Every finding on record at Denton Village by PureHealth

Based observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Residents #2) reviewed for catheter care. The facility failed to ensure Resident #2's catheter bag was off the floor on 08/19/2026. This failure could place the residents at risk of urinary tract infection.Findings included: Record review of Resident #2's Face Sheet, dated 08/19/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness). Record review of Resident #2's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 07/17/2026, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS (screening tool used to assess cognitive status) score of 15. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter (a thin, flexible tube inserted in the bladder to allow the urine to flow in the catheter bag). Record review of Resident #2's Comprehensive Care Plan, dated 07/29/2026, reflected the resident had an indwelling catheter and one of the interventions was to monitor for signs and symptoms of UTI (infection in any part of the urinary system).Record review of Resident #2's Physician's Order, dated 03/19/2026, reflected Urinary Catheter (a thin, flexible tube inserted in the bladder to allow the urine to flow in the catheter bag) Care every shift. During an observation and interview on 08/19/2026 at 8:49 a.m., revealed Resident #2 was in her bed, awake. A catheter bag (collects urine from the urinary bladder), with a privacy bag, was observed hanging at the side of her bed and was touching the floor. The resident said she had the catheter for almost five months because she had difficulty voiding. She said the staff were the ones emptying her catheter bag. She said the staff were the ones raising and lowering her bed. During an observation and interview on 08/19/2026 at 8:51 a.m., LVN B said Resident #2's catheter bag should not be touching the floor to prevent cross contamination and development of urinary tract infection (infection in any part of the urinary system). She said she did not notice that the catheter bag was touching the floor when she checked on the resident. She went inside the resident's room and repositioned the catheter where it would not touch the floor even though the bed was in a low position. She said she would also tell the CNAs where to hang the catheter so it would not touch the floor. She said she would change the catheter bag as soon as she was done with her treatment.During an interview on 08/18/2026 at 10:23 a.m., the DON said the expectation was for catheter bags to not be touching the floor and that the staff would change the bags when seen touching the floor. He said catheter bags touching the floor could lead to UTI. He said he would start an in-service to re-educate the staff about catheter care and would figure out where to put the catheter bag so it would not touch the floor when the bed was lowered.During an interview on 08/19/2026 at 12:11 p.m., ADON A said catheter bags should always be off the floor because it could cause UTI. She said the expectation was that catheter bags would always be off the floor to prevent cross contamination and probable infection. She said they would re-educate the staff about the risk when catheters touched the floor and they needed to make sure that catheters were off the floor before they left the room.During an interview on 08/19/2026 at 2:20 p.m., CNA C said he did not notice that Resident #2's catheter bag was touching the floor. He said it should be off the floor because the floor was dirty and could cause infection.During an interview on 08/19/2026 at 2:32 p.m., the Administrator said the expectation was catheter bags would be off the floor to prevent infection. She said she would coordinate with the DON to do an in-service about the concern identified and would monitor closely that the staff understood the in-service. Record review of the facility's policy, Catheter Care, Urinary Strategy, Delivery, Performance revised September 2024 reflected Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infection . General Guidelines . Infection Control . 2. Be sure catheter tubing and drainage bag (collects urine from the urinary bladder) are kept off the floor.

Based on observation, interview, and record review, the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of ten residents (Residents #1) reviewed for medication storage. The facility failed to ensure that there was no nasal spray, anti-fungal powder, and barrier cream inside Resident #1's room on 08/19/2026. This failure could place the residents at risk of misuse of medications, possible adverse reactions, and overdosing.Findings included: Record review of Resident #1's Face Sheet, dated 08/19/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and muscle weakness.Record review of Resident #1's Comprehensive MDS Assessment, dated 07/04/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had chronic obstructive pulmonary disease, muscle weakness, and was incontinent (unable to control) for bowel and bladder.Record review of Resident #1's Comprehensive Care Plan, dated 08/05/2026, reflected the resident had impaired gas exchange (disruption in the exchange of gases in the lungs) and one of the interventions was to administer oxygen and medications. The plan indicated the resident had an ADL self-care performance deficit and needed assistance in toilet use.Record review of Resident #1's Physician's Order, dated 04/25/2026, reflected Flonase Allergy Relief Nasal Suspension (Fluticasone Propionate (Nasal) 1 application in both nostrils (openings of the nose) one time a day for allergies both nares (nasal passageway).Record review of Resident #1's Physician's Order, dated 01/15/2026, reflected HOUSE BARRIER CREAM AFTER EACH INCONTINENCE EPSIODE as needed.Record review on 08/19/2026 of Resident #1's Physician Orders, reflected the resident did not have an order for the anti-fungal powder.Record review on 08/19/2026 of Resident #1's Clinical Assessment List, reflected the resident did not have an assessment for self-administration of medications or an assessment that the resident was competent to manage her own medications.During an observation and interview on 08/19/2026 at 8:46 a.m., revealed Resident #1 was inside her room, sitting in her wheelchair. A nasal spray, anti-fungal powder, and a tube of zinc oxide (medicated cream used to prevent skin irritation) was noted on top of the resident's overbed table that was positioned near the door of the room. The resident said the staff left the nasal spray inside her room, and she was the one administering it. She said the barrier cream was used everytime the staff would clean her up. She said the anti-fungal powder had always been on top of her table and the staff did not ask her anything about the powder.During an observation and interview on 08/19/2026 at 10:23 a.m., the DON said medications should not be inside the residents' rooms or left inside the rooms because the residents might use them inappropriately and that could result in adverse reactions and overdosing. He said residents could administer their medications if they had an assessment that they could safely administer their medications. He said the residents, who could administer their own medications, should have lock boxes inside their room to keep the medications not accessible to other residents who might be confused. He went inside Resident #1's room and saw the anti-fungal powder and the tube of zinc oxide. He took the anti-fungal powder and the tube of zinc oxide and gave them to LVN B. He also told LVN B to check if the resident had an order for the anti-fungal. He said the expectation was for the staff to be vigilant when they entered the residents' rooms to check for any medications and for staff not to leave any medication inside the residents' rooms. He said he would start an in-service about medications storage. He said he would also remind the residents that they could not keep any medications inside their rooms. He said he did not see the nasal spray inside the resident's room but would ask LVN B if she already took the nasal spray.During an interview on 08/19/2026 at 12:11 p.m., ADON A said LVN B asked her the morning of 08/19/2026 about a resident that wanted to administer her own nasal spray. She said she did not know that LVN B went ahead and left the nasal spray inside Resident #1's room. She said she told her that an assessment for self-medication should be done first, and depending on the result of the assessment, before it could be decided if the residents could administer their own medications. She said without the assessment, no medications should be inside the rooms of the residents because confused residents might mistakenly consume them or use them inappropriately. She said not just the nasal spray, but the anti-fungal powder and the zinc oxide should not be inside as well. She said the expectation was for the staff to be diligent enough to scan the rooms of the residents for any medication and not to leave any medication because the staff would not know how often the resident used the nasal spray from the time it was left and from the time it was observed to be inside the room. She they would include other staff in the in-service so they could notify the nurses if they saw any medications inside the rooms of the residents.During an interview on 08/19/2026 at 2:12 p.m., LVN B said Resident #1 insisted for her to leave her nasal spray inside her room and that the resident would be the one administering it. She said she should have explained to the resident that an assessment should be done first instead of just leaving the nasal spray. She said she already took the nasal spray from the resident's room. During an interview on 08/19/2026 at 2:32 p.m., the Administrator said the expectation was for the staff to make sure there were no medications inside the rooms of the residents because the residents might use them more that what was required. She said she would collaborate with the DON about the issue regarding the medications inside the room of the resident. She said they would talk to the residents and the family members to notify the staff if there were buying or bringing medications so proper instruction could be provided. Record review of the facility policy, Medication Labeling and Storage Strategy, Delivery, Performance revised August 2024 reflected Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys . Policy Interpretation and Implementation . Medication Storage . 2. The nursing staff is responsible for maintaining medication storage.

Based on observation, interviews and record reviews, the facility failed to ensure the resident had the right to be free from neglect as defined in this subpart for one (Resident #1) of six residents reviewed for neglect. 1. On [DATE] LVN B failed to notify Resident #1's doctor or hospice provider after she checked Resident #1's BS level of 576; and on [DATE] and [DATE] LVN B failed to notify Resident #1's doctor or hospice provider after she checked Resident #1's BS levels over 600. 2. On [DATE] and [DATE] the facility failed to ensure Resident #1 was given his dayshift dose of his diabetic Metformin medications to prevent his BS level from getting higher and on [DATE] the facility failed to ensure Resident #1 received his dayshift dose of his potassium chloride medication. (There was no evidence provided that the facility contacted the pharmacy, doctor, hospice or obtained the medications from the E-kit or checked Resident #1's BS Levels). 3. On [DATE] RN A failed to check Resident #1's BS after Resident #1 fell to the floor and injured his head, it was unknown what his BS level was. Subsequently, Resident #1 was sent to the hospital [DATE] and was admitted for having a ground level fall, SAH (Subarachnoid hemorrhage- (Brain bleed), hypotension (low blood pressure) and BS level of 812 (very high). On [DATE] Resident #1 passed away. An Immediate Jeopardy (IJ) was identified on [DATE]. An IJ Template was provided to the facility on [DATE] at 5:00 pm. While the Immediate Jeopardy was removed on [DATE] at 5:57 pm, the facility remained out of compliance at a scope of pattern with a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place all diabetic residents at risk of not getting their medications which could cause increased BS levels to be untreated and result in nerve damage, eye disease, diabetic coma, or death. Findings included: Record review of Resident #1's Hospice Patient Fact report dated [DATE] revealed, Metformin ER 500 extended release 24 hr start date [DATE] (no end date). 500 mg take 1 tab by mouth twice daily at breakfast and dinner oral. Insulin glargine, human recombinant analog U-100 insulin 100 start date [DATE] (no end date). 100 unit/ml (3 ml) inject 6 units subcutaneous at dinnertime once a day subcutaneous. Reason for medication: Diabetes. Record review of Resident #1's admission MDS assessment dated [DATE] revealed an [AGE] year-old male who admitted [DATE] from home, had a BIMS score of 00 (Severe cognitive impairment) and active diagnoses that included debility and cardiorespiratory conditions. His diagnoses were heart failure, peripheral vascular disease (circulation disorder), renal insufficiency (Poor kidney function), acute chronic systolic (congestive) heart failure. He had repeated falls, and a cognitive communication deficit. He had no pain issues but had a fall in the last 2-6 months prior to admission and had a swallowing disorder. His weight was 155 pounds and was on a mechanically altered diet. He received five insulin injections in the past seven days, oxygen therapy and hospice care. Resident #1 had an overall goal for discharge and was established to return to the community with family. (He had no diabetic or seizure diagnoses). Record review of Resident #1's Care Plan dated [DATE] revealed he had a cognitive communication deficit, acute on chronic systolic (congestive) heart failure, stage 3 chronic kidney disease (Kidney function loss), peripheral vascular disease, risk for falls - repeated falls. On [DATE] he had a urinary tract infection, terminal prognosis, and was under hospice care. Further review revealed there was no care plan related to diabetes. Record review of Resident #1's [DATE] Physician's Orders dated [DATE] by Doctor F revealed, Insulin subcutaneous solution 100 unit/ml inject 8 unit subcutaneously at bedtime for diabetes (start [DATE] - stop [DATE]). Metformin oral tablet give 500 mg by mouth two times a day for diabetes (start [DATE] - stop [DATE]). Potassium Chloride extend release 10 MEQ give 1 tablet by mouth one time a day for potassium replacement (start [DATE]- [DATE]). (There was no physicians order to check his BS twice per day as Doctor ordered by NP Q). Record review of Resident #1's [DATE] MAR dated on [DATE] by MA I revealed, his 10 MEQ potassium chloride Extended release was not given and coded 9 other/see progress notes. On [DATE] and [DATE] his 500 mg metformin was not given and coded 9 other/see progress notes. Record review of Resident #1's Vitals Section for blood sugar dated [DATE] at 9:12 am by RN A revealed his BS level was 212. Further review revealed there was no other BS level readings in this section. Record review of Resident #1's Nurses note dated [DATE] at 7:31 pm by LVN B revealed, Insulin subcutaneous solution 100 unit/ml - inject 8 units subcutaneously at bedtime for diabetes. BS 576!! Further review revealed no documented evidence his doctor or hospice provider was notified of Resident #1's BS level. Record review of Resident #1's Nurses note dated [DATE] at 8:52 pm by LVN B revealed, Resident resting in bed with eyes closed with TV (television) on. No visible signs of distress noted. Took pt's blood sugar prior to administering of his HS insulin. Blood sugar came back above 600. Administered order for 8 units of long acting. No orders for sliding scale insulin. Bed in lowest position and call light within reach. Further review revealed no documented evidence his doctor or hospice provider was notified of Resident #1's BS level or that it had been rechecked that day. Record review of Resident #1's Nurses note dated [DATE] at 9:27 am by MA I revealed, Metformin oral tablet 500 mg - give 500 mg by mouth two times a day for diabetes not available nurse notified. And at 9:45 am Potassium chloride ER tablet extended release 10 MEQ - give 1 tablet by mouth one time a day for potassium replacement, not available nurse notified. Record review of Resident #1's Nurses note dated [DATE] at 8:03 pm by LVN B revealed, Insulin subcutaneous solution 100 unit/ml - Inject 8 unit subcutaneously at bedtime for Diabetes. Blood sugar reading was over 600. Further review revealed no documented evidence his doctor or hospice provider was notified of Resident #1's BS level or that it had been rechecked that day. Record review of Resident #1's Nurses note dated [DATE] at 12:14 pm by MA I revealed, Metformin oral tablet 500 mg - give 500 mg by mouth two times a day for diabetes, not available nurse notified. Record review of Resident #1's Nurses note: Change in Condition report dated [DATE] at 8:00 am by RN A revealed, Falls - BP 103/64 and Blood glucose: BS 212 - [DATE] at 9:21 am. Further review revealed there was not a current BS level documented on [DATE]. Record review of Resident #1's Incident report dated [DATE] at 8:00 am revealed by RN A, Called in by CNA that patient was on the floor bleeding. On assessment patient found on the floor with skin tear to forehead. Nurse ask what had happened and was told the patient got out of chair and try to walk and fell to the floor. Nurse ask patient andall [sic] he stated he needs water to drink. Thicken water given to patient and he calm down. Skin tear noted to forehead and arm. Will continue to monitor. Was the incident witnessed No, neuro checks, vitals, monitor frequently, floor mat, pressure apply to patient forehead [sic]. Record review of the Resident #1's Paramedic's Patient Care record dated [DATE] revealed, a call was made at 10:25 am and at 10:31 at the facility. At 10:33 am he had a hematoma and laceration / abrasion on left side of forehead and at 10:39 am his clinical impression was altered mental status and diabetic hyperglycemia. His chief complaint Fall - altered mental status - hyperglycemia. There was a blunt injury (medical and trauma) and at 10:40 am he was given saline IV therapy and at 10:41 am his blood glucose was high. He had a Glasgow coma score <= 13 (mild traumatic brain injury) and Resident #1 was transported to the emergency room hospital. Record review of Resident #1's Hospital records revealed he was admitted on [DATE] in critical condition for a ground level fall, (primary diagnosis) subarachnoid hemorrhage and hypotension. His glucose (BS) level was 812 (critically high), HPI [AGE] year-old male with advance dementia, diabetes, CAD s/p.A-fib on Eliquis, PAD, CAD, CKD3 presented on 10/29[2025] after a ground level fall was found to have subarachnoid hemorrhage (brain bleed) and uncontrolled blood sugars possibly in hyperosmolar hyperglycemic syndrome (Very high BS for a long period of time). Patient remined in persistent shock, likely cardiogenic. Record review of Resident #1's Hospital deceased Discharge summary dated [DATE] revealed his discharge diagnoses HHS (extremely high blood sugar level), T2DM (type 2 diabetes), Cardiogenic shock (inadequate blood flow to organs), SAH (brain bleed), Ground level fall, acute encephalopathy (sudden severe brain disorder), NSVT (irregular fast heartbeat), PVC's (extra early heartbeats) , Chronic AF (irregular heartbeat), CHF (heart not pumping blood regularly), AK (sun exposure skin lesions)on CKD (kidney damage). Time of death 7:38 pm. Interview on [DATE] at 2:23 pm, RN A stated Resident #1 was at this facility for a few days for a short stay while the FM had a procedure. She stated Resident #1 had no falls until the morning of [DATE] when they were getting the residents into the dining room for breakfast and during that time Resident #1 fell in the dining room. She stated she was not in the dining room and was gone for about 10 minutes at the time but heard Resident #1 got up from his wheelchair and fell. She stated a dietary aide was in the dining room and told her about it and when she went to the dining room she saw Resident #1 on the floor, then she assessed him. She stated he had a small skin tear that was 0.2 cm. long on his forehead that bled and did not notice any knots. She stated Resident #1 was able to talk and he shook his head and asked for some water; and she then she put pressure on his head and the bleeding stopped. She stated she gave Resident #1 some water and then took his vitals and was BS checked but did not document them anywhere that were normal and said she believed Resident #1 got up and tried to walk and fell. She stated Resident #1 was fine and ate his breakfast. She stated Resident #1 was able to feed himself with a spoon and they just had to watch him eat. She stated after that he was taken to his room and sometime later he started having a change. She stated she called the FM, but the FM did not answer, and hospice did not answer. She stated Doctor F was already at the facility and he went to check on Resident #1 and told her to call hospice and to see what the family wanted to do. She stated she called hospice again and the DON tried to call the FM and still was not able to talk to anyone. She stated she was told the FM was having a medical procedure and the reason why there was no response. She stated Resident #1 had not vomited or had signs of aspiration, but MR Nurse G said he had seizure like activity. She stated hospice Nurse E arrived one or two hours later. She stated she did Resident #1's incident report. She stated Resident #1 was not on a sliding scale and was given an insulin long-acting injection at bedtime. She stated Resident #1 had a lot of medications and said he had not missed getting them. She stated he was a one person assist and was able to pivot with transfers and he was A/O x 1 meaning his cognition was not good. She stated Resident #1 had floor mats on both sides of his bed and his bed was in the lowest position. Interview [DATE] at 3:17 pm, LVN B stated on [DATE] she received a report about Resident #1 being taken to the hospital because he had a fall during the morning shift. She stated Resident #1 was a diabetic who took Metformin and also took insulin long-acting injections at night. She stated she took Resident #1's BS level before giving his insulin at night which ran pretty high. She stated she told Resident #1's hospice nurse about his 600 BS levels but could not remember the hospice nurse's name or if the hospice doctor was contacted. She stated she spoke to one of the ADON's and overnight charge nurse about his high BS level but was unsure of their names. She stated Resident #1 did not have a sliding scale and believed she spoke to Doctor F about his 600 BS, was not sure when but thought Doctor F told her to refer to Resident #1's hospice provider. She stated she did not remember reaching out to the FM over the phone or in person about his high BS and could not remember if she spoke to the DON about his high BS. She stated hearing that Resident #1 went to the hospital and had a brain bleed. Interview on [DATE] at 4:19 pm, CNA C stated on [DATE] she did not see what happened because she was getting the residents into the dining room for breakfast. She stated she was not Resident #1's CNA but Dietary Aide D said, oh look he fell and when she turned around she saw Resident #1 on the floor on his side. She stated RN A came to assist him and he had a skin tear on his forehead that bled from falling and bumping his head on the floor. She stated RN A washed the spot and put gauze on it. She stated Resident #1 bled a small amount that had eventually stopped, and he was his normal self. She stated after RN A assessed Resident #1, she helped the nurse get him back into his wheelchair. She stated Resident #1 stayed in the dining room and ate his breakfast, which he ate pretty good. She stated hearing Resident #1 went to the hospital later that day. Interview on [DATE] at 5:49 pm, Hospice ED H stated everything was secondhand information and said he had no conversations from the facility nurse [DATE]. He stated he heard Resident #1 fell the morning of [DATE], that he was left unattended and he fell and hit his head and was sent to the hospital. He stated Resident #1 had a brain bleed. He stated there were no concerns with Resident 1 not getting his medications but heard his BS level was pretty high and assumed he did not get his insulin doses. He stated Resident #1's FM supplied his insulin and blood pressure medications, and some were from the facility's pharmacy. He stated not being aware of Resident #1 having a skin tear on his forehead after he fell but he got involved when he was transferred to the hospital. He stated the facility was responsible for doing his BS checks. He stated he had not spoken to the facility about Resident #1's stay. Interview on [DATE] at 5:15 pm, the DON stated Resident #1 admitted to the facility on respite care. He stated Resident #1 fell in the dining room the morning of [DATE] and was able to consume his meal and drink. He stated Resident #1's ST on his forehead was 2 cm x 0.5 cm. He stated after he ate, Resident #1 had a seizure, then he was taken to his room. He stated they were waiting for hospice to let them know if they could send him to the hospital and RN A said she had called the hospice provider twice, but they were not responding. He stated around 9:00 am, he went in Resident #1's room to assess him, and he was not responding, and they could not get the FM on the phone. He stated he tried to call the FM without a response. Then the hospice nurse arrived, and Resident #1 was taken to the hospital. He stated management talked about Resident #1's fall in the dining room but was not aware Resident #1 missed getting his Metformin on [DATE] and [DATE]. He stated when a resident's insulin was too high he expected the nurses to call the resident's doctor to see if medication could be given to get their BS down. He stated he was not aware Resident #1's BS was over 600 while he was at this facility. He stated their Admissions Director AA checked on Resident #1 at the hospital and found out he was deceased . Interview on [DATE] at 5:40 pm, LVN B stated when Resident #1 admitted , the FM said she would be out and not able to communicate and they needed to talk to hospice for any concerns. She stated she would be unavailable while she was gone for a medical procedure. Interview on [DATE] at 6:15 pm, the DON stated Resident #1 did not have any discontinued medications prior to his discharge and saw on his MAR he did not get his dayshift Metformin for two days. He stated he was not aware that MA I documented Resident #1's Metformin was unavailable and would have to talk to her about what happened. He stated he was unaware of Resident #1's 600 BS levels and missed diabetic medications and would have to address that with the nursing staff. He stated he would have to check with the pharmacy and E-Kit to see if the medication was given and not documented. He stated it was strange that Resident #1 received his night doses of his Metformin [DATE] and [DATE] but not the dayshift ones. He stated Resident #1's [DATE] SBAR assessment automatically showed his [DATE] BS level 200 and was not sure why the [DATE] BS was not used. He stated Resident #1's vitals were checked and had asked RN A was his BS checked, and she said yes but it was not documented. He stated for the days prior to discharging, Resident #1 had 600 BS readings, and the nurses should have notified the doctor or hospice to possibly send the resident to the hospital. He stated he thought it was kind of strange for the nurses not to follow through by calling Resident #1's doctor or hospice provider for orders and rechecking his BS levels. He stated Resident #1 received long-acting insulin at night with the use of pen injector but there was not an order for his insulin levels to be checked. He stated before Resident #1 went to the hospital RN A should have checked his BS level but failed to document it because if it was not documented it was not done. Interview on [DATE] at 9:20 am, Dietary Aide D stated she worked the morning of [DATE] when Resident #1 fell. She stated Resident #1 fell around 8:00 am and that breakfast had not started yet. She stated the staff were bringing the residents into the dining room. She stated she was putting drinks on the tables and there was a CNA standing at a table with her back to the residents sorting meal tickets. She stated Resident #1 was sitting in his wheelchair and then she heard a noise and Resident #1 said Ouch' after he slammed down to the floor so hard. She stated Resident #1 had an abrasion on his forehead that was bleeding. She stated RN A came to the dining room and cleaned him up. She stated there were other residents in the dining room. She stated his forehead was not bleeding a lot and the nurse was able to get it to stop bleeding, and Resident #1 ate his breakfast. She stated one resident asked why 911 was not called, and something was mentioned about hospice, and the nursing staff waited until after breakfast then took him to his room. Interview on [DATE] at 9:44 am, Hospice Nurse E stated she was on call and closest to Resident #1 when they received the call about Resident #1's fall. She stated she was not sure when she arrived because she did not have Resident #1's record on her to review. She stated whatever the time was she asked the staff why they were not called sooner. She stated RN A said Resident #1 fell and hit his head and had a seizure and when she arrived Resident #1 had a large bump on the left side of his forehead. She stated Resident #1's pupils were not responsive to light and his BP was not normal and low for him. She stated her main focus was Resident #1's internal bleeding because he was not responsive which meant he was bleeding on the inside of his brain. She stated Resident #1 had a brain bleed that the facility should have called them about sooner. She stated after she assessed Resident #1 she called the FM and was told to have Resident #1 sent to the hospital. She stated she spoke to RN A again for him to get transferred to the hospital and during the time she was there he did not vomit or seizure, but it was reported from the facility nurse he vomited and had a seizure before she arrived. She stated not being aware of his BS levels being 600 a few times since being at the facility. She stated when Resident #1 admitted to the hospital his BS level was 820 or 830 and was not sure why it was so high because he took diabetic medications at the facility. She stated hospice could order Resident #1's diabetic medications but did not manage it and that was the responsibility of the facility to do. She stated a sliding scale could have been initiated if they were notified of the BS issue. She stated missing one day dose of diabetic medication would definitely make a person's insulin go up. She stated Resident #1 was not getting sliding scale insulin at home because the FM did a lot of dietary management of his meals and drinks. Interview on [DATE] at 10:33 am, the FM stated Resident #1 admitted to the facility for respite care while they had a procedure and gave all of Resident #1's medications to the facility. They stated they were not told about Resident #1's 600 BS levels. They stated they received a call from Hospice Nurse E on [DATE] about Resident #1's complications from falling. They stated they told Hospice Nurse E to have Resident #1 sent to the hospital and the hospice nurse followed them to the hospital. They stated the hospital said his BS level was 840, she believed. They stated had Resident #1's BS been checked it would not have been that high and could not believe not one person noticed how high it was. They stated the Medical Examiner talked to them about Resident #1's fall and the condition of his body and his high BS. They stated they thought Resident #1 was being put in a good place and wondered how did he fall, why was he feeding himself and had so many questions. They stated they felt bad because they were not at the facility to have kept him from falling. They stated the day before [DATE] they had a video phone call with Resident #1, and he looked fine, but now he was deceased . They stated Hospice Nurse E said once she (Hospice Nurse E) arrived Resident #1 had started having a seizure and Hospice Nurse E suspected he had a brain bleed. They stated they did not have any missed calls from the facility. Interview on [DATE] at 10:58 am, Hospice Nurse J stated she was Resident #1's nurse who saw him twice and there were no reports of his BS level increasing. She stated he took diabetic medication but did not have sliding scale orders because his insulin levels were normal at home. Interview on [DATE] at 11:31 am, the Administrator stated Resident #1 fell [DATE] around 8:00 am and was a hospice patient. She stated their facility called his hospice provider and when they arrived he was sent to the hospital. She stated the facility notified Facility Doctor F immediately after Resident #1 fell from what she understood. She stated there were a few calls made to his hospice provider and hospice finally came out and evaluated Resident #1. She stated her staff assessed Resident #1 and notified Doctor F and they did everything they were supposed to do. She stated that she knew of Resident #1 did not go without any of his medications. She stated she was not aware Resident #1 had BS readings over 600 and did not receive his dayshift Metformin on [DATE] and [DATE] at the facility. She stated maybe he was given the Metformin from the E-kit and the staff did not document it. She stated the nurse might have pulled the diabetic medication out of the E-kit for Resident #1. She stated she was not aware the hospital said his BS was over 800 and stated he passed away two or three days after he discharged from the facility. She stated she did not investigate or report the incident to HHSC because of the new provider letter on reporting falls and deaths. Interview on [DATE] at 11:52 am, the DON stated he spoke to MA I who said she did not give Resident #1 two doses of his Metformin on [DATE] and [DATE] which was why she documented it was unavailable and notified the nurse, in the progress note. He stated MA I told him the Metformin was unavailable and thought the nurse may have reached out to the pharmacy or hospice provider. He stated not being sure how Resident #1 ran out of the Metformin that came with the resident and said he had one diabetic pill he took 1xd, Metformin 2xd and a long-acting insulin at bedtime. He stated Resident #1 did not have any type of diabetic monitors on him. He stated if the medication was still not available after two times MA I should have notified him or one of the ADONs to get the medication. He stated if Resident #1's BS levels were elevated LVN B should have called hospice since she was checking it. He stated LVN B said she was checking Resident #1's BS because she did not see anyone doing it and LVN B should have notified the hospice provider when Resident #1's BS was over 600. He stated he was not sure if LVN B called the doctor/NP about Resident #1's elevated BS levels but she should have notified his hospice provider to get further orders. He stated he did not see any documentation from the nurses notifying the hospice provider about Resident #1's elevated BS and what the hospice nurse said. He stated he saw concerns for the nurse's failure to document more thoroughly and give Resident #1 all of his Metformin. He stated there was a lot of confusion for getting more of his Metformin and that he should have been notified and his doctor and hospice and that did not happen. He stated if he had known Resident #1 was out of Metformin, he would have gotten it from their pharmacy. He stated two missed dosages could have a detrimental effect on a resident by increasing their BS even though he was taking two other diabetic medications. He stated he looked a lot at Resident #1's MARS and was not sure how he missed seeing Resident #1 did not get his Metformin. He stated he was not sure how the hospice provider policy was related to diabetic management and medication dispensing and would have to review it. He stated all the staff said Resident #1 stood up and fell and he said wanted some water. He stated because he was on hospice they notified hospice between 8:00 am and 9:00 am and talked to the answering service but not sure who RN A talked to. He stated being told the hospice provider was sending a nurse and after he received a report of Resident #1 having a seizure he thought about sending Resident #1 to the hospital, but did not know what hospice wanted to do. He stated not being aware Resident #1's BS was over 800 at the hospital but got word he had passed away from their Admissions Coordinator AA a few days after he discharged from the facility. He stated they did not know if the FM wanted him to go to the hospital and if Resident #1 were not on hospice he would have been sent right out to the hospital. Interview on [DATE] at 10:46 am, RN L stated when a resident had a 400 to 450 BS level they needed to contact the resident's provider. She stated normally residents taking diabetic medication had a sliding scale to give them a one-time order if their BS was too low or too high. She stated a 600 BS level was an emergency because that was way too high and needed immediate attention by calling the doctor. She stated high BS levels depended on the resident if they had some medical conditions or if they were on steroids that made their BS level so high. She stated if a resident's BS level was 600 she would first try to see what the resident's normal BS levels were and looked at their medical background then sought a treatment plan. She stated as a nurse they knew what they were supposed to do for high BS and if she did not hear from the doctor or hospice, she would see about getting the resident out to the hospital. She stated if a resident had a BS over 600 could depend on a lot and a resident could go into diabetic ketoacidosis (Acidic blood) and HHS (extremely high blood sugar levels). Interview on [DATE] at 10:55 am, MA M stated the nurses checked the diabetic residents' BS level. She stated when a resident ran out of medications she would first check everywhere and notify the nurse to see if it could be taken from the E-kit. She stated if the medication was not given she would document the medication was not available, notify the nurse if the medication was really not given. She stated if Metformin or blood pressure medications were not available it was very important for the nurse to get them from the E-kit and she would continue to notify the nurse that the medication was not available. She stated if the medication was not given after the second day would raise a concern and she would have to just continue to document the medication was unavailable, nurse notified. She stated she would press the issue with the nurse because Metformin was very important for the diabetic residents to received it and would ask if the nurse could she check the resident's blood sugar. She stated she would have to let Weekend Supervisor N know of the missing medication, if she were working weekends and if she worked during the week she would notify the DON. She stated the staff needed to control the resident's BS level with the medications prescribed. She stated a resident could go into a diabetic coma if their BS levels increased. She stated increased BS levels was emergent and needed to take control of this issue right away. Interview on [DATE] at 11:18 am, Weekend Supervisor N stated if a resident's diabetic medication were unavailable she would first check the E-kit or pharmacy and call family to assist. She stated Metformin was in their E-kit and on the outside of the E-kit, there was a list of what medications were in it. She stated if the medication was not in the E-kit she would get the medication from the pharmacy. She stated if a resident had a 600 BS level, she would first check to see if they had sliding scale insulin and if they did not she would call the doctor to get a doctor's order for a treatment. She stated she would of course assess the residents and monitor them and keep calling the doctor over and over again until the doctor was reached. She stated for a hospice resident she would follow the doctor's orders and if they did not have a sliding scale she would call hospice first and for no response she would call the resident's facility doctor. She stated she would notify the FM/RP about the 600 high BS if the resident was on hospice and would let the FM/RP know as well to get them to help with reaching out to hospice. She stated she would document everything in the resident's progress note for their attempts with whom she contacted at the hospice provider. She stated she would document why they were being contacted and who she spoke to and what the response was from the on-call office and hospice nurse. She stated once the hospice provider gave orders to treat she would document what the hospice provider said and made sure the orders were added to the orders for the next nurses to follow. She stated she would then follow through on the treatment plan and notify the next nurse what happened. She stated if there BS did not decrease it would be considered emergent, and she would call 911 and would definitely send the resident to the hospital then call the FM/RP and doctor or hospice provider. She stated if the resident did not get a treatment, they could go into diabetic ketoacidosis or a coma. She stated if a resident did not have medication she would document in the progress note and in the 24-hour report book and said if she noticed something needed to be taken care of that same day she would let the DON know about the situation. She stated she would follow the resident's sliding scale orders and administer the insulin needed for that BS level and would recheck their BS level a few minutes after giving it. She stated she would let the hospice nurse know about the 600 BS level and asked what did they need to do about it like giving a fast acting or smaller dose of insulin for example then rechecking the BS level 30 minutes later. She stated before sending a resident out she would do an assessment and check the resident's vitals including the BS and if they had a seizure she would review to

Based on interview and record review the facility failed to, in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that were complete and accurately documented for one (Resident #1) of six residents reviewed for medical records. The facility failed to ensure Resident #1's face sheet and care plans were complete and accurate. Resident #1 was diagnosed with diabetes and took diabetic medications and he had no diabetes diagnosis on his facility's EMR records. This failure could place all residents at risk of inadequate care if all of their diagnoses were not included in the resident's EMR records, which could result in a decline in the resident's health and psych-social well-being. Findings included: Record review of Resident #1's Face Sheet dated 11/14/25 revealed an [AGE] year-old male who admitted [DATE] with diagnoses of Acute on chronic systolic (Congestive) heart failure, Peripheral vascular disease, stage 3 chronic kidney disease, repeated falls, and cognitive communicative deficit. (There was no diabetic diagnosis). Record review of Resident #1's Hospice Patient Fact report dated 10/17/25 revealed, Metformin ER 500 extended release 24 hr start date 04/25/25 (no end date). 500 mg take 1 tab by mouth twice daily at breakfast and dinner oral. Insulin glargine, human recombinant analog U-100 insulin 100 start date 07/16/25 (no end date). 100 unit/ml (3 ml) inject 6 units subcutaneous at dinnertime once a day subcutaneous. Reason for medication: Diabetes. Record review of Resident #1's admission MDS assessment dated [DATE] revealed an [AGE] year-old male who admitted [DATE] from home, had a BIMS score of 00 (Severe cognitive impairment) and active diagnoses that included debility and cardiorespiratory conditions. His diagnoses were heart failure, peripheral vascular disease (circulation disorder), renal insufficiency (Poor kidney function), acute chronic systolic (congestive) heart failure. He had repeated falls, and a cognitive communication deficit. He had no pain issues but had a fall in the last 2-6 months prior to admission and had a swallowing disorder. His weight was 155 pounds and was on a mechanically altered diet. He received five insulin injections in the past seven days, oxygen therapy and hospice care. Resident #1 had an overall goal for discharge and was established to return to the community with family. (He had no diabetic diagnosis). Record review of Resident #1's Care Plan dated 10/23/25 revealed he had a cognitive communication deficit, acute on chronic systolic (congestive) heart failure, stage 3 chronic kidney disease (Kidney function loss), peripheral vascular disease, risk for falls - repeated falls. On 10/24/25 he had a urinary tract infection, terminal prognosis, and was under hospice care. Further review revealed there was no care plan related to diabetes. Record review of Resident #1's October 2025 Physician's Orders dated 10/23/25 by Doctor F revealed, Insulin subcutaneous solution 100 unit/ml inject 8 unit subcutaneously at bedtime for diabetes (start 10/23/25 - stop 10/29/25). Metformin oral tablet give 500 mg by mouth two times a day for diabetes (start 10/23/25 - stop 10/29/25). Record review of Resident #1's October 2025 MAR revealed, Insulin Subcutaneous solution 100 unit/ml inject 8 unit subcutaneous at bedtime for diabetes and Metformin oral tablet 500 mg give 500 mg by mouth two times per day for diabetes (start 10/23/25 -10/29/25). Record review of Resident #1's Vitals Section for blood sugar dated 10/23/25 at 9:12 am by RN A revealed his BS level was 212. Further review revealed there was no other BS level readings in this section. Interviews on 11/18/25 at 4:20 pm, ADON Z stated the Admissions Director completed the resident's face sheets and the Regional MDS Coordinator K was responsible for completing the care plans. Interview on 11/18/25 at 4:46 pm, Regional MDS Coordinator K stated he was the Corporate MDS Coordinator and the former facility MDS Coordinator stopped working at this facility last month [October 2025]. He stated he was not aware of Resident #1's face sheets and Care Plans were inaccurate. He stated his role was to review the residents' documentation that reflected what the staff were documenting. He stated the IDT was responsible for reviewing and ensuring the residents' records were accurate and complete, He stated the DON reinforced that leadership had all the information for the residents and to report any issues that they needed to address. He stated he did not want to say what could happen to a resident if their medical records were not accurate and complete. Interview on 11/18/25 at 5:07 pm, the DON stated the MDS Coordinator was responsible for ensuring all the residents' diagnoses were on their face sheets. He stated he was not sure how that was missed and said not having all of the residents' diagnoses could cause a resident to get improper care or lack of care, which could run into several complications as the end result. Interview on 11/18/25 at 5:46 pm, the Administrator stated she was not sure why Resident #1's diagnoses were not on his face sheet and care plan because she was not a nurse to have been able to say that was missing. She stated the clinical leadership team was responsible for the accuracy of the residents' records and the hospice provider was responsible with ensuring they gave them accurate information. She stated the IDT was responsible for ensuring the resident's records were accurate. She stated she did not know how to answer the question on how it could affect the residents if their medical records were not accurate and correct, but they had a protocol they went by. On 11/18/25 at 5:35 pm the facility's medical record policy was requested and the Administrator stated she would provide it. On 11/19/25 at 2:18 pm the Administrator stated they did not have a one.

Based on interview and record review the facility failed to ensure each assessment accurately reflected the resident's status and for each individual who completed a portion of the assessment must sign and certify the accuracy of that portion of the assessment for one (Resident #1) of six residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1's admission MDS Assessments was complete and accurate. Resident #1 was a diabetic who took diabetic medications and he had no diabetes diagnosis listed on this assessment. This failure could place all residents at risk of inadequate care if all of their diagnoses were not included in the residents' records, which could result in a decline in the residents' health and psych-social well-being. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] revealed an [AGE] year-old male who admitted [DATE] from home, had a BIMS score of 00 (Severe cognitive impairment) and active diagnoses that included debility and cardiorespiratory conditions. His diagnoses were heart failure, peripheral vascular disease (circulation disorder), renal insufficiency (Poor kidney function), acute chronic systolic (congestive) heart failure. He had repeated falls, and a cognitive communication deficit. He had no pain issues but had a fall in the last 2-6 months prior to admission and had a swallowing disorder. His weight was 155 pounds and was on a mechanically altered diet. He received five insulin injections in the past seven days, oxygen therapy and hospice care. Resident #1 had an overall goal for discharge and was established to return to the community with family. (He had no diabetic or seizure diagnoses). Record review of Resident #1's Hospice Patient Fact report dated 10/17/25 revealed, Metformin ER 500 extended release 24 hr start date 04/25/25 (no end date). 500 mg take 1 tab by mouth twice daily at breakfast and dinner oral. Insulin glargine, human recombinant analog U-100 insulin 100 start date 07/16/25 (no end date). 100 unit/ml (3 ml) inject 6 units subcutaneous at dinnertime once a day subcutaneous. Reason for medication: Diabetes. Record review of Resident #1's Care Plan dated 10/23/25 revealed he had a cognitive communication deficit, acute on chronic systolic (congestive) heart failure, stage 3 chronic kidney disease (Kidney function loss), peripheral vascular disease, risk for falls - repeated falls. On 10/24/25 he had a urinary tract infection, terminal prognosis, and was under hospice care. Further review revealed there was no care plan related to diabetes. Record review of Resident #1's October 2025 Physician's Orders dated 10/23/25 by Doctor F revealed, Insulin subcutaneous solution 100 unit/ml inject 8 unit subcutaneously at bedtime for diabetes (start 10/23/25 - stop 10/29/25). Metformin oral tablet give 500 mg by mouth two times a day for diabetes (start 10/23/25 - stop 10/29/25). Record review of Resident #1's October 2025 MAR revealed, Insulin Subcutaneous solution 100 unit/ml inject 8 unit subcutaneous at bedtime for diabetes and Metformin oral tablet 500 mg give 500 mg by mouth two times per day for diabetes (start 10/23/25 -10/29/25). Record review of Resident #1's October 2025 MAR dated on 10/27/25 by MA I revealed, his 10 MEQ potassium chloride Extended release was not given and coded 9 other/see progress notes. On 10/27/25 and 10/28/25 his 500 mg metformin was not given and coded 9 other/see progress notes. Record review of Resident #1's Vitals Section for blood sugar dated 10/23/25 at 9:12 am by RN A revealed his BS level was 212. Further review revealed there was no other BS level readings in this section. Interviews on 11/18/25 at 4:20 pm, ADON Z stated the Regional MDS Coordinator K was responsible for completing the MDS assessments. Interview on 11/18/25 at 4:46 pm, Regional MDS Coordinator K stated he was the Corporate MDS Coordinator and the former facility MDS Coordinator stopped working at this facility last month [October 2025]. He stated he was not aware of Resident #1's MDS Assessment was inaccurate. He stated his role was to review the residents' documentation that reflected what the staff were documenting. He stated the IDT was responsible for reviewing and ensuring the residents' records were accurate and complete, but the MDS Coordinator was responsible for ensuring the MDS assessments were accurate. He stated the DON reinforced that leadership had all the information for the residents and to report any issues that they needed to address. He stated he did not want to say what could happen to a resident if their medical records were not accurate and complete. Interview on 11/18/25 at 5:07 pm, the DON stated the MDS Coordinator was responsible for ensuring all the residents' diagnoses were on their MDS Assessments. He stated he was not sure how that was missed and said not having all of the residents' diagnoses could cause a resident to get improper care or lack of care, which could run into several complications as the end result. Interview on 11/18/25 at 5:46 pm, the Administrator stated she was not sure why Resident #1's diagnoses were not on his MDS Assessment because she was not a nurse to have been able to say that was missing. She stated the clinical leadership team was responsible for the accuracy of the residents' records and the hospice provider was responsible with ensuring they gave them accurate information. She stated the IDT was responsible for ensuring the resident's records were accurate. She stated she did not know how to answer the question on how it could affect the residents if their medical records were not accurate and correct, but they had a protocol they went by.

Based 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 four of fifteen residents (Resident #8, Resident #15, Resident #21, and Resident #37) reviewed for infection control. 1. The facility failed to ensure CNA F performed hand hygiene and changed her gloves during Resident #8's incontinent care on 09/18/2025. 2. The facility failed to ensure CNA F performed hand hygiene and changed her gloves during Resident #15's incontinent care on 09/18/2025. 3. The facility failed to ensure CNA E performed hand hygiene and changed his gloves during Resident #21's incontinent care on 09/18/2025. 4. The facility failed to ensure RN B wore a gown while giving Resident #37's formula via g-tube, who had an order for enhanced barrier protection, on 09/18/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings include: 1. Record review of Resident #8's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with kidney failure. Record review of Resident #8's Comprehensive MDS Assessment, dated 09/04/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident had kidney failure and incontinent for blader and bowel. Record review of Resident #8's Comprehensive Care Plan, dated 09/04/2025, reflected that the resident had incontinence and one of the interventions was to assist during toilet use or personal hygiene. An observation on 09/18/2025 at 12:58 PM revealed CNA F was about to do Resident #8's incontinent care. She washed her hands and put on a pair of gloves. She took a brief from a drawer and placed it on top of the resident's overbed table. She then took a towel from the drawer and wet it. She placed the wet towel on top of the brief. She then pulled off the resident's pants and unfastened the brief. She cleaned the resident's perineal area (area between the legs) using the wet towel. She turned the resident and cleaned the resident's bottom. After cleaning the resident's bottom, she took the brief from the resident's overbed table and placed it under the resident and fixed it. She did not change her gloves and did not hand hygiene all throughout the process. 2. Record review of Resident #15's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with a personal history of urinary tract infection. Record review of Resident #15's Comprehensive MDS Assessment, dated 08/21/2025, reflected that the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated that the resident was frequently incontinent for bladder and bowel. Record review of Resident #15's Comprehensive Care Plan, dated 09/12/2025, reflected that the resident had incontinence and one of the interventions was to assist during toilet use or personal hygiene. Observation on 09/19/2025 at 12:47 PM revealed CNA F was about to do Resident #15's incontinent care. She washed her hands and put on a pair of gloves. She took a brief and a towel from a drawer. She placed the brief on top of the drawer. She wet the towel and also placed it on top of the drawer. She took off the resident's pants, unfastened the brief, and pushed it in the middle of the legs. She then cleaned the resident's perineal area using the wet towel that she placed on top of the drawer. After cleaning the perineal area, she washed the face towel and cleaned the resident's bottom. After cleaning the resident's bottom, she took the brief from the top of the drawer and placed it under the resident. She rolled back the resident and fixed the brief. She did not change her gloves throughout the process of incontinent care. In an interview on 09/18/2025 at 1:08 PM, CNA F stated there were no wipes inside the room that was why she used the towel. She said for Resident #15, she said she was not aware that she put the face towel on top of the drawer. She said the top of the drawer might be dirty rendering her towel dirty when she used it. She said she did wash her hands before both incontinent care. She said she was supposed to change her gloves after cleaning the residents' bottom and before touching the new briefs to prevent using dirty gloves. She said using soiled gloves could cause transfer of germs to the new brief. She said the hands should also be sanitized if she changed her gloves. She said she would be mindful the next time she would do incontinent care. 3. Record review of Resident #21's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic kidney disease. Record review of Resident #21's Quarterly MDS Assessment, dated 09/09/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident was incontinent for bladder and bowel. Record review of Resident #21's Comprehensive Care Plan, dated 07/17/2025, reflected the resident had ADL self-care performance and one of the interventions was to provide assist during toilet use and personal hygiene. Observation on 09/19/2025 at 10:39 AM revealed CNA E about to do Resident #21's incontinent care. He washed his hands and put a towel on the resident's overbed table. He took the box of gloves from the wall and wipes and put it on the overbed table. He took a brief from the closet, opened it, and placed it beside the resident. He unfastened the brief and pushed it between the legs. He cleaned the perineal area with a wipe and then rolled the resident to her side. After rolling the resident to her side, he rolled the brief towards the middle and cleaned the resident's bottom. He then wet a face towel, put some perineal cleanser on it, and cleaned the resident's bottom again. After cleaning the bottom, he took another face towel to dry the bottom. He did not change his glove before touching the face towel that he used to dry up the resident's bottom. After drying the bottom, he took off his gloves and then put on a pair of gloves. He did not sanitize his hands before putting on the new pair of gloves. He then put some calmoseptine on the resident's bottom. He then rolled the soiled linen towards to the middle and then took the brief from the resident's side and placed it under the resident. He did not change his gloves after touching the soiled linen and before touching the new brief. He rolled back the resident and cleaned the perineal area again twice using a wet face towel. After cleaning the perineal area twice with a wet face towel. For both times, he used a face towel that was soaking wet. He used the soaking face towel to clean the perineal area starting from the sides to the middle. He took off his gloves and put on a pair of gloves. He did not sanitize before putting on the new pair of gloves. He then pulled the soiled linen with the soiled brief and fixed the brief. He did not change his gloves after touching the soiled linen. In an interview on 09/18/2025 at 11:04 AM, CNA E stated he should have sanitized his hands when he changed his gloves after touching the soiled linen and before touching the new brief. He said he should have sanitized his hands when he changed his gloves to make sure his hands were clean before touching the new pair of gloves. He said he did use a wet towel and since it was wet, the germs could seep to the other part of the face towel even though he folded the towel and used the other side. He said he would be extra careful in doing incontinent care. 4. Record review of Resident #37's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #37's Comprehensive MDS Assessment, dated 07/02/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated that the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach). Record review of Resident #37's Comprehensive Care Plan, dated 09/12/2025, reflected the resident required EBP due to his g-tube and one of the interventions was to use EBP as appropriate. Record review of Resident #37's Physician Order, dated 09/12/2025, reflected Enhanced Barrier Precautions due to PEG tube. Observation on 09/18/2025 at 11:28 AM revealed RN B was about to do Resident #37's bolus feeding via g-tube. She washed her hands, started to prepare the things needed for bolus feeding, and placed them on the resident's overbed table. She washed her hands again and put on a pair of gloves. She then proceeded with bolus feeding. She did not wear a gown before giving the resident's formula via g-tube. it was observed that there was sign outside the door that EBP was required because the resident had a g-tube. In an interview on 09/18/2025 at 11:46 AM, RN B stated Resident #37 had a g-tube and EBP was required. She said she did not know why she forgot to wear a gown when she administered the resident's bolus feeding. She said the gown was needed basically to prevent transmission of microorganisms from one resident to another. She said she would wear a gown the next time she would care for residents with g-tube. In an interview on 09/19/2025 at 7:01 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and spread of infection. He said staff should do hand hygiene before and after any care. He said gloves should be changed after cleaning the resident's bottom and before touching the new brief. he said the same principle applied after touching the soiled linen. He said using a soaked towel could also contribute to infection because the germs could seep to the whole face towel even though the staff folded the face towel. He said every resident that needed EBP had a sign outside to remind the staff that they needed to wear a gown and gloves every time they had contact with the resident. He said the EBP was used to protect the spread of infection from one resident to another. He said he already initiated an in-service about infection control and would closely monitor, along with the IP, the staffs' adherence to the policy of infection control. In an interview on 09/19/2025 at 7:33 AM, ADON A stated she was the infection preventionist of the facility and she was made aware about the issues regarding infection control. She said the staff should be mindful that they were not causing any spread of infection in the facility and one way to do that was to do hand hygiene before, after, and during any care. She said the staff should change their gloves after touching soiled like soiled brief, soiled linens and even after cleaning the residents' bottom. She said another way to prevent the spread of infection was to wear EBP when needed. She said residents with g-tube required an EBP to protect the resident and also the staff if the resident had any microorganism that could cling to them. She said the DON already started an in-service and she would closely monitor if the staff were following the policy and procedure for infection control. In an interview on 09/19/2025 at 8:02 AM, the Administrator stated they always remind the staff to be vigilant with hand hygiene. She said after touching something soiled, the staff should change their gloves and sanitize the hands in between changing of gloves. She said, she was not a clinician, but she knew that if there was sign to wear EBP, then the staff should wear a gown in addition to the gloves. She said the concerns discussed would all contribute to the development and spread of infection. She said the DON already started an in-service about infection control. She said they would re-educate the staff and closely monitor so they could correct the staff on the spot. Policy and procedure for Incontinent Care was requested via email to the Administrator on 09/18/2025 at 12:09 PM and 09/19/2025 at 10:21 AM but was not provided prior to exit. Record review of the facility's policy entitled Urinary Continence and Incontinence - Assessment and Management Strategy, Delivery, Performance revised 09/2024 reflected Policy Statement: 1. The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence . Policy Interpretation and Implementation . 2. Relevant information . f. additional information such as the type and frequency of physical assistance necessary for the resident. Record review of the facility's, undated policy Enhanced Barrier Precautions, reflected EBP are indicated for residents with any of the following . Wounds and/or indwelling medical devices . Indwelling medical device examples include feeding tubes . don gloves and gown. Record review of the facility's policy entitled Handwashing/Hand Hygiene Strategy, Delivery, Performance revised 08/2024 reflected Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . m. After removing gloves . 9. The use of gloves does not replace hand washing/hand hygiene . Applying and Removing Gloves . 1. Perform hand hygiene before applying non-sterile gloves.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The facility failed to ensure frozen food items were properly labeled and dated when stored in the freezer. The facility failed to ensure open food products requiring refrigeration were stored appropriately after opening. Failure to store open, perishable food products requiring refrigeration appropriately after opening may lead to the growth of harmful bacteria, increasing the risk of foodborne illness among residents.Tag: F812/N4363S/S= E Surveyor Name(s): Joycelynn [NAME] Supervisor: [NAME] Findings include:[SP1] [JB2] Observations on 09/17/25 from 9:15 AM to 9:30 AM in the facility's only kitchen revealed: One large sealed bag of frozen French fries, located in the freezer, was not labeled with the date stored. One large sealed package of beef, which appeared to be brisket, located in the freezer, was not labeled with the date stored. One large open container of teriyaki sauce, labeled Refrigerate After Opening, was stored unrefrigerated in the dry storage area. One large open container of soy sauce, labeled Refrigerate After Opening, was stored unrefrigerated in the dry storage area. In an interview on 09/19/25 at 9:05 AM, the DON acknowledged the importance of proper food storage to prevent foodborne illnesses. The DON stated that while he does not directly handle or label food in the kitchen, he is aware of the facility's food storage policies and the potential risks to residents if food is not stored appropriately. In an interview on 09/19/25 at 9:15 AM, the Chief Kitchen Manager, who reported being employed at the facility for seven years, stated that the current process for managing perishable condiments, such as soy sauce and teriyaki sauce, includes thoroughly wrapping, labeling, dating, and storing them in the appropriate area. He acknowledged that both containers should have been refrigerated after opening and stated they would be discarded now that he was made aware of the oversight. He stated the items may have been mistakenly placed in dry storage by another staff member after use. He confirmed there were standard operating procedures in place for handling opened condiments and sauces, and that food items were expected to be labeled, dated, and stored according to policy. He denied any recent issues or concerns from staff regarding the storage of perishable items. In an interview on 09/19/25 at 9:22 AM, the Food and Beverage Manager stated that, per facility policy, sauces such as soy sauce and teriyaki sauce must be labeled, dated, and refrigerated once opened, and that any product found improperly stored is disposed of. He reported that all staff were responsible for monitoring storage practices, with two team members, assigned to conduct regular sweeps to ensure compliance. He confirmed that staff receive training on proper food storage and safety procedures. He acknowledged that improper storage of food items could pose a risk to residents, including potential illness. In an interview on 09/19/25 at 9:33 AM, the Dietitian, who reported working at the facility since October 2021, stated that soy sauce can be stored at room temperature for up to 1-6 months to extend shelf life and was typically used within a month. Despite label instructions indicating refrigeration after opening, he expressed his belief that storing these items unrefrigerated was acceptable and noted he could reference external sources to support this practice. He acknowledged that perishable items removed from their original packaging should be labeled with an opened by and use by date and confirmed that proper food storage was essential to prevent health risks to residents. In an interview on 09/19/25 at 11:00 AM, the Administrator discussed food safety policies related to condiment storage. She stated that the facility has policies requiring proper storage of opened condiments, including refrigeration when indicated by labels. However, she also noted that the Dietitian has expressed that refrigeration may not always be necessary. The Administrator indicated that she would ultimately follow whatever the state regulatory authority decides regarding these guidelines. While she personally does not always refrigerate these items at home, she understands the importance of following labeling instructions in the facility to protect the health of the vulnerable resident population. She acknowledged that improper storage could pose risks to residents but appeared to defer final judgment to regulatory standards. In an interview on 09/19/25 at 11:20 AM, the Dietary Aide stated that everyone working in the kitchen was responsible for ensuring compliance with proper food storage practices. She emphasized that if any staff member observes food that was not properly labeled or stored, it was their duty to address the issue and notify one of the managers. She expressed awareness of the critical importance of maintaining proper food storage, especially because the facility serves a vulnerable population. She noted that improper food handling could lead to illness, which is particularly concerning given that many residents are already medically fragile. Record review of the facility's Food and Nutrition Services policy titled Food Storage (05/19/2025) revealed that all food must be stored properly to ensure safety and quality. The policy requires foods from approved sources to be stored in sanitary conditions, with perishable items covered, labeled, and dated upon opening or removal from original packaging. Time/temperature control for safety (TCS) foods must be discarded within designated timeframes, and refrigerators and freezers are to be maintained at specific temperatures with routine monitoring and documentation. The policy emphasizes proper rotation of stock using First-In, First-Out (FIFO), secure storage six inches off the floor, and segregation of personal food from facility food items to prevent contamination. Failure to comply with these standards may increase the risk of food spoilage and foodborne illness. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for eight (Residents #4, #7, #8, #21, #23, #31, #51, and #61) of eighteen residents reviewed for medication storage. 1. The facility failed to ensure that Resident #4's pain ointment was not inside the room on 09/17/2025. 2. The facility failed to ensure that Resident #7's TUMS, eye drops, and oral analgesia were not inside the room on 09/17/2025. 3. The facility failed to ensure that a wound cleanser was not left inside Resident #8's room on 09/17/2025. 4. The facility failed to ensure Resident #21's medication was not left inside the room on 09/17/2025 and 09/18/2025. 5. The facility failed to ensure that a tube of zinc oxide (medicated cream used to prevent skin irritation) was not left inside Resident #23's room on 09/17/2025. 6. The facility failed to ensure a bottle of hydrogen peroxide was not left inside Resident #31's room [ROOM NUMBER]/17/2025. 7. The facility failed to ensure a tube of zinc oxide was not left inside Resident #51's room on 09/17/2025. 8. The facility failed to ensure Resident #61's eye drop was inside the room on 09/17/2025. These failures could place residents at risk of misuse of medications that could lead to overdosing or underdosing. Findings include: 1. Record review of Resident #4's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with osteoarthritis. Record review of Resident #4's Comprehensive MDS Assessment, dated 07/21/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had osteoarthritis. Record review of Resident #4's Comprehensive Care Plan, dated 08/04/2025, reflected that the resident had chronic pain R/T arthritis to foot and one of the interventions was to monitor pain quality, severity, location, and aggravating factors. Record review of Resident #4's Physician's Order, dated 09/27/2023, reflected Voltaren Arthritis Pain External Gel 1 % Diclofenac Sodium (Topical)). Apply to . topically every 4 hours as needed for pain. During an observation and interview on 09/17/2025 at 9:08 AM revealed Resident #4 was in her bed, awake. A tube of diclofenac sodium topical gel was observed on top of the resident's overbed table. The resident said the ointment had been in her room and had always been on top of the overbed table or her side table where she easily accessed it. An observation on 09/18/2025 at 10:43 AM revealed the tube of diclofenac sodium topical gel was still on top of Resident 4's overbed table. During an observation and interview on 09/18/2025 at 11:28 AM, RN B stated the pain ointment should not be inside Resident #4's room. She said it should be inside the nurses' carts because the nurses were supposed to be the ones administering the pain ointment. She said she did not know who left the pain ointment with the resident and she did not notice there was a tube of pain ointment on the resident's overbed table. She said the resident might use it more than the recommended and could result in skin redness or dryness. RN B went inside the resident's room and took the tube of pain ointment. 2. Record review of Resident #7's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with gastro-esophageal reflux disease and dementia. Record review of Resident #7's Comprehensive MDS Assessment, dated 07/16/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had gastro-esophageal reflux disease and dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #7's Comprehensive Care Plan, dated 07/23/2025, reflected that the resident had gastro-esophageal reflux disease and dementia. Record review of Resident #7's Physician's Order, dated 04/25/2025, reflected Aluminum-Magnesium-Simethicone Suspension 200-200-20 MG/5ML (Alum &Mag Hydroxide-Simeth) Give 30 ml by mouth every 4 hours as needed for indigestion. Record review of Resident #7's Physician Order, dated 10/20/2021, reflected Refresh Solution 1.4 - 0.6 % (Polyvinyl Alcohol Povidone PF) Instill 1 drop in both eyes two times a day for Dry eyes. Record review of Resident #7's Physician Order on 09/17/2025 reflected no order for TUMS. Record review of Resident #7's Physician Order on 09/17/2025 reflected no order for oral analgesia. During an observation and interview on 09/17/2025 at 9:46 AM revealed Resident #7 was sitting at the side of her bed. A bottle of TUMS, 2 eyedrops, and a tube of oral analgesic were noted on the resident's side table. She said those were her medications and she always put them on top of her side table. 3. Record review of Resident #8's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with a personal history of diseases of the skin and subcutaneous (under the skin) tissue. Record review of Resident #8's Comprehensive MDS Assessment, dated 09/08/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident had skin issues. Record review of Resident #8's Comprehensive Care Plan, dated 09/04/2025, reflected that the resident had a skin tear on the left elbow and right forearm and one of the interventions was to provide wound care as ordered. Record review of Resident #8's Physician Order, dated 08/29/2025, reflected wound care: cleanse wound (left elbow) with NS, pat dry, apply moisturizer and cover arm with tubi grip (elastic tubular bandage) one time a day. Record review of Resident #8's Physician Order, dated 08/29/2025, reflected Wound care: cleanse wound to right forearm with NS, pat dry, apply moisturizer and cover with tubi grip one time a day. During an observation and interview on 09/17/2025 at 9:40 AM revealed Resident #8 was in her wheelchair, awake. It was observed that there was a wound cleanser on the resident's sink. She said the staff used it when she had a skin tear to both arms. She said the skin tears were already healed. 4. Record review of Resident #31's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with repeated falls. Record review of Resident #31's Quarterly MDS Assessment, dated 08/30/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated that the resident was at risk of repeated falls. Record review of Resident #31's Comprehensive Care Plan, dated 07/25/2025, reflected the resident had an actual fall due to poor balance and one of the interventions was to monitor bruises. Record review of Resident #31's Physician Order on 09/17/2025 reflected that the resident did not have any wound care. During an observation and interview on 09/17/2025 at 9:38 AM revealed Resident #31 was in her wheelchair, awake. A bottle of hydrogen peroxide was observed on top of the resident's sink. The resident said the hydrogen peroxide was for her feet. 5. Record review of Resident #51's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with benign prostatic hyperplasia with lower urinary tract symptoms. Record review of Resident #51's Quarterly MDS Assessment, dated 09/07/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident was incontinent for bowel. Record review of Resident #51's Comprehensive Care Plan, dated 09/05/2025, reflected the resident had an ADL self-care performance and one of the interventions was to inspect the skin. Record review of Resident #51's Physician Order, dated 09/03/2025, reflected BARRIER CREAM/OINT AFTER EACH INCONTINENT EPISODE AND PRN AS INDICATED every shift. An observation on 09/17/2025 at 9:43 AM revealed Resident #51 was not inside the room. A tube of zinc oxide of hydrogen peroxide was observed on top of the resident's sink. During an observation and interview on 09/18/2025 at 7:13 AM, RN C stated all medications should be inside the nurses' carts or the medication aide' cart. She said the zinc oxide, hydrogen peroxide, and the wound cleanser should also be stored inside the carts. She said medications should not be stored inside the resident's rooms because the residents might consume the medications more than the recommended and could result to overdose. She said zinc oxide, hydrogen peroxide, and wound cleanser should not be inside the room as well because the residents might accidentally consume them, especially confused residents, and could result to adverse reactions like stomach upset. She went inside the residents' rooms and took the eyedrops, TUMS, oral analgesia, hydrogen peroxide, and wound cleanser. She said she would also check the rooms on her hall to see if there were medications or items used to facilitate healing. In an interview on 09/18/2025 at 1:08 PM, CNA F stated RN C told her about the zinc oxide and calmoseptine that were found inside the room. She said the zinc oxide should be in the cart and just ask for it when needed. She said the zinc oxide could be placed in a small cup so that the tube would stay in the cart. She said the facility also had them in sachet so just bring one or two, depending on the need. She said they should not be left inside the room where the resident or other residents could reach it and accidentally put it in their mouth. She said she was not sure what could happen but she was sure zinc oxide and calmoseptine were not for consumption. She said the resident could put it in their eyes that could cause reactions. 6. Record review of Resident #21's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with anemia and kidney disease. Record review of Resident #21's Quarterly MDS Assessment, dated 09/09/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident had anemia and kidney disease. Record review of Resident #21's Comprehensive Care Plan, dated 07/17/2025, reflected the resident had anemia and encourage intake of foods high in iron and vitamin C. Record review of Resident #21's Physician Order, dated 09/16/2025, reflected Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth two times a day for supplement for 15 Days. Record review of Resident #21's Physician Order, dated 05/18/2025, reflected Metformin HCl Oral Tablet 500 MG (Metformin HCl). Give 1 tablet by mouth two times a day for DM. During an observation and interview on 09/17/2025 at 9:56 AM revealed Resident #21 was in her bed, awake. It was observed that the resident was about to take three pills from a small cup that was on her tray. She said the cup was left by the staff and the staff told her to take the medications after she was done with breakfast. In an interview on 09/18/2025 at 6:51 AM, MA G stated medications should not be left with the residents because the residents might not take them or just throw the medications away. She said she left Resident #21's medications because there was a resident that was about to fall. She said she should have brought the medication with her before leaving the room, put it back in the cart, or called somebody else to help the resident that she said was about to fall. An observation on 09/18/2025 at 10:29 AM revealed CNA E provided incontinent care to Resident #21. He brought with him three sachets of calmoseptine. Before fastening the brief, he opened a calmoseptine ointment and spread it on the resident's bottom. He then fastened the brief and washed his hands. He still had two sachets of calmoseptine on hand and he left them on top of the resident's dresser beside the bed and left the room. 7. Record review of Resident #23's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with weakness. Record review of Resident #23's Quarterly MDS Assessment, dated 07/15/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident was at risk for pressure ulcers. Record review of Resident #23's Comprehensive Care Plan, dated 08/07/2025, reflected the resident had impairment to skin integrity and one of the interventions was to use lotion on dry skin. Record review of Resident #23's Physician Order, dated 02/14/2025, reflected Moisture barrier ointment as indicated to keep irritants or moisture from skin surface every shift. During an observation and interview on 09/17/2025 at 10:43 AM revealed Resident #23 was in her bed, awake. A tube of zinc oxide was observed on top of the resident's overbed table. The resident just shrugged her shoulders when asked who left the zinc oxide on top of the overbed table. During an observation and interview on 09/18/2025 at 10:40 AM, LVN D said it should not be left inside the room she went inside and took the sachets. She called CNA E and told him not to leave the sachets inside the rooms of the residents because the resident might use them inappropriately or confused residents might consume them. She said pills should not be left with a resident. She said if the staff needed to leave, put the medication back to the cart. She also said the zinc oxide should be inside the cart and the staff should just ask if needed. 8. Record review of Resident #61's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with need for assistance with personal care and delirium Record review of Resident #61s Comprehensive MDS Assessment, dated 08/28/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had delirium. Record review of Resident #61's Physician's Order on 09/17/2025 reflected no order for eye drops. Observation and interview on 09/17/2025 at 9:28 AM revealed Resident #61 was in her bed, awake. It was observed that an eye drop was on top of the resident's side table. The resident said she was using the eye drop every morning because her eyes were dry in the morning most of the time. She said she was not sure if the staff knew she was using an eye drop. In an interview on 09/19/2025 at 6:47 AM, LVN H stated she was not aware that Resident #61 had an eye drop inside her room. She said the eye drop should be inside the cart because the staff were supposed to administer them. She said there should be no medications inside the residents' room because the resident might overuse it. In an interview on 09/19/2025 at 7:01 AM, the DON stated medications should not be stored inside the resident's room. He said TUMS, eyedrops, zinc oxide, hydrogen peroxide, pain ointments, and wound cleanser should be inside the carts to secure them. He said the resident could overdose and some form of medications that were applied topically could be harmful when ingested. He said when using calmoseptine, the staff should only get what was supposed to be used from the supply room. He said he already initiated an in-service about medication storage. In an interview on 09/19/2025 at 7:33 AM, ADON A stated medications should not be inside the residents' rooms and should be in the carts. The pills, eye drops, pain ointments, zinc oxides, hydrogen peroxide, and wound cleanser should be secured so the residents, especially the confused resident, would not get a hold of them. She said the residents could overdose because nobody was monitoring how often the resident was taking the medication. She said residents with poor eyesight could mistakenly thought that zinc oxide and calmoseptine were sauce and put them on their food. She said the expectation was for the staff not to leave any medication inside the room. She said the zinc oxides, hydrogen peroxide, and wound cleanser were forms of medication because they were used for wound care. She said the DON already started an in-service about medication storage. In an interview on 09/19/2025 at 8:02 AM, the Administrator stated the expectation was for the staff to be mindful not to leave any medication inside the room and to scan the room to make sure there were no medications inside the resident's rooms. She said the residents might consume the medications inappropriately. She said the DON already started an in-service about medication storage. Record review of the facility's policy entitled, Medication Labeling and Storage reflected Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys . 9. Antiseptics, disinfectants, and germicides used in any aspect of resident care . shall be stored separately from regular medications.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for four (Resident #4, Resident #7, Resident #21, and Resident #61) of twenty residents reviewed for pharmaceutical services. 1. The facility failed to ensure Resident #4 was not self-administering her pain ointment without an assessment on 09/17/2025. 2. The facility failed to ensure Resident #7 was not self-administering some medications without an assessment on 09/17/2025. 3. The facility failed to ensure Resident #21 was not self-administering her morning medications without an assessment on 09/17/2025. 4. The facility failed to ensure Resident #61 was not self-administering her eye drops without an assessment on 09/17/2025. These failures could place residents at risk of not receiving medications as ordered, potential overdose, and adverse effects. Findings include: 1. Record review of Resident #4's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with osteoarthritis (inflammation of the joints). Record review of Resident #4's Comprehensive MDS Assessment, dated 07/21/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had osteoarthritis. Record review of Resident #4's Comprehensive Care Plan, dated 08/04/2025, reflected that the resident had chronic pain R/T arthritis to foot and one of the interventions was to monitor pain quality, severity, location, and aggravating factors. The Comprehensive Care Plan did not indicate that the resident could self-administer her medications. Record review of Resident #4's Physician's Order, dated 09/27/2023, reflected Voltaren Arthritis Pain External Gel 1 % Diclofenac Sodium (Topical)). Apply to . topically every 4 hours as needed for pain. Record review of Resident #4's Clinical Assessment Notes on 09/17/2025 reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 09/17/2025 at 9:08 AM revealed Resident #4 was in her bed, awake. A tube of diclofenac sodium topical gel was observed on top of the resident's overbed table. The resident said she was the one applying the ointment and that the staff knew she was the one doing it every time she needed it. An observation on 09/18/2025 at 10:43 AM revealed the tube of diclofenac sodium topical gel was still on top of Resident 4's overbed table. During an observation and interview on 09/18/2025 at 11:28 AM, RN B stated the pain ointment should not be inside Resident #4's room. She said it should be inside the nurses' cart because the nurses were supposed to be the one administering the pain ointment. She said she did not know who left the pain ointment with the resident and she did not notice there was a tube of pain ointment on the resident's overbed table. She said the resident might use it more than the recommended could cause skin redness or dryness. 2. Record review of Resident #7's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #7's Comprehensive MDS Assessment, dated 07/16/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had gastro-esophageal reflux disease. Record review of Resident #7's Comprehensive Care Plan, dated 07/23/2025, reflected that the resident was at risk for pain or discomfort and one of the interventions was to observe any s/s of non-verbal pain like tearing eyes. Record review of Resident #7's Physician's Order, dated 04/25/2025, reflected Aluminum-Magnesium-Simethicone Suspension 200-200-20 MG/5ML (Alum &Mag Hydroxide-Simeth) Give 30 ml by mouth every 4 hours as needed for indigestion (pain or discomfort after eating). Record review of Resident #7's Physician Order, dated 10/20/2021, reflected Refresh Solution 1.4-0.6 % (Polyvinyl Alcohol Povidone PF) Instill 1 drop in both eyes two times a day for Dry eyes. Record review of Resident #7's Physician Order on 09/17/2025 reflected no order for TUMS. Record review of Resident #7's Physician Order on 09/17/2025 reflected no order for oral analgesia. Record review of Resident #7's Clinical Assessment on 09/17/2025 reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 09/17/2025 at 9:46 AM revealed Resident #7 was sitting at the side of her bed. A bottle of TUMS (medication for heartburn [burning pain in the chest] and indigestion), 2 eyedrops, and a tube of oral analgesic were noted on the resident's side table. She said those were her medications and she would sometimes take them if she needed them. During an observation and interview on 09/18/2025 at 7:13 AM, RN C stated there should be no medications inside the residents' rooms because the medication aide was the one administering most of the medications, the nurses were the ones giving the PRNs and doing the treatments as well. She said the residents had no reason to have medications inside the room. She went inside the resident's room and saw the bottle of TUMS, two eyedrops, and a tube of oral analgesia. She talked to the resident and took the medications mentioned. She said the resident was oriented and cognitive but unless they have an assessment that they could self-medicate, there should be no medications inside the residents' rooms. She said the resident did not have an assessment that she could administer her medications unsupervised. 3. Record review of Resident #21's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with anemia (low red blood cells in the blood). Record review of Resident #21's Quarterly MDS Assessment, dated 09/09/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident had anemia. Record review of Resident #21's Comprehensive Care Plan, dated 07/17/2025, reflected the resident had anemia and encourage intake of foods high in iron and vitamin C. Record review of Resident #21's Physician Order, dated 09/16/2025, reflected Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth two times a day for supplement for 15 Days. Record review of Resident #21's Physician Order, dated 05/18/2025, reflected Metformin HCl Oral Tablet 500 MG (Metformin HCl). Give 1 tablet by mouth two times a day for DM. Record review of Resident #21's Clinical Assessment on 09/17/2025 reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 09/17/2025 at 9:56 AM revealed Resident #21 was in her bed, awake. It was observed that the resident was about to take three pills from a small cup that was on her tray. She said the cup was left by the staff and the staff told her to take the medications after she was done with breakfast. She said the medications might be vitamin C, metformin, and she did not know what the third pill was. She said she already took the other pills. She said it was not the first time that her medications were left with her. She said she did not know the name of the staff that left the medications. In an interview on 09/18/2025 at 6:51 AM, MA G stated medications should not be left with the residents because the residents might not take them or just throw the medications away. She said even though a resident did not have any issue with swallowing, she should wait for the resident to consume all the medications before leaving the room. She said she left the medications because there was a resident that was about to fall. She said she told the resident that she would come back. She said she should have brought the medication with her before leaving the room, put it back in the cart, or called somebody else to help the resident that she said was about to fall. In an interview on 09/18/2025 at 10:39 AM, Resident #21 reiterated that the medication aide left her medications with her the day before and told her to take them after breakfast. She said the staff did not tell her that somebody was falling or that she needed to go assist another resident. She said the staff did not come back to check if she had already taken the medications. 4. Record review of Resident #61's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with need for assistance with personal care and delirium (disturbed mental state characterized with confusion and rapid changes in behavior). Record review of Resident #61s Comprehensive MDS Assessment, dated 08/28/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had delirium. Record review of Resident #61's Comprehensive Care Plan, dated 09/12/2025, did not reflect that the resident could self-administer her medications. Record review of Resident #61's Physician's Order on 09/17/2025 reflected no order for eye drops. Record review of Resident #61's Clinical Assessment Notes on 09/17/2025 reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. Observation and interview on 09/17/2025 at 9:28 AM revealed Resident #61 was in her bed, awake. It was observed that an eye drop was on top of the resident's side table. The resident said she was using the eye drop every morning because her eyes were dry in the morning most of the time. She said she was not sure if the staff knew she was using an eye drop. In an interview on 09/19/2025 at 6:47 AM, LVN H stated she was not aware that Resident #61 had an eye drop inside her room. She said there should be no medications inside the residents' room unless they were assessed that the residents were capable of taking medications unsupervised. She said she would talk to the resident to let her know that she would get her eye drop. She would also see if the resident needed eye drops so she could request an order for the eye drops. In an interview on 09/19/2025 at 7:01 AM, the DON stated the staff should never leave any medication inside the resident's room for them to take unsupervised. He said the resident might not take them, hide them, or take them with them along with the next dose. He said the resident could overdose or their underlying conditions were not getting well because they were not able to take their medications. He said the resident might choke and nobody would be there with her. He said the staff should make sure that the medications were consumed before leaving the room. He said, as per MA G, she left the pills because somebody was about to fall that was why she left the pills to the resident who was oriented but if the medication aide was on other halls when the pills were observed inside the room, then that was another story. He said pain ointments, eye drops, and TUMS were supposed to be administered by the staff. He said the residents should not be administering them unless they were assessed fit to administer them by themselves. He said the expectation was that the staff would not let the residents take the medication by themselves and for staff to scan the room if there were medication inside the room because one concern was the staff already gave them the medications and the resident would still get from her supply. He said he would also check if the staff requested physician orders for the medications that were inside the room if needed by the resident. He said he already initiated an in-service pertaining to not leaving any medication with the resident to take unsupervised and to scan the room for any medications. In an interview on 09/19/2025 at 7:33 AM, ADON A stated leaving pills inside the room was a no-no because a lot of things could happen. She said the resident might choke and nobody would be there to help her. She said the staff should wait for the resident to be done taking the medication before leaving the room. She said even oriented residents could have problems when swallowing the medications. She said oriented residents could have a clear mind to hide the pills if they do not want to take them. She said confused residents might enter other residents' rooms and take the medication. She said the same principle applied to the eyedrops, TUMS, and oral analgesia. She said the medications mentioned should be administered by the staff unless the residents were assessed competent with self-administration. She said the DON already initiated an in-service about medication administration. She said they would monitor closely because they could not wait for somebody to choke before the lesson was learned. In an interview on 09/19/2025 at 8:02 AM, the Administrator stated no medications should be left inside the room because the resident might overmedicate. She said the resident might take the medication inside their room every hour and nobody would know. She said the expectation was for the staff not to leave any medication inside the room for the resident to administer by himself. She said the DON already started an in-service about not leaving the medications with the resident. Record review of the facility's policy entitled, Administering Medications Strategy, Delivery, Performance revised 08/2024 reflected Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so . 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Based on observation ,interview and record reviews the facility failed to ensure informed consent prior to installation. The facility failed to ensure Resident #5, #9, #10, #11, #30, and #46 had physician orders for the pivot assist bars attached to the residents' bed. This failure could place residents at risk of having unnecessary equipment installed on their beds .Findings included: 1. Record review of Resident #5's Face Sheet, dated 09/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and Alzheimer's disease (cognitive decline). Record review of Resident #5's Comprehensive MDS Assessment, dated 08/15/25, reflected the resident had severe cognitive impairment with a BIMS score of 3. The Comprehensive MDS Assessment indicated that the resident had an active diagnosis of muscle weakness. Record review of Resident #5's Comprehensive Care Plan, dated 09/09/25, reflected the resident had a history of falls, with his last fall occurring on 08/31/25. The care plan did not include the pivot assist bars as an intervention. Record review of Resident #5's physician orders, dated 09/18/25, reflected no physician orders for the pivot assist bars. Observation on 09/17/2025 at 10:28 AM revealed Resident #5 had pivot assist bars on both sides of the bed. 2. Record review of Resident #9's Face Sheet, dated 09/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and history of falls. Record review of Resident #9's Comprehensive MDS Assessment, dated 07/02/25, reflected the resident had an intact cognitive response with a BIMS score of 14. The Comprehensive MDS Assessment indicated that the resident had an active diagnosis of repeated falls and muscle weakness. Record review of Resident #9's Comprehensive Care Plan, dated 07/18/25, reflected the resident had a history of falls, with his last fall occurring on 08/03/25. The care plan did not include the pivot assist bars as an intervention. Record review of Resident #9's physician orders, dated 09/18/25, reflected no physician orders for the pivot assist bars. Observation on 09/17/2025 at 11:25 AM revealed Resident #9 had pivot assist bars on both sides of the resident's bed 3. Record review of Resident #10's Face Sheet, dated 09/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with senile degeneration of brains. Record review of Resident #10's Comprehensive MDS Assessment, dated 07/27/25, reflected the resident had a moderate cognitive impairment with a BIMS score of 8. The Comprehensive MDS Assessment indicated that the resident had an active diagnosis of coronary artery disease (disease of the heart). Record review of Resident #10's Comprehensive Care Plan, dated 08/13/25, reflected the resident had a history of falls, but the care plan did not include the pivot assist bars as an intervention. Record review of Resident #10's physician orders, dated 09/18/25, reflected no physician orders for the pivot assist bars. Observation on 09/17/2025 at 10:35 AM revealed Resident #10 had pivot assist bars on both sides of the resident's bed. 4. Record review of Resident #11's Face Sheet, dated 09/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with a history of fall, and muscle weakness. Record review of Resident #11's Comprehensive MDS Assessment, dated 07/12/25, reflected the resident was moderately cognitively impaired with a BIMS score of 8. The Comprehensive MDS Assessment indicated that the resident had an active diagnosis of repeated falls and muscle weakness. Record review of Resident #11's Comprehensive Care Plan, dated 07/13/25, reflected the resident had a history of falls, but the care plan did not include the pivot assist bars as an intervention. Record review of Resident #11's physician orders, dated 09/18/25, reflected no physician orders for the pivot assist bars. Observation on 09/17/2025 at 11:06 AM revealed Resident #11 had pivot assist bars on both sides of the resident's bed. 5. Record review of Resident #30's Face Sheet, dated 09/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with a muscle weakness and the need of assistance for personal care. Record review of Resident #30's Comprehensive MDS Assessment, dated 07/02/25, reflected the resident had a moderate cognitive impairment with a BIMS score of 9. The Comprehensive MDS Assessment indicated that the resident had an active diagnosis of and muscle weakness. Record review of Resident #30's Comprehensive Care Plan, dated 07/13/25, reflected the resident had a history of falls, but the care plan did not include the pivot assist bars as an intervention. Record review of Resident #30's physician orders, dated 09/18/25, reflected no physician orders for the pivot assist bars. Observation on 09/17/2025 at 11:11 AM revealed Resident #30 had pivot assist bars on both sides of the resident's bed. 6. Record review of Resident #46's Face Sheet, dated 09/17/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #46 had diagnoses of muscles weakness. Record review of Resident #46's Quarterly MDS Assessment, dated 09/09/25, reflected Resident #46 had a moderate cognitive impairment with a BIMS score of 12. The Quarterly MDS Assessment reflected an active diagnosis of muscle weakness and osteoarthritis of both knees. Record review of Resident #46's Comprehensive Care Plan, dated 09/06/25, reflected the resident had a history of falls, but the care plan did not include the pivot assist bars as an intervention. Record review of Resident #46's physician orders, dated 09/18/25, reflected no physician orders for the pivot assist bars. Observation on 09/17/2025 at 10:51 AM revealed Resident #46 had pivot assist bars on both sides of the resident's bed. In an interview on 09/18/25 at 1:48 PM, LVN D, was told by the Surveyor of Resident #30 had pivot assist bars on both sides of his bed, but no physician orders were observed for the devices. She stated the resident did not have physician orders for the equipment. She stated the resident should have physician orders for the bars because it could be a form of restraint and safety hazards. In an interview on 09/18/25 at 2:15 PM, ADON A was told by the Surveyor of Resident #5, #9, #10, #11, #30, and #46 not having physician orders for the pivot assist bars on the beds. She stated the bed came with the bars on them. She stated the resident did use the bars to reposition themselves. She stated she did not think physician orders were needed for the bars. She stated she would follow up with the DON to see about getting physician orders for the equipment. In an interview on 09/19/25 at 11:08 AM, the DON was told by the Surveyor of Resident #5, #9, #10, #11, #30, and #46, not having physician orders for the pivot assist bars. He stated this was brought to his attention by ADON after the Surveyor brought it to ADON A's attention, and they were now completing bedrail assessments for the residents, care planning the use of the bedrails, and obtaining physician orders for the devices. He stated he was not sure of the risk for the resident because the bars had been on the beds for over six years, but they would ensure physician orders for the pivot assist bars were obtained going forward. The facility's policy RESTRAINTS dated 06/17 reflected, It is the policy of the facility to refuse to restrain residents for any cause. Should a resident have cause for need of a restraint, the physician will be notified immediately, and Texas state regulations will be followed.

Based observation, interview, and record review the facility failed to ensure residents who were incontinent with bladder received appropriate treatment and services to prevent urinary tract infection for three (Resident #8, Resident #15, and Resident #21) of three residents reviewed for incontinent care. 1. The facility failed to ensure that CNA F performed the right technique during Resident #8's incontinent care on 09/18/2025. 2. The facility failed to ensure that CNA F performed the right technique during Resident #15's incontinent care on 09/18/2025. 3. The facility failed to ensure that CNA E performed the right technique during resident #21's incontinent care on 09/18/2025. This failure could place residents at risk for urinary tract infection. Findings included: 1. Record review of Resident #8's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with cystitis (inflammation of the bladder) with hematuria (blood in the urine) and kidney failure (kidneys stop working). Record review of Resident #8's Comprehensive MDS Assessment, dated 06/21/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated that the resident was frequently incontinent for bladder and bowel. Record review of Resident #8's Comprehensive Care Plan, dated 09/04/2025, reflected that the resident had incontinence and one of the interventions was to assist during toilet use or personal hygiene. An observation on 09/18/2025 at 12:58 PM revealed CNA F was about to do Resident #8's incontinent care. She washed her hands and put on a pair of gloves. She took a brief from a drawer and placed it on top of the resident's overbed table. She then took a towel from the drawer and wet it. She then pulled off the resident's pants and unfastened the brief. She cleaned the resident's perineal area (area between the legs) using the wet towel. She cleaned the top part of the resident's perineal area and then the sides of the perineal area. After cleaning the sides of the perineal area, she cleaned the middle portion of the perineal area with the same face towel that she used to clean the sides of the perineal area. She turned the resident and used the same towel to clean the resident's bottom. She cleaned the resident's bottom from back to front. After cleaning the resident's bottom, she took the brief from the resident's overbed table and placed it under the resident and fixed it. 2. Record review of Resident #15's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with a personal history of urinary tract infection. Record review of Resident #15's Comprehensive MDS Assessment, dated 08/21/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated that the resident was frequently incontinent for bladder and bowel. Record review of Resident #15's Comprehensive Care Plan, dated 09/12/2025, reflected that the resident had incontinence and one of the interventions was to assist during toilet use or personal hygiene. Observation on 09/19/2025 at 12:47 PM revealed CNA F was about to do Resident #15's incontinent care. She washed her hands and put on a pair of gloves. She took a brief and a towel from a drawer. She wet the towel. She took off the resident's pants, unfastened the brief, and pushed it in the middle of the legs. She then cleaned the resident's perineal area using the wet towel. She cleaned the top part of the resident's perineal area and then the sides of the perineal area. After cleaning the sides of the perineal area, she cleaned the middle portion of the perineal area with the same face towel that she used to clean the sides of the perineal area. She turned the resident and used the same towel to clean the resident's bottom. After cleaning the resident's bottom, she took the brief from the top of the drawer and placed it under the resident. She rolled back the resident and fixed the brief. In an interview on 09/18/2025 at 1:08 PM, CNA F stated the proper technique during incontinent care would be to use a wipe and then discard. She said if she was using wipes, it should be one stroke then discard. She said she should have used another face towel to clean the middle portion of the resident's perineal area. She said she was not aware she cleaned Resident #15's bottom from back to front. She said her actions could cause urinary tract infections. She said she should slow down and think while she was doing incontinent care to protect the residents from infections. 3. Record review of Resident #21's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic kidney disease. Record review of Resident #21's Quarterly MDS Assessment, dated 09/09/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #21's Comprehensive Care Plan, dated 07/17/2025, reflected the resident had ADL self-care performance and one of the interventions was to provide assist during toilet use and personal hygiene. Observation on 09/19/2025 at 10:39 AM revealed CNA E about to do Resident #21's incontinent care. He washed his hands and put a towel on the resident's overbed table. He took the box of gloves from the wall and wipes and put it on the overbed table. He cleaned the perineal (area between the thighs) area with a wipe. He cleaned the top portion of the perineal area then the sides of the perineal area. after cleaning the sides, he used the same wipe to clean the middle portion of the perineal area. He rolled the resident and cleaned the bottom. After cleaning the bottom, he rolled the soiled brief towards the middle and cleaned the resident's bottom. After cleaning the bottom, he rolled back the resident and cleaned again the resident's perineal area twice with a wet towel. He cleaned the sides again and then the middle portion of the perineal area. After cleaning the perineal area, he fixed the brief. In an interview on 09/18/2025 at 11:04 AM, CNA E stated the wipes that he used to clean the side of the front part should have been discarded and he should have used a new wipe when he cleaned the middle part He said the wipe used on the sides where already dirty and Resident #21 might get a urinary tract infection. In an interview on 09/19/2025 at 7:01 AM, the DON stated the staff cannot use wipes or face towels that were used to clean the sides of the perineal area to clean the middle portion of the perineal area. He said the unwanted microorganisms (organisms that is too small to be seen) from the sides could be introduced and could eventually cause UTI especially for women. He said even though the staff cleaned the middle portion using a front to back technique, if they used soiled wipes and soiled face towels, it was still wrong. He said what should have done was one stroke, discard. He said, in cleaning the bottom, it should be from front to back and not the other way around because the microorganisms from the anal area will go to perineal area. He said, the staff should use wipes and not face towels because first, they have supplies of wipes, and second the face towel could be abrasive. He said he was made aware by CNA E and CNA F about the issue, and they already had a one-on-one in-service. He said they were checked off for incontinent care, so he did not know what happened. He said the expectation was for the staff to do the proper technique when providing incontinent care. In an interview on 09/19/2025 at 7:33 AM, ADON A stated she was surprised when she heard about the issue during incontinent care because they just went over with the staff about pericare a few weeks ago. She said the aides did the procedure properly. She said the technique should have been, one wipe, discard. She said it was not acceptable to use the wipes used cleaning the sides of the perineal area and re-use to clean the middle part because the middle part was the one prone to female residents having UTI. She said cleaning the bottom was from front to back so as not to introduce microorganism to the perineal area. She said cleaning the bottom back to the front could also cause UTI. She said an in-service about incontinent care was already initiated and her expectation was for the staff to follow the proper technique when providing incontinent care. She said they would closely monitor the staff adherence to the procedure of incontinent care. In an interview on 09/19/2025 at 8:02 AM, the Administrator stated she was made aware about the issue during incontinent care. She said CNA E told her what happened. She said the aides had previous training so she did not know what happened. She said the expectation was for the staff to use one wipe at a time and to wipe the bottom from front to back. She said the DON already started an in-service about incontinent care. She said it seemed like a lot more training about pericare should be done. Record review of the facility's policy entitled Urinary Continence and Incontinence - Assessment and Management Strategy, Delivery, Performance revised 09/2024 reflected Policy Statement: 1. The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence . Policy Interpretation and Implementation . 2. Relevant information . f. additional information such as the type and frequency of physical assistance necessary for the resident. Policy and procedure for Incontinent Care was requested via email to the Administrator on 09/18/2025 at 12:09 PM and 09/19/2025 at 10:21 AM but was not provided prior to exit. Record review of the facility's Competency Assessment Peri Care 2018 MED-PASS, Inc. revised February 2018 reflected A) Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . For a female resident . b. Wash perineal area, wiping from front to back . (2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth . e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of three residents (Resident #10 and #11) reviewed for respiratory care. The facility failed to ensure Resident 10's nebulizer mask was properly stored in a bag when not in use on 09/17/25. The facility failed to ensure Resident 11's nasal canula was properly stored in a bag when not in use on 09/17/25. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings include: 1. Record review of Resident #10's Face Sheet, dated 09/18/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Relevant diagnoses included Atherosclerotic heart disease (clogged arteries). Record review of Resident #10's Quarterly MDS assessment, dated 07/27/25, reflected he had moderate cognitive impairment with a BIMS score of 8. Active diagnosis included coronary artery disease. Record review of Resident #10's physician orders, dated 09/18/25, reflected saline nebulizer 0.9 % give 1 vial via every 4 hours, PRN. Record review of Resident #10's Quarterly Care Plan, dated 07/21/25, did not reflect a care plan for the resident's use of the nebulizer machine. In an interview and observation on 09/17/25 at 10:31 AM, LVN D stated Resident #10 used a nebulizer on an as needed basis. LVN D observed the resident's nebulizer mask connected to the nebulizer device, on top of a 3-drawer chest, unbagged. She stated the mask should be bagged when not in use to avoid the resident getting an infection. 2. Record review of Resident #11's Face Sheet, dated 09/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with acute respiratory failure (difficulty breathing). Record review of Resident #11's Comprehensive MDS Assessment, dated 07/12/25, reflected the resident had a moderate cognitive impairment with a BIMS score of 8. The Comprehensive MDS Assessment indicated that the resident had an active diagnosis of acute respiratory failure. Record review of Resident #11's Comprehensive Care Plan, dated 07/13/25, reflected the resident received oxygen therapy and an intervention included the use of an oxygen concentrator. Record review of Resident #11's physician orders, dated 09/18/25, reflected Oxygen at 2 liters per NC treatment for hypoxia/SOB every shift. In an interview and observation of 09/17/25 at 11:06 AM, LVN D stated Resident #11 used his oxygen concentrator on an as needed basis. LVN D observed the resident's nasal canula sitting on top of the resident's bed unbagged. She stated the nasal canula should be bagged when not in use to avoid the resident getting an infection. In an interview on 09/18/25 at 2:15 PM, ADON A was told by the Surveyor of Resident #10 not having his nebulizer mask bagged when not in use, and Resident #11 not having his nasal canula bagged when not in use. She stated she had trained the staff to ensure that the nasal canula and face mask were bagged or removed when not in use. She stated not bagging them could result in the resident getting an infection. In an interview on 09/19/25 at 11:08 AM, the DON was told by the Surveyor of Resident #10 not having his nebulizer mask bagged when not in use, and Resident #11 not having his nasal canula bagged when not in use. He stated the expectation was for the devices to be placed in a bag when not in use. He stated the nursing staff should check for this when they are assessing the resident. He stated the risk of not bagging the nasal canula and mask could be the resident's getting an infection. Review of the facility's policy Oxygen Administration, 09/2024, reflected The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.2. Review the resident's care plan to assess for any special needs of the resident.3. Assemble the equipment and supplies as needed.

Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth 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 3 residents (Resident #10) reviewed for care plans. The facility failed to ensure Resident #10's usage of a nebulizer was care planned. This failure could place the residents at risk of not receiving the necessary care and services required.Findings included: Record review of Resident #10's Face Sheet, dated 09/18/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Relevant diagnoses included Atherosclerotic heart disease (clogged arteries). Record review of Resident #10's Quarterly MDS assessment, dated 07/27/25, reflected he had moderate cognitive impairment with a BIMS score of 8 and an active diagnosis of coronary artery disease. Record review of Resident #10's physician orders, dated 09/18/25, reflected saline nebulizer 0.9 % give 1 vial via every 4 hours, PRN. Record review of Resident #10's Quarterly Care Plan, dated 07/21/25, did not reflect a care plan for the resident's use of the nebulizer machine. In an interview on 09/18/25 at 2:15 PM, ADON A was told by the Surveyor of Resident #10 not having his use of a nebulizer care planned. She stated it should have been care planned because it was a care provided to the resident. She stated they did not currently have an MDS nurse, so it was the responsibility of the ADON, DON, and Corporate MDS nurse to ensure it was added to the resident's care plan. She stated they try to ensure that every care provided to a resident was care planned when they have their care plan meetings, but this was overlooked. In an interview on 09/19/25 at 11:08 AM, the DON was told by the Surveyor of Resident #10 had orders for the use of a nebulizer but it was not care planned. He stated the resident had orders so he did not think it should be care planned, but he stated it was a plan of care needed for the resident. He stated the MDS nurse normally updated the care plan, but the facility he currently did not have an MDS nurse, so the nursing staff should have updated the resident's care plan with this care. He stated that it was missed. He stated it was the DON, the ADON, and the corporate MDS nurse's responsibility to update the care plan. Record review of facility's policy, Care Plans, Comprehensive Person-Centered (08/2024) 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. The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes.b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:(1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment for two (Resident #21 and Resident #37) of eight residents reviewed for resident rights. 1. The facility failed to ensure the LVN D closed Resident #21's door while checking her blood sugar on 09/18/2025 2. The facility failed to ensure RN B closed Resident #37's while providing his bolus feeding via g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) on 09/18/2025. These failures could place the residents at risk of not having their personal privacy maintained while treatment was provided. Findings included: 1. Record review of Resident #21's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with type 2 diabetes mellitus (high blood sugar). Record review of Resident #21's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 09/09/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS (screening tool used to assess cognitive status) score of 15. The Quarterly MDS Assessment indicated that the resident had diabetes mellitus. Record review of Resident #21's Comprehensive Care Plan, dated 07/17/2025, reflected the resident had diabetes mellitus and one of the interventions was FSBS AC and HS with sliding scale (a chart of insulin dosages). Record review of Resident #21's Physician Order, dated 08/26/2020, reflected Humalog Solution 100 UNIT/ML (Insulin Lispro). Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously (administer under the skin) before meals for Diabetes Mellitus > 400 CALL DR. Observation on 09/18/2025 at 11:09 AM revealed LVN D was about to check Resident #21's blood sugar. She sanitized her hands and then sanitized the glucometer. She inserted a test strip into the glucometer and put it inside a plastic cup. She also placed some alcohol wipes and a push button safety lancet on the plastic cup. She went inside the room and positioned herself on the resident's right side. She did not close the door nor pulled the privacy curtain while she was checking the resident's blood sugar. LVN D was facing the door and what she was doing could be seen from the hallway. After checking the blood sugar, she went back to her cart and prepared the insulin. After preparing the insulin, she went back inside the room and administered the insulin on the resident's left arm. She also did not close the door nor pulled the privacy curtain while administering the insulin. It was observed that several staff and residents were passing by the resident's room while the blood sugar was being checked and while insulin was being administered. In an interview on 09/18/2025 at 11:19 AM, LVN D stated she forgot to close the door while she was checking the resident's blood sugar and when she administered her insulin. She said the door should be closed to provide privacy during treatment or care. She said the resident might get embarrassed that other people could see what her treatments were. In an interview on 09/19/2025 at 6:54 AM, Resident #21 stated that some nurses would close her door when her blood sugar was checked or if her insulin was given but some would not. She said she got used to with the staff not closing her door, but it would be nice if her door was closed when given her insulin. 2. Record review of Resident #37's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #37's Comprehensive MDS Assessment, dated 07/02/2024, reflected the resident had a moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach). Record review of Resident #37's Comprehensive Care Plan, dated 09/01/2025, reflected the resident required tube feeding and one of the interventions was to see MD orders for current feeding orders. Record review of Resident #37's Physician Order, dated 08/15/2025, reflected Enteral Feed Order four times a day for nutrition FEEDING BOLUS: Jevity 1.5 46 cc. Every 6 hours bolus/gravity per G-Tube. Document the amount of formula provided every shift. Record review of Resident #37's Physician Order, dated 08/07/2025, reflected FLUSH tube with 220 cc of additional water every 6 hours OR at the start and stop of bolus/gravity/cyclic feeding cycle every 6 hours. Observation on 09/18/2025 at 11:28 AM revealed RN B was about to do Resident #37's bolus feeding via g-tube. She washed her hands, started to prepare the things needed for bolus feeding, and placed them on the resident's overbed table. She then proceeded with bolus feeding. She did not close the door nor pulled the privacy curtain while she was giving the resident's formula. The resident was facing the hallway and several staff, visitors, and residents were passing by. It could be seen from the hallway when she raised the resident's shirt to connect the syringe to the g-tube and when she was holding the syringe up with the formula in it. While she was in the process of waiting for the bolus feeding to be done, MA G entered the resident's room and asked RN B something. She then closed the door on her way out. In an interview on 09/18/2025 at 11:40 AM, Resident #37 did not reply when asked how he felt when other people saw his g-tube. In an interview on 09/18/2025 at 11:46 AM, RN B stated she should have closed the door when she was giving Resident #37's formula. She said the door should be closed to provide privacy for the resident. She said the door should be closed every time the resident was given his bolus feeding to provide dignity and privacy. In an interview on 09/18/2025 at 11:58, MA G stated she closed Resident #37's door to provide privacy while RN B was giving resident's bolus. She said the door should be closed because sometimes the resident might get embarrassed that he had a tube connected to him. In an interview on 09/19/2025 at 7:01 AM, the DON stated the door should be closed every time the staff provided care or treatment to provide privacy. He said checking the blood sugar, administering the insulin, and doing bolus feeding were treatments done for the resident so their doors should be closed so others, like non-clinical personnel, visitors, and other residents would not see the treatments being done. He said the door should be closed or the privacy curtain pulled to avoid embarrassment. He said, aside from being embarrassed, closing the door could make the resident more comfortable during treatment. He said the expectation was for the staff to provide privacy during treatment. He said he was made aware about the issue of not closing the door during treatment and he already started an in-service regarding privacy during care. In an interview on 09/19/2025 at 7:33 AM, ADON A stated the staff should close the door when they were providing care to the residents. She said the staff need to get used to providing privacy during treatment because it could affect the resident's dignity and how they see themselves. She said it did not matter if the residents mind or not, but the expectation was for the staff should be sensible enough that if they were in the residents' position, they would not want everybody in the hallway to see what was being done to them. She said she and the DON were made aware of the issue and an in-service about closing the door during treatment was already initiated. In an interview on 09/19/2025 at 8:02 AM, the Administrator stated the staff must make sure that the residents were provided privacy when providing care to prevent awkwardness. She said it was important that the residents were provided privacy so they would be comfortable when treatment was provided. She said the expectation was for the staff to be mindful about privacy when providing treatment. She said the DON already started an in-service about privacy and they would closely monitor the staff adherence to the policy. Record review of the facility's policy entitled, Resident Rights Strategy, Delivery, Performance revised 08/2024 reflected Policy Statement: Employees shall treat all residents with kindness, respect, and dignity . Policy Interpretation and Implementation . 1. Federal and state laws guarantee certain basic rights to all residents . t. privacy and confidentiality.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident #46) reviewed for dignity. CNA E failed to honor Resident #46's request to adjust the straps wrapped around the resident's leg, which was holding the catheter bag in place, when she advised it was too tight. This failure placed residents at risk of not having their right to a dignified existence and self-determination maintained and led Resident #46 to feeling frustrated and ignored.Findings included: Record review of Resident #46's Face Sheet, dated 09/17/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #46 had diagnosis of urinary and flaccid neuropathic bladder (weak bladder muscles). Record review of Resident #46's Quarterly MDS Assessment, dated 09/09/25, reflected Resident #46 had a moderate cognitive impairment with a BIMS score of 12. The Quarterly MDS Assessment reflected an active diagnosis of a neurogenic bladder. Record review of Resident #46's Comprehensive Care Plan, dated 09/09/25, did reflected the resident's use of a Suprapubic urinary catheter and an intervention was the use of a catheter leg bag when the resident was in her wheelchair and participating in activities. Record review of Resident #46's Physician Order, dated 09/18/25, reflected urinary catheter draining bag. In an observation and interview on 09/17/25 at 10:51 AM, Resident #46 stated the straps around her leg, holding the catheter bag in place, were too tight. She stated she told CNA E of this repeatedly, but he told her that it was not too tight, and he needed to ensure that it would stay in place. She also stated she had told him the strap was twisted in the back, both instances made her uncomfortable. She stated she was frustrated because she felt CNA E was ignoring her concerns. Resident #46 lifted up her pant leg and showed the catheter bag with the straps attached and the straps did appear too tight on the resident, and the top strap could be observed twisted on the back portion of her leg. In an interview on 09/18/25 at 1:28 PM, CNA E stated he was at the facility nearly a year. He said Resident #46 complained to him the catheter bag straps were too tight, and the strap was twisted, but he ignored her. He stated he loosensed the strap on the leg holder whenever the resident stated it was too tight. He was shown a picture of the strap around the resident's leg, and he stated it appeared too tight and he would locate the resident to adjust the straps and untwist it. He stated the risk of the strap being too tight could stop the resident's blood flow. In an interview on 09/18/25 at 1:48 PM, LVN D stated she was employed at the facility for a month. She was told about Resident #46 complaining to CNA E about the catheter straps being too tight. LVN D was shown a picture of it by this surveyor. She stated CNA E told her this was discussed. She stated the CNA should have adjusted the straps because the resident requested it. She stated not adjusting the strap made the resident uncomfortable and could impact the resident's blood circulation. She stated the resident had not mentioned this to her today, but she did adjust it yesterday when it was brought to her attention. She stated when she observed the straps, it did appear too tight. In an interview on 09/19/25 at 11:00 AM, ADON A was told Resident #46 complained to CNA E about the catheter straps was too tight and twisted, but CNA E refused to adjust it. She stated the CNA should have adjusted the strap because the resident complained to him it was too tight for her. She stated it could cut off her blood circulation. In an interview on 09/19/25 at 11:08 AM, the DON told Resident #46 complaining to CNA E about the straps holding her catheter bag against her leg, was too tight and twisted, but CNA E refusing to adjust it. He was advised it was also observed, and the straps appeared too tight and was twisted. He stated the CNA should have adjusted the strap because the resident had complained to him it was too tight for her. He stated it was the resident's right to have it adjusted to her comfort level. Record review of facility's policy, Resident Rights, dated 08/2024, revealed Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence.b. be treated with respect, kindness, and dignity.c. be free from abuse, neglect, misappropriation of property, and exploitation.e. self-determination

Based on observation, interview and record review, the facility failed to ensure the residents' rights to privacy for 15 (#4, #44, #8, #11, #49, #10, #157, #16, #43, #13, #15, #40, #21, #22, #27) of 15 residents reviewed for personal privacy. The facility failed to ensure LPN D locked the computer screen, displaying the names of 15 residents, while LPN D was in a resident's room administering a treatment. This failure could allow residents' protected HIPAA information to be shared with individuals who did not have a need or right to know. The findings included: An observation 08/21/24 at 09:58 AM revealed an open laptop on the nurse's cart on hall 300. The screen displayed the full name and room number of 15 residents on hall 300. The nurse was in a resident's room providing a treatment at the time. The cart was outside the door of the room the nurse was in. No visitors or other residents were near the laptop when the observation was made. During an interview 08/22/24 at 07:13 AM, LPN D stated she was supposed to lock the screen when away from the computer. She stated it was a HIPAA violation to leave the screen open, unattended, with resident information displayed. During an interview with the DON 08/22/24 at 08:18 AM, he stated LPN D should close the computer when not using it, because resident information could be seen. He stated this was a privacy issue. During an interview with the QAPI Nurse Manager 08/22/24 at 08:57 AM, she stated when a staff member was not using a computer, they should lock the screen or close the computer. She stated anyone who walked by the open screen could look at residents' information and information should be kept private. Review of the facility policy, revised 11/16/23 and titled Resident Dignity, stated maintaining an environment . able to be seen by visitors and/or other residents that includes confidential clinical or personal information.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth 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 a resident for three (Resident #9, Resident #15, and Resident #106) of eight residents reviewed for Care Plans. 1. The facility failed to ensure Resident #9 was care planned for indwelling Foley catheter. 2. The facility failed to ensure Resident #15 were care planned for oxygen administration. 3. The facility failed to ensure Resident #106 were care planned for oxygen administration. These failures could place the residents at risk of not receiving the necessary care and services. Findings included: 1. Review of Resident #9's Face Sheet, dated 08/21/2024, revealed Resident #9 was a [AGE] year-old male who was admitted to the facility 07/22/2024. Relevant diagnoses included benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged and not cancerous) with lower urinary tract symptoms and chronic kidney disease. Review of Resident #9 Quarterly MDS Assessment, dated 07/28/24, revealed Resident #9 was cognitively intact with a BIMS score of 15, an indwelling foley catheter, and was dependent on staff for toileting hygiene. Review of Resident #9's Physician Order, dated 07/22/2024, revealed Catheter: 18 f (French: unit used to indicate the size of the catheter) with cc balloon to dependent drainage. Review of Resident #9's Comprehensive Care Plan on 08/21/2024 reflected no care plan for indwelling catheter. Observation on 08/21/2024 at 12:46 PM revealed Resident #9 had a foley catheter hanging on his wheelchair. It was in a privacy bag and not touching the floor. 2. Review of Resident #15's Face Sheet, dated 08/20/2024, reflected that the resident was an [AGE] year-old male admitted on [DATE]. Resident #15 was diagnosed with chronic respiratory failure (condition where there is not enough oxygen in the body or too much carbon dioxide in the body) with hypoxia (insufficient amount of oxygen in the body). Review of Resident #15's Quarterly MDS Assessment, dated 07/23/2024, reflected that Resident #15 was cognitively intact with a BIMS score of 15. Resident #15's Quarterly MDS Assessment indicated that the resident had oxygen therapy while a resident of the facility. Review of Resident #15's Physician Order, dated 07/27/2022, reflected Oxygen via nasal cannula 1-4 liters per minute continuously and as needed for dyspnea (difficulty in breathing), hypoxia (low level of oxygen in the blood) or acute angina (chest pain). As needed for dyspnea, hypoxia, acute angina, AND every shift. Review of Resident #15's Comprehensive Care Plan on 08/20/2024 reflected no care plan for oxygen therapy. Observation on 08/20/2024 at 9:09 AM revealed Resident #15 was on his bed, asleep. It was observed that Resident #15 had oxygen administration via nasal cannula at 3 liters per minute. The nasal cannula was connected to an oxygen concentrator. In an interview with Resident #15 on 08/20/2024 at 11:27 AM, Resident #15 stated he had been using oxygen for almost two years. He said he used the oxygen day and night. 3. Review of Resident #106's Face Sheet, dated 08/21/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Resident #106 was diagnosed with pneumonia (inflammation and fluid in the lungs caused by a bacterial, viral, or fungal infection) and anxiety disorder. Review of Resident #106's Quarterly MDS Assessment, dated 04/30/2024, reflected Resident #106 was cognitively intact with a BIMS score of 15. Resident #106's Quarterly MDS Assessment did not indicate that the resident was on oxygen therapy. Review of Resident #106's Physician Order, dated 08/16/2024, reflected Oxygen at 2 LPM (per nasal cannula, face mask, facial tent) via O2 concentrator and/or tank at bedtime every night shift for SOB. Review of Resident #106's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy. Observation and interview with Resident #106 on 08/20/2024 at 9:09 AM revealed that Resident #106 was on her bed, awake. It was observed that she had a nasal cannula connected to an oxygen concentrator. According to Resident #106, she would use the oxygen at night. In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated it was important that residents had a care plan to fully provide the care and services the residents needed. The ADON said that for this case, there should be a care plan for the indwelling catheter and oxygen administration. She said without the care plan, there could be confusion on the care of the residents and their needs would not be addressed. She said she was responsible in making the care plan. She said the expectation was all the issue of the residents were care planned. In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated every resident needed a comprehensive care plan to make sure the residents received the applicable and appropriate care needed. The DON said the care plan should be in place so that the staff providing care would be on the same page. The DON stated the care plan was important because it reflected the resident's needs. He said the care plan should be resident-centered and should show what specific care the resident needed. He said the expectation was for all residents to have a complete and detailed care plan. He said he would coordinate with the ADON and the MDS Nurse to audit the care plans of the resident. In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated all the residents should have a care plan appropriate to their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. The Administrator concluded that the expectation was for the staff to ensure that the residents were care planned accordingly. She said she would coordinate with the DON and the MDS Nurse to make sure all the residents were care planned. Observation and interview with MDS Nurse on 08/22/2024 at 8:16 AM, the MDS Nurse confirmed that Resident #9 did not have a care plan for the indwelling catheter. She also confirmed that Resident #15 and Resident #106 did not have a care plan for oxygen therapy. She stated she missed it and would add the care plan for the indwelling catheter and oxygen therapy. The MDS Nurse stated care plans were important to ensure the residents were getting the care needed. She said care plans served as guides on how the staff would take care of the residents. The MDS Nurse added that without the care plans, the staff could miss significant interventions needed by the residents. Record review of facility's policy, Comprehension Care Plan and Care Conferences - Rehab/Skilled Rehab/Skilled & Long-Term Care: Therapy & Rehab revised 12/04/2023 revealed Purpose: to develop a person-centered care plan for each resident . Procedure . 5. Formulating the care Plan . a. The care plan is driven by identified resident issues/conditions.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 6 (room [ROOM NUMBER], #1111, #1113, #1114, #1115, and #1116) of 12 resident rooms and the facility's high traffic areas reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms #1109, #1111, #1113, #1114, #1115, and #1116 were thoroughly cleaned and sanitized. This failure could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 08/20/24 at 10:44 AM of Resident room [ROOM NUMBER] reflected the corners of the floor in the resident bathroom had dirt particles and built-up dust. The widow blinds had a film of this dust on them. The trashcan in the bathroom had no trash bag in it, and it had two unused adult diapers in it. The backside of the entry door had black dirt stains near the door handle and the door frame. An observation on 08/20/24 at 10:49 AM of Resident room [ROOM NUMBER] reflected the corners of the floor in the resident bathroom and behind the toilet, had dirt particles and built-up dust. The sink drain hole had rust on the metal ring circling the drain hole. An observation on 08/20/24 at 10:53 AM of Resident room [ROOM NUMBER] reflected the corners of the floor in the resident bathroom and behind the toilet, had dirt particles and built-up dust. An observation on 08/20/24 at 10:57 AM of Resident room [ROOM NUMBER] reflected the corners of the floor in the resident bathroom and behind the toilet, had dirt particles and built-up dust. The sink drain hole had rust on the metal ring circling the drain hole. The light greenish bedside table in the resident's room had dried up brownish stains and black dirt stains along the bottom of the table. An observation on 08/20/24 at 11:18 AM of Resident room [ROOM NUMBER] reflected the corners of the floor in the resident bathroom and behind the toilet, had dirt particles and built-up dust. The trashcan in the resident room had reddish and brownish stains all over the outside of the trashcan. An observation on 08/20/24 at 11:23 AM of Resident room [ROOM NUMBER] reflected the corners of the floor in the resident bathroom and behind the toilet, had dirt particles and built-up dust. There was a dead cricket near the trashcan in the bathroom. The floor in front of the toilet had yellowish stains. In an interview on 08/22/24 at 10:13 AM, Housekeeper A stated she had been cleaning for [AGE] years. She stated she cleaned the 100 and 400 halls, but they sometime switched up. She stated they were supposed to clean everything in the room, such as the bathroom, floors, and wipe things down. She stated the residents liked her because she got things done. She was shown pictures of the concerns observed in resident room [ROOM NUMBER], #1111, #1113, #1114, #1115, and #1116, and she stated she was concerned that her peers were not consistent when cleaning rooms and she had received feedback from residents with the same concerns. She stated she worked to ensure the residents room were thoroughly cleaned but her peers skipped over areas and then the dirt would build up. She stated she had pointed this out to housekeeping supervisor, but she had not seen any changes in their behaviors. In an interview on 08/22/24 at 10:26 AM, the Environmental services supervisor stated he had been at the facility for [AGE] years. He stated housekeeping were supposed to clean everything in the room, but sometimes they were unable to clean everything every day. He was shown pictures of the concerns observed in resident room [ROOM NUMBER], #1111, #1113, #1114, #1115, and #1116, and he stated he had inspected the rooms to ensure they were cleaned but needed to look a little closer. He stated deep cleaning was done as needed, but it was primarily done once a month. He stated the concerns observed were an infection control concern, and it could also impact their morale. In an interview on 08/22/24 at 10:50 AM, the Administrator stated she had not been made fully aware of the concerns observed in the resident rooms. She was shown pictures of the concerns observed in resident rooms #1109, #1111, #1113, #1114, #1115, and #1116. She stated that she would follow-up with the Environmental services supervisor to ensure these concerns were addressed. She stated her expectation was for housekeeping to ensure they were thoroughly cleaning rooms. She stated the risk of not thoroughly cleaning resident rooms could result in infections and it was not good for their dignity. Review of the facility's policy on Housekeeping (undated) reflected Rehabilitation/skilled care settings provide care and services to residents who are often vulnerable to infections and effects of infections due to weakened immune systems. As such, thorough, routine, and high-quality cleaning procedures are necessary to minimize the prevalence of infection.

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure the ice machine and the ice scoop holder in the kitchen area, was thoroughly cleaned. 2. The facility failed to ensure expired foods in the facility's refrigerator and freezer were discarded according to guidelines. 3. The facility failed to ensure foods in the refrigerator and freezer were properly sealed from air-borne contaminations. 4. The Dietary Manager failed to properly wear a beard covering while breakfast was being prepared and served, in the kitchen area. 5. The facility failed to place a cover on top of the tea dispenser. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on [DATE] from 09:03 AM to 09:14 AM in the facility's only kitchen reflected: The Dietary Manager was observed in the kitchen area during breakfast service, wearing his beard covering dangling from one ear, and not worn correctly covering his beard (approximately ,d+[DATE] inch in length). One large tea dispenser, located in the Assisted living dining area (also used by skilled nursing), was sitting uncovered and full of tea. The tea was exposed to air-borne contaminants. One bag of seedless red grapes in the refrigerator was open and not sealed. One large piece of cooked ham in a pan in the refrigerator, had use by date of [DATE]. One bag of franks in the refrigerator was open and not sealed. One large ziplocked bag of bread rolls in the refrigerator, had use by date of [DATE]. The ice machine had dust and dirt particles along the outside of the unit. The inside of the unit had rust like substance near the door hinges of the lid, which trickled down to the ice. The metal ice scoop holder had rust along the bottom of the holder. In an interview on [DATE] at 10:37 AM, the Dietary Manager stated he had been at the facility for 3 years. He was advised of the findings in the kitchen and dining area, and he stated he had made a lot of the corrections that were initially observed, especially cleaning the ice machine. He stated all kitchen staff were responsible for throwing away expired foods, ensuring the foods were sealed, and making sure the lid was placed back on top of the tea dispenser; however, it was overall his responsibility to ensure that all of it was being completed. He stated the tea was prepared at 07:00 AM and the dietary aide who prepared the tea often forget to place the lid back on the top of the dispenser and he often had to remind them. He stated the tea was shared by both skilled nursing and assisted living. He stated he knew he should have worn his beard covering correctly but had gotten hot and it was hard for him to breath with it on. He stated the risk of these issues not being addressed could result in residents getting sick. In an interview on [DATE] at 10:50 AM, the Administrator stated she had not been made aware of some the concerns observed in the kitchen area. She was advised of the concerns that were observed in the kitchen and she stated that she expected the kitchen area to meet all guidelines and comply with state and federal regulations. She stated the risk of the concerns not being addressed could result in infection control. Record Review of the Facility's policy on Food Storage dated [DATE], revealed To ensure that food is stored properly. USE By/USE or Freeze By* (expiration date) - This is used on Time/temperature Control for Safety Foods (TCS). Safety phrasing will inform customers that these products should be consumed on or before the date listed on the package. The product should not be consumed after the date on the package due to the product's perishable nature and the product should be disposed of. This date label is for perishable products with potential safety implications or material degradation of critical performance, such as nutrition. Record Review of the Facility's policy on General Kitchen Sanitation, dated [DATE], reflected To provide guidelines that limit the chance of foodborne illness at locations that prepare and/or serve food. The location stores, prepares, distributes and serves food under sanitary conditions at all times. The location's food preparation, kitchen, serving areas and dry storage are cleaned and sanitized on a regular basis to limit contamination and prevent foodborne illness. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE] - ,d+[DATE].

Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #7, Resident #29, Resident #39, and Resident #40) of fifteen residents observed for Infection Control. 1. The facility failed to ensure that CNA C performed hand hygiene while providing incontinent care to Resident #7 and Resident #39. 2. The facility failed to ensure that CNA B would not lower the catheter bag to the floor before transferring Resident #29. 3. The facility failed to ensure that LPN D perform hand hygiene during Resident #40's wound care. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #7's Face Sheet, dated 08/21/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Resident #7 was diagnosed with spastic hemiplegia (muscles on one side of the body being in constant state of contraction) affecting left side. Review of Resident #7's Comprehensive MDS Assessment reflected that the resident was not able to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated Resident #7 was frequently incontinent for bladder and bowel and dependent on staff for self-care needs. Review of Resident #7's Comprehensive Care Plan, dated 07/02/2024, reflected that the resident had bowel and bladder incontinence and one of the interventions was to provide skin care after each incontinent care. Observation on 08/21/24 at 10:52 AM revealed CNA C and CNA F washed their hands in resident's room prior to providing incontinence care. CNA C explained to Resident #7 what the staff was going to do. CNA F stood on the opposite side of the bed. CNA F assisted CNA C to pull Resident #7's pants down and unfasten tabs on the brief. CNA C cleaned one side of the labia, from the top down, repeated on the other side, and then the vaginal area from the top down. A clean wipe was used with each pass. CNA C removed the soiled gloves and put on clean gloves. CNA C did not sanitize her hands before putting on the new gloves. CNA F assisted CNA C to roll Resident #7 on her right side and CNA F held Resident #7 while CNA C cleaned Resident #7s bottom. CNA C cleaned each side of Resident #7's bottom, then the rectal area, wiping away from the vagina. A clean wipe was used with each pass. CNA C removed the soiled gloves and applied clean gloves. CNA C did not sanitize her hands before putting on the new gloves. CNA C placed a clean brief under Resident #7 and Resident #7 was turned to lie flat on the bed. CNA F and CNA C secured the tabs on the front of the brief and pulled up Resident #7's pants. CNA C and CNA F removed their gloves washed their hands in the sink before leaving Resident #7's room. Review of Resident #39's Face Sheet, dated 08/21/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Resident #39 was diagnosed with need for assistance with personal care. Review of Resident #39's Comprehensive MDS Assessment, dated 05/17/2024, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated Resident #39 was frequently incontinent for bladder and bowel. Review of Resident #39's Comprehensive Care Plan, dated 05/17/2024, reflected that the resident had an ADL selfcare performance deficit and one of the interventions was to assist to bathroom every 2 hours while awake. Observation on 08/21/2024 at 7:11 AM revealed CNA C was about to transfer Resident #39 to her wheelchair because the resident wanted to go to the bathroom. CNA C put on a pair of gloves. He did not do hand hygiene before putting on the gloves. CNA C then transferred Resident #39 from bed to wheelchair and ushered the resident to the bathroom. When inside the bathroom, CNA C transferred the resident from the wheelchair to the toilet. While the resident was sitting on the toilet, CNA C took off the resident's hospital gown and put a new blouse on. CNA C then took the waste can and pulled a plastic bag from beneath the waste can. He did not change his gloves nor did hand hygiene after touching the waste can. When the resident said she was done, CNA C ripped the soiled brief on both sides and threw it in the waste can. CNA C then requested the resident to stoop forward and cleaned the resident's bottom. After cleaning the resident's bottom, CNA C took the new brief from the sink and put it on the resident. After putting the new brief, CNA C put on the resident's pants. He did not change his gloves nor performed hand hygiene after cleaning the resident's bottom. CNA C then transferred the resident to her wheelchair. CNA C washed his hands after incontinent care. An interview with CNA C on 08/21/2024 at 11:00 AM, CNA C stated hands should be washed or sanitized before and after doing incontinent care. He said the hands should also be sanitized before putting on clean gloves. CNA C said hand hygiene was important to prevent the spread of germs and that staff had an in-service on incontinence care about a month ago. He said he should have done hand hygiene and changed his gloves after touching the waste can, after touching the soiled brief, after cleaning the resident's bottom, and before touching the new brief. In an interview with LPN A 08/22/2024 at 08:32 AM, LPN A stated hand sanitizer and handwashing was part of the staff's uniform, especially those that were providing direct care. She said staff should use sanitizer before going inside a room and when they come out of the room. She said, during incontinent care, the staff should do hand hygiene before and after. She continued that the gloves should be changed after touching anything that was dirty or soiled and before touching the clean items. She said hands should also be sanitized in between changing of gloves. She said sanitizers were available in the halls and sanitizers in a container were provided by the facility. LPN A said if hand hygiene and changing of gloves were not done, cross contamination and infection could happen. An interview with the QAPI Nurse Manager on 08/22/24 at 08:57 AM revealed when she made her rounds and staff observation, she reminded them to sanitize before going inside the room of the residents and before touching the residents. She said staff should wash hands or sanitize before putting on new gloves. She said staff should wash their hands or use hand sanitizer before and after providing care. She said by doing so, cross contamination could be prevented. 2. Review of Resident #29's Face Sheet, dated 08/21/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Resident #29 was diagnosed with neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness). Review of Resident #29's Quarterly MDS Assessment, dated 07/14/2024, reflected Resident #29 had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated that the resident had an indwelling catheter. Review of Resident #29's Comprehensive Care Plan, dated 08/13/2024, reflected Resident #29 had an indwelling catheter related to neurogenic bladder (the normal bladder function is disrupted due to nerve damage) and one of the interventions was catheter care every shift. Review of Resident #29's Physician Order, dated 11/07/2023, reflected CATHETER: 16fr (French: unit used to indicate the size of the catheter) with 10 cc balloon to dependent drainage. Change catheter and drainage bag monthly on the 13th, and PRN if dislodged or plugged and unable to clear with irrigation. One time a day starting on the 13th and ending on the 13th every month related to NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED AND as needed for patency. Observation on 08/20/2024 at 9:47 AM revealed CNA B was about to transfer Resident #29 from wheelchair to the recliner. It was observed that the resident had catheter bag hanging at the bottom of the wheelchair. The catheter bag was inside a privacy bag. Before transferring the resident to the recliner, CNA B took the catheter bag from the privacy bag and put it on the floor. CNA B proceeded with the transfer. When the resident was already in the recliner, CNA B took the catheter bag from the floor and hung it on the side of the recliner. CNA B put the catheter bag inside the privacy bag. The privacy bag was touching the floor. In an interview with CNA B on 08/21/2024 at 2:07 PM, CNA B stated the catheter bag or the privacy bag should not be touching the floor because germs could get inside. She said she should have transferred the resident first and then hook the catheter bag at the side of the recliner or hook first the catheter bag on the recliner then transfer the resident. She said instead of transferring the catheter bag to the recliner, she should have just placed it at the side of the wheelchair to make sure the privacy bag was not touching the floor. In an interview with LPN A on 08/22/2024 at 8:32 AM, LPN A stated the Foley bag should not touch the floor because it would pick up germs and could cause infection such as urinary tract infection. She said even though the catheter bag was inside privacy bag, the privacy bag should not touch the floor. She said she would check to ensure Resident's 29's bag was not touching the floor. 3. Review of Resident #40's Face Sheet, dated 08/21/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Resident #40 was diagnosed with venous thrombosis (blood clot forms in the veins) and venous embolism (clot travels through the vein). Review of Resident #40's Comprehensive MDS Assessment, dated 05/21/2024, reflected that the resident had a severe impairment in cognition with a BIMS score of 01. The Comprehensive MDS Assessment indicated Resident #40 was at risk of developing pressure ulcer (injury to skin due to prolonged pressure). Review of Resident #40's Comprehensive Care Plan, dated 06/30/2024, reflected that the resident had an actual impairment to skin integrity R/T immobility to right lateral ankle and one of the interventions was to monitor location, size, and treatment of skin injury. Review of Resident #40's Physician Order, dated 08/09/2024, reflected Apply skin prep to peri (around) wound, apply Alginate Calcium cover with island dressing daily, x 30-day one time a day for right lateral ankle. Observation and interview on 08/21/2024 at 9:57 AM revealed LPN D was about to do wound care. She sanitized her hands and put on a gown and a pair of gloves. LPN D prepared the things needed for wound care. She said the treatment for the resident's wound to the right ankle was cleaned with normal saline, apply calcium alginate, and then cover with a border dressing. Before doing the wound care, she took off her gloves, went to the other side of the bed, grabbed the waste basket with her bare hands, and placed it on her side. After touching the waste basket, LPN D proceeded to put on a pair of gloves. After placing the waste basket on her side, LPN D proceeded with wound care. She did not perform hand hygiene before putting on a new pair of gloves. She said she should have worn a pair of gloves before touching the waste basket because apparently the waste basket was dirty. She also said that she should have washed her hands after touching the waste basket. She said not changing the gloves and doing hand hygiene could cause infection. In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated hand hygiene was included in all the procedures of any care. She said the staff should be mindful that they were to take care of the residents and not give them additional medical issues. She said the staff should do hand hygiene before and after any care. She said gloves should be changed when transitioning from dirty to clean. She said for these instances, after touching the waste can, after touching the soiled brief, and after cleaning the residents' bottom. She said the hands should be washed or sanitized before putting on a new pair of gloves. She also said that the catheter bag should always be off the floor, even though the catheter bag was inside a privacy bag. She said all the issues discussed were causes of cross contamination and probable development of infections. She said the expectation was for the staff to do hand hygiene before and after every care, after changing their gloves, when transitioning from a dirty area to a clean area, sanitizing their hands when changing their gloves, and not to put the catheter bag on the floor. The ADON said she would coordinate with the DON on how to go forward. In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated all the staff should know that hand hygiene was the most effective way to prevent cross contamination and infection. He said, first, the gloves should be changed after touching any soiled items. He said for this case, the gloves should have been changed after removing the soiled brief, after cleaning the resident's bottom, and after touching the waste basket. He continued that secondly, every time staff change their gloves, they should do hand hygiene before putting on a new pair of gloves. He said there could be instances that while they were providing care, the staff did not notice the gloves were torn, and the germs could enter the gloves and soil the hands. He said that was why it was important to do hand hygiene when changing the gloves. He said this should have been done during incontinent care and wound care. He also said, the catheter bag should not be placed on the floor during transfer. He said the staff could have just left it on the side of the wheelchair to be sure it was off the floor. He said the expectation was for the staff to do hand hygiene before and after any care, to change their gloves from dirty to clean, to do hand hygiene when changing the gloves, and not to put the catheter bag on the floor. He said he would do an in-service about infection control immediately after the interview and he would monitor the staff. In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated not doing hand hygiene before and after any care, not changing the gloves after touching soiled items, not sanitizing the hands in between changing of gloves, and placing the catheter bag on the floor could contribute to cross contamination and probable infection. She said the expectation was for the staff to follow the policy and procedures pertaining to infection control. She said he would collaborate with the DON to in-service the staff about infection control. Review of facility policy, Hand Hygiene Policy Infection Prevention revised 03/29/2022 revealed Purpose . to establish hand hygiene as the single most important factor in preventing the spread of disease-causing organisms . Policy . All employee in patient care areas will adhere . hand hygiene . 1. Entering room . 2. Before clean task . 3. After bodily fluid/Glove removal . 4. Exiting room . When moving from contaminated body site to clean body site. Review of facility policy, Catheter: Care, Insertion, & Removal, Drainage bags, Irrigation, Specimen - AL, R/S & LTC Policy Assisted Living: Rehab/Skilled & Long-term Care revised 07/30/2024 revealed Policy . Catheter tubing/drainage bags . should never be allowed to touch the floor.

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or a need to alter treatment significantly for one (Resident #1) of 20 residents reviewed for physician consultation. 1. LVN A failed to intervene and report immediately a change in condition for Resident #1 after the resident developed vomiting, abdominal pain, and bleeding following a [DEVICE] replacement. 2. CNA D failed to ensure the head of bed for Resident #1 remained elevated to a 30 to 45-degree angle per facility policy. The resident developed vomiting and aspirated. Resident #1 was transported to the hospital on [DATE] due to a change in condition. The resident was diagnosed with [REDACTED]. Resident # 1 expired on [DATE]. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. These failures placed residents at risk for not receiving the necessary interventions to treat their specific condition or diagnoses. Findings included: Review of Resident #1's MDS assessment dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #1's monthly physician orders [REDACTED]. Hold tube feeding if the residual is over 60 ml. HOB: Elevate HOB 45 degrees at all times during feeding and for at least 30 minutes after the feeding is stopped, dated [DATE]. Review of Resident #1's (MONTH) 2019 MAR/TAR revealed no designated area for recording enteral feeding or residual amounts checked. There was no designated area for recording beginning the enteral feeding or for ensuring the head of the bed was elevated 45 degrees as ordered by the physician. Review of Resident #1's care plan, dated (MONTH) (YEAR), reflected the resident had a [DEVICE]. There were no interventions to keep the head of bed elevated. Review of Resident #1's hospital records dated [DATE] revealed the resident was admitted to the hospital the night of [DATE] with: 1. Aspiration pneumonia 2.[MEDICAL CONDITION]ly due to aspiration pneumonia 3. Acute [MEDICAL CONDITION] Review of Resident #1's progress notes dated [DATE] at 10:50 AM revealed the resident was sent to the local hospital for pulling out her [DEVICE]. Review of Resident #1's Change in condition form dated [DATE] at 7:30 PM and signed by LVN A revealed the resident had abdominal pain, nausea, vomiting. Interview on [DATE] at 3:30 PM with LVN A revealed while taking report from the day shift nurse at approximately 2:00 PM on [DATE], CNA D reported to her that Resident #1 had returned from the hospital with a new [DEVICE] and had bleeding at the [DEVICE] site. LVN A and CNA D went to Resident #1's room. The resident had bleeding at the [DEVICE] site which had saturated the [DEVICE] dressing. There was a small amount of blood on the resident's sheet as well. LVN A notified RN C and advised CNA D to monitor the site and let her know if the bleeding worsened. A short time later, CNA D came and told LVN A the bleeding was still going on, so she stopped her medication pass at approximately 2:30 PM to 3:00 PM and returned to the resident's room. LVN A assessed the [DEVICE] site and saw active bleeding. The [DEVICE] dressing was saturated with blood and she cleaned the area with normal saline and changed the dressing. She checked [DEVICE] placement and residual which were normal. Resident #1 complained of abdominal pain, and LVN A used the non-verbal signs and symptoms of pain to determine the pain level was a 3 - 4 /minimum to moderate pain. LVN A administered a PRN dose of Tylenol 325 mg to the resident. At approximately 6:00 PM, LVN A assessed Resident #1 again and the resident demonstrated abdominal pain, guarding of her abdomen, and was curled up into the fetal position. Resident #1 also started trying to get out of bed. LVN A said the [DEVICE] dressing was dry at that time, but the [DEVICE] itself had blood in the tubing. LVN A called NP [NAME] at that time to advise them the resident was having increased pain and bleeding. NP [NAME] ordered Tylenol #3 and [MEDICATION NAME] at that time. LVN A said she administered Tylenol #3 - 1 tab via the [DEVICE] at approximately 6:30 PM and then she clocked out and went to break. When she returned from her break at 7:07 PM, she returned to the resident's room and found RN B in the room. RN B told her the resident had vomited and she had found the resident with the head of her bed down. LVN A said she stopped the tube feeding and obtained vital signs. LVN A said she instructed CNA D not to lay the head of the bed flat. RN C came in to the resident's room and said she was going to get a suction machine since Resident #1 had vomited. When Resident #1 vomited again, a dark substance was noted. LVN A said she was not sure if it was blood or not. At about 8:00 PM, CNA D told LVN A the resident was trying to get out of bed again. LVN A went to call the doctor, but RN C told her she had already called and had orders to obtain a stat (immediate) x-ray of the chest and abdomen. At approximately 9:00 PM, LVN A assessed the resident and she continued to show signs of pain, so LVN A called NP [NAME] and received orders to send the resident to the hospital. LVN A said the resident went to the hospital via non-emergent transport. When asked why she did not send Resident #1 to the hospital sooner, LVN A stated that she sent the resident out as soon as she received the order to send her, and she had called the non-emergent transport ambulance to transport her. Review of Resident #1's progress note dated [DATE] at 10:59 PM and signed by LVN A revealed Resident #1 was sent to local hospital for bleeding at the [DEVICE] site with concerns of aspiration with nausea. Doctor stated to send resident out to hospital. Family notified. Informed oncoming nurse. Transfer to hospital. Pain level of 7 per PAINAD scale (scale rating pain ,[DATE] based on severity with 10 being the most severe) to abdomen. Review of Resident #1's progress notes dated [DATE] at 5:00 PM and signed by RN C revealed: Called in by CNA (sic) that patient was vomiting. Assess patient. Patient needed to be suction due to vomiting large amount of feeding per nurse. Patient suction by me and moderate amount of feeding noted. Upper lobes clear, but crackles noted in lower lobes. NP notify (sic) to request stat! chest x-ray. Request granted and chest x-ray order by regular nurse. Review of Resident #1's progress note dated [DATE] at 7:52 PM and signed by RN C revealed This nurse try to check residual and noted 5 cc blood. NP notify again and new order for abdominal x-ray stat! Interview on [DATE] at 1:53 PM with RN C revealed Resident #1 was having some vomiting on the evening of [DATE] and she was asked to go in and assess her. She said she checked the lung sounds and heard crackles in the bases of her lungs. She then checked placement of the [DEVICE] and when she aspirated the tube, there was about 10 ml (milliliters) of bright red blood in the syringe. She said she called NP [NAME] and spoke to her. She said after about 15 minutes, she returned to the room to check on Resident #1 and noticed the gauze around the [DEVICE] site was soaked with bright red blood, so she called NP [NAME] again to update her and received the order to send Resident #1 to the hospital for evaluation. When asked what bright red blood indicated, RN C replied, acute onset bleeding. Interview with RN B on [DATE] at 2:26 PM revealed on the morning of [DATE], Resident #1 had pulled out her [DEVICE], was sent to the hospital and it was re-inserted. She returned to the facility later that same day. During her shift, after dinner, the resident's son asked RN B to come and see his mother because she was ill. She said that when she entered the room, she noted vomit coming from Resident #1's mouth and nose, and she saw the head of the resident's bed was down almost completely flat. She said she immediately raised the head of the bed and stopped the resident's feeding. She said she tried to position the resident so that the vomit would go out of the side of her mouth. Resident #1 was coughing and had some dark brown, coffee colored emesis mixed with the formula coming from her mouth. CNA D came into the room and RN B sent her to check the break room for another nurse. After a few minutes, RN C came in and ran to get the suction machine. RN B and CNA D changed Resident #1's clothing which was saturated with blood from the bleeding at the [DEVICE] site. RN B said she took the resident's vital signs and the readings were not alarming to her at the time. RN B said she gave RN C, who was the shift supervisor, the information and she asked permission to return to her hall. By that time LVN A, the primary nurse, was in the room. RN B said she returned to her hall. Later she heard that the resident was taken to the hospital. She stated she knew that Resident #1 had aspirated because the head of the bed was down, and she had been vomiting. RN B said she did not contact the physician, nurse practitioner or the family because she returned to her duties on her own hall and assumed that LVN A or RN C would make the calls since they had assumed care of Resident #1. Interview on [DATE] at 2:08 PM with the DON revealed she was notified about Resident #1 being sent to the hospital due to bleeding to the [DEVICE] site and vomiting after the resident was gone from the facility. The following morning, she reviewed the resident's clinical record and began the internal investigation of the incident. The DON interviewed LVN A, who said Resident #1 returned from the hospital on [DATE] at the beginning of her shift and had a small amount of bleeding at the [DEVICE] site that progressed to moderate bleeding, abdominal pain and vomiting. LVN A said she returned from break to find RN B and RN C in the room with Resident #1, then RN B was released to go back to her hall. The DON then interviewed RN C who said the resident had experienced vomiting, pain ,and bleeding to the [DEVICE] site which resulted in her being transported to a local hospital for evaluation. All nurses, including RN B, RN C, and LVN A received education and were scheduled for skills checks as a result of the incident. The DON said the facility would be conducting continued education and remedial training including skills checks upon hire, annually, and as needed. Interview on [DATE] at 12:18 PM with NP [NAME] (nurse practitioner) for Resident #1 revealed that sometimes there was bleeding with a [DEVICE] replacement. She said that her concern with Resident #1 was pain with bleeding, but LVN A told her that it was only a small amount of bleeding from the [DEVICE] site. She said she instructed LVN A to check the placement of the [DEVICE] and administer pain medications as ordered. When LVN A called her a second time and told her that the bleeding and pain were continuing, she then gave the order to send Resident #1 to the hospital for evaluation. She did not have documentation of the time the facility called her. Interview with MD F on [DATE] at 11:23 AM revealed he would have expected a small amount of bleeding at the insertion site of Resident #1's [DEVICE] after being dislodged and replaced. However, the continued bleeding with abdominal pain and vomiting were concerning and should have been evaluated sooner. The aspiration of bright red blood from the [DEVICE] was emergent and the staff should have responded more quickly to Resident #1's acute changes in condition. Review of the facility's current policy titled Tube (Enteral) Feeding revised (MONTH) (YEAR) reflected the following: Purpose: To maintain or improve the resident's nutritional status and/or weight .2. Head of Bed (HOB): Elevate HOB ,[DATE] degrees at all times during feeding . Review of the facility's current policy titled Interact-Change in Condition Evaluation revised (MONTH) (YEAR) reflected the following: Change in Condition: When to report to the MD/NP/PA. Immediate Notification Any symptom, sign, or apparent discomfort that is: *Acute or Sudden in onset and: * A marked Change (i.e. more severe) in relation to usual symptoms and signs, or *unrelieved by measures already prescribed Further review of Sign and Symptoms pathways contained in the Interact Change in Condition Evaluation form reflected: Signs and symptoms - Abdominal pain - Immediate: Abrupt onset severe pain or distention, OR fever with vomiting. Signs and Symptoms- Nausea- Immediate: Associated with fever, vomiting, or recent change in condition. Signs and Symptoms- Vomiting - Immediate: Persistent or recurrent (2 or more within 12 hours) vomiting, with or without abdominal pain, bleeding, distention/fever. Review of information on [DEVICE]s, obtained on [DATE] from https://www.managedhealthcareconnect.com/article/8614/opillam.aspirationriskandenteralfeeding:aclinicalapproach.[MEDICATION NAME]:,[DATE] reflected, aspiration is one of the most important and controversial complications in patients receiving enteral nutrition, and is among the leading causes of death in tube-fed patients due to aspiration pneumonia patients should be fed sitting up or at a 30- to 45-degree semi recumbent body position. Review of the website: www.aci.health.nsw.gov.au/data/assets/pdffile/,[DATE]/gastrostomy_guide-web.pdf A Clinician's Guide: Caring for people with gastrostomy tubes and devices, accessed on [DATE], reflected: Potential causes of vomiting include: Incorrect positioning of patient during feeding, interventions included ensure patient is upright (greater than 30 degrees) during feeding and for 30 minutes after feeding. Review of the website- http://dodd.ohio.gov/HealthandSafety/Documents/G%20Tube%20Article.pdf,, accessed on [DATE], reflected: [DEVICE] considerations for professionals who coordinate care or provide medical care: Gastrostomy Peritonitis: When the internal end of the feeding tube becomes displaced any fluid, medication or feeding given through the tube can cause severe discomfort, abdominal pain, fever, infection and ultimately death . some individuals may not be able to verbally express pain so check for other signs of pain (for example, changes in vital signs, irritability, or restlessness). Whenever a person has signs of pain associated with the use of a gastrostomy tube, caregivers must find the cause immediately. If there is any possibility that the tube has been displaced and has caused leakage into the abdomen or into the abdominal wall, emergency transfer is necessary . peritonitis can quickly overwhelm a person in fragile health. Findings: It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from [DATE] to [DATE]. The facility took the following actions to correct the non-compliance by [DATE]: Review of the facility's investigation, dated [DATE], revealed education and skills reviews for [DEVICE]s, head of bed elevation, and physician notification of resident changes would be completed upon hire, quarterly, and as needed. Yearly [DEVICE] skill checks for the nurses would be conducted by the DON, ADON, and education specialist. The plan was to be initiated immediately and the facility scheduled the skills checks for January, April, July, and (MONTH) moving forward. The MDS nurses would be responsible for updating the care plan and CNA Kardex to reflect the interventions needed to care for a resident with a [DEVICE]. The information would include head of bed elevation. The staff involved in the incident received counseling and in-services regarding the issues identified on [DATE] which included notification of the physician for changes in resident status, [DEVICE] care, and head of bed elevation. The facility also conducted an audit for all residents with gastrostomy tubes to update the clinical records including the care plans and Kardex with the interventions required for residents with a feeding tube. CNA D was terminated from employment Review of in-services records, dated [DATE], revealed LVN A received education regarding [DEVICE] care, change in condition and notification of physician, documentation, and appropriate times to clock out for break. Further review of the in-services reflected all nursing staff were trained on [DATE] and [DATE] for [DEVICE] care, physician notification with resident changes in status, abuse and neglect, and elevating the head of the bed 30 - 45 degrees for residents with [DEVICE]s. Interviews on [DATE] between 9:00 AM - 3:00 PM with staff on all shifts including LVN A, RN B, RN C, LVN G, LVN H, LVN I, CNA J, CNA K, CNA L, CNA M, and CNA N revealed they received in-services and skills reviews for [DEVICE]s, head of bed elevation, abuse and neglect, and physician notification of resident changes. They were able to verbalize knowledge and understanding of the in-services received. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey.

Based on interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident # 1) of 20 residents reviewed for feeding tubes. 1. LVN A failed to intervene and report immediately a change in condition for Resident #1 after the resident developed vomiting, abdominal pain, and bleeding following a [DEVICE] replacement. 2. CNA D failed to ensure the head of bed for Resident #1 remained elevated to a 30 to 45-degree angle per facility policy. The resident developed vomiting and aspirated. Resident #1 was transported to the hospital on [DATE] due to a change in condition. The resident was diagnosed with [REDACTED]. Resident # 1 expired on [DATE]. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. These failures placed residents at risk for not receiving the necessary interventions to treat their specific condition or diagnoses. Findings included: Review of Resident #1's MDS assessment dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #1's monthly physician orders [REDACTED]. Hold tube feeding if the residual is over 60 ml. HOB: Elevate HOB 45 degrees at all times during feeding and for at least 30 minutes after the feeding is stopped, dated [DATE]. Review of Resident #1's (MONTH) 2019 MAR/TAR revealed no designated area for recording enteral feeding or residual amounts checked. There was no designated area for recording beginning the enteral feeding or for ensuring the head of the bed was elevated 45 degrees as ordered by the physician. Review of Resident #1's care plan, dated (MONTH) (YEAR), reflected the resident had a [DEVICE]. There were no interventions to keep the head of bed elevated. Review of Resident #1's hospital records dated [DATE] revealed the resident was admitted to the hospital the night of [DATE] with: 1. Aspiration pneumonia 2.[MEDICAL CONDITION]ly due to aspiration pneumonia 3. Acute [MEDICAL CONDITION] Review of Resident #1's progress notes dated [DATE] at 10:50 AM revealed the resident was sent to the local hospital for pulling out her [DEVICE]. Review of Resident #1's Change in condition form dated [DATE] at 7:30 PM and signed by LVN A revealed the resident had abdominal pain, nausea, vomiting. Interview on [DATE] at 3:30 PM with LVN A revealed while taking report from the day shift nurse at approximately 2:00 PM on [DATE], CNA D reported to her that Resident #1 had returned from the hospital with a new [DEVICE] and had bleeding at the [DEVICE] site. LVN A and CNA D went to Resident #1's room. The resident had bleeding at the [DEVICE] site which had saturated the [DEVICE] dressing. There was a small amount of blood on the resident's sheet as well. LVN A notified RN C and advised CNA D to monitor the site and let her know if the bleeding worsened. A short time later, CNA D came and told LVN A the bleeding was still going on, so she stopped her medication pass at approximately 2:30 PM to 3:00 PM and returned to the resident's room. LVN A assessed the [DEVICE] site and saw active bleeding. The [DEVICE] dressing was saturated with blood and she cleaned the area with normal saline and changed the dressing. She checked [DEVICE] placement and residual which were normal. Resident #1 complained of abdominal pain, and LVN A used the non-verbal signs and symptoms of pain to determine the pain level was a 3 - 4 /minimum to moderate pain. LVN A administered a PRN dose of Tylenol 325 mg to the resident. At approximately 6:00 PM, LVN A assessed Resident #1 again and the resident demonstrated abdominal pain, guarding of her abdomen, and was curled up into the fetal position. Resident #1 also started trying to get out of bed. LVN A said the [DEVICE] dressing was dry at that time, but the [DEVICE] itself had blood in the tubing. LVN A called NP [NAME] at that time to advise them the resident was having increased pain and bleeding. NP [NAME] ordered Tylenol #3 and [MEDICATION NAME] at that time. LVN A said she administered Tylenol #3 - 1 tab via the [DEVICE] at approximately 6:30 PM and then she clocked out and went to break. When she returned from her break at 7:07 PM, she returned to the resident's room and found RN B in the room. RN B told her the resident had vomited and she had found the resident with the head of her bed down. LVN A said she stopped the tube feeding and obtained vital signs. LVN A said she instructed CNA D not to lay the head of the bed flat. RN C came in to the resident's room and said she was going to get a suction machine since Resident #1 had vomited. When Resident #1 vomited again, a dark substance was noted. LVN A said she was not sure if it was blood or not. At about 8:00 PM, CNA D told LVN A the resident was trying to get out of bed again. LVN A went to call the doctor, but RN C told her she had already called and had orders to obtain a stat (immediate) x-ray of the chest and abdomen. At approximately 9:00 PM, LVN A assessed the resident and she continued to show signs of pain, so LVN A called NP [NAME] and received orders to send the resident to the hospital. LVN A said the resident went to the hospital via non-emergent transport. When asked why she did not send Resident #1 to the hospital sooner, LVN A stated that she sent the resident out as soon as she received the order to send her, and she had called the non-emergent transport ambulance to transport her. Review of Resident #1's progress note dated [DATE] at 10:59 PM and signed by LVN A revealed Resident #1 was sent to local hospital for bleeding at the [DEVICE] site with concerns of aspiration with nausea. Doctor stated to send resident out to hospital. Family notified. Informed oncoming nurse. Transfer to hospital. Pain level of 7 per PAINAD scale (scale rating pain ,[DATE] based on severity with 10 being the most severe) to abdomen. Review of Resident #1's progress notes dated [DATE] at 5:00 PM and signed by RN C revealed: Called in by CNA (sic) that patient was vomiting. Assess patient. Patient needed to be suction due to vomiting large amount of feeding per nurse. Patient suction by me and moderate amount of feeding noted. Upper lobes clear, but crackles noted in lower lobes. NP notify (sic) to request stat! chest x-ray. Request granted and chest x-ray order by regular nurse. Review of Resident #1's progress note dated [DATE] at 7:52 PM and signed by RN C revealed This nurse try to check residual and noted 5 cc blood. NP notify again and new order for abdominal x-ray stat! Interview on [DATE] at 1:53 PM with RN C revealed Resident #1 was having some vomiting on the evening of [DATE] and she was asked to go in and assess her. She said she checked the lung sounds and heard crackles in the bases of her lungs. She then checked placement of the [DEVICE] and when she aspirated the tube, there was about 10 ml (milliliters) of bright red blood in the syringe. She said she called NP [NAME] and spoke to her. She said after about 15 minutes, she returned to the room to check on Resident #1 and noticed the gauze around the [DEVICE] site was soaked with bright red blood, so she called NP [NAME] again to update her and received the order to send Resident #1 to the hospital for evaluation. When asked what bright red blood indicated, RN C replied, acute onset bleeding. Interview with RN B on [DATE] at 2:26 PM revealed on the morning of [DATE], Resident #1 had pulled out her [DEVICE], was sent to the hospital and it was re-inserted. She returned to the facility later that same day. During her shift, after dinner, the resident's son asked RN B to come and see his mother because she was ill. She said that when she entered the room, she noted vomit coming from Resident #1's mouth and nose, and she saw the head of the resident's bed was down almost completely flat. She said she immediately raised the head of the bed and stopped the resident's feeding. She said she tried to position the resident so that the vomit would go out of the side of her mouth. Resident #1 was coughing and had some dark brown, coffee colored emesis mixed with the formula coming from her mouth. CNA D came into the room and RN B sent her to check the break room for another nurse. After a few minutes, RN C came in and ran to get the suction machine. RN B and CNA D changed Resident #1's clothing which was saturated with blood from the bleeding at the [DEVICE] site. RN B said she took the resident's vital signs and the readings were not alarming to her at the time. RN B said she gave RN C, who was the shift supervisor, the information and she asked permission to return to her hall. By that time LVN A, the primary nurse, was in the room. RN B said she returned to her hall. Later she heard that the resident was taken to the hospital. She stated she knew that Resident #1 had aspirated because the head of the bed was down, and she had been vomiting. RN B said she did not contact the physician, nurse practitioner or the family because she returned to her duties on her own hall and assumed that LVN A or RN C would make the calls since they had assumed care of Resident #1. Interview on [DATE] at 2:08 PM with the DON revealed she was notified about Resident #1 being sent to the hospital due to bleeding to the [DEVICE] site and vomiting after the resident was gone from the facility. The following morning, she reviewed the resident's clinical record and began the internal investigation of the incident. The DON interviewed LVN A, who said Resident #1 returned from the hospital on [DATE] at the beginning of her shift and had a small amount of bleeding at the [DEVICE] site that progressed to moderate bleeding, abdominal pain and vomiting. LVN A said she returned from break to find RN B and RN C in the room with Resident #1, then RN B was released to go back to her hall. The DON then interviewed RN C who said the resident had experienced vomiting, pain ,and bleeding to the [DEVICE] site which resulted in her being transported to a local hospital for evaluation. All nurses, including RN B, RN C, and LVN A received education and were scheduled for skills checks as a result of the incident. The DON said the facility would be conducting continued education and remedial training including skills checks upon hire, annually, and as needed. Interview on [DATE] at 12:18 PM with NP [NAME] (nurse practitioner) for Resident #1 revealed that sometimes there was bleeding with a [DEVICE] replacement. She said that her concern with Resident #1 was pain with bleeding, but LVN A told her that it was only a small amount of bleeding from the [DEVICE] site. She said she instructed LVN A to check the placement of the [DEVICE] and administer pain medications as ordered. When LVN A called her a second time and told her that the bleeding and pain were continuing, she then gave the order to send Resident #1 to the hospital for evaluation. She did not have documentation of the time the facility called her. Interview with MD F on [DATE] at 11:23 AM revealed he would have expected a small amount of bleeding at the insertion site of Resident #1's [DEVICE] after being dislodged and replaced. However, the continued bleeding with abdominal pain and vomiting were concerning and should have been evaluated sooner. The aspiration of bright red blood from the [DEVICE] was emergent and the staff should have responded more quickly to Resident #1's acute changes in condition. Review of the facility's current policy titled Tube (Enteral) Feeding revised (MONTH) (YEAR) reflected the following: Purpose: To maintain or improve the resident's nutritional status and/or weight .2. Head of Bed (HOB): Elevate HOB ,[DATE] degrees at all times during feeding . Review of the facility's current policy titled Interact-Change in Condition Evaluation revised (MONTH) (YEAR) reflected the following: Change in Condition: When to report to the MD/NP/PA. Immediate Notification Any symptom, sign, or apparent discomfort that is: *Acute or Sudden in onset and: * A marked Change (i.e. more severe) in relation to usual symptoms and signs, or *unrelieved by measures already prescribed Further review of Sign and Symptoms pathways contained in the Interact Change in Condition Evaluation form reflected: Signs and symptoms - Abdominal pain - Immediate: Abrupt onset severe pain or distention, OR fever with vomiting. Signs and Symptoms- Nausea- Immediate: Associated with fever, vomiting, or recent change in condition. Signs and Symptoms- Vomiting - Immediate: Persistent or recurrent (2 or more within 12 hours) vomiting, with or without abdominal pain, bleeding, distention/fever. Review of information on [DEVICE]s, obtained on [DATE] from https://www.managedhealthcareconnect.com/article/8614/opillam.aspirationriskandenteralfeeding:aclinicalapproach.[MEDICATION NAME]:,[DATE] reflected, aspiration is one of the most important and controversial complications in patients receiving enteral nutrition, and is among the leading causes of death in tube-fed patients due to aspiration pneumonia patients should be fed sitting up or at a 30- to 45-degree semi recumbent body position. Review of the website: www.aci.health.nsw.gov.au/data/assets/pdffile/,[DATE]/gastrostomy_guide-web.pdf A Clinician's Guide: Caring for people with gastrostomy tubes and devices, accessed on [DATE], reflected: Potential causes of vomiting include: Incorrect positioning of patient during feeding, interventions included ensure patient is upright (greater than 30 degrees) during feeding and for 30 minutes after feeding. Review of the website- http://dodd.ohio.gov/HealthandSafety/Documents/G%20Tube%20Article.pdf,, accessed on [DATE], reflected: [DEVICE] considerations for professionals who coordinate care or provide medical care: Gastrostomy Peritonitis: When the internal end of the feeding tube becomes displaced any fluid, medication or feeding given through the tube can cause severe discomfort, abdominal pain, fever, infection and ultimately death . some individuals may not be able to verbally express pain so check for other signs of pain (for example, changes in vital signs, irritability, or restlessness). Whenever a person has signs of pain associated with the use of a gastrostomy tube, caregivers must find the cause immediately. If there is any possibility that the tube has been displaced and has caused leakage into the abdomen or into the abdominal wall, emergency transfer is necessary . peritonitis can quickly overwhelm a person in fragile health. Findings: It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from [DATE] to [DATE]. The facility took the following actions to correct the non-compliance by [DATE]: Review of the facility's investigation, dated [DATE], revealed education and skills reviews for [DEVICE]s, head of bed elevation, and physician notification of resident changes would be completed upon hire, quarterly, and as needed. Yearly [DEVICE] skill checks for the nurses would be conducted by the DON, ADON, and education specialist. The plan was to be initiated immediately and the facility scheduled the skills checks for January, April, July, and (MONTH) moving forward. The MDS nurses would be responsible for updating the care plan and CNA Kardex to reflect the interventions needed to care for a resident with a [DEVICE]. The information would include head of bed elevation. The staff involved in the incident received counseling and in-services regarding the issues identified on [DATE] which included notification of the physician for changes in resident status, [DEVICE] care, and head of bed elevation. The facility also conducted an audit for all residents with gastrostomy tubes to update the clinical records including the care plans and Kardex with the interventions required for residents with a feeding tube. CNA D was terminated from employment Review of in-services records, dated [DATE], revealed LVN A received education regarding [DEVICE] care, change in condition and notification of physician, documentation, and appropriate times to clock out for break. Further review of the in-services reflected all nursing staff were trained on [DATE] and [DATE] for [DEVICE] care, physician notification with resident changes in status, abuse and neglect, and elevating the head of the bed 30 - 45 degrees for residents with [DEVICE]s. Interviews on [DATE] between 9:00 AM - 3:00 PM with staff on all shifts including LVN A, RN B, RN C, LVN G, LVN H, LVN I, CNA J, CNA K, CNA L, CNA M, and CNA N revealed they received in-services and skills reviews for [DEVICE]s, head of bed elevation, abuse and neglect, and physician notification of resident changes. They were able to verbalize knowledge and understanding of the in-services received. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey.