and this usually occurred on Sunday nights. She stated nurses can access Resident #60's order for the machine equipment to be changed on their computers. LVN A was asked why Resident #60's plastic bag that contained the O2 tubing, and water concentration bottle did not reveal an updated label and she stated it may have not been checked. She stated not providing or updating labels on the Oxygen concentrator equipment could place the resident at risk for infection. LVN A stated she would change and re-label the equipment. Observation on 8/29/23 at 12:40 PM in the presence of LVN A revealed the plastic bag that contained O2 tubing, attached to the Oxygen concentrator was still dated for 06/12/2023. The water concentrator bottle attached to the O2 concentrator was dated for 07/13/2023. During an interview on 08/30/23 at 1:07 PM, the DON stated that during patient rounds, nurses should check on O2 tubing to ensure it was working properly. The DON stated that when the Oxygen concentrator is not in use, the O2 tubing is placed in a plastic bag and attached to the machine. She stated that the O2 tubing is changed out weekly, and this task is usually done by the night shift nurse. The DON stated that Resident #60 has orders for the tubing and water concentrator to be changed, adding that sometimes, the date is placed on the actual tubing. She stated the plastic bag dated 06/12/23 that was observed attached to the Oxygen concentrator did not indicate if the tubing had not been changed as nurses need to date the actual tubing. The DON stated the plastic bag is only changed if it is needed. She stated the water concentrator bottle should change and re-labeled weekly. The DON stated that Resident #60's O2 tubing, and water concentrator should have been changed as not changing them poses the risk of infection to the resident. Observation on 08/30/23 at 1:15 PM of Resident #60's O2 tubing and water concentrator in the presence of the DON revealed the plastic bag attached to the Oxygen concentrator, the O2 tubing, and the water concentration bottle was dated for 08/30/2023. The DON was observed asking LVN A for the tubing, that was changed. The DON stated that observation of the tubing did not reveal the presence of a date. During an interview on 08/30/23 at 3:40 PM, the ADM stated that nurses were expected to check Oxygen concentrator machines weekly, adding that the tubing should be changed and labeled with a date. He stated the plastic bag attached and filter should be changed as needed. He stated the night nurse is responsible for ensuring the equipment is changed and labeled appropriately per Resident #60's orders. He stated this is important and not completing those tasks could pose infection control risks to the resident. Record review of facility policy and procedure titled Oxygen Administration, undated, revealed It is the policy of this facility that oxygen therapy is administered, as ordered by the physician. The policy further states Instructions for Tubing and Humidifier Changes . 1. Label humidifier with the day . 2. Oxygen tubing is to be replaced every 7 days.

Based on observation, interview, and record review, the facility failed to ensure each resident received services in the facility with reasonable accommodation of resident needs and preferences for 2 of 4 residents (Resident #23 and Resident #38) reviewed for accommodation of needs. The facility failed to ensure that Resident #23 and Resident #38 had properly fitting bariatric briefs available regularly for incontinent episodes to meet the needs of each resident. This failure could place residents at risk of not receiving safe and comfortable incontinent care. Findings include: Record review of Resident #38's face sheet dated 08/29/23 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Morbid obesity due to excess calories, Repeated falls, Heart Failure, Hypertension, Depression, Hypothyroidism (Low level of thyroid hormone), Constipation, Protein-calorie malnutrition, Chronic Kidney Disease, Obstructive Sleep Apnea (Interrupted breathing while sleeping), Major Depressive Disorder, Chronic Pain Syndrome and Muscle Weakness. Record review of Resident #38's MDS assessment dated [DATE] revealed her BIMS score was 15 of 15 which indicated no cognitive impairment. Resident #38 required 2-person assistance regarding transfers and required 2-person physical assistance with bed mobility, toileting, and bathing. Urinary Continence was coded as 3 -Always incontinent (no episodes of continent voiding) and Bowel continence was coded as 2 - frequently incontinent (2 or more episodes). Record review of Resident #38's weight summary revealed a height of 63 inches and as of 6/2/2023 a weight of 391.4 pounds with a BMI of 46.26 indicative of morbid (life threatening) obesity. In an interview on 08/29/23 at 11:00 AM Resident #38 stated there was no brief of her size available at the facility on that day. She stated she was comfortable with 3x size, however CNA A changed her brief with 2x size. Resident # 38 stated this happened at least 7 to 8 occasions since she was admitted to the facility in June 23. Resident #38 stated any size below 3x were not useful to her as they were very tight and came off easily from the sticking end. Resident #38 said she and her family reported about the irregular supply of 3x size brief on many occasions to the staff, however the issue remained as unresolved. In an interview on 08/29/23 at 2:00 PM CNA A stated he was an agency CNA and worked in Hall 100 where Resident #38 was. He said he had changed Resident #38's with 2x size brief due to the unavailability of 3x size, though it was smaller for her. CNA A said many times in the past he had to use size 2x for Resident #38. Record review of Resident #23's face sheet dated 08/30/23 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Hyperkalemia (high blood level of potassium), Chronic Obstructive Pulmonary Disease (Difficult to breathe) , Hypertension, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Obesity due to excess calories, Heart failure, Type 2 Diabetes Mellitus, Chronic Kidney Disease and Muscle Weakness. Record review of Resident #23's MDS assessment dated [DATE] revealed her BIMS score was 12 of 15 which indicated moderate cognitive impairment. Resident #23 required 2-person assistance regarding transfers and required 2-person physical assistance with bed mobility, toileting, and bathing. Urinary Continence was coded as 3 -Always incontinent (no episodes of continent voiding). Bowel continence was coded as 2 - frequently incontinent (2 or more episodes). Record review of Resident #23's weight summary revealed a height of 66 inches and as of 06/05/2023, a weight of 324 pounds with a BMI (measure used to calculate a healthy weight) of 52.29 indicative of obesity. In an interview on 08/28/23 at 4:00 pm, Resident #23 reported that her brief size was 3x and above, however she was wearing a 2x brief at that time. She stated there were many occasions in the past she had to wear smaller size as her size brief was not available at the facility. She stated she might compromise for a 2x size brief while sleeping, however 2x size was uncomfortable and inconvenient as they came off easily and made a mess while sitting or ambulating. She stated she complained in the past about the unavailability of the correct size briefs , however no actions were taken to resolve this issue. An observation on 08/29/23 at 03:00 PM, of the main central supply closet and the closets in all the halls revealed the absence of size 3x or 4x briefs. The largest size brief observed in the closets was 2x. The DON, who was accompanying with the investigator during the observations in the closets, also witnessed the unavailability of larger briefs. In an interview on 08/29/23 at 3:30 PM, the MRS stated she ordered medical and nursing care supplies every week. including briefs of all sizes. When the investigator asked the reason for the frequent unavailability of 3x briefs at the facility, MRS stated she was not aware of any shortage and thought the order she placed every time was sufficient for one week, until the next batch of supplies arrived. In an interview on 08/29/23 at 3:30 PM, the DON stated, at the facility there were two residents who needed 3x size briefs. She said she had received complaints from the residents and their families of not having appropriate briefs at the facility and communicated this message to the procurement department on time. DON said she believed they were not ordering enough 3x briefs every time when placing the order with the suppliers. She stated the unavailability of the right size briefs and diapers was uncomfortable to the residents and thus affected the quality of care. DON said the facility placed an interim order for 3x on that day to make sure they were available immediately. In an interview on 8/30/23 at 2:30 PM, the ADM stated, he was not aware that large size briefs were not available for residents on 08/29/23. When the investigator stated that the residents and families complained about the frequent unavailability of 3x briefs, the ADM stated sometimes the quantity of the briefs used were higher than anticipated. He added, in such situations the facility either borrowed from the neighboring facility or purchased from local market. He stated the uninterrupted supply of nursing care items were important for maintaining the quality of care. He said unfit briefs causes leaking of the content, poor blood circulation, and even skin integrity. Record review of facility policy titled Resident Rights dated 10/04/2016 reflected: As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States . . You have a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely .

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 9 residents (Resident #59) reviewed for privacy, in that: LVN A did not completely close Resident #59's privacy curtain and window curtain while providing [CONDITION(S)] care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #59's face sheet, dated 06/10/2022, revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #59's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 7, indicating she was moderately to severely impaired. Resident #59 required extensive assistance, had a [CONDITION(S)] and was always incontinent of bladder. Observation on 06/09/22 at 10:00 a.m. revealed LVN A provided [CONDITION(S)] care for Resident #59, exposing part of the end of the resident's bed which could be seen if someone had come in the room and by her roommate who was in the room. Further observation revealed LVN A did not close the window curtain. Resident #59's was sitting in a chair by the window during care and could have been seen by anybody in the parking lot of the facility. During an interview with LVN A on 06/09/2022 at 10:15 a.m., LVN A verbally confirmed the privacy curtain and the window curtain were not closed while she provided care for Resident #59 but they should have been to protect the privacy of the resident. During an interview with the DON on 6/10/22 at 9:26 a.m., the DON confirmed privacy must be provided during nursing care and Resident #59's privacy curtains and window curtain should have been closed completely. She confirmed privacy during care was part of the training received by the staff. Record review of the facility's Admission packet, dated 07/28/2021, revealed, You have the right to personal privacy, including accommodations, medical treatment [ .]

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 disease and infection for 2 of 9 residents (Residents #19 and, 76) reviewed for infection control, in that: 1. CNA C did not change her gloves and wash her hands before touching the resident's clean brief and after cleaning the resident's buttocks' area while providing incontinent care for Resident #19 2. CNA D did not change her gloves and wash her hands before touching the resident's clean brief and after cleaning the resident's buttocks' area while providing incontinent care for Resident #76 These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1. Record review of Resident #19's face sheet, dated 06/10/2022, revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .), Intellectual disability(limits to a person's ability to learn at an expected level and function in daily life), [CONDITION(S)]([CONDITION(S)] doesn't produce enough of certain crucial hormones), [CONDITION(S)] (blood has too many lipids (fats)), Obstructive sleep apnea(sleep-related breathing disorder), [CONDITION(S)] (brain disease, damage, or malfunction), Hypertension (high blood pressure), Ataxia(the loss of full control of bodily movements) Record review of Resident #19's Admission MDS, dated [DATE], revealed the resident had a BIMS score of 4, which indicated severe cognitive impairment, required extensive assistance of one to two person for most ADL, and was indicated to always be incontinent of bowel and bladder. Observation on 06/08/22 at 2:32 p.m. revealed while providing incontinent care for Resident # 19, CNA C cleaned Resident #19's buttock, then placed a clean brief on the resident. CNA C did not change gloves or wash her hands before touching the clean briefs and fastening the brief to the resident. During an interview with CNA C on 06/08/2022 at 2:39 p.m., CNA C verbally confirmed she had placed the clean brief under the resident prior to changing her gloves or washing her hands. CNA C verbally confirmed she should have first changed her gloves and washed her hands prior to placing the new brief on Resident #19. She verbally confirmed the staff was receiving infection control training regularly. 2. Record review of Resident #76's face sheet, dated 06/10/2022, revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #76's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 14, which indicated mild cognitive impairment, required extensive assistance of one person for most ADL, and was indicated to frequently be incontinent of bowel and bladder. Observation on 06/08/2022 at 2:45 p.m. revealed while providing incontinent care for Resident #76, CNA D cleaned Resident #76's buttock, then placed a clean brief on the resident. CNA D did not change gloves or wash her hands before touching the clean briefs and fastening the brief to the resident. During an interview with CNA D on 06/08/2022 at 2:55 p.m., CNA D verbally confirmed she had placed the clean brief under the resident prior to changing her gloves or washing her hands. CNA D verbally confirmed she should have first changed her gloves and washed her hands prior to place the new brief on Resident #76. She verbally confirmed the staff was receiving infection control training regularly. During an interview with the DON on 06/10/2022 at 9:26 a.m., the DON verbally confirmed the CNAs should have changed their gloves and washed their hands prior to placing the clean briefs under the residents to prevent risk of cross contamination and prevent infection for the residents. She verbally confirmed the staff was receiving infection control training frequently and their skills were checked yearly. Review of facility's policy, titled Infection control prevention and control program - Hand hygiene, undated, revealed Use an alcohol-based hand rub [ .] After contact with blood or bodily fluids, k. after handling used dressings, contaminated equipment etc ., m. After removing gloves.

Based on observation, interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Residents #287) reviewed for hospice services, in that: The facility failed to obtain Resident #287's most recent hospice Plan of Care, Hospice Consent and Election Form and Physician Certification of Terminal Illness. This failure could place the resident who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #287's face sheet, dated 06/08/2022, revealed the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #287's Social Service's admission assessment, dated 06/03/2022, revealed a BIMS score of 10, which indicated the resident to have moderate cognitive impairment. Further review revealed [Resident] is a patient of [Hospice Company] services. Record review of Resident #287's Care Plan, dated 05/30/2022, revealed no focus area for hospice services. Further review of an initial care plan worksheet dated 05/27/2022, effective date 05/30/2022, revealed no focus area for hospice. Record review of Resident #287's electronic medical record Order Summary Report of Active Orders as of 06/08/2022, revealed an order on 05/27/2022 for: Admit to Cedar Pointe Health and Wellness Center [Hospice Company] DX Cerebral Arthrosclerosis. Record review of Resident #287's handwritten order from [Hospice Company] scanned into electronic medical record, dated 05/27/2022, revealed an order: Admit pt (patient) to Cedar Pointe Health and Wellness under [Hospice Company] DX Cerebral Arthrosclerosis. During an observation and interview with MA F on 06/09/2022 at 2:51 p.m., revealed MA F was unaware that Resident #287 was on hospice services or where to look for a hospice POC and information. MA F stated, I don't usually work on this side. During an observation and interview with the ADON on 06/09/2022 at 2:58 p.m., the ADON revealed Resident #287's hospice binder could not be located at the nurses' station. The ADON stated, it should be right here, but let me see if I can find it. In a follow up interview with the ADON on 06/09/2022 at 4:10 pm, the ADON stated she had asked the SW to contact the hospice agency to see if they were aware if the binder had been left at the facility. In an interview with the SW on 06/09/2022 at 4:22 pm, the SW stated she had spoken to the hospice agency and they were sending it over. The SW was asked about the hospice coordination process at the facility and the SW revealed that once the order for an evaluation was received from the physician, the SW contacted family to meet with a hospice agency to discuss services. The SW further revealed after that the nurses, the ADON or floor nurses usually talk to the hospice nurses. In an observation and interview with the DON on 06/09/2022 at 4:34 pm, the DON provided a teal notebook with recent CNA and Nursing progress notes the hospice agency delivered upon request. Record review of the binder revealed the following information had not been obtained from the hospice agency: a hospice Plan of Care, the Hospice Consent and Election Form and the Physician Certification of Terminal Illness. The DON confirmed the hospice agency had provided the information at the request of the SW and stated we should have a binder for every hospice resident at the nurse's station or the appropriate information uploaded into their electronic record. When asked what staff is responsible for the coordination of the hospice resident's care the DON stated, basically everyone on the IDT team works together to see that it is done. The DON further revealed she is new, and this is something she plans to focus on to ensure all the documents are in place to ensure the resident's hospice POC is available for all staff. Record review of the facility's hospice services agreement with [Hospice Company], with effective date 08/01/2021, revealed, in Coordination of Responsibilities: Hospice and Facility shall develop a process to exchange information between the IDG and Facility staff regarding development and updating of the POC and evaluation of car outcomes to ensure that each Hospice patient receives necessary and appropriate care and services. Each Party will designate one or more liaisons to facilitate cooperation and communication between the Parties to assure that individual and family needs are met. Each Party will notify the other promptly of any change in the designated liaison. Further review revealed in Exhibit E: Hospice and Facility to be responsible for the development, review, and revision of the POC. Hospice and facility agree to develop a plan of communication for each hospice patient and further agree as required by state or federal regulations, to enter all necessary information into the patients' medical chart. Record review of the facility's policy titled, Residents with Hospice Services, revised 7/2018, noted as Page 1 of 1, revealed, The facility will work closely with Hospice personnel to ensure: 1. A copy of the Hospice Plan of Care is obtained and kept in the resident's file. 2. Coordinate services provided to the resident with the Hospice personnel. 3. Report any deviation from the established plan of care to the resident's physician within 24 hours after the deviation occurs. The facility Administrator will follow state regulation with regards to retaining a resident on Hospice services.

Based on interview and record review the facility failed to review and revise the Resident's care plan for 1 of 24 ( Resident # 21) residents in that: The facility failed to revise Resident #21's care plan to reflect the current DNR status. This failure could place Residents at risk for not having their individual needs met according to their comprehensive assessments and cause Residents' wishes to not be followed. Findings include: Record review of chart shows Resident #21 was admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 21's quarterly MDS dated [DATE] indicated a BIMS score of 5 which indicated severe cognitive deficit. Record review of Resident #21's care plan dated 4/15/22 indicated a full code status. Record review of an advanced directive dated 9/25/21, indicated Resident #21 had a code status of DNR. Record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the face sheet dated 6/9/22 indicated Resident #21 had DNR listed in the code status. An Interview with facility social worker (SW) was conducted on 6/9/22 at 120pm. The social worker confirmed that the resident had a DNR status noted in his advance directive dated 9/25/21, on the face sheet dated 6/9/22, and in the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The SW stated that she should have updated the resident's current care plan to reflect the resident's DNR status. The SW was asked what the potential harm could be to the resident if a resident was listed as having a DNR code status while at the same time having care plan stating full code status. The SW stated that this could be confusing to the staff who are providing the resident's care and the resident's wishes would not be honored on the care plan. An interview with MDS nurse coordinator was conducted on 6/9/22 at 1:25pm. She confirmed that the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS nurse was asked what the potential risk may be to the resident by having a resident with a DNR order and a current care plan stating full code status. The MDS nurse stated that she felt a nurse would only look at the chart's face sheet and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of facility policy and procedure on advance directives noted that the care plan team should periodically review with the resident or his/her family what the advance directives/DNR is in order to ensure that the care plan reflects the wishes of the resident.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 4 residents (Resident #287) reviewed for baseline care plan, in that: Resident #287's baseline care plan was missing information related to hospice care and code status. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings were: Record review of Resident #287's face sheet, dated 06/08/2022, revealed the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #287's Social Service's admission assessment, dated 06/03/2022, revealed a BIMS score of 10. Further review revealed [Resident] is a patient of [Hospice Company] services. Record review of Resident #287's Baseline Care Plan, dated 05/30/2022, revealed no focus area for hospice services or code status. Further review of an initial care plan worksheet dated 05/27/2022, effective date 05/30/2022, revealed no focus area for hospice or code status. Record review of Resident #287's electronic medical record Order Summary Report of Active Orders as of 06/08/2022, revealed an order on 05/27/2022 for: Admit to Cedar Pointe Health and Wellness Center [Hospice Company] DX Cerebral Arthrosclerosis. Further review revealed an order on 05/27/2022 for: DNR/Do Not Attempt Resuscitation. Record review of Resident #287's handwritten order from [Hospice Company] scanned into the resident's electronic medical record, dated 05/27/2022, revealed an order: Admit pt to Cedar Pointe Health and Wellness under [Hospice Company] DX Cerebral Arthrosclerosis. Record review of Resident #287's electronic medical record revealed an OOH-DNR, dated 11/20/20. In an observation and interview with the MDS Coordinator and ADON on 06/09/2022 at 2:02 p.m., the MDS Coordinator confirmed hospice and code status were not included in the baseline care plan. The ADON revealed a care plan worksheet utilized by the facility as a baseline care plan. The ADON further revealed the information from the worksheet carried over to the care plan to create the comprehensive care plan. The ADON stated the worksheet does not have a code status or hospice option and does not allow for additional information to be added. In an observation and interview with the DON on 06/10/2022 at 10:25 a.m., the DON confirmed hospice and code status were not included in the baseline care plan and that the worksheet the facility used does not have a code status or hospice option. The DON revealed the facility had addressed the issue of code status with corporate because I know that needs to be there for Texas, but our form comes from out of state. The DON revealed she had entered code status to the existing care plan manually after the surveyor discussed with ADON and MDS coordinator. The DON stated she did not know that hospice needed to be included on the baseline care plan. Record review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised 08/2017, revealed, The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. The baseline care plan will include minimum healthcare information necessary to properly care for a resident including, but not limited to: a) initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for three of five residents (#1, #2, and #3) reviewed for infection control. HA A failed to use clean cups for 3 residents while emptying and refilling water cups from ice chest and perform hand hygiene during use of scooping ice and touching water pitchers. These failures placed residents at an increased risk of exposure to infections to include COVID- 19, decreased quality of life, or hospitalization s. The findings were: Review of Resident # 1's Face Sheet dated 01/20/2022, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 1's 5-Day PPS Assessment MDS, dated [DATE], reflected she had a BIMS score of 14 indicating intact cognitive response. Review of Resident # 1's Care Plan, dated 10/22/2021, reflected she Risk for Depression Related to Admission, Dementia, Disease Process, Will remain free of signs, symptoms of distress, symptoms of depression, anxiety, or sad mood. Resident's dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 2's Face Sheet dated 01/20/2022, reflected he was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 2's Quarterly MDS, dated [DATE], reflected he had a BIMS score of 15 indicating intact cognitive response. Review of Resident # 2's Care Plan, dated 10/05/2021, reflected Risk for Impaired Thought Processes Related to Dementia and/or, Acute Infection. Resident's impaired thought processes could lead to decreased awareness of infection control practice. Review of Resident # 3's Face Sheet dated 01/20/2022 reflected she was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 3's Quarterly MDS, dated [DATE], reflected she had a BIMS score of 04 indicating severe cognitive impact. Review of Resident # 3's Care Plan, dated 10/22/2021, reflected Cognitive impairment as evidenced by: [CONDITION(S)] exhibited by inattention and disorganized thinking, history of behaviors/[CONDITION(S)], related to of anxiety/Alzheimer's (progressive disease that destroys memory and other important mental functions) disease/depression. Resident's impaired cognition could lead to decreased awareness of infection control practice. During an observation on 1/20/2022 at 9:54 AM, HA A revealed HA A entered RES #1's room, picked up RES #1's used drinking cup off the bedside table with one bare hand and removed the used lid and straw with the other bare hand. HA A emptied old water from cup in RES #1's bathroom and put the lid with the straw on the cup at an angle. HA A carried RES #1's cup out into the hallway to the hospitality cart which contained ice and filled water pitchers covered with plastic film, on top of cart. HA A opened the top of cart to the ice compartment and removed ice scoop. HA A removed a scoop of ice from the ice scoop container hanging on the side and filled RES #1's cup. HA A returned ice scoop back into container and shut the top of the hospitality cart. Without performing hand hygiene, HA A peeled back the plastic film from a water pitcher and poured fresh water into RES #1's cup. HA A smoothed the plastic film back over the water pitcher to cover it and tightened RES #1's cup lid with the straw to close off the opening of RES #1's cup. HA A carried RES #1's cup back into RES #1's room and put it on the bedside table. The ADM continued to follow HHSC surveyors during the walk through of the facility and entered RES #1's room with HA A. The ADM walked up to into HA A and spoke to HA A in a low voice. The ADM and HA A exited RES #1's room and, HA A walked to a hand sanitizer dispenser on the wall and sanitized her hands. During an observation on 1/20/2022 at 9:56 AM revealed, HA A entered RES #2's room and obtained RES #2's used drinking cup. HA A repeated the same deficient process, previously observed with RES #1's cup, by refilling RES #2's cup with ice without performing hand hygiene hands, and returned the ice filled cup to RES #2's bedside table. HA A exited the room and sanitized her hands. During an observation on 1/20/2022 at 10:00 AM revealed, HA A entered RES #3's on the next hall and obtained RES #3's used drinking cup. HA A repeated same deficient process, previously observed with RES #1 and RES #2's cups, by refilling RES #3's used cup with ice without performing hand hygiene during the process, and returned the ice filled cup to RES #3's bedside table. HA A exited the room and sanitized her hands. During an interview on 01/20/2022 at 10:02 AM ADM inquired if there were infection control issues and if the surveyors would give him education while he pointed to the hospitality cart because they would stop and change their practice. The ADM was informed the surveyors could not provide education or guidance. During an interview on 01/20/2022 at 12:14 PM, CNA B stated having been employed at the facility for almost 5 years. CNA B described the ice pass process is performed by the hospitality aide. CNA B stated HA A gets clean cups from the kitchen and prefills them. CNA B stated HA A passes them out to each resident and then HA A picked up all the dirty cups from each resident and takes them to the kitchen to be washed and sanitized. CNA B stated this is how they were trained in case they need to pass ice and has been the normal process since has worked there. During an interview on 01/20/2022 at 1:06 PM the DON, also the ICP, stated the facility did not have a specific policy and procedure regarding passing ice. The DON stated she provides oral education to all new employees on passing ice. The DON stated her education included reasons that safe and sanitary practices should it be performed, and the risk to residents if infection control practices were not implemented by all staff. The DON stated the facility practice was HA A passed the ice twice a day. The DON stated HA A first cleans out the ice chest and refills it. The DON stated HA A stocks the hospitality cart with clean water pitchers and clean water cups for residents. The clean water cups are all prefilled with ice and water. The DON stated HA A takes the hospitality cart down the hall and passes each resident a new water cup and then HA A goes back down the hall again and retrieves the dirty water cups, puts them on top of the hospitality cart, and returns entire cart and contents to kitchen to be washed and sanitized. The DON stated she has educated staff on performing proper hand hygiene frequently as part of her monthly inservices, and multiple times in the past few weeks when staff or resident tests positive for COVID-19. She oversees that skills check offs are performed on all staff routinely. During an interview on 01/20/2022 at 1:35 PM, HA A stated she has been employed at facility since mid-September 2021. HA A stated she receives training on COVID-19 and infection control practice monthly by the DON/ICP and also when there is a staff member that tests positive for COVID-19. HA A states they also undergo skills check offs in hand washing monthly or at random times. HA A stated after breakfast she gets the ice cart from the nourishment room, takes it the kitchen to drain, clean, sanitize, and refill it. HA A stated she sets the clean big water pitchers and clean personal water cups on top of the cart. HA A stated she prefills the personal cups, then takes ice cart down the hall and passes them out to each resident. She stated she collects the dirty cups as she gives each resident a new pitcher. HA A was asked why she didn't follow the procedure that morning and she responded the morning routine was different that morning and she forgot. HA A was asked how she practiced infection control during her ice passing that morning and she responded Oh I see. The cups were dirty and there was cross contamination when I was going back and forth to the clean cart that could cause infection. According to the CDC (Centers for Disease Control) Hand Hygiene Guidelines in Healthcare Settings: When and How to Perform Hand Hygiene Immediately before touching a patient Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal When hands are visibly soiled After caring for a person with known or suspected infectious diarrhea After known or suspected exposure to spores (e.g. B. anthracis, C difficile outbreaks) When using alcohol-based hand sanitizer: Put product on hands and rub hands together Cover all surfaces until hands feel dry This should take around 20 seconds When cleaning your hands with soap and water: Wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. Avoid using hot water, to prevent drying of skin.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for three of three ice machines reviewed for clean and sanitary to prevent contamination of the ice. The ice machines were observed to have a black and orange moldy substance on portions of the ice bin. This failure had the potential to affect all of the 75 residents at the facility at the time of the survey. Findings include: Review of the physical environment complaint, intake number TX 857, revealed that on 03/05/20 Resident 8 (R) said since being admitted (8/18) the ice machine is filthy and contains mold. The ice tastes like mold. R8 stated he/she is concerned this could cause illness among the residents. Observation on 05/25/21 at 3:45 PM, in the 500-hall ice room, the ice machine was wiped clean on the outside. Surveyor was unable to view the inside of the machine where the ice was stored. Observation on 05/26/21 at 1:12 PM, in the 500 hall ice room with the Director of Maintenance (DOM) it was requested that the DOM open the ice machine [manufacturer - Hoshizaki America, Inc., Cubelet Icemaker/Dispenser, model DCM-300BAH(-OS)] so the ice holding area (storage bin) could be viewed by the surveyor. Upon looking in the ice storage area there was orange and black matter on white plastic in the area of the bin control bracket and the [MEDICATION(S)] (flapper to stop automated ice production). The DOM stated this machine had been cleaned three to four months ago. The DOM explained that there are two other ice machines of this type in the facility. Surveyor and DOM proceeded to the second ice machine, located in the kitchen, and upon removing the storage bin cover there was a mold like substance on the rubber lining the outer edge of the cover. The DOM stated this ice machine is rarely used (there is a larger ice machine located in the kitchen). Surveyor and DOM proceeded to the third ice machine located on the 100 Hall. Upon removal of the bin cover there was noted to be a small amount of a black substance at the bin control bracket and the [MEDICATION(S)] and there was on orange and black substance on the ice shoot. During an interview on 05/26/21 at 1:30 PM, with the DOM, stated he tries to clean/sanitize the ice machines every three to four months which he documents in the Tels system. The DOM explained there was not a contract with an outside company to clean the three ice machines. Surveyor requested a copy of the documentation of cleaning times, manufacturer's cleaning instructions and facility 's cleaning policy. Review of the maintenance policy titled, Ice Machine revised 07/26/17 stated, Procedures:4. Turn off unit, remove ice, and place in plastic bag. 5. Clean storage bin with towel and mild disinfectant solution. 6. Pour ice back into storage bin and turn unit on Review of the Work History Report for the ice machines revealed that on 04/02/21, 01/04/21, 10/02/20 and 07/01/20 (task completion dates) the ice machines/ice bins had the interior sanitized and were delimed if necessary (Task Description). The Work History report did not clarify which machine had been sanitized and the DOM could not recall when each machine was sanitized. During an interview on 05/26/21 at 1:52 PM, the DOM said during each task completion date he did a visual inspection, may have cleaned the machine and usually does all three machines at that time. During an interview on 05/26/21 at 3:15 PM, with the Administrator, stated she thought all of the ice machines were cleaned/maintained by an outside company. The Administrator explained the facility had a contract with a company to provide ice machine maintenance, but now realizes the contract only covered the larger ice machine in the kitchen and did not cover the three Hoshizaki Cubelet machines. Review of the maintenance policy titled, Ice Machine revised 07/26/17 stated, Procedures:4. Turn off unit, remove ice, and place in plastic bag. 5. Clean storage bin with towel and mild disinfectant solution. 6. Pour ice back into storage bin and turn unit on. Review of the Cubelet Icemaker/Dispenser Instruction Manual revised 02/13/15 stated, .A Cleaning and Sanitizing Instruction Hoshizaki recommends cleaning and sanitizing this unit at least twice a year. More frequent cleaning and sanitizing, however, may be required in some existing water conditions. 1. Water System a) Cleaning solution Dilute 9.6 fl. Oz of Hoshizaki Scale away with 1.6 gallons of warm water. b) Cleaning Procedure .3) .dispense all the ice from the storage bin .6) Pour the cleaning solution over the extruding head until the evaporator assembly and reservoir are full .c) Sanitizing Solution Dilute 0.82 fl. Oz. of a 5.25% sodium hypochlorite solution (chlorine bleach) with 1.6 gal. of warm water. d) Sanitizing Procedure - Following Cleaning Procedure .4) Pour the sanitizing solution over the extruding head until the evaporator assembly and reservoir are full, and the solution starts to overflow into the drain pan . During an interview on 05/26/21 at 3:15 PM with the Administrator, stated she thought all of the ice machines were cleaned/maintained by an outside company. The Administrator explained the facility had a contract with a company to provide ice machine maintenance, but now realizes the contract only covered the larger ice machine in the kitchen and did not cover the three Hoshizaki Cubelet machines.

Based on observation, interview, record review and review of facility policy, the facility failed to assure that three (Resident (R)3, R6, and R12) of 10 sampled residents reviewed for falls received the supervision and/or assistive devices needed to prevent accidents. The residents, who were at risk for accidents and sustained multiple falls, failed to receive interventions such as fall mats, low beds, call lights in reach, toileting programs/timely incontinence assistance, and/or material in their wheelchairs to prevent sliding from the chair. Findings include: 1. Review of R3's undated Face Sheet, located under the Face Sheet tab in the electronic medical record (EMR), revealed diagnoses which included dementia with behavioral disturbance as a primary diagnosis, [CONDITION(S)] disease, muscle weakness, wasting and atrophy, lack of coordination, repeated falls, restlessness and agitation, cognitive communication deficit, and [CONDITION(S)]/[CONDITION(S)] of the right, dominant side, and visual hallucinations. Review of R3's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/08/20, revealed the resident was severely cognitively impaired, had no behaviors, needed extensive assistance with transfers, bed mobility, dressing, and toilet use. R3 did not walk during the assessment period and required extensive assistance with locomotion in her wheelchair. The resident was always incontinent of bowel and bladder and needed extensive assistance with toileting. She was only able to stabilize balance with staff assistance when moving on/off the toilet. Per this MDS, the resident had two or more falls with no injuries since her previous assessment. Review of R3's most recent MDS, a quarterly assessment with an ARD of 03/04/21, revealed the resident was assessed and had moderate cognitive impairment, based on a Brief Interview for Mental Status (BIMS) score of 8/15. The resident continued to require extensive assistance with bed mobility, transfers, locomotion, and toilet use, remained incontinent of bowel and bladder, and had not sustained any falls since the previous assessment. a. Review of R3's Resident Progress Notes in the Progress Note tab of the EMR revealed that the resident sustained multiple falls in 2020. Per the Resident Progress Notes, R3 also sustained falls on 03/23/21 and 04/08/21, when she was found on the floor and it appeared, she slid from the wheelchair. Review of R3's hard copy comprehensive care plan, provided by the facility, revealed that the Falls care plan, initiated 07/09/19, noted the resident was at risk for falls as evidenced by decreased/impaired mobility, weakness, self-transfer without calling for assistance, lack of safety awareness, hx [history] of CVA [[CONDITION(S)] accident - stroke] w [with] right sided weakness/recurrent falls/Lewy bodies dementia/[CONDITION(S)]. The resident's care plan was updated on 03/24/21 to show that the resident should have dycem (substance used to prevent sliding) in her wheelchair. It was also updated on 04/08/21 with the need to adjust the resident's wheelchair seat. Further review of the Resident Progress Notes entries revealed that on 05/13/21, R3 was, noted face first on the floor with her wheelchair behind her. She is bleeding from her head and right hand. Head to toe assessment completed with cut to her scalp, bruise to her right temple area and skin tear to right hand. Pressure held on cut on scalp and skin tear cleaned .Resident was lifted with Hoyer [mechanical lift] and placed into her bed. Per this note, the Nurse Practitioner (NP) was called and ordered the resident to be sent to the hospital. Review of a hard copy Provider Investigation Report (final report), submitted to the State Survey Agency (SSA) on 05/21/21, revealed that R3's cut to the scalp was documented in the emergency room as 1 in [inch], superficial laceration to top of head and closed with 5 staples. Per Resident Progress Note, dated a 05/14/21 at 1:01 AM, the resident returned to the facility from the hospital with the staples in the head to be removed in seven - 10 days. Review of the hard copy Investigation Summary provided by the facility revealed that, Evidence shows that interventions were in place. These interventions have been reviewed at regular intervals and updated as needed to reflect the goals of the resident. Symptoms of UTI [urinary tract infection] may have caused confusion and contributed to the fall. Review of the hard copy Patient/Resident Incident/Accident Investigation Worksheet provided by the facility which was completed in response to this fall revealed that in response to the question, Safety Interventions in use at the time? staff responded, No. The Investigation Worksheet form stated that the resident was found face down on the floor with her wheelchair behind her. However, the investigation failed to identify whether the dycem was in the wheelchair seat, which had previously been identified as an approach to prevent falls, was in place at the time of this accident. b. Review of the resident's comprehensive care plan revealed that the Falls care plan, initiated 07/09/19, also included the intervention to keep bed in lowest position w/brakes locked in safety. Review of Active Orders in the Orders tab in the EMR also revealed that, since 08/13/19, staff were to Please have bed at lowest level due to impulsivity and H/O [history of] falls. Review of the Resident Profile, (a care plan used by direct care staff located in electronic kiosks along the hallways) also revealed that the resident's equipment included low bed and noted the need to have the bed at the lowest level due to the resident's impulsivity and history of falls. Observation on 05/27/21 at 1:15 PM, revealed the resident was asleep in bed. During this observation, the resident's bed was noted to not be in a low position. The Director of Nursing (DON) was present during this observation and confirmed that the height of the bed was not in accordance with the care plan or physician orders. She then lowered the bed over one foot in height to the low position. c. Review of the Falls Care plan revealed that since 07/09/19, staff were to place call light and personal items within resident's reach - encourage use of call light to ask for assistance. The Falls Care plan also included an intervention, initiated 05/13/21 to increase incontinence rounds. During an observation on 05/24/21 at 4:20 PM, the resident was in bed, awake. Although her head and torso were still on the bed, her legs were swung off the side of the right side of bed onto the floor. The resident's call light was under the bed and she could not reach it, asking, Where is it? The survey team used the call light to summon staff, and Certified Nursing Aide (CNA) 71 responded and swung the resident's legs back onto the bed. At this time, the resident stated, Bed's all wet and indicated that was why she was trying to get out of the bed. d. Review of the resident's Active Orders in the Orders tab in the EMR revealed that, since 09/04/20, in addition to the low bed, the resident was to have a fall mat in place. Review of the Resident Profile used by direct care staff revealed that the resident's equipment was also to include: Fall mat in place. Observations on 05/24/21 at 12:50 PM, 2:20 PM, and 4:20 PM, and 05/25/21 at 8:33 AM, 1:30 PM, and 2:35 PM revealed that the resident was in bed. However, there were no fall mats on either side of the resident's bed. An interview was conducted with CNA 80 on 05/25/21 at 2:35 PM in R3's room, and he stated that the resident had lots of falls. CNA 80 was asked about measures to prevent falls and responded with several interventions; however, he did not mention fall mats. When asked directly if the resident was supposed to have fall mats, he stated, I thought she did, but I don't see any. CNA 80 confirmed that not only were there no mats in use by the resident's bedside, there were none visible in the room for use. Interview on 05/25/21 at 2:40 PM, with Licensed Vocational Nurse (LVN) 20 revealed that she was aware of R3's fall history, stating, that due to the resident's dementia, she doesn't understand when we tell her not to do something [i.e. get out of bed or try to stand/walk.] She stated that the staff used lots of redirection and distraction but it doesn't work. Observation and interview on 05/25/21 at 2:45 PM, LVN 20 came to R3's room with the survey team to observe the resident. At this time, a fall mat was noted on the left side of the resident's bed. CNA 80 confirmed that after being interviewed by the survey team, he had checked and gotten a mat for the resident. During this interview LVN 20 was asked why there was no fall mat on the right side of the resident's bed, especially since this was the side of the bed that the resident had been trying to get out of/observed with her legs hanging onto the floor on 05/24/21. LVN 20 stated, There's not enough room to get one of the mats between the wall and floor. However, observation revealed that, with the exception of the head and leg posts, the space between the wall and left side of the bed was sufficient to fit the width of the fall mat. Additional observations on 05/27/21 at 12:35 PM and 1:15 PM revealed that the resident, who was asleep in bed, continued to not have a fall mat in place on the right side of her bed. Interview with the DON, who was present during the 1:15 PM observation, confirmed there was no fall mat in use on the right side of the bed. The DON verified that the resident could also fall from the side of the bed which had no mat, and she would look into finding a mat to fit the area between the wall and bed. An interview was conducted with R3's family member (FM3) on 05/24/21 at 2:20 PM in R3's room. FM3stated that she visited each Monday for the last four weeks since COVID restrictions had been lifted, and there had been no fall mats in use during any of those visits, adding, You can see, there's none down now. During this visit, a yellow piece of dycem was noted to be sitting on top of a pile of clothing in the resident's wheelchair and was not affixed in place to prevent falls/sliding from the chair. FM3 stated that she had never seen dycem in the resident's wheelchair prior to this date. FM3 stated that the resident had sustained multiple falls with injury, including the last one where she required staples to her head. During this observation, FM3 showed where the staples, which were now removed, had been, and the area appeared to have healed with no sign of infection. When discussing the 05/13/21 fall, FM3 stated the resident was often left sitting wet with urine, adding, She gets UTIs. That's how the last fall occurred. 2. Review of R6's closed record revealed the resident was admitted to the facility in 2019. Per the resident's undated Face Sheet under the Face Sheet tab in the EMR, his diagnoses included dementia without behavioral disturbance, muscle wasting and atrophy, abnormality of gait and mobility, lack of coordination and weakness. Review of the resident's annual MDS, with an ARD of 07/24/20, revealed the resident had moderate cognitive impairment, based on a BIMS score of 11/15. Per the MDS, the resident had no behaviors, needed limited assistance with transfers and bed mobility, and the only assistance needed for ambulation/locomotion was supervision. The resident was frequently incontinent of bowel and bladder and needed extensive assistance with toileting. The MDS documented the resident sustained no falls since the previous assessment. The Falls Care Area Assessment (CAA) was triggered due to the resident's issues with balance (not steady but able to stabilize without staff assistance.) The CAA identified the resident with multiple diagnoses which placed him at risk for fall/injury, including his dementia., [CONDITION(S)], reduced mobility, need for assistance with personal care, failure to thrive (the resident was on palliative care since 04/20), constipation, chronic pain, and [CONDITION(S)] of the hip. The CAA noted the resident used both diuretics and opioids and made the decision to care plan for falls risk as the resident required assistance with transfers. A quarterly MDS dated [DATE] revealed that the resident remained moderately cognitively impaired (BIMS score of 10/15). The resident now required extensive assistance for transfers but continued to be able to ambulate with supervision. The resident continued to be unsteady but able to balance without staff assistance and did not sustain any falls since the previous assessment. A hard copy of the resident's comprehensive care plan was provided by the facility. The Falls Care Plan, initiated 08/25/19, stated the resident was at risk for falls as evidenced by decreased/impaired mobility, weakness, his history of dementia and occasional syncopal episodes, and included an intervention for an exercise program to target strength, gait, and balance PRN (as needed). The comprehensive care plan, review date of 07/27/20, called for staff to assist with Activities of Daily Living as needed, encourage the resident to be as independent as possible, answer the call light in a reasonable time frame at all times, and provide incontinent care /toileting every two hours and as needed. This care plan also noted that as of 04/27/20, the resident was receiving Palliative Care. Review of R6's Resident Progress Notes under the Progress Notes tab in the EMR revealed that on 09/02/20, the resident sustained his first fall in 2020. The hard copy Patient/Resident Incident/Accident Investigation Worksheet provided by the facility indicated R6 was found sitting on the floor next to his bed with his back against the nightstand. He states that he was attempting to get up when he slid off the bed pad and fall [sic]. The facility investigation found that the resident's bed was in the lowest position and the call light was within reach; however he did not call for help. Recommendations/Interventions listed in the form to prevent further falls included increased monitoring and for the facility to Provide toileting program. Review of the hard copy care plan provided by the facility revealed that it was updated on 09/03/20 with a new intervention to Place on toileting program. Review of R6's EMR, including all information under the Progress Notes and Observations (assessments) tabs, revealed no evidence that the resident was ever assessed for, or placed on a toileting program. Review of the Resident Progress Notes dated 11/20/20 revealed that R6 sustained an additional fall that day at 12:30 AM when the resident failed to use his call light, which was available, and got up without asking for staff assistance. The resident was transferred to the hospital for evaluation and was found to have a fracture to the femur/knee area and did not return to the facility. Interview with the DON on 05/25/21 at 4:05 PM, revealed that it did not look like the facility ever started the toileting program that was identified on the care plan on 09/03/20. The DON reviewed R6's care plan and confirmed that this intervention was still listed as active as of the date of the resident's discharge and was never discontinued. She stated that the resident may not have been a good candidate for a toileting program, as he became aggressive with staff. The DON related that if this intervention was identified as not practicable (due to the resident's physical or cognitive status) it should have been discontinued and the Interdisciplinary Team (IDT) should have come up with new interventions and updated the care plan with them to prevent further accidents. The DON stated that she would continue reviewing facility records and look for any other information regarding the resident's falls, as well as the initiation of a toileting program. Additional interview with the DON on 05/27/21 at 12:35 PM, revealed that she was unable to provide any further evidence that the resident was ever assessed for or provided a toileting program. She reiterated that it did not appear, based on a review of the record, that the resident was appropriate for a toileting program. The DON stated that immediately after a fall, staff were to identify a new intervention to prevent falls and update the care plan. However, she continued, all falls were then reviewed during the next morning meeting as well as during weekly Quality of Care meetings. She explained that during these meetings, the IDT would review the immediate approaches identified, and if they were not appropriate, would then revise the care plan with new interventions. The DON confirmed that if the facility did identify that the toileting program was not an appropriate intervention, this approach should have been discontinued from the care plan, and the care plan then revised with different approaches to prevent further falls. 3. Review of R12's undated Face Sheet, in the EMR under the Face Sheet tab, revealed his diagnoses included dementia as a primary diagnosis, muscle weakness, wasting and atrophy, lack of coordination, repeated falls, restlessness and agitation, and cognitive communication deficit. Review of his most recent MDS with an ARD of 05/05/21 revealed the resident was moderately cognitively impaired, as evidenced by a BIMS score of 12/15. Per the MDS, the resident had no behaviors, did not walk, and required extensive assistance for bed mobility, transfers, and locomotion in the wheelchair. The resident was frequently incontinent of bowel and bladder and required extensive assistance with toileting. Per this MDS, the resident had sustained two or more falls, with no injury since his previous assessment. Review of the Resident Progress Note entries, under the Progress Note tab, revealed the resident had multiple falls during 2020 - 2021. Per these entries, falls involving sliding from or being found by the wheelchair occurred on 04/22/20, 05/14/20, 09/06/20, 09/17/20, 12/31/20, 01/06/21, 03/27/21, and 04/04/21. Interview on 05/27/21 at 11:10 AM, with the Director of Rehab revealed the resident had [CONDITION(S)] Disease and very poor safety awareness. When asked about the multiple falls involving the resident's wheelchair, she stated that maintenance staff had put anti tip devices on the wheelchair. She stated that, in addition, He should have dycem in his chair. He should be care planned for that. Review of a Therapy Screening Form dated 10/14/19 revealed that the resident was seen for repeated falls. The form noted, Therapy recommend [sic] dycem placement in w/c [wheelchair]. A second Therapy Screening Form dated 11/26/19 revealed that the resident was again seen for repeated falls. Review of this form revealed that therapy staff checked for dycem in the resident's wheelchair and it was replaced at that time. Review of R12's hard copy comprehensive care plan, provided by the facility, revealed that the resident was identified as at risk for falls since 06/05/19. Review of all interventions on the comprehensive care plan revealed that it did not include the intervention of dycem to prevent sliding from the wheelchair. Observation on 05/27/21 at 11:25 AM, revealed that the resident was sitting in his wheelchair in the television (TV) area in front of the nurses' station. LVN 29 was present at the nurses' station and was asked to assist in an observation of the resident's wheelchair. She lifted the resident from his sitting position in the wheelchair. Observation at this time revealed that there was no dycem in the resident's wheelchair, either on or under the cushion on which he was sitting. LVN 29 confirmed there was no dycem present, and stated, I can go get some. Interview with the DON on 05/27/21 at 12:35 PM, revealed that, to her knowledge, the resident had never had dycem in his wheelchair. She stated she was unaware of the therapy screens which noted the need for dycem and, as a result, this had never been care planned. Further interview with the DON revealed that it appeared that the issue was that nursing staff were not receiving the therapy screens. Review of the facility's policy titled Fall Management, revised 03/29/19, revealed that, 3. The facility provides assistive devices based on individual resident needs to facilitate mobility and prevent falls . 5. If a fall occurs, qualified staff evaluates patient/resident for injury from the fall and determines what may have caused or contributed to the fall .and determines appropriate interventions to prevent future falls.

Based on interview, record review, review of facility documents, and review of facility policy, the facility failed to implement all components of its Abuse policy to assure that two (Resident (R) 1 and R24) of 23 sampled residents were free from abuse and/or neglect. The facility failed to conduct a thorough investigation which included interviews with all persons having knowledge of the allegation. The facility failed to identify a potential victim of the alleged abuse/neglect so that steps to protect the resident could be implemented. Findings include: Review of a Provider Investigation Report (final investigation report) submitted to the State Survey Agency (SSA) on 05/25/21 revealed that the facility reported an allegation of Neglect of R1 on 05/18/21. Per the Description of the Allegation, on 05/17/21 at 2:00 AM, Certified Nursing Aide (CNA) 66, was rude during care and when resident asked what [CNA 66] was doing for care, [CNA 66] responded by holding up a dirty brief and saying, You're doing this so I'm doing this (referring to the brief she was waving.) Interview with resident revealed that she felt [CNA 66] did not want to provide care. The Investigation Summary portion of the Provider Investigation Report noted that the CNA was angry that night and that staff heard her yelling at the resident and slamming the door when she left .There was a witness to the outburst and the patient felt as if she had been neglected. All evidence points to this occurring. The finding supports confirming this allegation. The Investigation Findings on this report were marked as Confirmed. (Please refer to F600.) Interview with the Administrator on 05/26/21 at 11:25 AM, revealed that he was the facility's Abuse Coordinator. He stated that although the report form to the state marked the incident as a confirmed allegation of neglect, the facility saw and reported the incident as both abuse and neglect. Review of the facility's investigation revealed that it identified only one resident, R1, affected by the confirmed Neglect. However, interview with CNA 8 on 05/26/21 at 12:45 PM, revealed that R24 (R1's roommate) was also an alleged victim. CNA 8 stated that she was the staff who received the initial allegation from R1 and then reported it for investigation. CNA 8 stated that on 05/18/21, R1 told her that one of the aides was so mean to her roommate the previous night. CNA 8 said that R1 told her that during incontinence care, a staff said to her roommate (R24), So why did you poop? I told you not to poop. R1 then asked CNA 8, That's abuse, isn't it? CNA 8 stated R1 did not disclose any allegations about how she, herself, was treated during this initial report. CNA 8 stated that she had attended multiple trainings on abuse and neglect, and as soon as the resident made this statement, she immediately reported it to her supervisor, the CNA/Staffing Coordinator. Interview with the CNA/Staffing Coordinator on 05/26/21 at 12:30 PM, confirmed that on 05/18/21, CNA 8 came to her and reported that R1 was very upset about something that happened last night. The CNA/Staffing Coordinator stated she went directly to R1's room to gather more information. She stated that R1 told her that an aide (CNA 66 by physical description) went to change her roommate (R24) and told R24, You're always[OBSCENITY]ing all the time. I'm tired of your[OBSCENITY] During this interview, R1 also told the CNA/Staffing Coordinator that when CNA 66 came to change her (R1), She just shoved me to the side of the bed, snatched the diaper off me, didn't wipe me, didn't clean me, then hung the dirty diaper in my face and said, This is what you do all the time. The CNA/Staffing Coordinator stated she could not interview R24 about the allegation, as the resident was out to the hospital. She then immediately reported the allegation to the Director of Nursing (DON) and an investigation began. Although these were the first two staff to whom the allegation of abuse/neglect was reported, review of the facility's investigation documents revealed no evidence of witness statements or documentation of interviews with either the CNA/Staffing Coordinator or CNA 8. Review of the facility's investigation documents revealed no evidence that the facility identified R24 as a possible victim of abuse and/or neglect, even though both CNA 8 and the CNA/Staffing Coordinator stated that R1 named R24 in the initial allegation. Review of R24's MDS tracking data revealed the resident went out to the hospital on 05/17/21 and returned to the facility on [DATE]. Although the facility's investigation was not completed until 05/25/21, there was no evidence that the facility attempted to interview R24, upon her return to the facility to determine if she was a possible witness, had knowledge of, or was impacted by the alleged abuse/neglect. During an additional interview with the Administrator on 05/26/21 at 1:25 PM, he stated a thorough investigation should include interviews with all persons who might have knowledge regarding the allegation. However, interview with the Administrator revealed this did not occur. The Administrator related he was not aware, until surveyor intervention, that R1 had actually alleged that CNA 66 was abusive to R24. He confirmed that the facility's investigation failed to identify that R24 was a possible victim, stating that he thought he heard that R24 simply echoed what R1 stated. Further interview with the Administrator revealed he thought that the CNA/Staffing Coordinator was the first person to whom R1 reported the allegation. The Administration confirmed that he was unaware that, and the facility's investigation failed to identify, that CNA 8 was actually the first outcry witness (person who had knowledge of what R1 was alleging). He stated that CNA 8 was not interviewed as part of the facility's investigation and confirmed that interviews with both CNA 8 and the CNA/Staffing Coordinator should have been conducted and documented as part of a thorough investigation. During the interview on 05/26/21 at 1:25 PM, the Administrator also confirmed that R24 was not interviewed as part of the investigation. He stated the facility was just laser-focused on what [R1] said happened to her. The Administrator stated that the facility quickly found staff who heard CNA 66 yelling and slamming R1/R24's door and had been able to substantiate R1's allegation of abuse/neglect, as he understood it. The Administrator stated that during the investigation, If we had identified [R24] as a possible victim the facility would have assessed the resident for emotional needs and possible support. However, because this was not identified during the facility's investigation and he was unaware of her involvement, this did not occur. Review of the facility's policy titled, Organizational Ethics: Abuse, Neglect, Exploitation or Mistreatment, revised 10/23/19, revealed that, The facility's Leadership prohibits neglect, mental, physical, and/or verbal abuse . Component III: Prevention: 4. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: a. the use of derogatory/harassing language; b. rough handling; and c. Ignoring the patient'/resident's needs, requests, etc. Component IV: Identification: 2. Types of abuse include BUT ARE NOT LIMITED to .Mental abuse: Humiliation .Intentional disrespect or disregard for an individual's right to privacy and dignity as it relates to their person . Component VI: Investigation: 1. The facility maintains that all allegations of abuse, neglect .are thoroughly investigated and appropriate actions are taken . 4. Investigations are prompt, comprehensive . and contain founded conclusions. 5. The investigation may include, but is not limited to the following: b. Identification of the alleged victim e. Written summaries of interviews with individuals having first-hand knowledge of the incident Employees/witnesses will be interviewed by designated facility staff and the interviewed will record all witness accounts in a document, written, dated, and signed by the interviewer.

Based on interview, record review, review of facility documents, and review of facility policy, the facility failed to assure that two (Resident (R) 1 and R24) of 23 sampled residents were free from abuse and/or neglect in that the facility substantiated an incident of abuse/neglect during incontinence care. Findings include: Review of a Provider Investigation Report (final investigation summary submitted to the State Survey Agency (SSA) revealed that the facility reported an allegation of Neglect of R1 on 05/18/21. Per the Description of the Allegation, on 05/17/21 at 2:00 AM, Certified Nursing Aide (CNA) 66, was rude during care and when resident asked what [CNA66] was doing for care, [CNA66] responded by holding up a dirty brief and saying, You're doing this, so I am doing this [referring to the brief she was waving.] Interview with resident revealed that she felt [CNA66] did not want to provide care. The Investigation Summary portion of the Provider Investigation Report noted that the CNA was angry that night and that staff heard her yelling at the resident and slamming the door when she left .There was a witness to the outburst and the patient felt as if she had been neglected. All evidence points to this occurring. The finding supports confirming this allegation. The Investigation Findings on this report were marked as Confirmed. Review of R1's undated Face Sheet, found in the electronic medical record (EMR) under the Face Sheet tab, revealed the resident was admitted on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per an admission Minimum Data Set (MDS), with the Assessment Reference Date (ARD) date 03/01/21, the resident was cognitively intact with no memory issues, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. The resident had no behaviors and required extensive assistance with toileting and was frequently incontinent of bowel and bladder. Review of the resident's Progress Notes in the EMR under the progress notes tab revealed no information about this incident. Review of R1's MDS tracking data revealed the resident was discharged from the facility to another facility on 05/19/21, and the resident was not available for interview. Interview with the Administrator on 05/26/21 at 11:25 AM, revealed that he was the facility's Abuse Coordinator. He stated that although the report form to the state marked the incident as a confirmed allegation of neglect, the facility saw the incident as both abuse and neglect, and he had, in fact, marked both categories on the reporting screen (used to submit information to the SSA). He reported that CNA 66 was immediately suspended when the allegation was reported on 05/18/21. The Administrator added that, in response to the findings of the investigation, which included staff hearing CNA 66 yelling in the resident's room and slamming the door, the facility terminated CNA 66. He related that the corporate entity was currently reviewing the documentation and would be responsible for making a referral to the state's CNA registry, based on the findings of the investigation. Interview with the CNA/Staffing Coordinator on 05/26/21 at 12:30 PM, revealed that on 05/18/21, CNA 8 came to her and reported that R1 was very upset about something that happened last night. CNA 8 told the CNA/Staffing Coordinator that the resident said an aide, pulled the [incontinence] brief off her and waived the soiled brief in her face and said, you do this all the time. The CNA/Staffing Coordinator stated she went directly to R1's room to gather more information. She stated that R1 told her, I'm really afraid to say anything, but was able to identify CNA 66 as the alleged perpetrator by physical description. The CNA/Staffing Coordinator stated that R1 told her that Last night, I put my light on for the girl to come and change me. She just shoved me to the side of the bed, snatched the diaper off me, didn't wipe me, didn't clean me, then hung the dirty diaper in my face and said, this is what you do all the time. R1 stated that CNA 66 then went to change her roommate (R24) and told R24, You're always[OBSCENITY]ing all the time. I'm tired of your[OBSCENITY] The resident stated she was really afraid to stay here and the CNA/Staffing Coordinator assured the resident that she was safe and that, We wouldn't let anything happen to her. The CNA/Staffing Coordinator then immediately reported the allegation to the Director of Nursing (DON) and an investigation began. The CNA/Staffing Coordinator concluded by stating, This lady was fearful for her life. We're not going to allow that. Interview with CNA 8 on 05/26/21 at 12:45 PM, confirmed that she was the staff who reported the initial allegation to the CNA/Staffing Coordinator. She stated that on 05/18/21, R1 told her that one of the aides was so mean to her roommate the previous night. Per CNA 8, R1 stated that a staff said to her roommate, So why did you poop? I told you not to poop. R1 then asked CNA 8, That's abuse, isn't it? CNA 8 stated R1 did not disclose any allegations about how she, herself, was treated during this initial report. CNA 8 stated that she had attended multiple trainings on abuse and neglect, and as soon as the resident made this statement, she immediately reported it to her supervisor, the CNA/Staffing Coordinator. An interview was attempted with R24 on 05/26/21 at 12:45 PM, the resident was confused and did not recall the incident. Review of R24's EMR revealed no information about this incident in the resident's Progress Notes tab. Review of R24's quarterly MDS, with the ARD date 04/01/21, the resident was severely cognitively impaired, as evidenced by a BIMS score of 3/15. The resident was always incontinent of bowel and required extensive assistance with toileting. An attempt to interview CNA 66 was made by telephone on 05/27/21 at 12:15 PM; however, the person answering the phone hung up when the survey team requested to speak to CNA 66. During an additional interview with the Administrator on 05/26/21 at 1:25 PM, he stated he was not aware, until surveyor intervention, that R24 was also present and involved in the incident which was confirmed as abuse and neglect. (Please refer to F607.) Review of the facility's policy titled, Organizational Ethics: Abuse, Neglect, Exploitation or Mistreatment, revised 10/23/19, revealed that, The facility's Leadership prohibits neglect, mental, physical, and/or verbal abuse . Definition: 1. Abuse. Abuse is the willful infliction of .intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm pain or mental anguish. It includes verbal abuse, physical abuse, and mental abuse .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . 5. Mistreatment means inappropriate treatment or exploitation of a resident 6. Neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 14 of 14 residents (Residents #1-14) and one of one hall (hall 200), in that: A. The facility failed to cohort residents according to COVID-19 status and had COVID-19 unknown residents housed on the 200 Hallway with COVID-19 negative residents. B. The facility failed to designate staff to work with each cohort (hot - COVID-19 positive residents, COVID-19 warm - unknown/presumptive residents, and COVID-19 cold - negative residents) and allowed staff to work with both COVID-19 unknown and COVID-19 negative residents on the same quarantine hall (hall 200). C. The facility failed to supply, order, and use the correct PPE. Administrative staff were aware they were wearing unapproved KN95 masks but did not make any attempts to obtain correct masks. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/18/2020. While the IJ was removed on 11/22/2020 at 5:45 pm, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not IJ and a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These failures could place residents at risk for extended discomfort, physical and psychosocial decline, and death. Findings include: A. During an observation on 11/16/2020, at approximately 12:35 PM, it was observed in the facility ' s 200-hallway that residents with unknown COVID-19 status and COVID-19 negative status were mixed. In an interview on 11/16/2020 at 5:22 P.M., DON stated the facility ' s practice is to mix quarantined residents with non-quarantined residents. In an interview on 11/17/2020 at 5:22 P.M., DON stated residents in the 200-Hallway consisted of initial fourteen-day quarantine residents, and one resident who had recently returned from a visit with family that had lasted four days in length. DON stated that only three residents were on isolation. Residents were tested upon admission, as-needed thereafter. If any staff come up COVID-19 positive, then all residents are tested as well. DON stated the facility planned on keeping to the current testing schedule of every seven days, most likely every Wednesday. According to DON, residents were last tested on [DATE], while staff were last tested on [DATE]. DON stated the facility had planned on placing COVID-19 positive residents in the currently vacant 100-Hallway, keeping the 200-Hallway the way, it was currently set up. According to DON, currently the facility only tested residents according to facility policy, which means testing residents upon admission, when they stay away from the facility longer than forty-eight hours, or when a staff member tests positive. According to DON, the current number of quarantined residents was ten. DON further stated the ten residents are under quarantine due to being new residents, and one resident having been out of the facility, with their family, for multiple days in a row. Observation of quarantined residents on 200 Hallway on 11/17/20 at 5:30PM revealed Resident D was observed and heard to have a persistent and wet cough while his door was open. Further observation revealed Resident D ' s door being left open all day on 11/16 and 11/17, despite Resident #5 being on droplet precautions, and being clearly marked as a quarantined resident. Review of progress notes for Resident D reflected upon 11/13/2020 admission to the facility, Resident D had tested negative for COVID-19. Admission records indicated Resident D had clear, regular, unlabored lung sounds. Review of subsequent notes by LVN C revealed the need to place Resident D on droplet precautions due to Resident D having chest sounds of scattered crackles. Droplet precautions would be renewed by LVN C through 11/17/2020. On 11/14/2020, LVN C also documented a fever in Resident D ' s chart. On 11/18/2020, observations made at 7:00 A.M., facility hallways were set up as follows: 200 - Warm 100 - Cold 300 - Cold 400 - Cold 500 - Cold On 11/18/2020, at 7:32 A.M., the facility had moved three residents off of the 200-hallway and onto the 100-hallway because they were past their 14-day quarantine period. The three residents Resident A, Resident B, and Resident J re-located from the 200-hallway to the 100-hallway were not quarantined. No barrier divided the two hallways, and the facility still operated an access/exit point in between the 200-hallway and 100-hallway without any kind of restriction or protection in place. B. During an observation 11/17/2020 at 9:10AM. Observed LVN A using the same med cart on 200 Hall that she used on 100 Hall prior to breakfast. During an observation on 11/17/2020, at 1:02 PM, wound care nurse LVN B was observed rolling a medical cart for wound care from the facility ' s 100-hallway into the atrium outside of the 200-hallway. LVN B stated intent to provide wound care to the residents in the facility ' s warm zone in the 200-hallway. No PPE observed other than a KN-95 mask and a box of gloves on the cart. In an interview on 11/17/2020 at 5:06 P.M., DOR stated staff were expected to make a list of residents to be seen each morning, with the residents in the warm hallway to be seen last, and only by one person from the therapy department. When asked if DOR had seen the facility house cold residents with warm residents, DOR stated the practice of the facility was to do that since, Warm residents are supposed to be presumed negative. Observation on 11/18/2020 throughout the morning shift. Off duty staff were observed entering the quarantined 200 Hallway from the double doors of service corridor to the double doors of the non-quarantined 100 Hallway housing three residents where COVID-19 testing was on-going: Two staff members at 9:00AM One staff member at 9:15AM Three staff members at 9:45AM One staff member at 10:03AM One staff member at 10:14AM Two staff members at 10:38AM One staff member at 10:48AM Four staff members at 10:56AM Two staff members at 11:14AM One staff member at 11:20AM One staff member at 11:28AM One staff member at 11:40AM In an interview on 11/18/2020 at 7:33AM CNA A stated that she was providing care to both quarantined and non-isolated residents on the 100 and 200 Halls. In an interview on 11/18/2020 at 7:50PM LVN A stated she was providing care to both quarantined and non-isolated residents on the 100 and 200 Halls. On 11/18/2020, at 8:10 A.M., OT A and PT A were observed walking into the warm zone without PPE. They were later confirmed to be therapy personnel. In an interview on 11/18/2020 at 8:24PM OT A and PT A both stated they provide therapy services to residents on 200 Hall as well as the rest of the facility. In an interview on 11/18/2020 at 9:13AM ADON stated the nurses use the same med cart and nurse cart for both 100 and 200 Halls. There was not a cart dedicated to each hall. In an interview on 11/18/2020 at 9:39AM NP stated she knew about mixing of quarantined and residents off isolation on the 100 and 200 Halls. She said it ' s what the facility decides is policy and to ask the DON about it. Observation on 11/18/2020 at 10:04 AM. Surveyors observed wound care nurse LVN B entering COVID unknown resident room with supplies in hand to provide wound care and then closed door behind him. LVN B then left the room with a trash bag, indicating the wound care was complete. LVN B then proceeded to provide wound care to COVID negative residents. Interview with the wound care nurse LVN B, on 11/18/2020 at 10:35AM revealed LVN B provides wound care to five residents on the 200-Hallway, as well as the rest of the facility. C. Surveyors observed staff wearing unapproved KN95 masks when entering COVID-19 unknown resident rooms. The ADM and the DON were both aware the KN95 masks were unapproved but were used because they could not obtain any N95 masks. They stated they had not attempted to reach out to their sister facilities to obtain N95 masks. According to the facility ' s Nursing Policies and Procedures document with subject title: Staffing, Nursing Department in Pandemic. Their policy last updated on 9/09/2020 states: 4. The facility will provide appropriate Personal Protective Equipment (PPE) to the staff according to the need of the established unit. All facility staff will wear a facemask while in the facility covering their nose and mouth. Staff that are caring for the COVID-19 positive and unknown COVID-19 status will wear a N95 mask, gown, and goggle or face shield. Surveyors observed a CNA entering a COVID-19 unknown resident room without proper PPE. No gown was worn. CNA stated she was rushing and needed to answer a call light and did not notice it was an isolation room. On 11/17/2020, at 7:15 P.M., observation of the facility ' s central supply areas revealed two boxes of N-95 masks (300 masks per box) on hand, inside the facility. CNA B stated the facility ' s main supplier had told the facility, With the recent spike in COVID-19 cases, priority for N-95's are hospitals. DON and ADM also reiterated this information. However, when asked to produce a paper trail for this information, the facility stated they could have more supplies come in from sister facilities in Round Rock, Hutto, and Austin. During an observation and interview on 11/18/2020 at 7:50AM revealed LVN A wearing a KN95 mask, instead of the required N95 mask, and stated that she wears whatever mask the facility provides the staff. During an observation on 11/18/2020 at 8:24AM OT A and PT B. Both donning PPE prior to entering resident room on 200 Hall and then exiting room immediately (due to resident eating breakfast). Face shields cloudy and visibly soiled and placed it in the bottom drawer of isolation cart with two other face shields without disinfecting. During an observation on 11/18/2020 at 8:30AM of room [ROOM NUMBER], LVN A exited the room removed the face shield that was visibly soiled and placed it in the bottom drawer of the isolation cart with two other face shields without disinfecting. According to the facility ' s Nursing Policies and Procedures document with subject title: Staffing, Nursing Department in Pandemic. Their policy last updated on 9/09/2020 states: 3. The facility will designate staff to work on each unit established. The staff will work that unit until need resolves and then quarantined or tested to move to another unit. The staff will only work one established unit until cleared per protocol to move to another. Crossover of staff between units is discouraged to the extent practicable and possible, for source control. The ADM was notified on 11/18/2020 at 8:56PM. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the ADM on 11/18/2020 at 8:56PM. A Plan of Removal was first submitted by the ADM on 11/18/2020 at 9:45PM. and the following Plan of Removal was accepted on 11/20/2020 at 8:19AM. Plan of Removal Actions Taken/Plan of Removal included: Residents that have been admitted or readmitted to the facility within the past 14 days have been placed in the designated quarantine unit of the facility with room doors closed. Residents having been in the quarantine unit for 14 days with no signs or symptoms of Covid-19 were relocated to warm areas of the facility on 11/17/20. They were then relocated to cold areas on 11/18/20. Residents on the Quarantine Unit with an unknown status and Employees of the facility were tested for Covid-19 on 11/18/20 with all results being negative. The Administrator and Director of Nursing were re-educated by the Clinical Consultant on 11/17/20, on the placement of admitted or readmitted residents in the quarantine unit for 14 days and then the relocation of those residents to a clean area after 14 days with no signs or symptoms of Covid-19. Implemented on 11/18/20. The facility has designated staff working in the quarantine unit of the facility. This was initiated on 11/18/20. The designated staff includes licensed nurse, certified nursing assistant and members of the therapy department. The assigned licensed nurse will provide any needed wound care to residents in the quarantine unit. The Administrator and Director of Nursing were re-educated on 11/17/20 by the Clinical Consultant on expectation that dedicated staff should be assigned to work in the quarantine unit. This will be monitored by review of the staffing sheets each day by the Administrator /designee to validate that the assignment reflects dedicated staff in the quarantine unit. Implemented on 11/18/20. The facility obtained and implemented N95 facemasks on 11/18/20. Residents residing in the quarantine unit of the facility are receiving care by staff utilizing full Personal Protective Equipment (PPE) including eye protection, gown, gloves and N95 facemask. The Administrator and Director of Nursing were re-educated by the Clinical Consultant on 11/17/20, on obtaining and providing N95 facemasks to the designated staff in the quarantine unit. Implemented on 11/18/20. Facility Staff will be re-educated by the Director of Nursing/designee regarding the following by 11/19/20: Admissions and readmissions will be placed in the designated quarantine unit with room doors closed, for 14 days, then relocated to clean areas if Covid-19 symptom free. Designated staff will work in the quarantine unit of the facility. Staff working in the quarantine unit will utilize full PPE of eye protection, gown, gloves and N95 facemask during the provision of care. Before working again all staff will be in-serviced by 11/19/20 with the exception of those on FMLA, sick days or vacation. Those exempted will be in-serviced before returning to work. Admission and re-admissions will be reviewed during stand-up meeting Monday through Friday by the administrator and members of nursing management to validate location in the designated quarantined unit is appropriate starting 11/19/20. The Medical Director was notified on 11/18/20 of the Immediate Jeopardy. Ad Hoc Quality Assurance Performance Improvement Meeting with the Administrator, Director of Nursing, Clinical Consultant and medical director was held on 11/18/20 to discuss contents of this plan and will be reported by the administrator to Quality Assurance Performance Improvement committee monthly for review and recommendations until pandemic plan no longer necessary. The survey team monitored the plan of removal from 11/20/2020 through 11/22/2020 as follows: Observations from 11/20/2020 through 11/22/2020 revealed compliance with cohorting residents from hot, warm, and cold zones. The 200 hall and 100 hall on the atrium side of the double fire doors are designated as the hot zone. The 100 hall rooms in between the two sets of double fire doors are designated as the warm zone. The long-term care side of the facility is the designated cold zone. Observations from 11/20/2020 through 11/22/2020 revealed compliance with the facility utilizing designated staff for the residents located in the hot, warm, and cold. Observations from 11/20/2020 through 11/22/2020 revealed compliance with the facility maintaining closed doors to isolate quarantined residents from non-quarantined residents. Observations from 11/20/2020 through 11/22/2020 revealed compliance with the facility supplying, ordering, and using correct PPE. N95 masks are being worn on the hot and warm zones. Interview conducted on 11/20/2020 at 10:00 PM. LVN stated that DON and ADON came in on Wednesday 11/18/2020 during evening and night change of shift to provide staff training and reeducation on cohorting of residents, including new admissions and readmissions, utilizing designated staff for each cohort and no comingling of any discipline, keeping doors closed to isolate quarantined residents from non-quarantined residents, and proper use of PPE. DON and both ADONs at facility to follow-up on training and reeducation. Interview conducted on 11/20/2020 at 10:25 PM. CNA stated that DON and ADON came in on Wednesday 11/18/2020 during evening and night change of shift to provide training and, reeducation. Training consisted of keeping doors closed to isolate quarentined and non-quarentined residents, hand hygiene, wearing proper PPE including N95 masks. Interview conducted on 11/20/2020 at 10:37 PM. CNA stated that DON and ADON came in on Wednesday 11/18/2020 during evening and night change of shift to provide training and reeducation. Training included using designated staff for each cohort, what PPE to use for each cohort, wearing N95 masks from now on, and hand hygiene. Observation on 11/20/2020 at 10:41 PM of the double fire doors by main dining room and service corridor were shut separating the hot and cold zones. Interview conducted on 11/20/2020 at 10:43 PM. LVN stated that DON and ADON came in on Wednesday 11/18/2020 during evening and night change of shift to provide training and reeducation. Training consisted of keeping doors closed to isolate quarantined and non-quarantined residents, hand hygiene, wearing proper PPE including N95 masks. Observation on 11/20/2020 at 11:10 PM of the warm and hot zones. Double fire doors closed off sectioning both zones. No residents currently on the hot zone. Five residents on the warm zone. Doors closed to resident ' s rooms. Both LVN and CNA are wearing N95 masks. Interview conducted on 11/20/2020 at 11:19 PM in the hot zone. LVN stated that the ADON from the hot and warm zones provided training and reeducation on both Wednesday and Thursday during evening and night shift change on cohorting for hot, warm, and cold residents, using the same designated staff for all cohorts, keeping doors closed in the hot zone, and wearing the proper PPE. Interview conducted on 11/20/2020 at 11:26 PM in the hot zone. CNA states the ADON came in on Wednesday 11/18/2020 during evening and night change of shift to provide training and reeducation. Training consisted of keeping doors closed to isolate quarantined and non-quarantined residents, hand hygiene, watching for signs and symptoms of COVID-19, wearing proper PPE including N95 masks. Observation on 11/21/2020 at 11:00 AM. Double fire doors by main dining room and service corridor is shut separating the hot and cold zones. Interview conducted on 11/21/2020 at 11:23 AM. CNA stated that DON and ADON both have provided training and reeducation prior to her starting shift. Training consisted of keeping doors closed to isolate quarantined and non-quarantined residents, hand hygiene, wearing proper PPE including N95 masks. Interview conducted on 11/21/2020 at 11:33 AM. CNA stated that ADON provided training and reeducation prior to her starting shift on Thursday 11/19/2020. Training consisted of keeping doors closed to isolate quarantined and non-quarantined residents, hand hygiene, wearing proper PPE including N95 masks. Interview conducted on 11/21/2020 at 11:41 AM. CMA stated that ADON provided training and reeducation prior to her starting shift on Thursday 11/19/2020. Training consisted of keeping doors closed to isolate quarantined and non-quarantined residents, hand hygiene, wearing proper PPE including N95 masks. Interview conducted on 11/21/2020 at 11:48 AM. CNA stated that ADON provided training and reeducation prior to him starting shift on Saturday 11/121/2020. Training consisted of keeping doors closed to isolate quarantined and non-quarantined residents, washing hands and using hand sanitizer, wearing proper PPE including N95 masks. Interview conducted on 11/21/2020 at 11:59 AM. CNA stated that ADON provided training and reeducation prior to him starting shift on Thursday 11/19/2020. Training included wearing PPE and N95 masks from now on, using designated staff for residents that are COVID-19 negative, unknown or presumptive, and positive residents, and keeping doors closed when quarantined. Interview conducted on 11/21/2020 at 12:06 PM. CNA stated that DON and ADON both have provided training and reeducation prior to her starting shift. She states she does know the difference between the N95 mask and KN95 mask now. Her training included which PPE to use and when to use it, designated being assigned to the different cohorts. Interview conducted on 11/21/2020 at 12:12 PM. LVN stated that ADON provided training and reeducation prior to her starting shift on Thursday 11/19/2020. Training included wearing PPE and N95 masks from now on, using designated staff for residents that are COVID-19 negative, unknown or presumptive, and positive residents, and keeping doors closed when quarantined. Interview conducted on 11/21/2020 at 12:26 PM. Med Aide stated that DON and ADON provided training and reeducation during her shift on Wednesday 11/18/2020. Training included wearing PPE and N95 masks from now on, using designated staff for residents that are COVID-19 negative, unknown or presumptive, and positive residents, and keeping doors closed when quarantined. Interview conducted on 11/21/2020 at 12:36 PM. CNA stated that DON and ADON provided training and reeducation during his shift on Wednesday 11/18/2020. Training included wearing PPE and N95 masks from now on, using designated staff for residents that are COVID-19 negative, unknown or presumptive, and positive residents, and keeping doors closed when quarantined. Interview conducted on 11/21/2020 at 12:40 PM. CNA stated that ADON provided training and reeducation during her shift on Wednesday 11/18/2020. Interview conducted on 11/21/2020 at 12:55 PM. ADM and DON both state that they immediately started training during day shift on Wednesday 11/18/2020 with all staff members working and have come to facility during change of shifts to provide training as well. DON states on 11/19/2020, she and ADONs removed all KN95 from facility and replaced them with N95. N95 masks are now required to be worn in cold, warm, and hot zones throughout facility. Observation on 11/21/2020 from 11:00 AM to 1:00 PM on the cold zone, all staff members are wearing N95 masks. Observation on 11/21/2020 at 1:08 PM on the warm zone, all staff members are wearing N95 masks and full PPE. Interview conducted on 11/21/2020 at 1:10 PM on the warm zone, CNA stated that ADON provided training and reeducation during her shift on Wednesday 11/18/2020. She is only assigned to the warm zone. Training consisted of keeping doors closed to isolate quarantined and non-quarantined residents, hand hygiene, wearing proper PPE including N95 masks. Interview conducted on 11/21/2020 at 1:17 PM on the warm zone, LVN stated that ADON provided training and reeducation during her shift on Thursday 11/19/2020. She is the designated nurse for the warm zone. She states all visitors and staff members working in the warm zone must use their door for entering and exiting and she conducts temperature screenings and health questionnaire before entry is allowed. She states all other visitors or essential workers must use the main entrance on the cold zone. Interview conducted on 11/22/2020 at 4:40 PM. RN stated she was trained and reeducated on cohorting hot, warm, cold residents, utilizing designated staff for each cohort, keeping doors closed, and wearing proper PPE and reminds the staff she works with on precautions to avoid the transmission of COVID-19. Observation on 11/22/2020 at 5:10 PM of the warm and hot zones. Double fire doors closed off sectioning both zones. No residents currently on the hot zone. Three residents on the warm zone. Doors closed to resident ' s rooms. Both RN and CNA are wearing N95 masks. Interview conducted on 11/22/2020 at 5:32 PM. RN states she is the designated nurse for this unit and was trained and reeducated on cohorting of residents and having designated staff for each zone. Training consisted of keeping doors closed to isolate quarantined and non-quarantined residents, hand hygiene, wearing proper PPE including N95 masks. While the IJ was removed on 11/22/2020 at 5:45 pm, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not IJ and a scope of pattern due to a need for ongoing monitoring.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent avoidable accidents for 1 of 18 residents reviewed for accidents. (Resident #32) The facility failed to ensure Resident #32's personal food was heated to a safe temperature which caused a third-degree burn and infection to Resident #32's right thumb that resulted in the amputation of her appendage. This failure could place residents who require assistance with reheating food of an avoidable accident. Findings include: Review of the Face Sheet revealed Resident #32 was 54-years-old with an initial admitted [DATE]. Resident #32 was diagnosed with [REDACTED]. A review of the quarterly MDS dated [DATE] revealed Resident #32 had a Brief Summary Review for Mental Status score of 15, meaning she had no cognitive impairment. Resident #32 required extensive assistance with all activities of daily living, except eating where she required set up assistance only. The MDS further revealed Resident #32 required assist of two persons for transfers. Review of Resident #32's care plan dated 10/04/2018 revealed she was unable to transfer and required a mechanical lift for all transfers. Further review of the care plan did not reveal any interventions for Resident #32's [MEDICAL CONDITION] relating to temperature sensitivity. Review of Nursing Progress Notes dated 8/14/2018 revealed Resident #32 had a burn to the right hand and they were to continue to monitor. Review of Nursing Progress Notes dated 8/16/2018 revealed Resident #32 stated she did not have feeling in her right hand but there were no signs or symptoms of infection. Review of the Physician's Visit Report dated 8/17/2018 revealed Resident #32 had a full thickness third degree thermal burn to her right hand. Further review revealed the burn had a large (67-100%) amount of necrotic tissue. Further review revealed Resident #32 burned her right thumb, hand, and wrist on a hot sausage biscuit. Resident #32 was being treated with 1% [MEDICATION NAME] cream and observed for signs of infection. Review of Nursing Progress Notes dated 8/19/2018 revealed Resident #32 was transported to the hospital following complaints of nausea. Review of the Hospital Wound Care Consultation dated 8/30/2018 revealed Resident #32 underwent a right thumb amputation on 8/22/2018 following a two week history of pain and fever caused by the burning of her hand. In an interview on 10/11/2018 at 11:25 a.m., CNA A stated Resident #32 recently had an amputation of her thumb because someone warmed up a food item too hot and she burned her thumb. CNA A stated the facility is not sure which shift the injury occurred on. CNA A stated Resident #32 has the cognitive ability to say what happened. In an interview on 10/11/2018 at 11:32 a.m., CMA A stated Resident #32 requires assistance with everything. CMA A stated, someone had heated up a biscuit sandwich and Resident #32 did not realize how hot it was which resulted her being burned. CMA A stated she is not sure if the facility staff discovered the injury immediately or the next day. CMA A stated the burn became infected and Resident #32 had to have her thumb amputated. In an interview on 10/11/2018 at 11:43 a.m., Resident #32 stated she asked a staff member to heat up her biscuit for her and it was overheated. Resident #32 stated she can't feel temperature due to her [MEDICAL CONDITION]. Resident #32 stated she did not know she had been burned until the next day. Resident #32 stated the burn became infected and she was sent to the hospital. Resident #32 stated during the operation to amputate her right thumb she suffered a [MEDICAL CONDITION]. In an interview on 10/12/2018 at 8:45 a.m., CMA B stated he works during the week and the weekend. CMA B was aware of the incident that occurred with Resident #32. CMA B stated Resident #32 burned her finger on hot food. CMA B stated following the incident he was told not to heat up any of the residents' food and to have kitchen staff address those needs. In an interview on 10/12/2018 at 8:50 a.m. LVN C stated Resident #32 burned her finger from a biscuit that was too hot. LVN A stated residents should not heat up any food but any staff member can heat up food for residents and the food temperature needs to be checked before handing the food to the resident. LVN A stated there were no in-services provided after the incident to ensure similar incidences do not occur again in the future. In an interview on 10/12/2018 at 9:00 a.m., CNA B stated Resident #32 told her she burned her finger on a hot biscuit but didn't say who warmed it up for her. CNA B stated all food should be taken to the kitchen to be warmed up. CNA B stated there were microwaves in the nourishment rooms but they have since been removed. In an interview on 10/12/2018 at 9:15 a.m., LVN D stated she was never in-serviced following the incident with Resident #32 from reoccurring. LVN B stated if a resident asked to have their food heated she would check the temperature before handing it back to the resident. LVN B was not aware that microwaves were removed from the nourishment rooms. In an interview on 10/11/2018 at 2:34 p.m., the Director of Nursing (DON) stated Resident #32 is not physically able to get up and heat her own food in the microwave. The DON stated after the burn was discovered she had the wound care doctor come and assess her. Resident #32 was placed on antibiotics and an attempt was made to treat her in the facility. The DON stated once the wound care doctor felt like it was not improving, Resident #32 was sent to the hospital. The DON stated Resident #32's condition of [MEDICAL CONDITION] compromises her skin's healing properties. The DON stated Resident #32's care plan should reflect that the resident had [MEDICAL CONDITION] and the staff should have been aware of the burn risk due to [MEDICAL CONDITION]. In an interview on 10/12/2018 at 10:33 a.m., the Administrator stated he was not aware of the full extent of the situation. The Administrator stated he had started two days prior to the burn being discovered. He understood Resident #32's thumb had been blistered and that it was being treated by the wound nurse. The Administrator stated he kept checking the progress notes and documentation but did not see anything alarming. The Administrator stated he was not aware Resident #32's thumb was amputated until 10/11/2018. Review of facility policy dated 10/2/2017 on Safe Handling of Food Brought in By Family/Friends for Patient/resident Consumption reads in part, All food and beverages brought into the facility by visitors should be prepared using safe food handling practices and in accordance with the patient/resident's dietary plan.