Every finding on record at Crowley Nursing and Rehabilitation

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen services.The Dietary Manager and Dietary Aides failed to follow hygienic practices and performed hand hygiene.The Dietary Manager wore an effective hair restraint.Dietary Aide B failed to wear an effective hair restraint on 08/20/26.The facility failed to ensure staff did not touch their hair or face while handling food.The facility failed to ensure five cases of food were not stacked on the floor and dated in the refrigerator and freezer. The facility failed to ensure five cases of goods and two unidentifiable cases were not stored on the pantry floor.The facility failed to ensure staff wore hair restraints while in the facility kitchen. These failures could place residents at risk for food borne illnesses, infections, and possible hospitalization. Findings included:During the initial kitchen observation, on 08/18/2026 at 9:15 AM revealed the following: At the kitchen entrance to kitchen the coffee and tea pre-filled packages were observed on the serving table exposed to environmental impact of others passing through. On top of juice machine was a red and black coffee container and open box of plastic PVC sheets (sheet packaging uses clear, durable plastic sheets to create protective, highly visible containers, blister packs, and folding cartons for retail and industrial goods.) Prep station (table to prepare food)1 large empty opened box on the floor under the prep table near puree equipment.Dry Storage: 8 cases of food (fruit cocktail, diced tomatoes, mandarin oranges, black beans, pineapple tidbits Delivery boxes stored on the floor in the dry pantry. 1 large box labeled (DO NOT) contained 1 lbs. bag of opened and undated potatoes chips. The bag was sealed. 4-5 lb. containers of chicken salad were undated. 6 cases were on the floor in the freezer. Kitchen Fryer grease was mahogany brown with food particles floating and clinging to the edges. Dietary Aide-M was observed choosing bottom plate warmers filled with water then emptying the water on the floor. Dietary Aide-M was observed getting residents' rubberbanded meal tickets on the serving counter and thumbing through and returned to serving in food. Dietary Aide-B was observed preparing meal trays on the cart with the same gloves throughout meal tray preparation. Dietary Aide-H removed disposable gloves and installed a second pair without hand washing, then opened the cooler and retrieved a container and placed on the resident cart. Dietary Manager- removed gloves and stored them on the prep table next to an empty glove box 3 times. Dietary Manager removed a wet bottom plate warmer from the cart and placed it on prep table due to wet food observation. The Dietary Manager after 20 minutes took the same wet plate warmer and rinsed in the dishwasher area and returned it to serving stack. Dietary Aide-W- was wearing a black baseball hat with hair exposed in the back. Dietary Aide-B- removed gloves and donned a second pair without hand washing. Dietary Aide-B touched serving line tray, serving cart, and trays with the same gloves. During an interview with the Dietary Manager on 08/18/2026 at 9:20 AM, she revealed she was promoted from a part-time Dietary Aide to Dietary Manager two days ago. She stated she was short staff today, however a food truck delivered boxes today at 6:00 AM, and she and the staff had not dated and stored them on the shelves. She stated it was dietary protocol to change the fryer grease every 3 days. She did not know when the last cleaning occurred. The tea and coffee should be stored properly in the dry storage until ready to brew. She was not aware the potatoes chips were stored in boxes opened.During a second interview on 08/20/26 at 12:30 PM with the Dietary Manager, she stated the Administrator was assisting her today with the kitchen inspection, due to the newly appointed assignment as Dietary Manager. She stated it was her expectation for all staff to date, label, and store the food on their perspective shelves in the dry pantry, refrigerator, and freezer for safe food storage. She stated she was nervous during the lunch preparation observation and failed to dispose removed gloves in the trash can, send the soiled wet dishes through the dishwasher for sanitation, remove gloves after each task and hand wash prior to starting a new task. She expected all dietary staff to practice handwashing sanitation prior to installing gloves and after removing them to prevent cross-contamination from surfaces to the food. She expected the gloves to be disposed of in the trash immediately. She was not aware her hair was exposed while working in the kitchen. She stated all staff were expected to wear a hair net covering all hair which included facial hair before working in the kitchen. The Dietary Manager said the green ice scoop was stored in the dish container on top of the ice machine for the staff to access for resident hydration carts. The Dietary Manager stated it was her expectation the staff followed dishwashing protocol and storage for sanitation and to prevent infection control, which included: sanitizing and washing dishes via dishwasher, ensure the container and dishes were clean and free of food, and stored downward on the dishrack for sanitation. She expected the dishes and containers to be free of water, food, and environmental particles to protect residents from the risk of infection control. She stated there were no reported food illnesses at the facility. During an interview on 08/20/2026 at 12:35 PM with the AM, she stated the Dietary Aide was expected to serve the food on the line, prevent other staff from engaging and cross-contamination. She stated the Dietary Manager was not responsible for assisting with serving and dishwashing during meal tray service. The DAS said all staff should wear hair nets while in the kitchen covering their hair to prevent cross-contamination. She said the Dietary Aide should not have been touching tickets, and other surfaces during test preparation without conducting glove removal and hand sanitation. She stated food must be dated and stored on the designated shelves in the dry storage, refrigerator, and freezer immediately upon arrival to prevent infection control and potential food bore illnesses. She stated staff were expected to cover all hair while in the kitchen, store the ice scoop in the designated blue container next to the machine. She started it was unsanitary for the Dietary Manager to wear the same gloves while gathering cooking utensil then preparing food, (spatula and large spoons). She concluded all tasks observed were not in keeping with food sanitation and storage, and the staff would be educated. During an interview on 08/202026 at 1:30 PM with DHD, she stated the Dietary Manager was new to her position, and the direct supervisor was out on leave. She stated the Dietary Manager should have been provided with some training and additional assistance in the kitchen once the survey was initiated. She stated staff were expected to cover all hair while in the kitchen, store the ice scoop in the designated blue container next to the machine, handwashing was important to prevent infections and cross-contamination. The Dietary Manager should not have been on the serving line. The staff were expected wash hands before donning gloves and removing and disposing gloves in the trash for sanitation purposes. One staff member should serve and remove gloves and handwash when the task changed. She said the DA should not have been touching meal tickets during tray preparations. During an interview on 08/20/2026 at 4:44 PM with the Administrator, he stated it was his expectation for dietary staff to follow protocols for safe food storage, sanitation procedures according to guidelines, which included washing dishware. He said failing to conduct appropriate food handling and serving guidelines could result in harmful germs and food borne illness.Record review of the facility's dietary in-service, by the Dietary Health Director, dated 08/20/2026, reflected Food serving sanitation protocol, dishwashing, and dish sanitation. Attendees Dietary Aide-B, Dietary Aide-A, Dietary Aide-M, and Dietary Manager.Record review of the facility's dietary in-service, by the Dietary Health Director, dated 08/20/2026, reflected educations on Hair coverings, handwashing, food storage protocols. Attendees Dietary Aide-B, Dietary Aide-A, Dietary Aide-M, and Dietary Manager. Record review of the facility's current, undated Staff Hygienic Dress Code Policy Statement reflected: .Dress Code Guidelines: Hair and Facial Hair: Staff must keep hair tied back or off the shoulders and secured under a hair net or cap. Facial hair should also be neatly restrained to prevent contamination. Authorized Kitchen Personnel.Policy Statement: Access to areas involved in food preparation, storage, and service will be strictly regulated to authorized. individuals only with the aim of reducing the risk of cross contaminations.Dry Goods Storage Policy and Procedure.Policy Statement: This policy ensures that all dry goods are stored in compliance with FDA Food Code standards to maintain their quality and safety.Procedure: Storage Guideline.Elevation of Goods: All dry goods must be kept on shelves at least 6 inches off the floor to prevent contamination and facilitate cleaning. 5. Condition of Stored Items: All packaged and canned foods must be maintained in a clean, dry state and properly scaled to preserve their integrity.Cold Food Storage Policy and Procedure . Food Storage Practices: To prevent cross contamination, all foods must be stored in a manner that is wrapped, covered, or contained within labeled and dated packages or containers. Foods should be organized to allow for easy access and to maintain cleanliness.Policy Statement.At [contractor Name], we prioritize the safety of our residents/patients, especially those with infectious diseases, by adhering to protocols established by the Federal Center for Disease Control (CDC) and directives from local or state health authorities in meal service and dish cleaning. Procedures: Verification of Meal Delivery: Nursing staff oversee the accurate preparation and distribution of meals to residents/patients.Handling of Soiled Dish ware: Soiled dishes are handled with utmost care using universal precautions. Our staff utilizes personal protective equipment such as gloves, goggles, and disposable aprons to minimize the risk of infection spread.Meal Service and distribution Policy and Procedures: Policy statement.Our aim is to transport meals to the dining areas in a way that ensures the food is free from contamination, guarantees timely and precise delivery. Operational Guidelines: Safe Food Handling: For meals assembled at the point of service, we employ food.handling techniques that prevent contamination and ensure the maintenance of Manual Ware washing policy and procedures: policy statement .[Contractor's Name) maintains strict procedures for manually cleaning and sanitizing all cookware, dishware, and service ware that cannot be washed by machine, adhering to the highest health and safety standards. Procedures Staff Proficiency: Our Dieta1y Service staff are trained in manual washing techniques, including: Proper soap usage.Maintaining wash water temperatures at a minimum of 110 F.Correct application of chemical sanitizer.Testing and adjustment of chemical sanitizer concentrations as needed.Sanitizer Concentration Testing: We use: test strips to accurately measure the concentration of the sanitizer solution during the washing process. The results are recorded systematically in the Three-Compartment Sink Log to ensure compliance and effectiveness.Drying and Storage: All cleaned service ware and cookware are thoroughly air dried before storage to prevent bacterial growth and contamination.

Based on observation, interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 resident (Resident #2) reviewed for quality of care.The facility failed to ensure Resident #2 had a boot to her heel per physician orders on 08/18/26 and 08/20/26. This failure could place the resident at risk of her diabetic wound worsening. Findings included:Record review of Resident #2's Quarterly MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2's had diagnoses which included dysphagia (difficulty swallowing) following a stroke, diabetes mellitus (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), Non-Alzheimer's dementia (conditions that impair memory, cognition, and daily functioning due to causes other than Alzheimer's), and non-pressure chronic ulcer of the right heel and midfoot. Resident #2's BIMS score was zero, which indicated severe cognitive impairment. Resident #2 had a diabetic foot ulcer and surgical wound. Record review of Resident #2's care plan reflected the following:- Resident #2 has amputation of BKA of left knee, date initiated 05/11/24- Resident #2 has actual impairment to skin integrity r/t diabetic wound to right heel. Resident at risk for pain and infection. *3/18/26 MD updated to Arterial Wound. *4/15/26 MD updated to Post Surgical Wound of the right, inferior, lateral heel, revised on 04/17/26. An intervention of Podus Boot was, dated 04/17/26. - Resident #2 has inappropriate behavior; Resistive to treatment/care related to: Cognitive impairment Dx: Dementia, Disbelief in value of treatment. Refuses medications, refuses to wear compression stocking on stump, continues to not use wheelchair when ambulating from room to bathroom, continues to crawl out of bed without notifying staff, revised on 04/27/26. Record review of Resident #2's physician orders reflected the following: - Podus boot to bilateral heel every shift for Promote Wound Healing, start date 06/05/26. Record review of Resident #2's progress notes, dated 06/01/26 to 08/20/26, did not reflect any entries that Resident #2 refused to wear the boot or took the boot off. Observation on 08/18/26 at 1:58 PM, Resident #2 was observed sitting in her wheelchair in the hallway and did not have a boot or heel protector on her foot. Observation and interview on 08/20/26 at 12:59 PM, Resident #2 was sitting up in her wheelchair in the hallway outside of her room and appeared to be sleeping. Resident #2 woke up but was not able to answer any questions. No boot or heel protectors were observed on her right foot.Interview on 08/20/26 at 1:22 PM, the Wound Care Nurse stated Resident #2 was to have the podus boot on at all times and it was to promote healing. She stated the nurse would be responsible for ensuring it was on and if Resident #2 did not want it on or took it off the refusal should be documented. She stated if not worn it had the potential to make her wound worse. Interview on 08/20/26 at 1:43 PM, LVN I was in Resident #2's room assisting her roommate. In the corner were a pair of soft purple heel protectors. LVN I stated Resident #2 was to wear the heel protector at all times and the nurse was responsible for ensuring they were on. She stated they were to promote healing and Resident #2 would not keep it on. LVN I stated if Resident #2 refused it should be documented. She said if not worn it could make her wound worse. Interview on 08/20/26 at 3:38 PM, the ADON stated the nurses should ensure Resident #2 was wearing the boot. She said her wound could get worse or she could develop a pressure ulcer.Interview on 08/20/26 at 4:03 PM, the DON stated Resident #2 should have the boot on and she had a care plan about behaviors as she removed things and would get on the floor. The DON stated the nurses would still need to go in and check to ensure it was in place. She said if there was a tendency to breakdown there could be a negative outcome if she was not wearing it. The DON stated the ADON and DON were to monitor the nurses by checking the orders and rounding to ensure the nurse put it on. Interview on 08/20/26 at 4:27 PM, the Administrator stated his expectation was for staff put the boot on Resident #2 per physician orders and the DON and nursing management were to monitor that it was being done. Record review of the facility's Support Surface Guidelines revised September 2013, reflected: PurposeThe purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown.General Guidelines4. Elements of support surfaces that are critical to pressure ulcer prevention and general safety include pressure redistribution, moisture control, shear reduction, heat dissipation/ temperature control, friction control, infection control, flammability, and life expectancy.

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #74) reviewed for pressure ulcers.The Wound Care Nurse failed to keep Resident #74's left foot elevated during wound care. This failure could place residents at risk for contamination of their wounds and cause unnecessary infections.Findings included:Review of Resident #74's quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's disease (brain conditions that cause memory and thinking problems due to physical issues other than Alzheimer's disease), heart failure, peripheral vascular disease (a blood circulation disorder that slows or blocks blood flow in the vessels outside the heart and brain, most commonly affecting the legs), end-stage renal disease (the final stage of long-term kidney damage), type 2 diabetes (health condition that happens when your body cannot make enough insulin) with foot ulcer. The resident had a BIMS of 13, which indicated her cognition was intact. The MDS further reflected Resident #74 had limited range of motion to her lower extremities and used a manual wheelchair for mobility. The MDS also reflected the resident had a diabetic foot ulcer. Review of Resident #74's care plan, revised on with a target date of 08/08/26, reflected she had the potential for alteration in skin integrity. Interventions included weekly treatment documentation and any other notable changes or observations.Review of Resident #1's Order Summary Report for August 2026 reflected to cleanse with normal saline, pat dry, apply collagen powder and anasept (broad-spectrum antimicrobial skin and wound care product) gel, wrap with kerlix and secure with tape each day shift. Observation and interview on 08/20/26 at 9:27 AM revealed Resident #74 in bed as the Wound Care Nurse set up for the resident's wound care. The resident said she got the wound to her left heel from self-propelling her wheelchair with her heels. The resident also said she was told by the staff to stay off of her feet, but because she did not listen, she caused the wound on her heel to worsen. Observation of the Wound Care Nurse revealed she put on a gown, face mask, and gloves. The Wound Care Nurse cut the old bandage off exposing an open wound to the side of her heel, removed her dirty gloves, applied hand sanitizer and put on a new pair of gloves. She then cleaned the wound and let it dry while she held Resident #74's foot up. The Wound Care Nurse let go of the resident's foot while she got the treatment off the bedside table. At that time, Resident #74 placed her left foot on her right foot with the open clean wound touching the sock. The Wound Care Nurse did not re-clean the wound and she applied the treatment and wrapped the foot with the kerlix bandage. Interview on 08/20/26 at 9:42 AM with the Wound Care Nurse revealed she did not realize Resident #74 was not holding her foot up the entire time or that the resident had placed the open wound on the sock of the right foot. The Wound Care Nurse said the wound should have been cleaned again after the resident placed it on the sock because that meant the wound was contaminated again. Interview on 08/20/26 at 3:44 PM with the ADON revealed if Resident #74's open wound touched a dirty surface, the Wound Care Nurse should have cleaned it again because they did not know what type of germs the sock had and that put the wound at risk for infection and/or damage to the tissue. Interview on 08/20/26 at 4:10 PM with the DON revealed if Resident #74's wound touched the sock during wound care; the wound should have been cleaned again for infection control purposes. The DON said that could cause the wound to worsen because it was no longer clean. Review of the facility's Wound Care policy, revised October 2010, reflected the following: Purpose The purpose of this procedure is to provide guidelines for the care of wound to promote healing.7. Use a no-touch technique.12.Be certain all clean items are on a clean field.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #6) reviewed for care plans. The facility failed to ensure Resident #6's care plan was updated to address that the resident could also transfer with the use of a transfer pole and one person assist.This failure could place residents at risk of not receiving necessary care and services.Findings include:Record review of Resident #6's Quarterly MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included stroke, hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side, and Non-Alzheimer's Dementia (conditions that impair memory, cognition, and daily functioning due to causes other than Alzheimer's). Resident #6's BIMS score was 5, which indicated severe cognitive impairment. Resident #6 was dependent on staff for transferring to and from a bed to a chair. Record review of Resident #6's care plan, dated 12/29/24, reflected Resident #6 Exhibits ADL Self Care Performance Deficit, requires assistance: cognitive deficit secondary to dementia disease progression, hemiplegia, limited mobility, Stroke with an intervention that included Transfer: requires total assist x 2 staff participation assist. With Hoyer Lift. A transfer pole and assistance by one staff was not documented on the care plan.Interview on 08/19/26 at 2:29 PM, PT E stated Resident #6 had therapy from 06/16 to 08/14/26 and was now able to transfer using the pole and it was communicated with nursing. Interview on 08/19/26 at 2:47 PM, the DOR stated Resident #6 was receiving therapy and she spoke to the nurse about her also being able to transfer without the Hoyer lift and use the transfer pole. She stated Resident #6 varied cognitively and had some different behaviors day to day so there was some discussion leaving Resident #6 as a Hoyer transfer depending on the times Resident #6 needed to use one.Interview on 08/20/26 at 12:52 PM, the MDS Coordinator stated Resident #6 still needed to use the Hoyer at times, but the care plan should be updated to reflect she could use the transfer pole with assistance. She stated it was important to keep the care plan updated for continuing care and if it was an ongoing thing it would be added under the interventions. The MDS Coordinator stated the DOR communicated changes to her. She said the risk if not updated, was the resident may have a fall from staff not knowing what type of transfer the resident needed. Interview on 08/20/26 at 4:03 PM, the DON stated the care plan should be updated to reflect the type of transfer and assistance needed. She said if it was an acute care plan it was the nurse manager's responsibility, otherwise the MDS Coordinator was responsible for updating them. The DON stated it was important to have an updated and accurate care plan to know the correct way to care for the patient. Interview on 08/20/26 at 4:27 PM, the Administrator stated the care plan should reflect how residents should be transferred. He said if the care plan was not updated, and a new staff member went to pull the Kardex and it showed a transfer that was not appropriate for the resident, it could potentially lead to injury. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, revised December 2016, reflected: Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and Implementation.13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.14. The Interdisciplinary Team must review and update the care plan:1. When there has been a significant change in the resident's condition; .Record review of the facility's Safe Lifting and Movement of Residents policy, revised July 2017, reflected: Policy StatementIn order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.Policy Interpretation and Implementation.3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include:Resident's preferences for assistance;Resident's mobility (degree of dependency);Resident's size;Weight-bearing ability;Cognitive status;Whether the resident is usually cooperative with staff; andThe resident's goals for rehabilitation, including restoring or maintaining functional abilities.

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained free of accident hazards as was possible for 1 of 5 residents (Resident #6) reviewed for accident prevention. CNA C failed to use a gait belt when she attempted to transfer Resident #6 from her bed to the wheelchair on 08/18/2026.This failure could place residents at risk of falls and injury. Findings included:Record review of Resident #6's Quarterly MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included stroke, hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side, and Non-Alzheimer's Dementia (conditions that impair memory, cognition, and daily functioning due to causes other than Alzheimer's). Resident #6's BIMS score was 5, which indicated severe cognitive impairment. Resident #6 was dependent on staff for transferring to and from a bed to a chair. Record review of Resident #6's care plan, dated 12/29/24, reflected Resident #6 Exhibits ADL Self Care Performance Deficit, requires assistance: cognitive deficit secondary to dementia disease progression, hemiplegia, limited mobility, Stroke with an intervention which included Transfer: requires total assist x 2 staff participation assist. With hoyer lift.Record review of incident log, dated 04/18/26 to 08/18/26, reflected Resident #6 had no falls. Observation and interview on 08/18/26 at 10:13 AM, revealed Resident #6 lying in bed, while CNA C was getting ready to transfer Resident #6 from her bed to the wheelchair. CNA C had a gait belt around her waist, lowered Resident #6's bed, raised the head up, and assisted Resident #6 to sit up on the side of the bed. The wheelchair was near the foot of the bed. CNA C was in front of Resident #6, did not put the gait belt around the resident and then prompted Resident #6 to grab onto the transfer pole on Resident #6's left side. Resident #6 attempted but could not stand up, then CNA C tried to assist Resident #6 up by holding on to her right arm, but Resident #6 still could not stand up. CNA C stated she was going to get another aide to help her. Interview on 08/18/26 at 10:19 AM, CNA C came back to Resident #6's room and stated she would get her up before lunch and left the room. Resident #6 stated she could usually stand up on the first try but had a bad night last night and did not sleep. Resident #6 said CNA C sometimes used a gait belt when she transferred her. Resident #6 said she felt safe when transferred by CNA C. Resident #6 stated she was getting PT everyday and usually went right before or after lunch. Interview by phone on 08/19/26 at 2:06 PM, CNA C stated she normally transferred Resident #6 without a Hoyer lift. She said Resident #6 was a Hoyer transfer from March until the end of July [2026]. CNA C said Resident #6 was working with therapy and they put a pole in her room. She said she saw Resident #6 transfer from her bed to the chair and the end goal was to have Resident #6 be able to transfer with one person. CNA C stated yesterday (08/18/26) when trying to get Resident #6 up, she did not know if it was because the state surveyor was in the room, but Resident #6 became dead weight, which surprised her. CNA C stated Resident #6 normally held the pole and was able to take a step, while she was in front of Resident #6, and sat down in the wheelchair. CNA C said she always had her hand behind her in case of her standing and could grab her pants. CNA C said she did not know what happened and ended up transferring her with a Hoyer later that morning. She said she asked MA H to help, and when they went to Resident #6's room, asked Resident #6 if she wanted to use the Hoyer and Resident #6 said yes. CNA C stated therapy told her Resident #6 could transfer without the Hoyer lift. She said therapy would normally tell nursing staff how a resident was able to transfer and show them. Interview on 08/16/26 at 2:29 PM, PT E stated Resident #6 had therapy from 06/16 to 08/14/26 and was now able to transfer using the pole and that was communicated with nursing. PT E stated therapy had done transfer training with CNAs and Nurses for Resident #6. She stated Resident #6 was able to transfer using the pole and with a caregiver in front of her. PT E stated a gait belt should be used when assisting Resident #6 for patient and staff safety. She stated if not, the resident could fall. Interview on 08/16/26 at 2:47 PM, the DOR stated a gait belt should be used in every transfer to increase safety for the patient and the person doing the transfer. The DOR stated the risk to residents was they could fall or injure themselves.In a follow up phone interview on 08/16/26 at 2:55 PM, CNA C stated she should have used a gait belt when attempting to transfer Resident #6. She stated she did not normally use a gait belt with her because Resident #6 would grab the pole and she was not trained to use a gait belt with her. She stated it was important to use a gait belt to help residents transfer in case the resident fell and to help the resident be more stable when standing. Interview on 08/16/26 at 3:16 PM, PTA F stated she had shown CNA C how to transfer Resident #6 with the transfer pole in the therapy gym. She said staff should use a gait belt for the safety of the staff member and the patient. She stated if not, the resident could fall and get injured. PTA F stated the therapy department did transfer training [for nursing staff], which included the use of a gait belt and would demonstrate from chair to chair or chair to wheelchair transfers. PTA F said therapy would communicate to the aides and nurses if there was a change in how a resident was to be transferred. Interview on 08/20/16 at 11:43 AM, LVN G stated he started training as a nurse this week but worked with Resident #6's as a CNA before this week. He stated he received training from the therapy department once Resident #6 was able to transfer without the Hoyer and use the transfer pole. He stated he was to use a gait belt during the transfer for safety and to keep her from losing her balance. He stated if a gait belt was not used, she could lose her balance and fall and possibly injure herself. Interview on 08/20/26 at 3:38 PM, the ADON stated her expectation was for staff to use gait belts during transfers for safety, and so residents would not fall[TF5.1]. Interview on 08/20/26 at 4:03 PM, the DON stated staff were to use a gait belt when transferring a resident for the resident and the staff member's safety. She said if not the resident could get injured.Interview on 08/20/26 at 4:27 PM, the Administrator stated his expectation was staff always used a gait belt for safety. He stated injury could occur if not used.Record review of CNA C's restraint and fall reduction training, dated 05/05/26, reflected she received training on fall prevention and the use of gait belts. Record review of the facility's Safe Lifting and Movement of Residents policy, revised July 2017, reflected: Policy StatementIn order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.Policy Interpretation and Implementation. 4.Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 9 residents (Resident #1) reviewed for care plans. The facility failed to develop a comprehensive care plan which addressed and included measurable objectives and timeframes related to Resident #1's indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to drain urine), which he had from approximately 01/29/25 until 04/09/25. This failure placed residents with indwelling urinary catheters at risk of experiencing urethral/bladder/kidney injury, pain, and possible infection. Findings include: Record review of Resident #1's face sheet dated 04/11/25 reflected the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] and most recently re-admitted on [DATE]. He was diagnosed with infection and inflammatory reaction due to indwelling urethral catheter, type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), chronic kidney disease, stage 4 (significant decline in kidney function, nearing kidney failure), hypertensive heart disease with heart failure (when prolonged high blood pressure weakens the heart muscle, eventually leading to the heart's inability to pump blood effectively), and cognitive communication deficit (difficulties with communication caused by problems with underlying cognitive processes). Record review of Resident #1's significant change MDS dated [DATE] reflected he had a BIMS score of 4 (severe cognitive impairment); Resident #1 used a walker and manual wheelchair for ambulation; Resident #1 was dependent on staff for toileting; Resident #1 had an indwelling catheter; Resident #1 was frequently incontinent of bowel; Resident #1 was diagnosed with renal insufficiency (also called renal failure - when the kidneys lose the ability to remove waste and balance fluids)/renal failure/ or end-stage renal disease (see renal failure); and Resident #1 had been diagnosed with a UTI (an infection that can affect any part of the urinary system) within the previous 30 days. Record review of Resident #1's baseline care plan dated 03/17/25 reflected, . 3. Health Conditions . C. Bowel and Bladder. 1. Urinary continence - Always continent . 4. Bowel and bladder appliances - Indwelling catheter . Record review of Resident #1's physician's orders for February 25 - April 25 reflected the following: - Flush [catheter] with 60cc's NS every day, PRN, every shift. Start date: 02/01/25. End date: 02/11/25. - [Catheter] care: Output Q shift every day and night shift. Start date: 02/01/25. End date 02/11/25. - Change [Catheter] and drainage bag PRN for obstruction or when closed system is compromised as needed. Start date: 02/25/25. End date: 03/07/25. - Flush [catheter] with 60cc's NS every day, PRN, as needed. Start date: 02/26/25. End date: 03/07/25. - Flush [catheter] with 60cc's NS every day, PRN, every shift. Start date: 03/18/25. End date: 04/11/25. - [Catheter] care: Output Q shift every day and night shift. Start date: 03/17/25. End date 04/09/25. Reason: [Catheter] discontinued. - Remove [catheter], if not voided in 8 hours, replace [catheter] one time only for 1 day, remove at 3:00 PM Order date 04/09/25. End date: 04/10/25. Record review of Resident #1's comprehensive care plan, revised 04/09/25 reflected the following care areas: - [Resident #1] has acute renal failure. Goal included: [Resident #1] will have no s/sx of complications related to fluid deficit (dehydration - when the body loses more fluid than it takes in). Interventions included: Give medications as ordered by physician. Monitor changes in mental status. Monitor for s/sx of infection, UTI. Monitor lab reports of electrolytes and report to physician. - [Resident #1] has incontinence and limited mobility due to his multiple comorbidities putting him at risk for skin breakdown. Goal included: The resident will maintain or develop clean and intact skin. Interventions included: Encourage good nutrition and hydration. Keep skin clean and dry. - [Resident #1] has urinary incontinence putting him at risk for having a UTI. Goal included: Resident #1's risk for septicemia (blood poisoning - a bloodstream infection where bacteria and their toxins are carried throughout the body) will be minimized/prevented via prompt recognition and treatment of symptoms of UTI. Interventions included: Clean peri-area with each incontinence episode. Encourage fluids during the day to promote prompted voiding responses. Ensure the resident has an unobstructed path to the bathroom. Incontinent: Check every 2 hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. - [Resident #1] is at risk for renal insufficiency due to him having chronic kidney disease stage 4. Goal included: Resident #1 will have no s/sx of complications related to fluid deficit. Interventions included: Monitor/document/report PRN any s/sx of acute renal failure. Further review of Resident #1's comprehensive care plan reflected no care area to address his indwelling urinary catheter. Record review of Resident #1's nursing progress notes for January 25 - April 25 reflected the following: - On 01/29/25 at 6:00 AM, an unidentified staff member wrote, admission details: Arrived by: ambulance. admission mode: stretcher . - On 01/30/25 at 4:14 PM, RN C wrote, Re-admit day 2/3 (Resident #1 was readmitted to the facility on [DATE]. There was no documentation about a catheter before this date). Resident is alert and oriented to self and situation . Resident's [catheter] is patent and draining clear, yellow urine. No color noted . - On 02/09/25 at 1:01 AM, LVN B wrote, . Genitourinary (urinary and genital organs): Catheter character: Patent (open or unobstructed). Catheter in place due to urinary retention (the inability to completely empty the bladder when urinating). Catheter size: 16 . - On 04/09/25 at 4:55 AM, LVN A wrote, Late Entry. Resident [catheter] discontinued per RP request and NP orders and tolerated well. Will monitor urine output through night per orders to reinsert if output not sufficient. Observation and interview with Resident #1 on 04/11/25 at 1:05 PM revealed he was alert and spoke Spanish. Through an interpreter with the HHSC approved language line, Resident #1 provided his name and birthdate. He did not have a catheter at that time. In an interview with the DON on 04/15/25 at 10:45 AM, she stated Resident #1 had a catheter at one time, but it was removed last week. She said she could not recall why Resident #1's catheter was removed, but she did not think he had it for a long time. In a follow-up interview with the DON on 04/15/25 at 12:58 PM, she stated Resident #1 may have returned from the hospital with the catheter on 3/17/25. She said Resident #1's catheter should have been listed as a care area on his care plan to inform staff how to care for it and to communicate what was going on with him. She said she was surprised to hear that Resident #1's catheter was not mentioned on his care plan. She stated the MDS Nurse was responsible for updating care plans and she was going to ask the MDS Nurse why there was no care area related to Resident #1's catheter. In an interview with Resident #1's Physician on 04/15/25 at 1:28 PM, she stated her records indicated Resident #1 first had the catheter around 02/08/25 due to urinary retention. She said the purpose of a care plan was to ensure staff knew what to do regarding the care areas, like Resident #1's catheter. She said staff never contacted her about any issues with Resident #1's catheter. She said as far as she knew, Resident #1's family requested to remove the catheter because they were taking him home. In an interview with the MDS Nurse on 04/15/25 at 2:30 PM, she stated she was responsible for updating residents' care plans. She said she and her assistant received information from morning staff meetings and the DON gave them lists of residents with feeding tubes, catheters, and tracheostomy tubes (a surgical procedure that creates an opening in the neck to insert a tube directly into the trachea). She said if any resident had a change in condition, she or her assistant would update their care plan. The MDS Nurse initially stated her assistant resolved (removed from the care plan) Resident #1's catheter information on 04/11/25. She said Resident #1 was readmitted on dialysis on 03/17/25, so she and her assistant completed a significant change assessment (completed a significant change MDS). She stated any resolved care area on a care plan would still be visible in their computer system. After reviewing Resident #1's comprehensive care plan on her computer, the MDS Nurse stated she did not see any care area related to Resident #1's catheter. She stated she was on leave when Resident #1 readmitted , but she heard the team (the nursing staff) talk about Resident #1 when she returned to work. The MDS Nurse stated she did not see any care area related to Resident #1's catheter which would have resolved from the care plan. She said Resident #1's catheter was addressed on his MDS and baseline care plan, but it did not carry over to his comprehensive care plan. She said the purpose of the care plan was to ensure all the staff knew each residents' plan of care and what interventions were in place. She said the care plan was also for new staff who were not familiar with the residents. She stated there were no negative effects related to Resident #1's catheter not being addressed on his care plan, but a negative effect would be that staff would not know information, like when to change him or how to care for him, and that could lead to infection. In an interview with the DON on 04/15/25 at 3:00 PM, she said Resident #1 had the catheter in February 2025. She said Resident #1 was discharged to the hospital and returned with the catheter. She stated Resident #1 did not experience any negative effects from not having the catheter addressed on his care plan because the staff followed orders from his physician. She said a negative effect would be infection. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, revised March 2022, reflected: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .c. includes the resident's stated goals upon admission and desired outcomes .e. Reflects currently recognized standards of practice for problem areas and conditions .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition .c. when the resident has been readmitted to the facility from a hospital stay .

Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 15 of 15 residents (Residents #7, #25, #31, #36, #38, #41, #74, #85, #90, #92, #201, #204, #205, #206, and #208) reviewed for medical record accuracy. 1. CNA F documented her care for Residents #7, #25, #31, #36, #38, #41, #74, #85, #90, #92, #201, #204, #205, #206, and #208 under LVN C's computer credentials on 06/03/25 and 06/04/25 2. CNA G documented her care for Resident's #7, #25, #31, #36, #38, #41, #74, #85, #90, #92, #201, #204, #205, #206, and #208 under CNA D's computer credentials on 06/03/25. These failures could place the residents at risk of inaccurate documentation of care. Findings included: Record review on 06/04/25 of Resident #90's Tasks reflected LVN H had documented personal care completed on 06/03/25 at 7:39 AM and again on 06/04/25 at 9:35 AM. Review of facility staffing schedule indicated LVN H had not worked on 06/03/25 or 06/04/25. His last shift was on 05/30/25 from 10:00 PM-6:00 AM. Resident #90 would have been cared for by CNA F from 6:00 AM-2:00 PM on 06/03/25 and 06/04/25, and by CNA G from 2:00 PM-10:00 PM on 06/03/25 according to the schedule. In an interview on 06/04/25 at 11:00 AM, ADON A stated staff are not allowed to share their log-in credentials for the facility's EHR system with each other, each staff member has their own unique log-in. She stated the only way for someone to document under someone else's credentials would be for the person to share their credentials, or to have not logged off a computer when they walked away from it. ADON A checked the computers at the nurse's station and discovered LVN H had saved his log-in credentials to the computer. Anyone clicking on the log-in would have automatically logged in as LVN H. In an interview on 06/04/25 at 11:05 AM, CNA F stated she had provided personal hygiene to Resident #90 on 06/03/25 and 06/04/25. She stated she had documented her cares in the EHR under LVN H's credentials because she was busy, and her credentials were not working, and she did not have time to ask the DON to fix it. She stated when she clicked on the log-in, LVN H was logged in and she did her documentation. CNA F stated she knew she was not allowed to document under someone else's credentials. She stated she did not know it was considered false documentation. In an interview on 06/04/25 at 11:17 AM, the DON and Administrator both stated it was not accepted practice to share credentials with other staff, or to document under someone else's credentials. The DON stated it was also not acceptable to save your log-in credentials on a computer so that someone else could document as you. The Administrator stated he did not know if there was a policy addressing using another person's login as it was just common sense not to share your credentials with others. Record review on 06/04/25 from 11:30 AM-11:50 AM of resident cares documentation for all residents cared for by CNA F reflected on 06/03/25 and 06/04/25 she had documented personal hygiene, bathing, incontinent care, oral care, and positioning as LVN H for Residents #7, #25, #31, #36, #38, #41, #74, #85, #90, #92, #201, #204, #205, #206, and #208. It was also discovered CNA G had also documented personal hygiene, oral care, positionig, and incontinent care on the 2:00 PM-10:00 PM shift on 06/03/24 using CNA I's credentials In a phone interview on 06/04/25 at 12:35 PM, CNA G stated she had documented her cares under CNA I's credentials because her credentials were not working, and she was too busy to go to the DON to have them reset. She stated she asked CNA I for her credentials. She stated she knew she was not supposed to use someone else's credentials to chart, but she stated she did not know it was considered false documentation to do so. In a phone interview on 06/04/25 at 12:53 PM, LVN H stated he worked at the facility PRN, and he worked at multiple facilities, so he saves his EHR log-in to the computers, so he did not have to remember multiple log-in credentials. He stated he did not know someone else could or would log-in as him and document in the chart. In a phone interview on 06/04/25 at 1:05 PM, CNA I she stated she had not shared her credentials with anyone. She stated she must have no logged out of a computer when she was done. She stated her last shift at the facility was on 06/01/25. Follow-up interview on 06/04/25 at 1:20 PM, ADON A she stated CNA I's credentials had been saved to a computer on the 200 Hall, the same as LVN H had done. Record review of the facility's Charting and Documentation policy, dated July 2017, reflected: .3. Documentation in the medical record will be objective, complete, and accurate .

Based on interview and record review, the facility failed to ensure the quality assessment and assurance committee (QAA) met at least quarterly and consisted of the required members for 11 of 11 quarterly QAA meetings. The facility failed to ensure the Medical Director, or his/her designee, attended 11 QAA committee meetings held on 06/11/24, 07/15/24, 08/08/24, 09/12/24, 10/10/24, 12/13/24, 01/07/25, 02/11/25, 03/10/25, 04/10/25, and 05/13/25. This failure could place residents at risk for quality deficiencies being unidentified and with no appropriate guidance developed or implemented. Findings included: Record review of the QAA meeting sign in sheets revealed the Medical Director or his/her designee did not attend on the following dates: 06/11/24, 07/15/24, 08/08/24, 09/12/24, 10/10/24, 12/13/24, 01/07/25, 02/11/25, 03/10/25, 04/10/25, and 05/13/25. Interview with the Administrator on 06/05/25 at 2:22 PM revealed the facility Medical Director rarely attended the QAA meetings. The Administrator stated the Medical Director was notified of the date and time of the QAA meetings by the Chairperson of the QAA committee. The Administrator said it was his responsibility to follow up with the Medical Director to ensure that he attended the QAA meetings. The Administrator revealed when the Medical Director did not attend the QAA meetings there was a communication breakdown about the residents' care and the long-term plans about the facility and future residents. Interview with the Medical Director on 06/05/25 at 2:47 PM revealed he had not been invited to any QAA meetings by the facility and had not attended any QAA meetings. Record review of facility's QAA Policy, dated 11/28/17, revealed the QAA Committee consisted of at a minimum the Committee Chairperson, Administrator, Director of Nursing, and the Medical Director.

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 of 4 residents (Resident #75) reviewed for accidents. The facility failed to remove Resident #75's fall mat, next to her bed, when she would take a few steps to her bedside commode, which posed a trip hazard. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: Record review of Resident #75's MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, non-Alzheimer's dementia and muscle weakness. Resident #75 had a BIMS of 8 indicating her cognition was moderately impaired. The MDS further reflected the resident required substantial/maximal assistance for bed to chair and toiler transfers and she was not coded as having recent falls. Record review of Resident #75's care plan initiated on 01/10/25 reflected she was at risk for falls related to a history of falls due to unsteady gait, and poor safety awareness. Interventions included to provide a safe environment such as even floors free from spills and/or clutter. Observation and interview on 06/03/25 at 11:21 AM of Resident #75 revealed she was in her room sitting on the side of her bed and she was on continuous oxygen. Next to the bed there was a bedside commode and next to that was a wheelchair. There was a fall mat noted on the floor and three wheels of the resident's bedside table were on the fall mat. Resident #75 stated she was able to independently self-transfer/walk to the bedside commode and to her wheelchair but she was afraid she would trip on the fall mat. The resident stated it was difficult for her to move her bedside table out of the way when she would transfer herself to the bedside commode because the wheels would get stuck on the mat. Resident #75 said her family had tried to remove the mat but the staff said it needed to stay in place because she was a high fall risk. Interview on 06/03/25 at 11:26 PM with Resident #75's family revealed they did not like the fall mat on the floor next to the resident's bed because they felt like the resident would trip on it going to her bedside commode. The family further stated they had asked the staff to remove it but they told them the fall mat was being used to help the resident during a fall. Interview on 06/04/25 at 1:44 PM with LVN B revealed Resident #75 was able to self-transfer to the bedside commode in her room and to her wheelchair. LVN B said the resident had not had any recent falls and the fall mat stayed on the floor at all times as a fall prevention. She said the family had tried to remove it but the staff would put it back on the floor. Interview on 06/04/25 with CNA D at 1:53 PM revealed Resident #75 was able to transfer herself to the bedside commode and did not have any recent falls. The CNA said the fall mat stayed on the floor next to the resident's bed as a fall prevention. CNA D further stated had noted the bedside table was leaning a bit because it was sitting on the curvature of the fall mat. Interview on 06/04/25 at 2:03 PM with CNA E revealed the Resident #75 required limited supervision with ADLs and was able to transfer herself to the bedside commode. CNA E said the fall mats were in place to protect her in case they resident fell, and the resident had never complained to her about the mat being a trip hazard. Interview on 06/09/2025 at 2:12 PM with the Physical Therapist revealed the nursing staff were responsible for the fall mats and deciding which residents had one. It was her professional opinion that if a resident was mobile or ambulatory, a fall mat should only be in place when they are lying in bed and picked up throughout the day because the fall mat could be a trip hazard making it unstable to walk on and could cause a resident to fall on it. Interview on 06/05/25 with the ADON revealed Resident #75 required a fall mat day and night as a fall prevention because she was in bed most of the time. The ADON said if the fall mat was placed correctly, it should not have been a trip hazard. The ADON further stated she had spoken to the resident the day prior (06/04/25) and the resident had said she was afraid she would fall on the fall mat as she transferred to and from her commode chair. Interview on 06/05/25 at 1:40 PM with the DON revealed Resident #75's fall mat did not need to be in picked up because it was not a trip hazard of they were positioned properly and wheelchairs could be maneuvered over it. Record review of the facility's Falls - Clinical Protocol policy, revised April 2007, reflected the following: .a. Risk factors for subsequent falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environment hazards

Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 6 residents (Resident #76) reviewed for enteral feeding. The facility failed to have a physician's order for an abdominal binder that was being used to secure/protect the resident from pulling out her g-tube. This failure could place residents at risk for diminished quality of care. Findings included: Record review of Resident #76's MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. She had a diagnosis of gastrostomy status (refers to the presence or absence of a gastrostomy tube or a percutaneous endoscopic gastrostomy (PEG) tube). Resident #76 had a BIMS of 0 which indicated her cognition was severely impaired. The MDS further reflected the resident was dependent with all ADLs with the assistance 2 or more staff members and she was on a feeding tube. Record review of Resident #76's care plan revised on 07/24/25 reflected she required a tube feeding related to a swallowing problem. Interventions included to check for tube placement per protocol and document. Record review of Resident #76's monthly physician orders for June 2025 reflected the resident to give Nestle Nova source Renal at 35 ml/hr per GT X 22 hours every shift. Further review reflected there were no orders for an abdominal binder. Record review of Resident #76's progress notes reflected the following: 03/17/25 - nurse notified by aide that while giving resident a bed bath resident pulled out G-Tube. Nurse immediately assessed resident. Physician notified Non-emergency transport contacted to transport to [hospital] to replace tube. 04/26/25 - the aide taking care of resident notified this nurse that the resident pulled out her G-Tube. MD notified, and ordered that resident be transferred to the ER for a G-Tube replacement Observation 06/05/25 at 9:17 AM of Resident #76 revealed Resident #76 was in bed with her eyes open and was not able to carry a conversation due to her impaired cognition. The aide pulled up the resident's gown and an abdominal binder was noted to be in place covering the g-tube site. Interview on 06/04/25 at 1:33 PM with LVN B revealed Resident #76 had pulled out her g-tube out a couple of times because she was very mobile during care and would fidget with her hands and if she got agitated she would pull out her tube. LVN B said they kept the dressing at the g-tube site and an abdominal binder in place to help prevent it from being pulled out. Interview on 06/04/25 at 1:47 PM with LVN D revealed Resident #76 had pulled out her g-tube while she was giving her a bed bath. LVN D said the resident was very mobile and would try to grab her g-tube during care. Resident #76 now had an abdominal binder in place and they had not had any incidents where the resident had pulled her g-tube out. Interview on 06/04/25 at 1:59 PM with CNA E revealed Resident #76 had not pulled out her g-tube since they placed the abdominal binder on the resident. Interview on 06/05/25 at 1:32 PM with the DON revealed resident's did not require a physician order for an abdominal binder because it was not a treatment and only being used for protection. Interview on 06/05/25 at 3:36 PM with the Physician revealed he would expect the resident to have an order for an abdominal binder as part of their care. Record review of the facility's policy titled Enteral Nutrition revised January 2014 reflected the following: Adequate nutritional support through enteral feeding will be provided to residents as ordered

Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for two of nine (Residents #1 and #2) residents reviewed for discharges. The facility failed to provide and document that Residents #1 and #2 were given sufficient preparation and orientation prior to discharging the residents from the facility. These failures could place residents at risk of being discharged without a safe and effective transition of care, an accurate reason for discharge and inaccurate information communicated to the receiving health care institution or provider. Findings included: 1. Record review of Resident #1's Admission Record dated 08/15/24 reflected Resident #1 was an [AGE] year-old female with an original admitted [DATE]. Record review of Resident #1's MDS assessment dated [DATE] reflected the resident had a BIMS score of 05, which meant the resident had a severe cognitive impairment. MDS also revealed that Resident had Behavioral Symptoms of verbal behavioral symptoms directed toward other 1-3 days per week. MDS also revealed that Resident #1 has diagnoses of non-Alzheimer's dementia, hypertension, renal insufficiency, hyperlipidemia, anxiety, and depression. Record review of Resident #1's undated care plan reflected: Goal . Resident will not verbally abuse others. Care plan did not reflect a date or incident of physical aggression. The care plan only reflected information about verbal aggression. Record review of Resident #1's care plan conference summary dated 05/01/24 revealed, Mood/Behavior-Pleasant and appropriate/easily agitated. Record review of Resident #1's Progress note dated 07/10/24 at 12:34 PM by ADON A reflected: Resident was in WC on 100 hall wheeling from dining room to her room and saw another resident sitting in her WC in her door way. Resident #1 took her shoe off and hit the other resident on both arms. The other resident started yelling. The other resident [sic] to BOM office and reported incident. Resident #1 placed on one on one with staff. MD, ADMIN, DON, RP notified. Record review of Resident #1's Progress note dated 07/10/24 at 9:07 PM by LVN C reflected:Resident discharged to home this evening. Picked up by her [family member] Resident discharged with her medications and took with all her belongings. Record review of the Incident Report dated 07/10/24 at 12:30 PM written by ADON A reflected: Head to toe assessment done and no marks of any kind noted on this resident as of yet No injuries post incident. Interview on 08/14/24 at 1:10 PM with Resident #1's POA and husband revealed they received a phone message voicemail from the BOM on 07/10/24 in the afternoon. When the POA and her her husband returned the phone call later that afternoon, they were told the facility had faxed out referrals to other nursing facilities because Resident #1 was a danger to others. They were also informed that another facility accepted her, and they would be transferring her later that day. The POA stated they would not allow the facility to transfer their mother without visiting the facility first. The POA and her husband went to the facility and picked up Resident #1 that evening and took her home with them. Interview on 08/15/24 at 12:58 PM with LVN E revealed she had worked at the facility four years. LVN E also revealed she had been Resident's #1's nurse previously when she worked on the secured unit. LVN E stated Resident #1 was verbally aggressive. LVN E said the incident that occurred on 07/10/24 was the only incident that involved Resident #1 hitting another resident. LVN E also revealed that Resident #1 had improved and was transferred from the secured unit to Hall 100. Resident #1 had been on her hall about 3-4 months. LVN E stated she did not believe they would transfer Resident #1 off the secured unit if she had physical aggression toward other residents. Interview on 08/15/24 at 1:20 PM with CNA D revealed she had provided care to Resident #1. CNA D stated the resident was verbally aggressive with residents and staff, but she had not known Resident #1 to hit a resident before this incident. Interview on 08/15/24 at 2:20 PM with the BOM revealed she was the highest level of management in the building when the incident occurred with Resident #1. The BOM stated she contacted the Administrator about the incident when it occurred. The BOM also said that to her knowledge, no injury occurred to the resident that Resident #1 struck with her shoe. The BOM also revealed after informing the Administrator of the incident involving Resident #1, the Administrator stated to discharge the resident. The BOM stated she called and left a message for Resident #1's POA. The BOM said the POA returned the call and said she would come and pick up the resident because she did not want Resident #1 discharged to a facility that day that she had no knowledge about and had not seen. The BOM said that Resident #1 had not been physically aggressive towards other residents to her knowledge. Interview on 08/15/24 at 3:54 PM with ADON B revealed she provided care to Resident #1. ADON B stated Resident #1 was verbally aggressive when she was on the unit, but Resident #1 was not physically aggressive toward other residents. ADON B concluded by stating that she had seen other residents hit other residents with no resulting injury, but they were not discharged . Those residents had care planned interventions such as separating the residents before there was a discharge discussed. Interview on 08/15/24 at 5:30 with the DON revealed she did not work at the facility at the time of the incident. There was another DON at the time of the incident. However, the DON was not in the building and was away on vacation at the time. The DON stated there should have been a care plan meeting to reduce future incidents involving psych, medical, and any testing that could rule out any behavioral issues and possibly moving her to a different hall before enforcing an immediate discharge. The DON also stated if these measures did not help the resident, then the facility could examine possibly moving her to a different hall. Then the DON said if this did not help, then the facility could look at moving Resident #1 back to the secured unit. The DON could not locate the 48-hour discharge notice that she acknowledged should be in the EHR. The DON also could not locate a physician's note reflecting Resident #1 was a harm to herself or others. The DON stated the risk to the resident of an unsafe discharge was the resident does not have proper resources set up. Interview on 08/15/24 at 6:04 PM with the Administrator revealed he was on vacation when Resident #1 was discharged . The Administrator stated he was not aware the resident was discharged so quickly, meaning the same day the incident occurred. The Administrator also stated they typically issued a formal discharge and did not discharge a resident the same day as an incident occurred. The Administrator said recently there was past physical aggression on the secured unit, so he reacted too quickly to discharge Resident #1. The Administrator also revealed they did not have a letter from the Medical Director reflecting Resident #1 was a threat to herself or others and was unaware that was needed. The Administrator stated because their policy was not followed, there were not resources set up for the resident prior to discharge, which created a risk to the resident's physical and mental health. 2. Record review of Resident #2's Admission Record dated 08/15/24 reflected Resident #2 was an [AGE] year-old male with an original admitted [DATE]. Record review of Resident #2's MDS assessment dated [DATE] reflected the resident had a BIMS score of 11, which meant the resident had a moderate cognitive impairment. MDS also revealed that Resident #2 had 0 behaviors and diagnoses of Alzheimer's disease, muscle weakness, cognitive communication deficit, difficulty in walking, and repeated falls. Record review of Resident #2's undated care plan reflected no focus, goals, or interventions related to physical aggression or sexual inappropriateness. Record review of Resident #2's Notice of Proposed Transfer w Discharge (Texas) dated 06/03/24 reflected the transfer/discharge to home with [family member] Effective: 6/5/24. The document also reflected: Reason for proposed Transfer/discharge Safety of individuals in the facility is endangered. This was issued as a 48-hour emergency discharge on 06/03/24. Record review of Resident #2's Progress Notes dated 05/31/24 at 3:20 PM written by ADON A reflected: Staff member reported to this staff member [sic] reported to this nurse that she observed resident touching another resident's breast. When asked this resident stated that he doesn't remember if he touched her breast or not. He then stated that his memory isn't that good. The residents were separated. Admin, DON, MD, RP for both residents notified. This resident placed on one on one with staff. Record review of Resident #2's Progress Notes dated 05/31/24 at 10:32 PM written by the Social Worker reflected: .POA .was open to alternative placement but did not want to take the resident home. SW sent out residents clinicals to multiple different facilities and awaits answer. Resident remains on one on one. Record review of Resident #2's Progress Notes dated 06/04/24 at 9:09 AM written by LVN F reflected: Resident continues on 1:1 for behaviors. Some tearfulness noted this morning R/T upcoming discharge home. Resident says, 'I will miss everyone.' Resident verbally consoled by staff. Record review of Resident #2's Progress Notes dated 06/05/24 at 11:00 PM written by LVN D reflected: Resident discharged home with [family member] with meds and all personal belongings in good condition Interview on 08/15/24 at 12:53 PM with LVN G revealed she never saw Resident #2 touch a resident inappropriately, and she did not believe that he did. LVN G said she never heard Resident #2 talk inappropriately to a resident either. Interview on 08/15/24 at 1:27 PM with CNA D revealed she never saw Resident #2 being sexually aggressive or inappropriate with a resident. CNA D also said she never saw Resident #2 be physically aggressive toward residents either. Interview on 08/15/24 at 1:31 PM with Laundry Aide H revealed she observed Resident #2 with his hand on a female's breast on the outside of her shirt. Laundry Aide H stated Resident #2 dropped his hand when he was observed by her. She stated she had never seen Resident #2 touch another resident inappropriately prior to this incident. She said she reported the incident immediately to administration. Interview on 08/15/24 at 4:03 PM with ADON B revealed she was Resident #2's nurse previously. ADON B stated she had not heard of Resident #2 touching a resident inappropriately prior to this incident. ADON B also said residents in the past would have interventions put in place before discharge, such as being placed on a secured unit. Interview on 08/15/24 at 5:02 PM with the DON revealed she did not work at the facility at the time of the incident. There was another DON at the time of the incident. The DON stated she had never seen the resident be physically or sexually aggressive toward other residents. The DON also stated that before you discharge a resident, you should attempt interventions. The DON said that possible interventions that could have been attempted were separating and relocating the residents involved in an incident. The DON said one on one was a possible intervention. The DON was unable to locate a note from the physician stating that the resident was a harm to himself or others. The DON revealed she was unaware of the discharge policy. The DON concluded by stating there was risk of harm to the resident when there was an unsafe discharge. Interview on 08/15/24 at 6:19 PM with the Administrator revealed there was not a letter from the physician or medical director stating that Resident #2 was a harm to himself or others The Administrator revealed that he determined when a resident should be discharged without consulting the medical director or the resident's physician. The administrator stated that if he deemed a resident a threat to themselves or others, he issued a discharge notice. The Administrator also revealed no one oversaw this process or monitored the process. The Administrator stated because their policy was not followed, there was a possibility of risk to the resident's physical and mental health. Review of the facility's Transfer or Discharge Documentationpolicy and procedure, dated December 2016, reflected: When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider .the following information will be documented in the medical record .If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include .the specific resident needs that cannot be met; the facility attempt to meet those needs; and the receiving facility services(s) that are available to meet those needs .A summary of the resident's overall medical, physical and mental condition .Should the resident be transferred or discharged for any of the following reason, the basis for the transfer or discharge will be documented in the resident's clinical record by the resident's Attending Physician: The transfer or discharge is necessary for the resident's welfare, and resident's needs cannot be met in the facility .The safety of individuals in the facility is endangered due to the clinical or behaviors status of the resident; or the health of individuals in the facility would otherwise be endangered .Information will be communicated to the receiving facility or provider .The basis for the transfer or discharge .The specific resident needs that cannot be met; the facility's attempt to meet those needs; and the receiving facility's services that are available to meet those needs .Contact information of the practitioner responsible for the care of the resident .Comprehensive care plan goals; and all other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable , to ensure a safe and effective transition of care.

Based on interview and record review, the facility failed to notify the resident, resident representative and send a copy to the Office of the State Long-Term Care Ombudsman, of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for one of nine residents (Resident #1) reviewed for discharge rights. 1. The facility initiated an emergency discharge for Resident #1 due to safety concerns by notifying the resident's RP by phone only and not in writing. The facility failed to provide Resident #1 an emergency discharge letter with the required information and resources, including discharge instructions with plan of care. 2. The facility failed to notify the State Long-Term Care Ombudsman by phone or in writing of Resident #1's discharge. These failures could place residents at risk of not receiving preparation and knowing their rights related to discharge, as well as necessary services to meet their needs upon discharge, which could exacerbate their medical condition and a diminished quality of life. Findings included: Record review of Resident #1's Admission Record dated 08/15/24 reflected Resident #1 was an [AGE] year-old female with an original admitted [DATE]. Record review of Resident #1's MDS assessment dated [DATE] revealed the resident had the following diagnoses: non-Alzheimer's dementia, hypertension, renal insufficiency, hyperlipidemia, anxiety, and depression. The MDS reflected the resident had severe cognitive impairment with a BIMS score of 5 and had verbal behavioral symptoms directed toward other 1-3 days per week. Record review of Resident #1's EHR on 08/15/24 revealed no Notice of Proposed Transfer Discharge (Texas). Record review of Resident #1's EHR on 08/15/24 also reflected no documentation indicating notifications was made to the State Long-Term Care Ombudsman either by phone or in writing of Resident #1's emergency discharge. Record review of Resident #1's undated care plan reflected: Goal . Resident will not verbally abuse others. Care plan did not reflect a date or incident of physical aggression. The care plan only reflected information about verbal aggression. Record review of Resident #1's care plan conference summary dated 05/01/24 reflected: Mood/Behavior-Pleasant and appropriate/easily agitated. Record review of Resident # 1's Progress Note dated 07/10/24 at 12:34 PM by ADON A reflected: Resident was in WC on 100-hall wheeling from dining room to her room and saw another resident sitting in her WC in her doorway. Resident #1 took her shoe off and hit the other resident on both arms. The other resident started yelling. The other resident[sic] to BOM office and reported incident. Resident #1 placed on one on one with staff. MD, ADMIN, DON, RP notified. Record review of Resident #1's Progress note dated 07/10/24 at 9:07 PM by LVN C reflected: Resident discharged to home this evening. Picked up by her [family member] Resident discharged with her medications and took with all her belongings. Record review of the Incident Report dated 07/10/24 at 12:30 PM by ADON A reflected: Head to toe assessment done and no marks of any kind noted on this resident as of yet No injuries post incident. Further review of Resident #1' clinical records reflected there was no physician's documentation related to the basis for the discharge, specific resident needs that could not be met by the facility, attempts to meet the resident's needs and/or services that would be available at the receiving facility to meet the resident's needs. Interview on 08/14/24 at 1:10 PM with Resident #1's POA revealed they received a phone message from the BOM. When she and her husband returned the phone call, they were told the facility was faxing out referrals to other nursing facilities because Resident #1 was a danger to others. They were also informed that another facility accepted her, and they would be transferring her immediately that day. The POA stated they would not allow the facility to transfer their mother without visiting the facility. The POA and her husband went to the facility and picked up Resident #1 that evening. Interview on 08/15/24 at 12:58 PM with LVN E revealed she had worked at the facility four years. LVN E also revealed she had been Resident's #1's nurse previously when she worked the secured unit. LVN E stated Resident #1 was verbally aggressive. LVN E said the incident that occurred on 07/10/24 was the only incident that involved Resident #1 hitting another resident. LVN E also revealed Resident #1 had improved and was transferred from the secured unit to Hall 100. Resident #1 had been on her hall about 3-4 months. LVN E stated she did not believe that they would transfer Resident #1 off the secured unit if she had physical aggression toward other residents. Interview on 08/15/24 at 1:20 PM with CNA D revealed she had provided care to Resident #1. CNA D stated the resident was verbally aggressive with residents and staff, but she had not known Resident #1 to hit a resident before this incident. Interview on 08/15/24 at 2:20 PM with the BOM revealed she was the highest level of management in the building when the incident occurred with Resident #1. The BOM stated she contacted the Administrator about the incident when it occurred. The BOM also said to her knowledge, no injury occurred to the resident that Resident #1 struck with her shoe. The BOM also revealed after informing the Administrator of the incident involving Resident #1, the Administrator stated to discharge the resident. The BOM stated she called and left a message for the POA. The BOM said the POA returned the call and said she would come and pick up the resident because she did not want Resident #1 discharged to a facility that day that she had no knowledge about and had not seen. The BOM said Resident #1 had not been physically aggressive to other residents to her knowledge. Interview on 08/15/24 at 3:54 PM with ADON B revealed she provided care to Resident #1. ADON B stated Resident #1 was verbally aggressive when she was on the unit. ADON B said that Resident #1 was not physically aggressive toward other residents. ADON B concluded by stating that she had seen other residents hit other residents with no resulting injury, but they were not discharged . Those residents had care planned interventions such as separating the residents before there was a discharge discussed. Interview on 08/15/24 at 5:30 with the DON revealed she did not work at the facility at the time of the incident. There was another DON at the time of the incident. However, the DON was not in the building and was away on vacation at the time. The DON stated there should have been a care plan meeting to reduce future incidents involving psych, medical, and any testing that could rule out any behavioral issues and possibly moving her to a different hall before enforcing an immediate discharge. The DON also stated if these measures did not help the resident, then the facility could examine possibly moving her to a different hall. Then the DON said that if this did not help, then the facility could look at moving Resident #1 back to the secured unit. The DON could not locate the 48-hour discharge notice that she acknowledged should be in the EHR. The DON also could not locate a physician's note stating Resident #1 was a harm to herself or others. The DON stated the risk to the resident of an unsafe discharge was the resident does not have proper resources set up. Interview on 08/15/24 at 6:04 PM with the Administrator revealed he was on vacation when Resident #1 was discharged . The Administrator stated he was not aware that the resident was discharged so quickly, meaning the same day as the incident occurred. The Administrator also stated they typically issue a formal discharge and do not discharge a resident the same day as the incident occurs. The Administrator said recently there was past physical aggression on the secured unit, so he reacted too quickly to discharge Resident #1. The Administrator also revealed they did not have a letter from the Medical Director stating that Resident #1 was a threat to herself or others and was unaware that was needed. The Administrator stated because their policy was not followed, there were not resources set up for the resident prior to discharge, therefore creating a risk to the resident's physical and mental health. Review of the facility's current, undated Transfer and Discharge policy and procedure reflected: Purpose: To ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider .Policy: 1. The facility may transfer or discharge a resident for the following reasons: .C. The safety of the individuals in the Facility is endangered by the resident's presence; .IV .Situations that may prevent 30 days' notice include: A. The resident poses a threat to the health or safety of other individuals at the Facility; V. Cases in which 30 days' notice is not possible, notice of transfer or discharge should be provided to the resident of his/her responsible party as soon as practicable; .Procedure: .IV. The Facility may use Notice of Transfer/Discharge or another comparable form to provide the resident or his/her personal representative with advanced notice of the transfer or discharge. The notice will include the following information: A. The reason the resident is being transferred/discharged , B. The effective date of the transfer/discharge; C. The name, complete address and telephone number to which the resident is being transferred, D. A statement that the resident has the right to appeal the action to the state, contact information for the state entity which receives appeal hearing requests, and information on who to request and appeal, E. The name, address, and telephone number of the State Long Term Care Ombudsman .XIV. Documentation: When a resident is transferred/discharged , Social Services Staff include a copy of the written notice of transfer/discharge provided to the resident in his/her personal representative in the resident's medical record; E/ Proper to discharging the resident, the Facility will prepare a Discharge Summary and will document the summary in the resident's medical record. At a minimum, the Discharge Summary will contain a summary of the resident's status, including a description of the resident's: i. Medically defined condition(s) and prior medical history; ii. Medical status measurement ., iii. Physical, mental, psychosocial functional status ., iv. Sensory and physical impairments ., v. Nutritional status and requirements, vi. Special treatments or procedures, vii. Discharge potential, viii. Dental condition, ix. Ability to participate in activities, x. Rehabilitation potential, xi. Cognitive status, xii. Drug therapy; .H. The medical record will contain written documentation from a Physician if the resident is transferred/discharged because: i. The safety of individuals in the Facility is endangered by the resident's presence; .I. The resident or his/her representative will be provided with a copy of the Discharge Care Plan and Discharge Summary.

Based on interview and record review the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for two of nine residents (Residents #1 and #2) reviewed for discharge requirements. The facility failed to ensure documentation was made by the physician for the basis of Resident #1's discharge and/or the specific resident needs that could not be met by the facility. These failures could place residents at risk of being discharged without a safe and effective transition of care, an accurate reason for discharge and inaccurate information communicated to the receiving health care institution or provider. Findings included: 1. Record review of Resident #1's Admission Record dated 08/15/24 reflected Resident #1 was an [AGE] year-old female with an original admitted [DATE]. Record review of Resident #1's MDS assessment dated [DATE] reflected the resident had the following diagnoses non-Alzheimer's dementia, hypertension, renal insufficiency, hyperlipidemia, anxiety, and depression. The MDs assessment reflected the resident had severe cognitive impairment with a BIMS score of 5, and the resident had verbal behavioral symptoms directed toward others 1-3 days per week. Record review of Resident #1's undated care plan reflected: Goal . Resident will not verbally abuse others. The care plan did not reflect a date or incident of physical aggression. The care plan only reflected information about verbal aggression. Record review of Resident #1's care plan conference summary dated 05/01/24 revealed, Mood/Behavior-Pleasant and appropriate/easily agitated. Record review of Resident # 1's Progress Note dated 07/10/24 at 12:34 PM by ADON A revealed, Resident was in WC on 100 hall wheeling from dining room to her room and saw another resident sitting in her WC in her door way. Resident #1 took her shoe off and hit the other resident on both arms. The other resident started yelling. The other resident [sic] to BOM office and reported incident. Resident #1 placed on one on one with staff. MD, ADMIN, DON, RP notified. Record review of Resident #1's Progress Note dated 07/10/24 at 9:07 PM by LVN C revealed, Resident discharged to home this evening. Picked up by her [family member] Resident discharged with her medications and took with all her belongings. Record review of the Incident Report dated 07/10/24 at 12:30 PM by ADON A revealed, Head to toe assessment done and no marks of any kind noted on this resident as of yet No injuries post incident. Further review of Resident #1' clinical records revealed there was no physician's documentation related to the basis for the discharge, specific resident needs that could not be met by the facility, attempts to meet the resident's needs and/or services that would be available at the receiving facility to meet the resident's needs. Interview on 08/14/24 at 1:10 PM with Resident #1's POA and husband revealed they received a phone message voicemail from the BOM on 07/10/24 in the afternoon. When the POA and her husband returned the phone call later that afternoon, they were told the facility had faxed out referrals to other nursing facilities because Resident #1 was a danger to others. They were also informed another facility accepted her, and they would be transferring her later that day. The POA stated they would not allow the facility to transfer their mother without visiting the facility first. The POA and her husband went to the facility and picked up Resident #1 that evening and took her home with them. Interview on 08/15/24 at 12:58 PM with LVN E revealed she had worked at the facility four years. LVN E also revealed she had been Resident's #1's nurse previously when she worked the secured unit. LVN E stated that Resident #1 was verbally aggressive. LVN E said that the incident that occurred on 07/10/24 was the only incident involved Resident #1 hitting another resident. LVN E also revealed Resident #1 had improved and was transferred from the secured unit to Hall 100. Resident #1 had been on her hall about 3-4 months. LVN E stated she did not believe they would transfer Resident #1 off the secured unit if she had physical aggression toward other residents. Interview on 08/15/24 at 1:20 PM with CNA D revealed she had provided care to Resident #1. CNA D stated the resident was verbally aggressive with residents and staff, but she had not known Resident #1 to hit a resident before this incident. Interview on 08/15/24 at 2:20 PM with the BOM revealed she was the highest level of management in the building when the incident occurred with Resident #1. The BOM stated she contacted the Administrator about the incident when it occurred. The BOM also said that to her knowledge, no injury occurred to the resident that Resident #1 struck with her shoe. The BOM also revealed after informing the Administrator of the incident involving Resident #1, the Administrator stated to discharge the resident. The BOM stated he called and left a message for the POA. The BOM said the POA returned the call and said she would come and pick up the resident because she did not want Resident #1 discharged to a facility that day that she had no knowledge about and had not seen. The BOM said that Resident #1 had not been physically aggressive to other residents to her knowledge. Interview on 08/15/24 at 3:54 PM with ADON B revealed she provided care to Resident #1. ADON B stated Resident #1 was verbally aggressive when she was on the unit, but Resident #1 was not physically aggressive toward other residents. ADON B concluded by stating that she had seen other residents hit other residents with no resulting injury, but they were not discharged . Those residents had care planned interventions, such as separating the residents before there was a discharge discussed. Interview on 08/15/24 at 5:30 PM with the DON revealed she did not work at the facility at the time of the incident. There was another DON at the time of the incident. However, the DON was not in the building and was away on vacation at the time. The DON stated there should have been a care plan meeting to reduce future incidents involving psych, medical, and any testing that could rule out any behavioral issues and possibly moving her to a different hall before enforcing an immediate discharge. The DON also stated that if these measures did not help the resident, then the facility could examine possibly moving her to a different hall. Then the DON said that if this did not help, then the facility could look at moving Resident #1 back to the secured unit. The DON could not locate the 48-hour discharge notice that she acknowledged should be in the EHR. The DON also could not locate a physician's note stating Resident #1 was a harm to herself or others. The DON stated the risk to the resident of an unsafe discharge was the resident does not have proper resources set up. Interview on 08/15/24 at 6:04 PM with the Administrator revealed he was on vacation when Resident # 1 was discharged . The Administrator stated that he was not aware that the resident was discharged so quickly, meaning the same day as the incident occurred. The Administrator also stated they typically issue a formal discharge and do not discharge a resident the same day as the incident occurs. The Administrator said that recently there was past physical aggression on the secured unit, so he reacted too quickly to discharge Resident #1. The Administrator also revealed that they did not have a letter from the Medical Director stating that Resident #1 was a threat to herself or others and was unaware that was needed. The Administrator stated because their policy was not followed, there were not resources set up for the resident prior to discharge, therefore creating a risk to the resident's physical and mental health. 2. Record review of Resident #2's Admission Record dated 08/15/24 reflected Resident #2 was an [AGE] year-old male with an original admitted [DATE]. Record review of Resident #2's MDS assessment dated [DATE] revealed the resident had diagnoses of Alzheimer's disease, muscle weakness, cognitive communication deficit, difficulty in walking, and repeated falls. The MDS reflected the resident had moderate cognitive impairment with a BIMS score of 11 and had no behavioral symptoms. Record review of Resident #2's undated care plan revealed no focus, goals, or interventions related to physical aggression or sexual inappropriateness. Record review of Resident #2's Notice of Proposed Transfer w Discharge (Texas) dated 06/03/24 revealed that the transfer/discharge to home with [family member] Effective: 6/5/24. The document also revealed Reason for proposed Transfer/discharge Safety of individuals in the facility is endangered. This was issued as a 48-hour emergency discharge on 06/03/24. Record review of Resident #2's Progress Notes dated 05/31/24 at 3:20 PM written by ADON A reflected: Staff member reported to this staff member [sic] reported to this nurse that she observed resident touching another resident's breast. When asked this resident stated that he doesn't remember if he touched her breast or not. He then stated that his memory isn't that good. The residents were separated. Admin, DON, MD, RP for both residents notified. This resident placed on one on one with staff. Record review of Resident #2's Progress notes dated 05/31/24 at 10:32 PM written by the Social Worker reflected: .POA .was open to alternative placement but did not want to take the resident home. SW sent out residents clinicals to multiple different facilities and awaits answer. Resident remains on one on one. Record review of Resident #2's Progress Notes dated 06/04/24 at 9:09 AM written by LVN F reflected: Resident continues on 1:1 for behaviors. Some tearfulness noted this morning R/T upcoming discharge home. Resident says, 'I will miss everyone.' Resident verbally consoled by staff. Record review of Resident #2's Progress Notes dated 06/05/24 at 11:00 PM written by LVN D reflected: Resident discharged home with [family member] with meds and all personal belongings in good condition Further review of Resident #2's clinical records reflected there was no physician's documentation related to the basis for the discharge, specific resident needs that could not be met by the facility, attempts to meet the resident's needs and/or services that would be available at the receiving facility to meet the resident's needs. Interview on 08/15/24 at 12:53 PM with LVN G revealed she never saw Resident #2 touch a resident inappropriately, and she did not believe that he did. LVN G said she never heard Resident #2 talk inappropriately to a resident either. Interview on 08/15/24 at 1:27 PM with CNA D revealed she never saw Resident #2 sexually aggressive or inappropriate with a resident. CNA D also said she never saw Resident #2 be physically aggressive toward residents either. Interview on 08/15/24 at 1:31 PM with Laundry Aide H revealed she observed Resident #2 with his hand on a female's breast on the outside of her shirt. Laundry Aide H stated Resident #2 dropped his hand when he was observed by her. She stated she had never seen Resident #2 touch another resident inappropriately prior to this incident. She said she reported the incident immediately to administration. Interview on 08/15/24 at 4:03 PM with ADON B revealed she was Resident #2's nurse previously. ADON B stated she had not heard of Resident #2 touching a resident inappropriately prior to this incident. ADON B also said residents in the past would have interventions put in place before discharge, such as being placed on a secured unit. Interview on 08/15/24 at 5:02 PM with the DON revealed she did not work at the facility at the time of the incident. There was another DON at the time of the incident. The DON stated she had never seen the resident be physically or sexually aggressive toward other residents. The DON also stated that before you discharge a resident, you should attempt interventions. The DON said that possible interventions that could have been attempted were separating and relocating the residents involved in an incident. The DON said one on one was a possible intervention. The DON was unable to locate a note from the physician stating that the resident was a harm to himself or others. The DON revealed that she was unaware of the discharge policy. The DON concluded by stating that there was risk of harm to the resident when there is an unsafe discharge. Interview on 08/15/24 at 6:19 PM with the Administrator revealed there was not a letter from the physician or medical director stating that Resident #2 was a harm to himself or others The Administrator revealed that he determined when a resident should be discharged without consulting the medical director or the resident's physician. The administrator stated that if he deemed a resident a threat to themselves or others, he issued a discharge notice. The Administrator also revealed that no one oversaw this process or monitored the process. The Administrator stated because their policy was not followed, there was a possibility of risk to the resident's physical and mental health. Review of the facility's Transfer or Discharge Documentation policy and procedure, dated December 2016, reflected: When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider .the following information will be documented in the medical record .If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include .the specific resident needs that cannot be met; the facility attempt to meet those needs; and the receiving facility services(s) that are available to meet those needs .A summary of the resident's overall medical, physical and mental condition .Should the resident be transferred or discharged for any of the following reason, the basis for the transfer or discharge will be documented in the resident's clinical record by the resident's Attending Physician: The transfer or discharge is necessary for the resident's welfare, and resident's needs cannot be met in the facility .The safety of individuals in the facility is endangered due to the clinical or behaviors status of the resident; or the health of individuals in the facility would otherwise be endangered .Information will be communicated to the receiving facility or provider .The basis for the transfer or discharge .The specific resident needs that cannot be met; the facility's attempt to meet those needs; and the receiving facility's services that are available to meet those needs .Contact information of the practitioner responsible for the care of the resident .Comprehensive care plan goals; and all other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care.

Based on observations, interviews, and record reviews the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 3 (Residents #82, #37, and #26) of 5 residents reviewed for ADL care. The facility failed to ensure Residents #82, #37, and #26 were shaved regularly, and failed to keep their fingernails trimmed, according to their wishes. This failure placed residents at the facility at risk of diminished quality of life. Findings included: Review of Resident #82's undated Admission Record revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (blood disorder cause by illnesses), major infection, communication deficit, and diabetes. Review of Resident #82's admission MDS, dated [DATE], revealed a BIMS score of 15 indicating he was cognitively intact. His Functional Status indicated he required some help with his self-care, particularly personal hygiene. Review of Resident #82's care plan, dated 5/05/24, revealed he had a self-care deficit related to weakness. The Goal was the resident would be clean, well-groomed, and appropriately dressed. Interventions were to be carried out by the CNAs. Observation/Interview on 5/14/24 at 11:51 AM of Resident #82 revealed he had several days of facial hair growth. Resident appeared to be clean; he could not recall his last shower. Resident #82's fingernails were overgrown. Resident stated he liked to be clean shaven, and his nails kept trimmed. Review of Resident #82's May 2024 shower log revealed his last shower was on 5/13/24. Review of Resident #82's May 2024 Personal Hygiene log revealed personal hygiene was performed daily. Personal hygiene consisted of combing hair, brushing teeth, shaving, and washing face and hands. Observation on 5/16/24 at 12:00 PM revealed Resident #82 had not been shaved, he was scratching at his facial hair and dry flaky skin was falling onto his shirt. Resident #82 stated he had not been showered since his first interview. Interview on 5/16/24 at 12:45 PM with CNA L stated Resident # 82's shower days were Monday, Wednesday, and Friday on the 2p-10p shift. She stated she did not know when his last shower was since it was scheduled on the evening shift. CNA A stated as far as she knew Resident #82 was not one to refuse care. Review of Resident #37's undated Admission Record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included fracture of left upper leg, left upper arm, and multiple fractures of left ribs. Review of Resident #37'S admission MDS revealed a BIMS score of 14, indicating he was cognitively intact. Review of his Functional Status revealed he required assistance with his hygiene. Review of Resident #37's care plan, dated 5/05/24, revealed he had an ADL self-care deficit, with goals of being cleaned, well groomed, and appropriately dressed and the interventions are to be performed by the CNAs. Observation and interview on 5/16/24 at 12:05 PM of Resident #37 revealed he had several days of facial hair growth and his fingernails needed to be trimmed. Resident #37 stated he used to be a limo driver and his appearance was very important. Resident #37 stated the CNAs did not trim their nails unless they asked for it. Review of Resident #37's hygiene log for May 2024 revealed hygiene was performed daily for the resident. Review of Resident #26's undated Admission Record revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, stroke, and muscle wasting. Review of Resident #26's quarterly MDS, dated [DATE], revealed a BIMS score of 8, indicating he was moderately cognitively impaired. His Functional Status indicated he required assistance with his personal hygiene. Review of Resident #26's care plan, dated 5/08/24, revealed he had a self-care deficit with a goal of having his ADL needs met by staff. Observation/Interview on 5/16/14 at 12:18 PM revealed Resident #26 had several days growth of facial hair. Resident was unable to answer questions about his preferences. Review of Resident #26's hygiene log for May 2024 revealed hygiene had been performed daily . Interview on 5/16/24 at 2:20 PM the DON stated her expectation was for all residents to have basic hygiene performed daily, including trimming fingernails and shaving the male residents according to their preferences. The CNAs could trim fingernails, or if they were uncomfortable with doing so, they should notify the nurse so the nurse could trim them. The DON did not know why the CNAs would document hygiene being performed if they had not done all the steps. The DON stated not performing daily hygiene could lead to infections. Review of the facility's policy Care of Fingernails/Toenails dated April 2007, reflected: The purposes of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for 8 of 12 staff (CNA D, CNA E, CNA F, MA G, CNA H, RN I, LVN C, LVN J,) reviewed for training, in that: The facility failed to ensure Trainings-Resident Rights, Dementia, HIV, Falls, Restraints, and ANE (Abuse, Neglect, and Exploitation) were completed during orientation and prior to start date. These failures could place residents at-risk for abuse and neglect due to lack of training. The findings were: 1. Record review of the Staff Roster, undated, revealed the CNA D was hired on 3/18/20. Record review of CNA D's training history revealed CNA D's training transcript did not indicate when last previous restraint training had been completed. 2. Record review of the Staff Roster, undated, revealed CNA E was hired on 11/8/23. Record review of CNA E's training history revealed CNA E's training transcript did not indicate when last previous restraint training had been completed. 3. Record review of the Staff Roster, undated, revealed CNA F was hired on 11/1/23. Record review of CNA F's training history revealed CNA F's training transcript did not indicate when last previous restraint training, falls, dementia, HIV, and ANE (abuse, neglect, and exploitation) had been completed. 4. Record review of the Staff Roster, undated, revealed MA G was hired on 5/21/21. Record review of MA G's new hire history revealed MA G's training transcript did not indicate when last previous restraint training had been completed. 5. Record review of the Staff Roster, undated, revealed CNA H was hired on 3/13/08. Record review of CNA H's new hire history revealed CNA H's training transcript did not indicate when last previous restraint training had been completed. 6. Record review of the Staff Roster, undated, revealed RN I was hired on 7/11/2019. Record review of RN I's required annual training history revealed RN I's training transcript did not indicate when last previous restraint training had been completed. 7. Record review of the Staff Roster, undated, revealed LVN C was hired on 10/1/2021. Record review of LVN C's required annual training history revealed LVN C's training transcript did not indicate when last previous restraint training had been completed. 8. Record review of the Staff Roster, undated, revealed LVN J was hired on 7/13/18. Record review of LVN J's required annual training history revealed LVN J's training transcript did not indicate when last previous restraint training, falls, dementia, HIV, and ANE (abuse, neglect, and exploitation) had been completed. Interview with ADON A on 5/16/2024 at 4:31 PM revealed that the responsibility to train staff was the DON's responsibility. ADON A stated, for example, if staff were not trained properly on restraints, it can result in physical or psychosocial harm to the patient. In addition, ADON A said that nurses and MA's need to know what can be considered a chemical restraint to also prevent harm to a restraint. Interview with the DON on 5/16/2024 at 4:35 PM revealed that the DON was aware that the facility had not completed their required annual restraint training with their staff. The DON stated that when staff members do not complete their annual trainings which are falls, HIV, restraints, ANE (abuse, neglect, and exploitation), and dementia there was a risk that the staff member does not know how to carry out all appropriate aspects of their job which can result in harm to a resident. The DON went on to say that this can especially be seen when nurses or MAs over medicate a resident because the facility was restraint free, and a resident should not experience a chemical restraint. The DON stated that LVN J and CNA F work the night shift and therefore frequently miss the required in-services. The DON also stated that it is the ADON's responsibility to monitor the in-service trainings. Record review of facility policy titled Staff Development Program, origination revised 8/2010 revealed, .The following in-service training classes are mandatory: a. Hepatitis B b. HIV c. Tuberculosis d. Infection Control e. Resident Rights f. Resident Abuse g. Fire Safety and Disaster Preparedness h. Hazard Communication Plan (i.e., exposure to chemicals) i. Exposure Control (i.e., exposure to blood or body fluids).

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 20 residents (Resident #59) reviewed for care plans. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #59' non-compliance with keeping a device in her hand for contractures. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Review of Resident #59's MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included CVA (stroke), hemiplegia (paralysis to one side), paraplegia, and seizure disorder. The resident had a BIMS score of 9 indicating she had moderately impaired cognition, was understood and able to understand others. The MDS further reflected Resident #59 had impaired range of motion on both sides to upper and lower extremities. Resident #59 was dependent for all ADLs. Review of Resident #59's care plan revised on 05/15/24 revealed the resident had arthritis and contractures and at risk for pain, decline in ADLs, and mobility. Interventions included observe/document/report to MD signs or symptoms or complications related to arthritis: joint pain, joint stiffness, usually worse on wakening, swelling, decline in mobility, decline in self-care ability and contracture formation. Observation and interview on 05/14/24 at 12:26 PM with Resident #59 revealed she was in bed with her legs drawn up to her body and contractures were noted to both hands and there was no contracture management device in place. Resident #59 stated she usually had a carrot in her hand, but it would fall out of her hands. There was not carrot noted in the room at the time. Observation and interview on 05/16/24 at 8:27 AM revealed Resident #59 was in bed being fed by CNA B. After the resident was done eating CNA B slowly tried to open Resident #59' right hand and her palm appeared to be clean and free of odors. The resident's nails on her middle, ring, and pinkie finger were long, about half an inch, and the pointer finger and thumb were cut down. CNA B said they usually tried to keep a carrot or wash rag in the resident's hand contractures, but the resident would usually pull them out and throw them on the bed or floor, stating they were hurting her hands. Interview on 05/16/24 at 11:53 AM with LVN C revealed Resident #59 usually had carrots or wash rags in her hands for her contractures but the resident would complain her hands were in pain and take them out. LVN C further stated the Hospice Doctor had sent a letter stating Resident #59's hand could not be rehabbed, and the resident was to be kept comfortable. Review of a hospice note dated 05/15/24 signed by the hospice doctor reflected Resident #59 was on hospice services and the resident had too much pain when her hands were opened, and they were just trying to keep the resident comfortable. Interview on 05/16/24 at 12:21 PM with the Director of Rehab revealed Resident #59 had been on occupational therapy services for contracture management to her hands and she just been discharged from therapy services the week prior. During therapy services they got some carrots to put in the resident's hands for her contracture, but the resident would pull them out saying it hurt her. Once the carrots were put in her hands by therapy staff, they would go back about 5 minutes later, and the resident had already taken them out. Resident #59 was also non-compliant with having her palms cleaned and fingernails cut. The Director of Rehab further stated they had tried to use wash rags in the resident's hands, but she would begin to yell at them to take them out. Interview on 05/16/24 at 1:32 PM with the DON revealed adding resident care plans were a shared responsibility between nursing and the MDS nurse. The DON said the refusal care plan for Resident #59 should have been in place to let staff know how to care for the resident. Interview on 05/16/24 with the MDS Nurse revealed she w.as not aware of Resident #59's refusal to keep the carrots in her hand. The MDS nurse further stated the refusal should have been part of the resident's care plan and it was important to make sure all staff were aware of her choices and behaviors. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised December 2016 reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. .c. Describe services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for medication administration. The ADON failed to administer medications for Resident #1, leaving the cup with two pills on the resident's shelf in the room. This failure placed residents at risk of not receiving medications as prescribed, decreased therapeutic effects of the medications, risk for drug diversion, delay in medication administration and worsening of their medical conditions. Findings included: Review of Resident #1's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included hypertension, diabetes, cerebral palsy, seizure disorder, gastric ulcer, and hypothyroidism. Resident #1 had a BIMS score of 12 which indicated moderate cognition and was usually understood when she would express ideas. Review of Resident #1's care plan initiated on 06/12/23 reflected the resident had the potential for discomfort, complications or signs or symptoms related to diagnosis of GERD. Interventions included to give medications as ordered. The care plan further reflected Resident #1 had hypothyroidism. Interventions included to administer thyroid replacement medication to help restore the level of thyroid hormone. Review of Resident #1's physician orders for May 2024 revealed she was taking the following medications: Levothyroxine Sodium Oral Tablet 75 MCG; Give 1 tablet by mouth in the morning for Hypothyroidism. Omeprazole 20 MG Capsule delayed release; Give 1 tablet by mouth in the morning related to Gastro-esophageal reflux disease without esophagitis. Review of Resident #1's Medication Administration Record revealed both the Omeprazole and Levothyroxine were to be given daily at 5:30AM. Observation and interview on 05/16/24 at 8:41 AM with Resident #1 revealed she was in her motorized wheelchair going down the hall towards the nurse's station holding a medicine cup with two pills inside. The resident was asked why she was holding the pills and she stated she had found them on top of her drawer. Resident #1 said she did not know who left them there and did not know if they were her medications. Interview on 05/16/24 at 8:50 AM with MA A revealed Resident #1 had taken all her medication she had given her that morning and the two pills in the medication cup were Omeprazole and her thyroid medication which would have been given by the night shift nurse. Interview on 05/16/24 at 12:37 PM with the ADON revealed she had worked the night shift and she was giving Resident #1 her omeprazole and Levothyroxine, but the aides were in the process of transferring the resident into her wheelchair, so she set the medication cup with the two pills on the drawer. The ADON said she meant to go back after the aides had gotten Resident #1 up to give her the medication, but she forgot and took full responsibility. The ADON further stated it was important to ensure all residents received their medication because they were treating specific health conditions. Interview on 05/16/24 at 1:26 with the DON revealed the pills in the medication cup Resident #1 were omeprazole and levothyroxine. The DON said the ADON told her she had forgotten to give the resident the pills because the aides were getting the resident up for the day so she set them down and would return after the resident had gotten up. The DON said it was important for Resident #1 to receive her medications to maintain her health status especially her levothyroxine because that was being used to maintain the resident's TSH level. Review of the facility's policy titled Administering Medications revised December 2012 reflected the following: Medications shall be administered in a safe and timely manner, and as prescribed. .3. Medications must be administered in accordance with the orders, including any required time frame

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored securely for 1 of 5 residents (Resident #1) on one hall reviewed for storage of medications. The ADON failed to administer medications for Resident #1, leaving the cup with two pills on the resident's shelf in the room. This failure could place residents at risk of consuming unsafe medications. Findings included: Review of Resident #1's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included hypertension, diabetes, cerebral palsy, seizure disorder, gastric ulcer, and hypothyroidism. Resident #1 had a BIMS of 12, moderate cognition, and was usually understood when she would express ideas. Review of Resident #1's care plan initiated on 06/12/23 reflected the resident had the potential for discomfort, complications or signs or symptoms related to diagnosis of GERD. Interventions included to give medications as ordered. The care plan further reflected Resident #1 had hypothyroidism. Interventions included to administer thyroid replacement medication to help restore the level of thyroid hormone. Review of Resident #1's physician orders for May 2024 revealed she was taking the following medications: Levothyroxine Sodium Oral Tablet 75 MCG; Give 1 tablet by mouth in the morning for Hypothyroidism Omeprazole 20 MG Capsule delayed release; Give 1 tablet by mouth in the morning related to Gastro-esophageal reflux disease without esophagitis. Review of Resident #1's Medication Administration Record revealed both the Omeprazole and Levothyroxine were to be given daily at 5:30AM. Observation and interview on 05/16/24 at 8:41 AM with Resident #1 revealed she was in her motorized wheelchair going down the hall towards the nurse's station holding a medicine cup with two pills inside. The resident was asked why she was holding the pills and she stated she had found them on top of her drawer. Resident #1 said she did not know who left them there and did not know if they were her medications. Interview on 05/16/24 at 8:50 AM with MA A revealed Resident #1 had taken all her medication she had given her that morning and the two pills in the medication cup were Omeprazole and her thyroid medication which would have been given by the night shift nurse. Interview on 05/16/24 at 12:37 PM with the ADON revealed she had worked the night shift and she was giving Resident #1 her omeprazole and Levothyroxine but the aides were in the process of transferring the resident into her wheelchair, so she set the medication cup with the two pills on the drawer. The ADON said she meant to go back after the aides had gotten Resident #1 up to give her the medication, but she forgot and took full responsibility. The ADON further stated it was important to make sure medications were not left unattended because another resident could walk in and take them. Interview on 05/16/24 at 1:26 PM with the DON revealed the pills in the medication cup Resident #1 had were omeprazole and levothyroxine. The DON said the ADON told her she had forgotten to give the resident the pills because the aides were getting the resident up for the day so she set them down and would return after the resident had gotten up. The DON said it was important that medications are not left out due to the danger to other residents if they accidentally took them. Review of the facility's policy titled Storage of Medications revised April 2007 reflected the following: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

Based on interview and record review, the facility failed to ensure medical records were accurately documented in accordance with accepted professional standards for 1 of 5 residents (Resident #41) reviewed for medical records. The facility failed to ensure nursing documentation was accurate for Resident #41. This failure could lead to errors in treatment based on incorrect information. Findings included: Review of Resident #41's undated Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included stroke, liver disease, and cystic fibrosis. Review of Resident #41's admission MDS, dated [DATE], revealed a BIMS score of 5, indicating severe cognitive impairment. Her Functional Status indicated she required assistance with her ADLs. Review of Resident #41's care plan, dated 04/03/24, she was at risk for bowel and bladder incontinence and had an ADL self-care deficit. Review of Resident #41's EHR revealed she had developed a UTI and was placed on antibiotics for three days, 05/06/24-05/09/24. Review of Resident #41's physician orders revealed an order for Sulfamethoxazole-Trimethoprim Tablet 800-160 mg. Give 1 tablet by mouth two times a day for bacterial infection for 3 Days Start Date-05/07/2024 0600 [6:00 AM] Review of Resident #41's MAR for May 2024 reflected her last dose of antibiotics was on 05/09/24. Review of Resident #41's nursing documentation reflected nurses continued to document the resident was on antibiotic therapy for a UTI from 05/10/24 until 05/14/24. Interview on 05/15/24 at 1:40 PM with RN M revealed her documentation of Resident #41 still being on antibiotic therapy after it had been completed was just a mistake. RN B stated incorrect documentation could provide false information to providers. Interview on 05/15/24 at 1:45 PM the DON stated there was no explanation or excuse for nurses to document incorrectly. Accurate documentation was a basic expectation for professional nurses, and other providers and disciplines relied on accurate documentation. Review of the facility's policy Charting and Documentation, dated July 2017, reflected: .All services provided to the resident .shall be documented in the resident's medical record. .3. Documentation in the medical record will be objective, complete, and accurate.

Based on observation, interview, and record review, the facility failed to ensure staff followed an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Residents #41 and #42) reviewed for infection control. MA A failed to sanitize a reusable blood pressure cuff between Resident #41 and #42. This failure could place residents at risk of transmitting disease from one resident to another resident. Findings included: Review of Resident #42's undated Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included brain disorder causing dying brain tissue, senile degeneration of the brain, and diabetes. Review of Resident #41's undated Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included stroke, liver disease, and cystic fibrosis. Observation on 05/15/24 at 8:22 AM revealed MA N checking Resident #42's blood pressure with a re-usable blood pressure cuff. MA A did not disinfect the cuff after use, and placed it back in her cart. Observation on 05/15/24 at 8:47 AM revealed MA A checking Resident #41's blood pressure with the same re-usable blood pressure cuff used on Resident #42 without disinfecting it before or after using it and placing it back in her cart. Interview on 05/15/24 at 10:10 AM with MA A revealed she knew to disinfect the blood pressure cuff, but she was nervous. She stated failing to disinfect it could cause a disease to spread from one resident to another. Interview on 05/16/24 at 2:20 PM with the DON revealed all staff had been in-serviced on infection control multiple times, including disinfecting re-usable medical equipment. The DON stated there should be no reason staff should forget to wipe down equipment between resident uses. Review of the facility's policy Cleaning and Disinfection of Resident-Care Equipment, dated August 2009, reflected: .4. Reusable resident care equipment will be decontaminated and/or sterilized between residents .

Based on 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 3 residents reviewed for accidents. The PT failed to ensure Resident #1's body, to include her lower extremities, were positioned properly during a transfer using a sliding board, which is a rigid board used to bridge the gap between two surfaces to assist with transferring from one surface to another. During set-up of the transfer, the PT lowered the bed on or against the resident's foot causing a laceration that required 13 sutures. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: Review of Resident #1's MDS, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included paraplegia, scoliosis, pressure induced deep tissue damage of right hip, spinal cord injury at C7 (cervical vertebrae), and colostomy status. The MDS further reflected the resident had intact cognition, and she had lower extremity impairment to both sides. Review of Resident #1's care plan, revised on 12/01/23, reflected she had limited physical mobility related to paraplegia. Interventions included to provide supportive care, and assistance with mobility as needed. Review of the facility's provider investigation report, dated 12/20/23, reflected the following: The facility's investigation revealed that on 12/13/23, during a sliding board transfer, a paraplegic patient, who requires a two-person transfer, was being assisted by both a physical therapist (PT) and an occupational therapist (OT). The patient, seated in a wheelchair, was being prepared for transfer with appropriate precautions As the PT lowered the bed to ease the transfer a laceration to the patient's lower left extremity was discovered resulting in immediate medical attention and a hospital visit for suture treatment Review of Resident #1's progress notes, dated 12/13/23, reflected the following entries: .upon entering resident room resident R leg observed propped on side of mattress. [PT] was standing next to resident leg holding sheet over it and calling for help. Sheet, bed, floor and stool with blood on them. when asking what happened [PT] stated he was doing therapy and when bed was lowered resident leg was too close to it and the bed went down on it. Resident denies pain to leg D/T not having feeling in BLE. upon removing sheet from leg large open wound with significant bleeding noted. wound cleansed resident sent to [ER] 21:21 [11:21 PM] Resident returned from hospital, 13 sutures noted to [right] foot with edema noted elevated foot on pillow will continue to monitor Review of Resident #1's hospital records, dated 12/13/23, reflected the following: .Diagnoses Acute pain due to trauma Laceration of right lower leg .Instructions Suture removal in 10 days Daily dressing change with antibiotic ointment There were no further details on the size or appearance of the laceration in the hospital records. Interview on 01/24/24 at 10:35 AM with Resident #1's family revealed the resident could not be interviewed because she was undergoing surgery at the time, unrelated to the transfer incident. The family said Resident #1 told them therapy had lowered the bed on her foot. The family further stated the resident was not able to feel her cut because she was paralyzed to her lower extremities. The family said the laceration extended from one side of her ankle to the other. Interview on 01/24/24 at 9:56 AM with the PT revealed Resident #1 was a paraplegic who had no movement or feeling to her lower extremities. The resident was there for rehab therapy and they had been working on strengthening sliding board transfers, which they had successfully did several times in the past. The OT was assisting because Resident #1 did not have great balance and trunk control. As they were setting the resident up for the transfer, they were using a step stool for the resident's feet positioning. The step stool belonged to the resident that she used when she was home to help her with her transfers. They had made the necessary adjustments with the stool to make it safe for the resident when she discharged home. The PT positioned the wheelchair next to the bed and they were trying to place the sliding board underneath the resident. At that time the PT realized the bed appeared to be slightly higher and Resident #1's foot must have slipped off the stool, so as he began to lower the bed, it slid down the resident's leg and cut her. The PT then looked down and noticed blood and he applied pressure to the resident's leg, they called for assistance and 911 was called and the resident was sent out to the hospital for treatment. The PT further stated because the resident could not feel, she was not able to notice anything was wrong or that the bed had cut her. Once Resident #1 returned from the hospital, she continued to go to therapy. Interview on 01/24/24 at 10:16 AM with the OT revealed she was assisting the PT with Resident #1's transfer from her wheelchair to her bed. The OT was standing behind the resident as the PT positioned the resident's feet on the stool. The PT placed the sliding board underneath the resident and as he was lowering the bed, the PT began to call for assistance. The OT stated because she was behind the resident, she was not able to see what happened or the extent of Resident #1's injury. Interview on 01/24/24 at 12:42 PM with the DOR revealed she was told by the PT and OT they were doing a sliding board transfer with Resident #1 and the bed was lowered on the resident's foot causing a laceration. The DOR said they had done many of the same transfers in the past, but it appeared the resident's foot fell off the stool this time as the therapist was lowering the bed. When she entered Resident #1's room and saw the PT had pressure to the injury site and they were waiting on EMS to arrive. The resident appeared to be in good spirits and in no distress at the time. The DOR further stated it appeared to be human error because all the safety precautions had been put in place. The DOR said after the incident they inspected the bed for anything sticking out and they concluded it was just the frame of the bed that cut the resident. Review of the facility's Two Person Transfers policy, revised October 2011, reflected the following: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to life perform two-person transfers

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 2 residents reviewed for quality of care. On 09/17/21, Resident #1 was sent to the emergency room after the family noted drainage, redness, and a mass on the back of the resident's head. The resident admitted to the hospital with an infected surgical wound infection that required surgical incision and drainage. Facility nursing staff failed to assess, monitor and document the condition of Resident #1's surgical site to ensure there were no complications. An Immediate Jeopardy (IJ) was identified on 09/23/21 at 4:30 p.m. While the IJ was removed on 09/24/21, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures affected one resident (Resident #1) with a surgical site and could potentially affect other residents with surgical sites by placing them at risk for delays in treatment and care which could result in serious injury, harm and/ or death. Findings included: Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year old female admitted to the facility on [DATE]. She was always incontinent of bowel, utilized an indwelling urinary catheter, had no speech, no rejection of care, required limited physical assistance of one person for bed mobility, dressing and eating. The resident's BIMS score was 13 indicating the resident was cognitively intact. Section M1040 reflected the resident had no ulcers, wounds or skin problems. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's hospital transfer orders dated 09/07/21 revealed three sutures from the top of the resident's head and a running suture from the back of the resident's head were removed on 08/30/21 prior to admission to the facility on [DATE]. Resident #1's facility nursing admission assessment dated [DATE] reflected four surgical wounds and/or scars reflected the resident's skin was noted to be discolored at the abdominal feeding tube site. There was no assessment of any surgical sites or scars. Review of Resident #1's entire clinical records revealed no assessments of any surgical sites or assessments of the resident's skin. Resident #1's baseline care plan reflected admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no interventions goals to address this diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the MDS Coordinator on 09/23/21 at 3:00 p.m. revealed Resident #1's comprehensive care plan had not been completed because it was not due to be completed. She stated nurses were responsible for baseline care plans on admission. Interview with Resident #1's primary physician on 09/22/21 at 1:50 p.m. revealed facility nurses notified him on 09/17/21 of the resident having some type of abscess. He stated he provided orders to transfer the resident to the ER. When asked if the resident had any wounds, incisions or surgical sites, the physician initially stated, I don't know. He then stated he never saw or assessed the resident's surgical sites. Review of Resident #1's progress notes dated 09/17/21 documented by LVN E revealed at 4:30 p.m. the resident was noted with a soft mass to the back of the head and clear fluid coming from the back of the neck. The physician was notified, and orders were received to transfer to ER for evaluation. Interview with agency nurse, LVN E on 09/23/21 at 1:17 p.m. revealed she provided care for Resident #1 on multiple occasions and received orders to transfer the resident to the hospital on 09/17/21. She stated she recalled the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the resident often complained of a headache that was relieved with mediation. On 09/17/21 Resident #1's family informed her there was fluid/wetness noted on the resident's pillow. The nurse stated she went to check the resident and saw a small, spongey, raised area on the lower back portion of the resident's head. She stated there was clear fluid leaking from the back of the head and the resident's hair was matted, but she did not see an incision or any open area. LVN E stated she did not perform any routine assessments of Resident #1's head but had seen the back of the resident's head before and during rounds and there had been no redness or opening. The nurse was unable to recall when she had last seen the back of the resident's head. LVN E stated there was no documentation of her observations, because she documented by omission and if there were no problems, she did not document anything. Interviews on 09/22/21 at 3:21 p.m. with the interim DON (IDON) revealed the facility currently had no administrator. She stated she had been in the role since 08/13/21 and the current DON had worked at the facility since 09/20/21, less than one week. The IDON was asked about any assessments of Resident #1's skin and/or surgical sites. The IDON stated on 09/20/21 the hospital accused the facility of allowing the resident's surgical site to become infected and surgery would need to be performed again. She further stated she had been on vacation when Resident #1 admitted . She stated the ADON and Treatment Nurse (TN) wrote a statement reflecting they performed an assessment of Resident #1's skin on admission (09/07/21) and there were no open areas on the resident's skin. She stated the assessment should have been documented in the resident's clinical record and there were no other assessments of the resident's surgical sites. Interview with the ADON on 09/22/21 at 3:33 p.m. she stated she and the TN had performed a complete head to toe assessment for Resident #1 on admission (09/07/21). The ADON stated the resident had not received approval for admission and somehow slipped through the normal admission process. She stated something told her to check the resident because she read the hospital clinical records reflecting Resident #1 had several cerebral surgeries. She stated when she was made aware of the hospital accusing the facility of being responsible for the resident's infection, she notified the IDON that an assessment had been completed and there had been no open areas. She stated she and the TN wrote a statement on 09/20/21 reflecting the assessment was completed on 09/07/21 and of the findings. The ADON stated she thought the TN documented the assessment. Interview with the ADON and TN on 09/22/21 at 3:35 p.m. the TN confirmed she and the ADON had completed a head to toe assessment of Resident #1 on admission. She stated she documented the assessment on a shower sheet and would provide the sheet for review. They both stated the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . They both stated a Steri-Strip (wound closure tape) was noted entangled in the resident hair but there were no visible open areas or drainage noted in Resident #1's head. On 09/22/21 the TN provided a Skin Monitoring Shower Sheet dated 09/07/21 for Resident #1. The sheet reflected the resident was noted with old scars to the left and right side of the forehead, a feeding tube site, and an old scar to the back of the head near the nape of the neck. There was no description of the scars to include color or measurements. Interview with CNA B on 09/22/21 at 3:56 p.m. revealed he was an agency staff. He stated he recalled providing care for Resident #1 but was not aware she had surgery and never noticed any issues when turning and repositioning the resident. Resident #1 was observed on 09/23/21 at 9:45 on the neurology unit of the hospital. The resident was asleep with a large dressing to the back of the head/neck area. The hospital RN stated the resident was receiving intravenous antibiotics to treat an infected surgical wound. She stated the resident had recently undergone a surgical incision and drainage procedure to clean out the infection. Review of Resident #1's hospital records reflected an admitted [DATE]. The physician's history and physical dated 09/18/21 reflected Resident #1 admitted with oozing and drainage from the head surgery wound. The resident's surgical history included craniectomy surgery on 08/18/21 for evacuation of hematoma. Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Neurosurgeon on 09/23/21 at 10:37 a.m. revealed Resident #1 readmitted to the hospital with a surgical site infection. He stated on discharge to the facility 09/07/21, the surgical site was healing and looked good. He stated infections were common with the type of surgery the resident had, but he expected the facility to provide basic nursing care. The resident's initial surgery was very traumatic, and the surgical site should have been monitored and assessed for complications. The abscess noted on admission to the hospital was not new, and the site had to have been open for a few days. Interview with facility nurse, LVN B on 09/23/21 at 12:06 p.m. revealed she provided care for Resident #1 for approximately 3 days. She stated she noticed one scar to the right side of the resident's temple that was closed and healed. She stated she was not aware of any other surgical incisions, did not notice any other scars or incisions and did not complete a skin assessment. Interview with agency nurse, LVN C on 09/32/21 at 12:15 p.m. revealed she provided care for Resident #1 during one shift. She stated she did not recall the resident having any wounds or incisions and she did not complete a skin assessment. Prior to working at the facility, she was provided a general orientation to include a skills check list, a facility packet, information related to the computer program, facility tour and face to face nursing reports. In a telephone interview with agency nurse, LVN D on 09/23/21 at 1:02 p.m. revealed she was the admitting nurse for Resident #1. She stated she completed the physical assessment on admission and was aware the resident had some type of aneurysm and a new feeding tube. She stated the resident had an incision to the back of the head near the nape of the neck that appeared to be closed with glue and there was glue in the resident's hair, or the hair was matted. The nurse stated she checked the resident's skin to the best of her ability but did not get a clear look at the incision because the resident would not turn. When asked about why she did not document any of the observations of the incision she stated there was a bad phone connection and the call disconnected. Attempts to continue the interview were unsuccessful, called back but there was no answer, message left, and no return call was received. Interview with agency nurse, LVN F on 09/23/21 at 2:31 p.m. revealed she provided care for Resident #1. She stated she did not recall the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she medicated the resident for complaints of a headache at times and the medication was effective. She was not aware of any wounds or incisions and did not complete a skin assessment. An email communication dated 09/20/21 between the hospital Case Manager and the facility's corporate staff was provided by the Corporate Nurse on 09/23/21. The email reflected Resident #1 required no actual wound care just visual checks by nursing staff to ensure it was looking okay. According to Lippincott NursingCenter.com viewed on 09/28/21, A surgical site infection (SSI) is an infection that develops within 30 days after a surgical procedure, or within one year if an implant was placed and the infection appears to be related to the surgery. SSIs are the most common healthcare associated infections in patients undergoing surgery in the United States and can cause a significant number of complications and deaths. A thorough assessment can help recognize an SSI early. The path to improving early detection and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The IDON and DON were notified on 09/23/21 at 4:30 p.m. that an Immediate Jeopardy was identified on 09/23/21. The IJ template was provided to the DON. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. Interview with the Corporate Nurse on 09/23/21 at 5:40 p.m. she stated she would expect nursing staff to assess a surgical incision and document that it was healed. Interview with IDON on 09/24/21 at 10:28 a.m. stated her expectations for nursing assessments of Resident #1's surgical sites was nurses should have assessed/observed the resident's surgical site for as long as needed to ensure there were no complications and document the assessment. Interview with the DON on 09/24/21 at 1:14 p.m. revealed the facility had no policy/procedure related to assessments of surgical wounds /incisions. The Facility's Plan of Removal was accepted on 09/24/21 at 4:58 p.m. and reflected the following: Licensed nurses are being in-serviced by the DON, initiated on 9-21-21 and ongoing, for assessing and documenting skin conditions of newly admitted residents. These assessments are to be entered into the resident electronic medical permanent record when done. DON will in-service nurses on ensuring assessments regarding incision sites are recorded in the medical record. Any licensed nurse as well any newly hired nurse and agency nurses, that has not attended the in-service will be educated by DON/designee prior to the start of their next shift. New admission assessments will be reviewed daily in morning stand-up by the DON and ADON's to ensure completeness and accuracy. DON/designee will monitor daily in morning stand-up new admission charts to ensure skin assessments have been completed and are accurate. The Nurses, treatment nurse and ADON, that stated they did a skin assessment on admission of identified resident, have been counseled by the DON, as to the importance of documentation in the clinical record and not on a shower sheet, following facility policy. The resident identified was assessed by a licensed nurse when found to have drainage coming from the back of the neck. There was no identified open site found near the 8-18-21 surgical site. Nurse notified physician and was instructed to transfer to hospital for further evaluation. The resident remains in the hospital at this time. Complete skin rounds were made on 9-22-21 by the administrative nursing staff. No new areas were identified on any resident. No new or healed surgical incisions were identified with any signs or symptoms of infection. Any licensed nurse, including new hires and agency nurses, that has not been in-serviced will be educated prior to the start of their next shift. Skin assessments will be completed weekly on current residents by licensed nurses. DON/designee will monitor a minimum of 3 skin assessments daily to ensure accuracy and completeness. In-services by DON/designee were initiated, 9-22-21 and are ongoing, to licensed nurses and aides to document weekly skin assessments in the clinical records. If any changes are noted, licensed nurse is to be notified for follow-up immediately. For any newly admitted resident with a recent surgical site, orders will be received and placed in medical record to monitor that surgical site q shift for redness, inflammation, drainage, etc. and to notify physician of any changes. This was initiated 9-22-21 by DON and will be ongoing. DON/designee will monitor documentation in the clinical record of at least 3 residents daily to ensure documentation is in place. DON/designee will in-service licensed nurses, including new hires and agency nurses, when any identified concern is found so the concern can be addressed. Concerns identified will be followed up on immediately by the DON/designee and addressed in morning standup and be reviewed in monthly QAPI from 9-22-21 forward. The following interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following: Interviews conducted with 6 LVNs (agency and facility nursing staff) across multiple shifts on 09/24/21 from 11:26 p.m. to 12:25 and from 3:15 p.m. to 4:26 p.m. revealed the nurses verbalized comprehension of the in-service training provided. They stated they had been in-serviced on completing full head to toe skin assessments on new admissions to include assessments of surgical sites and documenting the assessments in the clinical records. They stated they were to document all skin issues to include scars and healed areas. If a resident had a surgical incision it was to be assessed and the assessment documented each shift. The physician should be notified of any changes. Interviews conducted with 8 CNAs (agency and facility nursing staff) across multiple shifts on 09/24/21 from 11:26 p.m. to 12:25 and from 3:15 p.m. to 4:07 p.m. revealed the CNAs verbalized comprehension of the in-service training. They stated they had received in-service training regarding reporting any noted changes in skin or new skin issues to the charge nurse immediately. Review of in-service training records dated 09/22/21 and 09/23/21 revealed staff received training related to ensuring every surgical incision was to be evaluated and documented in the medical chart every shift. Required skin assessments should be completed in a timely manner and documented in the chart. New admits must have head to toe assessments completed on admission and all skin abnormalities identified in the chart. Any skin abnormalities that are identified or noted with changes while caring for a patient must be reported to the charge nurse or ADON immediately. The Interim Administrator, IDON, DON and Corporate Nurse were notified on 09/24/20 at 5:10 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 09/24/21, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still monitoring their plan of removal.

Based on observation, interview, and record review, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, for one (Resident #2) of five residents reviewed for nutrition. The facility failed to ensure Resident #2, who received all of his nutrition via g-tube, had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not receive regular enteral feedings, or have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in the resident losing a total of 13 pounds. An Immediate Jeopardy (IJ) situation was identified on 08/12/21 at 5:12 PM. While the IJ was removed on 08/13/21, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The failure placed residents at risk of not receiving necessary care and services which could result in serious harm, malnutrition, and weight loss. Findings included: Review of Resident #2's, admitted [DATE], MDS assessment, dated 07/13/21, reflected the resident was a [AGE] year-old male, who was cognitive intact with a BIMS score of 14. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received 100% of his nutritional intake via enteral feedings, and the resident was totally dependent upon staff for nutritional intake seven days a week. Review of Resident #2's current Care Plan, revised on 11/27/20, revealed the resident had altered nutritional status related to a g-tube. The care plan goals reflected: Resident will maintain weight within 5 pounds of admit weight for the next 90 days. Review on 07/30/21 of Resident #2' re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 08/01/21 at 10:10 AM of Resident #2's physician orders, dated 07/29/21, that resident was to receive two cans of [MEDICATION(S)] 1.5 cal three times a day. The order was revised on 07/30/21 to administer [MEDICATION(S)] 1.5 cal at 65 ml per hour for 20 hours per day. Review on 08/01/21 at 9:30 AM of Resident #2's electronic record revealed from 07/10/21 (156.8 pounds) to 07/31/21 (143.6 pounds) the resident had a 13-pound weight loss, an 8.4% weight loss, over 21 days which was significant weight loss. Resident has orders for monthly weights but was weighted using the lift, his normal method, when he readmitted and then after the error was discovered. Interview on 08/01/21 at 9:00 AM with Administrator revealed Resident #2 went to the hospital on 07/06/21 for respiratory issues and returned on 07/07/21. Upon return, the agency nurse on duty (LVN E) input his discharge orders from the hospital, which did not include enteral feeding orders. Interview on 08/01/21 at 9:10 AM with the DON revealed Resident #2 had a primary nurse that cared for him Monday through Friday 6:00 AM - 2:00 PM and agency nurses filled in the other shifts at that time. His primary nurse, LVN B, did not notice the lack of a feeding order and continued with his previous enteral feeding orders which were two cans of formula three times a day. The DON revealed agency staff did not know what Resident #2's orders were and fed him what they thought was appropriate, without notifying anyone that there was not an order. The DON revealed some of the agency staff were interviewed, and the facility determined Resident #2 was fed one or two cans of [MEDICATION(S)] three times a day when they cared for him, instead of the six cans per day, which he received prior to the hospitalization . The DON revealed the error was not noticed until 07/29/21 when another nurse, LVN C, from another hall was assigned to Resident #2's hall. She stated LVN C immediately notified the DON and the resident's physician. As a result of the inconsistent feeding, the DON revealed Resident #2 had a 13-pound weight loss over 20 days. The DON revealed the expectation was that nurses reviewed the orders for any new orders and that the orders were appropriate for residents. She revealed unless specified differently by a doctor's order all residents. including Resident #2, were weighed oncea month. Observation and interview on 08/01/21 at 9:40 AM with Resident #2 revealed he was a [AGE] year-old male with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was non-verbal, but he was able to communicate using a communication board, a tablet, or texting via his phone. He revealed he felt like he was being cared for better now, he was concerned about dehydration but not anymore. He felt like he was putting weight back on with the change in his enteral feedings. He was unaware that he was not receiving the appropriate feedings when he returned to the facility. When he would tell staff that he was thirsty and needed water and they would give him water boluses via his g-tube. Observation revealed the resident was receiving continuous feedings of [MEDICATION(S)] 1.5 cal at 65 ml per hour via feeding pump. Observation of the formula revealed the bag and tubing were dated 08/01/21 and timed as being hung at 7:54 AM. Interview on 08/01/21 at 1:30 PM with the DON revealed the normal protocol for a resident that went to the hospital was to pause their orders, and then reactivate them when they returned to the facility. The former DON had discontinued Resident #2's orders instead of pausing them; therefore, all of his orders, including the orders for his enteral feeds, were deleted. The agency nurse that was on duty when the resident returned to the facility on ly had the resident's discharge orders from the hospital to go by and they did not contain enteral feed orders, therefore did not enter an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She revealed that the nurse should have performed a full assessment upon admission and noted the resident's feeding tube, this should have clued her about possible g-tube feeding orders. Interview on 08/01/21 at 2:00 PM with LVN B revealed she had cared for Resident #2 for over a year and knew his routine. She did not notice the lack of a feeding order for Resident #2, but she knew he was supposed to get two cans of [MEDICATION(S)] three times a day via bolus feedings. She stated she did not check the resident's orders because she was familiar with his care. She revealed that she should have checked the resident's orders, but her familiarity with his care lulled her into complacency. She became upset when she was made aware of the issue and the resident's weight loss, and that led to her decision to resign her position. Review on 08/01/21 of facility's incident investigation file revealed on 07/29/21 the facility convened an ad hoc QAPI with corporate leadership and a second QAPI with the Medical Director and facility leadership. On 07/29/21, the facility performed an in-service with all nurses on g-tube feedings to include checking orders, checking for residuals, and administration. The facility also performed an in-service with all staff on resident neglect, falls, fall prevention, and abuse. In-service was completed on 07/30/21. The facility instituted a process of the DON and ADONs reviewing all new admits and re-admits for complete orders. Also during their daily stand up meetings, all disciplines from the facility were in attendance to review new and re-admits for complete orders. All residents with g-tubes were audited for complete orders. The Medical Director ordered all residents to be weighed immediately and then weekly for four weeks to establish baseline weights on all residents. Interview on 08/12/21 at 3:30 PM with ADON revealed agency staff, that had worked at the facility, since facility staff had completed in-services identified by the QAPI on enteral feedings and order review, had not completed the in-services that the facility's staff had completed. She stated eleven agency nurses had worked at the facility since 07/30/21. She stated the agency nurses were expected to admit or re-admit residents assigned to their halls and were held to the same standards as the facility's nurses. She revealed the facility did not have a policy about admissions or re-admissions, but the expectation was that the admitting nurse would input all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Administrator was notified that an Immediate Jeopardy (IJ) situation was identified on 08/12/21 at 5:12 PM, and the Administrator was provided with the IJ template at that time. The facility submitted the following Plan of Removal and it was accepted on 08/13/21 at 2:18 PM: Summary of details which lead to outcomes: IJ called relating to facility not ensuring agency nurses are trained in how to assess and admit residents and to reconcile physician orders, that could likely result in serious harm to residents. The following plan of action outlines immediate interventions employed by the facility to abate any further concerns surrounding the above issue. 1. On 8-12-21, the two current agency licensed nurses were educated by the ADON, on facility protocols for assessing and admitting residents and reconciling physician orders. This included step by step directions on the admission process, user defined assessment, and detailed instructions on entering and reconciling orders. DON/designee, will continue to monitor, daily, in morning meeting, the assessments, admissions, and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. DON/designee educated facility licensed nurses on using the current process from 7-30-21, including new admissions, return admits, verifying physician orders, entering orders in PCC, and carrying out orders. This process has been effective since 7-30-21 going forward, with no concerns identified by DON/designee for any of the above. DON/designee continue to audit new admit records daily for completeness and accuracy regarding assessment and admission process, as well as order entry and reconciliation. 3. Morning clinical stand up has identified no other concerns since 7-30-21 going forward. 4. DON/designee will continue to monitor daily, for assessments, admissions, and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. All future agency licensed nurses will be educated by DON/designee, on the facility protocols regarding assessments, admission process, and orders, prior to going to the floor for duty on an ongoing basis. Agency nurses will sign attestations to being educated on facility protocols for admissions, admission assessments, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. During daily morning clinical meeting, new admissions from the past 24 hours will be reviewed by the DON/designee to ensure accuracy and completion. Since the identified concern noted on July 7, 2021, this process has been in place and no identified order entry errors from admission were identified per guidance. Any concern found will be addressed at the time identified. DON/designee will continue to audit admission and re-admission documentation daily on an ongoing basis to ensure nursing assessments, nursing admission process, and orders are completed and correct. 7. Completed an audit of agency nurses utilized by the facility on 08/12/2021, and immediately educated those present. DON/Designee will continue to educate agency staff before the start of their scheduled shifts. Staffing schedule audited for agency requests up to 08/16/2021 administrator assigned clinical designees to orient agency staff on assigned days. Weekend Supervisor will be trained on providing education on 08/13/2021. 8. Staffing meeting to be held three times weekly for 4 weeks and then weekly x 4 weeks, to review open shifts, agency requests, and clinical designees to orient agency staff on assigned days. 9. Review of agency orientation/education to be performed in morning meeting to ensure agency has been properly educated. Monitoring of the facility's accepted Plan of Removal revealed the following: 1. Two facility staff nurses completed the in-services identified in the QAPI. They were able to answer questions about checking for gastric residuals, medication administration, and order verification. 2. The agency nurse on duty on 08/13/21 from 6:00 AM to 10:00 PM completed the in-services identified in the QAPI on gastric tube feedings, order verification, and admissions. 3. ADON created a binder to track agency nurses as they completed the in-services on their first shift at the facility. 4. Weekend supervisor was trained on check off process for agency nurses on the weekend. Training verified by her signoff sheet. 5. Four other residents were identified with g-tubes, only three receive feedings via their g-tube, only one receives continuous feedings. Orders for all four were reviewed for accuracy. 6. All current staff (LVN C, LVN E, RN G), including the one agency nurse (LVN F) on duty, were interviewed on 08/13/21 from 9:20 AM to 1:00 PM. They had completed and were able to verbalize understanding to the surveyor for the following in-services that were identified in the QAPI: A. Assessing and Admitting Residents, both new and returning. B. Reconciling Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] C. Enteral Feedings (verifying order, checking residuals, and administering) Interview on 08/13/21 at 9:00 AM with Administrator revealed an additional ADON has been identified and a temporary DON has been assigned by the corporate office until a permanent DON could be hired. The DON and two ADONs would be focused on updating staff education files for any training needed; tracking and educating agency staff on the facility policies and in-services, and checking all resident admissions and re-admissions for physician order [MEDICAL RECORD OR PHYSICIAN ORDER] An Immediate Jeopardy (IJ) situation was identified on 08/12/21 at 4:59 PM. While the IJ was removed on 08/13/21, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Residents #1, #2, #3, #4, and #5) of five residents and one (LVN B) of 11 staff reviewed for infection control. 1. The facility failed to cohort Residents #1, #2, #3, #4, and #5based on their COVID-19 status. On 11/19/20 Residents #2, #3, #4, and #5 initially tested negative, but Resident #5's roommate, Resident #6, tested positive. Resident #1's test for COVID-19 was inconclusive, but she was placed in a room with Resident #2, who was negative. 2. LVN B failed to sanitize her face shield or change her N95 mask when providing care to Residents #1, #2, #3, #4, and #5. An Immediate Jeopardy (IJ) was identified on 11/21/20. The facility was provided with the IJ template on 11/21/20. While the IJ was removed lowered on 11/25/20, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk for exposure to COVID-19, which could result in serious illness and/or death. Findings included: Review of Resident #1's Face Sheet, dated 11/22/20, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's COVID-19 test result, dated 11/18/20, revealed Resident #1's test sample was rejected due to being defective/damaged. Review of Resident #1's hospital record, dated 11/22/20, revealed Resident #1 was diagnosed with [REDACTED]. Resident #1's hospital record reflected she was discharged with hospice on 11/22/20 to the facility. Review of Resident #2's Face Sheet, dated 11/22/20, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had [DIAGNOSES REDACTED]. Review of Resident #2's COVID-19 test result, dated 11/19/20, revealed Resident #2 was negative for the COVID-19. Review of Resident #3's Face Sheet, dated 11/22/20, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #3 had [DIAGNOSES REDACTED]. Review of Resident #3's COVID-19 test result, dated 11/19/20, revealed Resident #3 was negative for the COVID-19. Review of Resident #4's Face Sheet, dated 11/22/20, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #4 had [DIAGNOSES REDACTED]. Review of Resident #4's COVID-19 test result, dated 11/19/20, revealed Resident #4 was negative for the COVID-19. Review of Resident #5's Face Sheet, dated 11/22/20, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #5 had [DIAGNOSES REDACTED]. Review of Resident #5's COVID-19 test result, dated 11/19/20, revealed Resident #5 was negative for COVID-19. Review of the facility's COVID-19 [MEDICATION NAME] test result list, dated 11/23/20, revealed Resident #5 had a positive test result for COVID-19. Review of Resident #6's Face Sheet, dated 11/22/20, revealed she was a [AGE] year-old female and she was admitted to the facility on [DATE]. Resident #6 had [DIAGNOSES REDACTED]. Review of Resident #6's COVID-19 test result, dated 11/19/20, revealed Resident #6 had a positive test result for COVID-19. Interview with the DON on 11/21/20 at 10:26 AM revealed the facility currently had a total of 59 COVID-19 positive residents and five negative residents. She stated she had turned Hall 200, previously a warm zone, into a hot zone on 11/19/20 since seven out of twelve residents on the hall tested positive for COVID-19 on 11/19/20. The DON stated she moved Residents #1, #2, #3, #4, and #5 from Hall 200 to Hall 300 last night (11/20/20). Interview with CSS A on 11/21/20 at 9:30 AM revealed the facility had a total of three hot zones (Halls 100, 200, and 400) where 59 residents had tested positive for COVID-19. CSS A stated the facility had one cold zone (Non-COVID-19 hall/Hall 100). CSS A stated there were a total of five residents who had been moved yesterday (11/20/20) from Hall 200 (hot zone) since these five residents had negative test result for COVID-19. She stated Hall 200 had been a warm zone until 11/19/20 when seven out of twelve residents from Hall 200 tested positive for COVID-19. Review of the facility's Resident Census List, dated 11/19/20, revealed Resident #1, #2, #3, #4, #5 were currently housed on 200 Hall. The list revealed Resident #1 and Resident #2 were roomed together on 200 Hall. The list also revealed Resident #5 had been roomed with Resident #6, who tested positive for COVID, on her previous hall. Interview on 11/21/ 20 at 11:30 AM with the DON revealed Residents #1-#5 had not been immediately isolated from the positive resident on 11/19/20, because she did not have a nurse to take care of them on 11/20/20. The DON stated the facility had collected the COVID-19 swab samples for the residents from Hall 200 on 11/17/20 due to the facility's policy on weekly schedule testing. According to the Lab result received on 11/19/20, Resident #1's 11/17/20 sample obtained for COVID-19 test was leaked/damaged. However, the DON stated she considered as Resident #1 as a negative COVID 19 resident since Resident #1 had a negative COVID-19 test on 11/12/20. The DON stated Resident #1 and Resident #2 should not have room together. Then, the DON stated she was going to move Resident #1 from the 300 hall today (11/21/20). The DON acknowledged she should have placed Residents #1, #2, #3, #4, and #5 on the warm zone instead of the cold zone to minimize cross contamination. The DON stated she would have enough time to place the warning sign and setting up the warm zone if the surveyor did not show up on 11/21/20. The DON stated she assigned only one nurse for those five residents since 11/20/20 night shift. The DON stated she expected all nurses who worked on Hall 300 for all shifts since 11/20/20 to don a gown, N95 mask, face shield, and gloves before entering the residents' rooms and additionally gown from the designated gown from each resident on Hall 300 from their closet. Observations on 11/21/20 at 11:05 AM of the 300 hall revealed there were no warning signs (such as warm zone or stop sign) on the entrance door to Hall 300 and the double doors were open upon entering Hall 300. Residents #1 and #2 were observed sharing a room. Both residents were lying supine with no distress. One blue isolation gown designated for each resident was hanging on the closet door. LVN B was observed removing her gown and hanging it on Resident #1's closet door. She removed her gloves, performed hand hygiene and then exited from Residents #1 and #2's room without changing her N95 mask or sanitizing her face shield. Resident #3 was observed lying supine with no distress and her room door was open. Resident #4 was observed lying supine with no distress and her room door was open. Resident #5 was observed lying supine with no distress on and her room door was closed. Two different sizes of gloves, one hand sanitizer bottle, a couple of plastic yellow and red bags were observed on one plastic three-layer-drawer on the hall way of Hall 300, near room [ROOM NUMBER]. There were no disposable gowns. There were no isolation signs or warning signs observed on the doors for Residents #1, #2, #3, #4, and #5. The DON was observed bringing extra PPEs including gowns and placed them one of the empty rooms at Hall 300 and instructed LVN B to use it when needed. Interview with LVN B on 11/21/20 at 11:10 AM revealed she was an agency nurse and this was her first day on the floor. LVN B stated she was informed by the night shift nurse that all five residents (Residents #1, #2, #3, #4, and #5) were COVID-19 negative residents and she has been providing care for the residents non-COVID residents. LVN B stated she donned her N-95 mask and face shield at all times and was assigned to take care of only those five residents alone. LVN B stated she did not have to change her N-95 mask or sanitize her face shield since those residents were COVID-19 negative. LVN B stated she changed her gloves and performed hand hygiene after care to each of the residents. LVN B stated she also donned the designated gowns which have been hanging on the residents' closets during care. At 11:30 AM, LVN B stated she was not informed Resident #5 had cohorted with Resident #6 who had tested for COVID-19 prior to Resident #5's move from Hall 200 to Hall 300. Attempts were made to contact the previous Administrator on 11/22/20 at 3:30 PM. Contact was unsuccessful. Attempts were made to contact MD on 11/23/20 at 2:41 PM and 11/24/20 at 10:06 AM. Contacts were unsuccessful. Review of the facility's policy titled, Coronavirus, dated 10/22/20, revealed, Precautions: Healthcare personnel caring for patients with confirmed or possible COVID-19 should adhere to CDC recommendations for infection prevention and control (IPC): Assess and triage these patients with acute respiratory symptoms and risk factors for COVID-19 to minimize chances of exposure, including placing a facemask on the patient and isolating them in private room with the door closed . Resident Placement: All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator, eye protection, gloves, and gown. Separate patients and residents who have COVID-19 from patients and residents who do not or have an unknown status. Identify and designate unit and rooms with known COVID-19 positive and those with suspected COVID-19, ensuring they are separate from patients and residents who are COVID-19 negative . Cohort like residents. If adding a resident to another like resident room, you need to add 14 additional days to monitor if one turns symptomatic. An Immediate Jeopardy (IJ) was identified on 11/21/20 at 4:48 PM. The IJ template was provided to the DON on 11/21/20 at 4:48 PM. The Plan of Removal was accepted on 11/24/20 at 3:47 PM and revealed: On 11.21.2020, an abbreviated Compliant Survey was initiated at (facility name and address). At approximately 5:30 PM on 11.21.2020, a surveyor provided verbal notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health and safety. The notification of the alleged immediate jeopardy states as follows: 1. Failure after assessment to move isolate residents with room changes on Quarantine and COVID Halls as directed Facility Activities required for LTC COVID-19 Hall response to isolate potentially infected, infected and non-infected residents. Identify residents who could be affected Residents who have a change in condition could be affected by this alleged deficient practice.: 1. Resident # 1 is no longer in the center. 2. Residents #2, 3, 4 & 5 were placed in a quarantine unit on 11/20/20 with DON oversight. In-Service conducted: The in-service training was started on 11/21/202 at 9:45 PM one on one with staff members and will continue with all shifts until all staff members have been in-serviced and acknowledge understanding of information. The DON, DCO and appointed designee will continue with training until all staff members have completed required in-services. The staff members will not be allowed to return to work on the floor as stated in our Plan of Removal. The training has been completed on all employees that are scheduled to work as of 11/24/2020. Anyone on vacation or in Quarantine will not be allowed to return to work until they are properly in- serviced. 1. Infection Control Concept on infection Control Zones adhering to CDC recommendations 2. Understanding of how cross contamination occurs, monitoring for COVID 19 suspected or confirmed 3. Use of PPE education and training for staff for each cold, warm and hot units. 4. Monitoring for signs and symptoms for infection prevention and control 5. COVID Hall and Quarantine Hall will have donning and doffing rooms established and maintain. 6. Hand washing/ hand hygiene 7. Residents with invalid, damaged Covid-19 tests results will be retested as soon as notified from the lab. 8. Residents with unknown status will be placed in quarantine upon determination. 9. Residents with roommates who test positive will be placed in quarantine. 10. Residents with changes in condition will have the physician notified and implement orders per the ordering physician. Implementation of Changes: The Director of Nursing and staff implemented required resident relocations to quarantine rooms on designated hall effective on 11.20.2020 completed. Donning and Doffing set up established on the hall. Hall signs placed outside the doors on the quarantine and COVID Halls. Monitoring The Director of Nursing and /or designee will be responsible for monitoring of educational requirements. This process began on 11.21.2020, education will continue each shift until 100% of the staff is educated on the above criteria. All new hires will receive the same in-service education. Walking rounds will be made each shift on the floors to ensure compliance and documentation will be reviewed daily. Any non-compliance will be corrected immediately. At any time, education acknowledgment of not understanding of what is required to maintain compliance, clarification will be provided immediately with one on one in-servicing by the department head or assigned supervisor responsible. Involvement of Medical Director The Medical Director will be notified about the immediate Jeopardy on 11.22.2020. The Medical Director will be meeting with the Interdisciplinary team on 11.23.20 to discuss more about the Immediate Jeopardy and was to address the deficient practice. An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal. Monitoring of the plan of removal included: Interviews were conducted from 11/24/20 through 10/25/20 with facility and agency staff on all three shifts (Intern-ADM, DON, CSS A, CNA C, Med Aide D, CNA E, CNA F, RN G, CNA H, Cook I, HLS J, HS K, and LVN L). The facility had a total of three different shifts (6 AM to 2 PM, 2 PM to 10 PM, and 10 PM to 6 AM). Staff interviewed confirmed they received in-service training and were able to demonstrate competency in how to prevent cross contamination from COVID-19 infection, how COVID-19 virus spreads, how to don/doff PPE properly for each cold, warm and hot units, how to remove and place on proper isolations (cold, warm, hot units) the residents' roommate who had tested for COVID-19 positive or resident with unknown status. Observations between 10/24/20 from 4:00 PM to 6:15 PM and 10/25/20 from 10 AM to 1:45 PM revealed the facility staff followed the facility protocol on infection control including, how to don/doff PPE correctly, the warning sign posting and proper PPE supplies setting up on the isolation units (cold, warm, hot units) to prevent cross contamination, and the residents who were presumptive COVID-19 were under proper quarantine hall (warm unit). An Immediate Jeopardy (IJ) was identified on 11/21/20. The facility was provided with the IJ template on 11/21/20. While the IJ was lowered on 11/25/20, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal.