Every finding on record at Electra Healthcare Center

Based on interviews and record reviews, the facility failed to maintain an effective training program for 14 (ADMN, DON, SW, AD, DM, MS, ADON, LVN A, CNA B, CMA C, TA D, CNA E, LA F, HK G) of 16 existing staff reviewed for training records . The facility failed to ensure 2 of 16 staff (CNA B, LVN A) were not trained in Fall Prevention.The facility failed to ensure 2 of 16 (ADMIN, CNA B) staff were not trained in Infection Control.The facility failed to ensure 1 of 16 (ADMIN), staff were not trained in Abuse and Neglect.The facility failed to ensure 13 of 16 (ADMIN, DON, SW, AD, DM, MS, ADON, LVN A, CMA C, CAN B, LA F, HK G, TA D.) staff were not trained in HIV.The facility failed to ensure 2 of 16 (LVN A, CNA E) staff were not trained in Restraint Reduction. These failures could place residents at risk of receiving care from incompetent/untrained staff.The findings included:Record Review of document titled Personnel Files dated 3/23/2026 on 03/24/2026 at 10:05am it was revealed required training had not been completed for the following staff in the following areas: *ADMIN with hire date of 9/30/2024 in the areas of Infection Control (10-28-2024), Abuse & Neglect (1/29/2025) and HIV (3/24/2026).*DON with hire date of 7/09/2012 in the area of HIV (3-24-2026).*SW with hire date of 10/06/2008 in the area of HIV (3-24-2026).*AD with hire date of 9/2023 in the area of HIV (3-24-2026).*DM with hire date of 12/07/2023 in the area of HIV (3-24-2026).*MS with hire date of 6/09/1997 in the area of HIV (3-24-2026).*ADON with hire date of 3/01/2022 in the area of HIV 3-24-2026).*LVN A with hire date of 6/01/2024 in the areas of Fall Prevention (8-11-2024), HIV (3-24-2026), and Restraint Reduction (3-17-2025).*CMA C with a hire date of 3/31/2025 in the area of HIV (3-24-2026).*CNA E with a hire date of 9/16/2024 in the areas of and Restraint Reduction (3-18-2025).*CNA B with a hire date of 6/01/2024 in the areas of Infection Control (6-6-2024), Fall Prevention (6-10-2024), and HIV (7-21-2024).*LA F with a hire date of 2/17/2025 in the areas of HIV (3-23-2025) and Restraint Reduction (2-17-2025).*HK G with a hire date of 6/01/2024 in the area of HIV (3-23-2025).*TA D with a hire date of 7/29/2025 in the area of HIV (3-24-2026). During an interview on 3/23/2026 at 9:10am with LVN A it was revealed she had worked there for 6 years. LVN A stated she thought her trainings were up to date, but the facility used several different computer-based training sites and it was hard to keep up with. LVN A stated she could not remember the name of the sites they used. LVN A stated they received training from in-services as well and did not know if they counted for training. LVN A stated she did not know who was monitoring the training now as the staff who had been doing it had quit. During an interview on 3/24/2026 at 7:15am with CMA C it was revealed she had worked in the facility for 1 year. CMA C stated all training courses are done online and she did not remember the name of the website. CMA C stated when she logged into the program, it would advise her which trainings were due. CMA C stated she thought she was up to date on all training. CMA C stated no staff had advised her if she had any training that was due recently. During an interview on 03/24/2026 at 10:10 AM with CCO it was revealed that the personnel files were complete to her knowledge. She stated she knew there were some training courses that had not been completed and they were out of compliance. CCO stated she had just taken over the duties of making sure education was up to date and a plan to correct the deficit had been put into place. CCO stated she was not aware HIV training was a separate training on its own and thought infection control covered that area. CCO stated it was her expectation that all staff would have appropriate training to properly care for residents. CCO stated a negative would be that staff may not be able to provide appropriate care. During an interview on 3/25/2026 at 5:02pm with DON it was revealed there were 3 staff members responsible for ensuring education was done for all staff (DON, ADON, COO). DON stated it was an oversite that HIV education was not followed up on. DON stated as soon as they realized it was an oversite; they immediately called the staff that had not done it and told them it needed to be done immediately and it was completed on 3/24/2026. DON stated a negative outcome could be staff not understanding their job duties and staff not understanding the regulations and expectations. DON stated it could have resulted in negative resident care. DON stated they were having a meeting next week (Tuesday 3/31/2026) to appoint an education staff member to avoid oversite again. During an interview on 03/25/2026 at 5:08 PM with CCO provided the facility education calendar for 2025 and the revised calendar for 2026 and stated it was updated to include HIV training and the new calendar will be implemented next week after the meeting on education for staff. CCO stated her expectation for monthly educations was that they will be assigned every month and expectation was to be completed within 3 months. CCO stated the facility does not have a policy for required trainings. CCO stated a negative outcome for training not being up to date could be reduced knowledge of resident care and proper care may not be given. In an interview on 03/25/2026 5:31 PM with ADON it was revealed she was part of the education team. ADON stated they have all seen the holes in the training requirements since filling out the personnel training form. ADON stated they will be having a meeting next week to appoint COO to education coordinator, and she was already working on a new plan. ADON stated a negative outcome would be staff not understanding how to deal with residents correctly or not educated on how to care for them properly. Record Review on 3/25/2026 at 4:46pm of document titled Healthcare Center 2025 Calendar with no date, revealed monthly education topic areas assigned to staff for completion. The document stated [in part]:January- Infection ControlFebruary- Resident Abuse PreventionMarch- RestraintsJuly- HIV EducationNovember- Fall Prevention

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 15 residents (Resident #8) reviewed for Minimum Data Set (MDS) assessment accuracy. (Resident #8) The facility failed to code Resident #8's behavioral status accurately during the MDS look back period. This failure could place residents at risk of not receiving care and services to meet their needs.Findings included: Record review of Resident #8 face sheet dated 3/24/2026 indicated Resident #8 was a [AGE] year-old female initially admitted [DATE] and re-admitted [DATE] with diagnoses which included chronic obstructive pulmonary disease (progressive inflammatory lung disease), chronic respiratory failure with hypoxia (lungs cannot adequately oxygenate the blood), dependence on supplemental oxygen, atherosclerotic heart disease (narrowing of the arteries caused by plaque buildup), depression, bipolar disorder (mental health condition of fluctuating moods), pain, and anxiety. Record review of Resident #8's MDS assessment dated [DATE] indicated Resident #8's Potential Indicators of Psychosis was not checked for hallucinations or delusions nor any behavioral symptoms. Review of the most recent MDS Comprehensive assessment dated [DATE] revealed Resident #8's Potential Indicators of Psychosis was again not checked for hallucinations or delusions nor any behavioral symptoms. Record review of Resident #8's Care Plan dated with an admission date of 1/21/2026 revealed there was no care plan for hallucinations, or delusions. Record review of Resident #8's Progress Notes revealed the resident experienced behaviors, hallucinations, and/or delusions on 1/21/2026. In an interview on 03/25/2026 at 12:29pm LVN H, stated she has worked at the facility over a year, and she had interactions with Resident #8. The Resident had hallucinations since she was admitted and that most of them were of her boyfriend being in the room or frantically looking for him. She stated the resident received services with hospice due to her terminal prognosis and was on continuous supplemental oxygen. She stated the resident would take off her oxygen, become hypoxic (lack of oxygen to the brain), then she gets confused, and starts hallucinating. She further stated when a Resident had symptoms of hallucinations or delusions she would document it in the resident's chart, inform the DON, and pass along the information to the next shift coming on. She stated Resident #8 did not have these symptoms every day but that they had increased in the last couple of months. In an interview on 03/25/2026 at 12:44pm with CNA E, she stated she had worked for the facility for 2 years. She stated she was aware of Resident #8 and her hallucinations and delusions, that she had them off and on since admission. She stated they were more frequent in the last couple months. She stated the resident would yell out and when she would check on her, the resident would have taken her oxygen out of her nose, and that she would get really confused when that happened. Stated she would report to the nurse after she made sure the resident was ok. In a telephone interview on 03/25/2026 at 1:45pm with the Hospice Nurse, she stated she was Resident #8's nurse and was aware of the resident's symptoms of hallucinations and delusions. She stated the facility informs her when that happens and depending on the situation, she would come to the facility to assess the resident herself if needed but that the facility was good about informing her. In an interview on 03/25/2026 at 3:08pm with DON, she stated that it was ultimately her responsibility to make sure the MDS assessments sent to CMS were correct. She stated her expectations of the MDS assessments were that they are initiated or updated by the MDS coordinator and/or herself as scheduled or as needed, and then she would sign off on them and submit them appropriately. She stated that the process of completing the updates to a resident's assessment was to look back 7 days through all orders, physician and nurses progress notes, and labs to have a clear picture reflected in the MDS when submitted. She stated that a negative outcome could be that the resident would not have an accurate picture of his or her care and therefore incorrect reimbursements for the facility. She then stated she was aware that Resident #8 did have hallucination and delusions, and that she was notified when they happened. She also stated that the hospice nurse was aware of these hallucinations as well. She further stated she was responsible for verifying accuracy of all MDS assessments. In an interview on 03/25/2026 at 3:29pm with the MDS, she stated she had worked at the facility for almost a year but had been working with MDS Assessments for 15 years. She stated she was responsible for completing all MDS Assessments (admissions, quarterly, significant changes, and/or corrections) with the assistance of the DON when needed. She stated she would review and pull the information from care plans, orders, progress notes, and other evaluations to get a complete assessment for the residents for the previous 7 days but doesn't remember seeing that she was or was not having these symptoms. She stated that then the DON would sign to submit them to CMS. She stated the expectation was that they were accurate, and an adverse outcome would be the facility not being reimbursed correctly for services. Review of policy titled Certifying Accuracy of the Resident Assessment dated revised November 2019 revealed [in part]:2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment.3. The resident assessment coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the resident assessment coordinator, who is a registered nurse.

Based on record review, and interviews, the facility failed to develop and implement a comprehensive care plan to reflect current condition for 1 of 2 Residents (Resident #8) reviewed for care plan accuracy, in that: Resident #8's care plan was not revised to address the residents' hallucinations and delusions. This failure could place Resident #8 at risk of not having a comprehensive plan of care to address their needs.Findings included: Record review of Resident #8 face sheet dated 3/24/2026 indicated Resident #8 was a [AGE] year-old female initially admitted [DATE] and re-admitted [DATE] with diagnoses which included chronic respiratory failure with hypoxia (lungs cannot adequately oxygenate the blood), dependence on supplemental oxygen, depression, bipolar disorder (mental health condition of fluctuating moods), pain, and anxiety. Record review of Resident #8's MDS assessment dated [DATE] indicated Resident #8's Potential Indicators of Psychosis was not checked for hallucinations or delusions nor any behavioral symptoms. Review of the most recent MDS Comprehensive assessment dated [DATE] revealed Resident #8's Potential Indicators of Psychosis was again not checked for hallucinations or delusions nor any behavioral symptoms. Record review of Resident #8's Progress Notes revealed the resident experienced behaviors, hallucinations, and/or delusions on 1/21/2026 and 2/08/2026. Record review of Resident #8's Care Plan dated with an admission date of 1/21/2026 revealed there was no care plan for hallucinations, or delusions. In an interview on 03/25/2026 at 3:18pm with DON, she stated she was ultimately responsible to make sure the resident's care plans were completed and revised accurately. She stated that it was a group effort to keep up with all the changes that need to be made with the interdisciplinary team. She stated her expectation was for the resident's care plans to be complete and accurate in a timely manner, that a negative outcome could be the resident not receiving care needed but she was not sure how these symptoms did not make it into the care plan. She further stated she was responsible for verifying accuracy of all care plans. Review of policy titled Goals and Objectives, Care Plan dated revised April 2009 revealed [in part]:Policy Statement: Care plans shall incorporate goals and objectives that lead to the resident's highest obtained level of independence.3. Care plan goals and objectives are derived from information contained in the residents' comprehensive assessment.b. are behaviorally stated.4. Goals and objectives are entered into the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. Review of policy titled Care Plans, Comprehensive Person-Centered dated revised March 2022 revealed [in part]:Policy Statement: 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.2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MSD assessment (admission, annual, or significant change in status), and no more than 21 days after admission.7. The comprehensive, person-centered care plan:b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of policy titled Care Plans, Baseline dated revised March 2022 revealed [in part]:9. Care plan interventions are chosen only after gathering data, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents conditions change.

Based on record review and interview, the facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms for 27 of 31 rooms (Room #s 3, 5, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, and 35) reviewed for square footage. The facility failed to ensure multiple-bed resident rooms had the required 80 square feet of floor space per resident for room #s 3, 5, 8, 9, 10, 11, 12,13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 34, and 35. This failure could place residents residing in these rooms at risk for not having adequate living space and could adversely affect residents from attaining his or her highest practicable well-being.The findings included: Review of the facility's Form 3740 Bed Classifications, completed by the Administrator and dated 03/25/2026, revealed room numbers 3, 5, 8, 9, 10, 11, 12,13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, and 35 were included in the licensed bed capacity as double occupancy rooms. In an interview on 3/24/26 at 9:02 AM, the Administrator stated he wanted to continue the room size waiver for all the rooms listed on the Bed Classification form and Notification of Change letter.

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 1 of 1 kitchen reviewed for food safety. These failures could place residents at risk of food-borne illness and a diminished quality of life. 1. The trash can at the hand sink was full, smelled of rotten food, and had a pan of individually wrapped cookies on top of the lid. 2. Staff B touched food surfaces while filling plates with food. 3. The kitchen drawers had an accumulation of food debris in the bottom. 4. The dry storage room had plastic bins that were greasy and had debris in the bottoms. 5. The freezer had chicken and ham in it with freezer burn. 6. Dietary staff had hair that was not completely covered and hand washing was not done correctly. 7. The facility failed to ensure all food in the dry pantry and cold storage areas were properly sealed, labeled and dated. 8. Dishes were stored face up (open to air contamination 9. Aluminum cans of resident juices stored on the shelf with dishwasher chemicals 10. Cans in the dry storage room are dusty and dented. 11. Single use plastic lids for cups and bowls, and plastic soup spoons are stored open to air. 12. Chemicals were stored with the food. These failures could place residents at risk of food-borne illness and a diminished quality of life. Findings included: Initial observation and interview on 1/5/25 beginning at 9:40 a.m. revealed: - The trash can at the handwashing sink was full and smelled of rotten food. On top of the trashcan lid was a cookie pan with individually wrapped cookies on it dated 1/4/25. - By the handwashing sink was chemicals for the dishwasher stored next the resident juices. - Observation of the refrigerator revealed a pitcher of a red liquid that was unlabeled and undated. Staff A said it was fruit punch prepared on 1/4/25. There were also 3 bags of cheese left open to air. - Observation of the dry storage revealed: - storage bins holding condiments had an accumulation of grime on the outside. On the inside of the bin holding syrup was a puddle of syrup in the bottom. The other bins had an accumulation of food debris on the bottom of them. - the cans were dusty. Some of the cans were dented and mixed with undented cans. Staff A stated dented cans were not separated from undented cans and dented cans were used like undented cans. -Prepackaged coffee bags, box was left open leaving the contents open to air. - Observation of the freezer revealed freezer-burnt ham and chicken with an accumulation of ice crystal on them. - In boxes next to the freezer were open bags of plastic spoons, Styrofoam cups and lids all left open to air. Observation of the meal preparation and service on 1/6/25 beginning at 10:45 a.m. revealed: - At 11:20 a.m., Staff B rinsed with water for less than 5 seconds and put on gloves. Staff B began to plate food. Staff B touched the eating surface of every plate she served with both hands. - The two drawers holding knives and serving utensils had an accumulation of crumbs, splashes of dried liquid and dust. - Staff B, Staff C and the DM did not have effective hair restraints. Interview on 1/6/25 at 11:45 AM, the DM said eating surfaces on the plates should not be touched with either gloved or bare hands. Interview on 1/7/25 at 10:04 AM, the DM stated the expectation of the freezer burnt food in the freezer was it was not to be served. The DM said there was no training about what to do with freezer burnt food. The DM stated about the bins in the dry storage, some cleaning has been done since the hospital took over, we still have more to go. The DM stated the cookies on top the trash can were trashed and the expectation was to not serve it. The DM said there was no training about not serving food off an unsanitary surface. The DM stated the expectation was things were not left open to air, and that should not be happening. The DM stated it was in the policy to keep sealed but she no training on it. The DM said the staff should know better than to leave dented cans in the dry storage. The DM said her expectation on dented cans was the staff were not to use them and for them to be separated from the other cans; the DM stated there was a space in her office which was accessible at all times for the dented cans. The DM said this was not in policy and did not have any training for the staff on it. The DM said her expectations was hair be covered at all times in the kitchen. The DM admitted her hairnet was not on effectively because her bangs just slipped out. The DM was informed 3 of 4 staff including the DM during the lunch observation did not have on an effective hair net. The DM said it was not in the policy and she did not have any in-services on it. The DM said the juice mixed with dishwashing chemicals was not appropriated storage and that was covered in the facility's policies. Interview on 1/7/25 at 10:25 a.m., the Administrator was informed of the kitchen observations. Record review of the facility's policy titled Food Receiving and Storage dated 11/2022, revealed the following in part: .Non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. .Food services, or other designated staff, maintain clean and .Non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit. .Foods may not be stored: under other sources of contamination. : .Housekeeping personnel will empty garbage and refuse containers daily. .Foods may not be stored: in garbage rooms. .Foods may not be stored: under other sources of contamination. .Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. .All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date).

Based on interview and record review, the facility failed to include resident or the resident's representative in the IDT (Interdisciplinary team) in the comprehensive care planning within 7 days after completion of the comprehensive assessment for 2 of 4 residents (Resident #8 and Resident #10) reviewed for care plan timing/revision. The facility failed to ensure Resident #8 and Resident #10's care plan was reviewed by the IDT (Interdisciplinary team), which failed to include the resident or the resident's representative after the Comprehensive MDS assessment. This failure placed the residents at risk for not having individual needs identified and care and services provided to meet their needs and promote quality of care, feelings of well-being and quality of life. The findings included: Resident #8 A record review of Resident #8's Admission Record, dated 01/07/2025 revealed Resident #8 had an admitted [DATE]. Resident #8's had a primary diagnosis was unspecified dementia (a group of symptoms affecting memory, thinking and social abilities). A record review of the Resident #8's Quarterly MDS assessment, dated 12/12/2024, revealed a BIMS score of 00, which means the resident was severely impaired. A record review of Resident #8's comprehensive care plan revealed it was last Reviewed/Revised on 01/05/2025. There was no documented evidence that a care plan meeting was conducted for this care plan. A record review of Resident #8's progress notes revealed there was not a care plan meeting conducted since admission on 10/10/2024. In an interview with Resident #8 on 01/05/2025 at 10:25 am, he failed to answer if he had been invited or had participated in a care plan meeting. Resident #10 A record review of Resident #10's Admission Record, dated 01/07/2025, revealed Resident #10 was a [AGE] year-old male/female who had an admitted [DATE]. Resident #10 had a primary diagnosis of Infection following a procedure, deep incisional surgical site, and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A record review of the Resident #10's Admission MDS assessment, dated 12/18/2024, revealed a BIMS score of 15, which means the resident was cognitively intact. A record review of Resident #10's comprehensive care plan revealed it was last Reviewed/Revised on 01/05/2025. There was no documented evidence that a care plan meeting was conducted for this care plan. A record review of Resident #10's progress notes revealed there was not a care plan meeting conducted since admission on 12/06/2024. In an interview with Resident #10 on 01/05/2025 at 1:36 pm, she said she had not been invited or had participated in a care plan meeting. In an interview with the DON on 01/07/2024 at 11:17 am, she said she was responsible for scheduling the care plan meetings. She said there was no documentation of a care plan meeting or that she can remember having a care plan meeting for Resident #8 since admission. The DON said she attempted to contact Resident #10's family for a care plan meeting and they never responded. She said it got pushed back due to the holiday activities. The DON said potential negative outcomes of not including the resident or their representative in a care plan meeting would be the resident or representative would not understand the care they were receiving, and the facility wouldn't know of resident's needs. A record review of the facility policy Care Planning - Interdisciplinary Team, dated as revised March 2022, revealed the following [in part]: Policy Statement: The Interdisciplinary Team is responsible for the development of resident care plans. Policy Interpretation and Implementation: 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an Interdisciplinary Team (IDT). 3. The IDT includes but is not limited to: e. to the extent practicable, the resident and/or resident's representative. 6. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record.

51011 Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 14 residents (Residents #120) reviewed for care plans. The facility failed to have a care plan for Resident #120's Hospice status. These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Review of the most recent Minimum Data Set (MDS), dated [DATE], revealed: Resident #120 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included stroke, Non-Alzheimer's Dementia, seizure disorder, and malnutrition. Resident #120 had a BIMS of 15 of 15 (indicating cognitively intact). Review of Resident #120's Care Plan last revised on 12/16/2024, revealed: Hospice status was not included in the care plan. Review of Resident #120's Physician Orders revealed order dated 07/31/2024: Admit to Hospice, Diagnosis Senile Dementia written by Resident #120's primary care physician. Review of Resident #120's Face Sheet revealed: Hospice Medicaid as the Primary Payer and a Hospice company as an External Facility involved in Resident #120's care. In an interview on 01/07/25 at 4:40 PM, the DON stated she was responsible for the Care Plans. The DON stated she did not realize that Hospice services needed to be care planned. The DON said she thought a hospice care plan would be necessary because so all staff are aware of the resident's needs. Record review of the facility's Care Plans, Comprehensive Person-Centered policy (revised 03/2022) read in part The comprehensive, person-centered care plan: describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on interview and record review, the facility failed to ensure all Preadmission Screening and Resident Review (PASARR) Level I (PL1) Screening residents diagnosed with mental illness were provided with a PASARR Level II (PE) Screening for 2 of 3 residents (Resident #10 and Resident #15) reviewed for a mental illness, intellectual disability, or developmental disability. The facility failed to ensure Resident #10 and #15 who had a diagnosis of mental illness had a PASARR Level II (PE) screening completed. This failure placed residents at risk of mental health needs not being met. The findings included: Resident #10 A record review of Resident #10's Admission Record, dated 01/07/2025, revealed Resident #10 had an admitted [DATE]. Resident #10 had a primary diagnosis of Infection following a procedure, deep incisional surgical site, and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A record review of a PASARR Level I (PL1) Screening, dated 12/04/2024, indicated Resident #10 had no evidence of mental illness. No PASARR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record. A record review of the Resident #10's Admission MDS assessment, dated 12/18/2024, revealed Active Diagnosis of Depression. The resident had a BIMS score of 15 which indicates the resident was cognitively intact. A record review of Resident # 10's Care Plan, with a revision date of 12/17/2024, indicated Resident #10 may develop Impaired coping related to diagnosis of Major Depressive Disorder. A record review of Resident #10's Physician Order Summary Report, dated 01/07/2025, indicated Resident #10 received duloxetine 90mg daily for diagnosis of Major Depressive Disorder. Resident #15 A record review of Resident #15's Admission Record, dated 01/07/2025, revealed Resident #15 had an admitted [DATE]. Resident #15 had a primary diagnosis Parkinson's Disease (a neurodegenerative disease primarily of the central nervous system, affecting both motor and non-motor systems), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a group of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired). A record review of the Resident # 15's Admission MDS assessment, dated 11/22/2024, revealed Active Diagnosis of Anxiety Disorder and Depression. The resident had a BIMS score of 15 which indicates the resident was cognitively intact. A record review of a PASARR Level I (PL1) Screening, dated 11/15/2024, indicated Resident #15 had no evidence of mental illness. No PASARR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record. A record review of Resident # 15's Care Plan, with a revision date of 01/05/2025, indicated Resident #15 has depression related to disease process (Parkinson's). A record review of Resident #15's Physician Order Summary Report, dated 01/07/2025, indicated Resident #15 received sertraline 100mg daily for diagnosis of Major Depressive Disorder. In an interview on 01/07/2025 at 11:23 am, the DON stated the Social Worker was responsible for updating the PASARR's. She did not know a PASARR needed to be updated when they came from the hospital. She said a potential failure would be the resident would not receive services they would be eligible for. In an interview on 01/07/2025 at 2:04 pm, the Social Worker said she was responsible for PASARR's. She said Resident #10 and Resident #15 should have a new PASARR (PL1) screening completed due to having a diagnosis of Major Depressive Disorder but was not aware the residents had a diagnosis of a mental illness. She said a potential negative outcome of this failure would be a resident might not receive PASSAR services if they were eligible. Record review of the facility policy Admission Criteria, dated as last revised March 2019, revealed the following [in part]: Policy Interpretation and Implementation: 9. All new admission and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASAR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID or RD. b. If the Level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 3 of 6 (DON, DM, SW) staff reviewed for abuse protocol. The facility failed to complete annual Criminal Background Checks for the DON, DM, and SW. This failure could place residents at risk for abuse, neglect, and exploitation. Findings included: Record review of the DON's personnel file revealed no annual criminal background check completed since 07/03/2012. The DON had a hire date of 07/09/2012. Record review of the DM's personnel file revealed no criminal background check completed previously. The DM had a hire date of 11/06/1995. Record review of the SW's personnel file revealed no criminal background check completed previously. The SW had a hire date of 10/06/2008. In an interview on 01/07/25 at 04:45 PM, the CSM stated she was the staff member responsible for completing all background checks and that she did the DON, DM, and SW background checks on 1/7/25. She said when she pulled staff records for the survey, she realized they had not been done. CSM stated, I did not realize background checks are required on every staff member. I also did not know that background checks are required annually. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy (revised 04/2021) read in part Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, facility staff . Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.

Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistance devices was provided for 1of 2 residents reviewed for transfers. (Resident # 119). The facility did not assess Resident #119 for use of a lift device even though he was non-weight bearing. The facility failed to ensure staff transferred Resident #119 in a manner to prevent injuries. The staff performed one-person lifts by hugging the resident or hooking their arms under his shoulders. This failure could place residents who required assistance during transfers at risk for pain and injury. Findings included: Review of Resident #119's Admission Record dated 1/7/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including Lowe's Syndrome (a rare genetic order that causes weak muscle tone and abnormal spine). Review of Resident #119's Quarterly MDS assessment dated [DATE] revealed: He had severely impaired decision-making skills and signs of delirium to include inattention and disorganized thinking,. He used a wheelchair, He was completely dependent on staff for all ADL's including transfers, and He weighed 93 pounds. Review of Resident #119's care plan initiated 10/19/24 revealed: Focus: The resident has an ADL self-care performance deficit. Goal: The resident will achieve maximum functional mobility. Interventions included: Transfer: The resident is totally dependent on 1 staff for transferring. Review of Resident #119's Order Summary Report, dated 1/7/25, revealed orders: Non weight bearing bilateral (both) lower extremities dated 8/4/24. Review of Resident #119's vital signs revealed Resident #119 weighed 90 pounds on 1/2/25. Review of Resident #119's electronic record to include assessments and miscellaneous revealed no assessment on safe transfer ability. Interview on 1/6/25 at 1:51 p.m., CNA E stated Resident #119 was not weight bearing and was a one-person transfer. CNA E described a transfer Resident #119 as a hug, that Resident #119 would hug the staff and then the staff would just pick him up. CNA E said Resident #119 was 90 pounds if that. CNA E said Resident #119 was not weight-bearing and his feet would not touch the ground during the transfer. Observation on 1/6/25 at 4:32 p.m., CNA E locked Resident #119's wheelchair and then put Resident #119's hands on her shoulders. CNA E was observed putting her arms around Resident #119 under his arms and pulled him out of the wheelchair, pivoted, and placed Resident #119 in the bed. Resident #119 feet did not drag on the ground. Interview on 1/6/25 at 4:52 p.m., COTA G stated a safe one-person transfer would be to use a gait belt. COTA G stated the process was to put the gait belt on the resident, get the foot pedals out of the way if necessary, turn the resident's feet a little bit in the direction of the turn, have the resident put their hands on the aide's shoulder and on the count of three have the resident stand, assist to pivot and have the resident sit where they were transferring to. COTA G stated she did not think it was safe to transfer one-person if the person was non-weight bearing and the person would need some help to do it safely. COTA G stated in Resident #119's situation it would be safe because all he knew was, he wanted up at that moment and would not wait for another person to come. COTA G stated a gait-belt should be used. COTA G said if not gait belt was used the person could throw their arms up and slide out of the aide's arms and fall right out. COTA G stated she talked to the staff about transfers multiple times and the last time was right before Christmas. Interview on 1/6/25 at 5:22 p.m., the DON stated her expectation for a non-weight bearing transfer for someone like Resident #119 was he could be safely transferred one-person because he was 90 pounds. The DON said if he was having behaviors, she would expect the aides to ask for help The DON said the care plan was to pick him up and scoot him over so he does not fight the aides. The DON said alternates to the one-person transfer could be a slide-board if the wheelchair could accommodate it or a mechanical lift with a sling. Interview on 1/7/25 at 11:21 a.m. CNA F said Resident #119 had cysts on his back and the aides were afraid if they used the gait belt the cysts would be ripped open, and Resident #119 would become combative. CNA F and CNA E who was also present said Resident #119 would be appropriate for a mechanical lift transfer if someone held his hands during the transfer. Review of the facility's policy and procedure on Safe Lifting and Movement of Residents, dated 2001, revealed: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation: 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess the individual residents' needs for transfer assistance on an ongoing basis. Staff will document transferring and lifting needs in the care plan. Such assistance shall include the following: Resident's mobility (degree of dependency); Resident's size; Weight-bearing ability; Cognitive status; Whether the resident is usually cooperative with staff.

Based on record review and interview, the facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms for 35 of 36 rooms (Rooms #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36) reviewed for square footage. The facility failed to ensure multiple-bed resident rooms had the required 80 square feet of floor space per resident for rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36. This failure could place residents residing in these rooms at risk for not having adequate living space and could adversely affect residents from attaining his or her highest practicable well-being. The findings included: Interview on 1/5/25 at 10:48 a.m. the Administrator stated he was aware the facility had a room waiver granted on the 11/29/23 survey and wanted to continue to have the room waiver. Review of the facility's Form 3740 Bed Classifications, completed by the Administrator and dated 11/29/2023, revealed room numbers 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36, were included in the licensed bed capacity as double occupancy rooms. Review of the Texas Health and Human Services letter dated 6/9/22 revealed the rooms 3, 5, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, and 35 had the waiver for less square footage than required granted. In an interview on 1/7/24 at 11:42 a.m., the Administrator stated he wished to continue the room size waiver for all the rooms listed on the past Form 3762.

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, observed for kitchen sanitation. The facility failed to ensure the following: A. Appliances were clean. B. Food items in the refrigerator had not expired. C. Floors were clean. D. Dish machine temperature and sanitizing logs were documented. These failures could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness and food contamination. The findings include: In an observation and interview on [DATE] at 9:15 AM, during the initial tour of the kitchen revealed the following: - the exterior surface of the stove were soiled with dried food and grease; - the top exterior surface of the deep fryer were soiled with food crumbs and grease; - the interior of the microwave were soiled with dry food splatters; - the floor under the stove were soiled with food, grease and dirt; - the floor in the kitchen was sticky; - 3 expired quart containers of chicken salad were in the refrigerator, dated [DATE] with a best used date by [DATE]; - dish washing machine temperature and sanitizing log had not been completed from [DATE] to [DATE]. The Dietary Manager said she has been off for a month, and this was her first day back on the job. She said her expectation was for the stove, microwave, fryer, and floor to be cleaned daily. She said all expired food should be thrown away. She said the dish machine should be tested at breakfast, lunch and dinner and results logged. She said failure to do so has the potential to make the residents sick. In an interview on [DATE] at 11:21 AM, Cook A said she tested the dish machine but does not always log it in the book. Cook A stated When asked what the dates on the food represents, she did not know if the date written on the food was when the food was opened or when the food expired. In an interview on [DATE] at 3:05 PM, the Administrator said the Dietary Manager walked out of the job on [DATE]. She was aware the stove needed to be cleaned and someone was scheduled to come out next week. She said she was unaware of expired food in the refrigerator. She said the dish machine should be tested at each meal. Failure to do so has the potential for the dish machine to not be sanitizing the dishes and the risk of food contamination and infection. A facility policy regarding kitchen sanitation was requested but not provided by exit. According to the Food Code, (https://www.fda.gov/food/fda-food-code/food-code-2022 accessed [DATE]), Food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained free of accidents and hazards and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Resident #2 and # 170) whose records were reviewed for accidents and supervision. The facility failed to ensure Resident #2 and Resident #170's wander guards were checked for functionality. This failure could place residents at risk of elopement or leaving area without supervision. The findings include: 1.Record review of Resident #2's face sheet, undated, revealed the resident was an [AGE] year-old female admitted to facility on 01/07/19 with diagnoses of Dementia with behavioral disturbance, Bipolar Disorder II (a mental health condition defined by periods of mood disturbances), Anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events), muscle wasting (loss of muscle mass), abnormal posture, Chronic pain, and hypertension (high blood pressure). In an observation on 11/28/23 at 09:28 AM Resident #2s wander Guard was placed on the wheelchair. Resident #2 had contractures of all extremities but could self-propel in a wheelchair around the facility without assistance. In an interview on 11/28/23 at 09:30 AM The ADON stated she checked the wander guard system every shift by pushing Resident #2 and wheelchair by the alarm. The ADON was not observed checking placement. 2.Record review of Resident # 170's face sheet, undated, revealed the resident was admitted to facility on 11/16/23 was a [AGE] year-old female with diagnoses of psychotic disorder with delusions due to known physical condition (fixed, false conviction in something that is not real or shared by other people). Record review of progress note dated 11/16/23 at 7:12 PM, written by unidentified LVN revealed Resident #170 had exit seeking behavior. Orders for Wander Guard documented. In an interview with the DON on 11/28/23 at 10:00 AM she said they check the alarms by placing the Resident #'s 2 and 170 in the wheelchair by the door alarm each shift in order to check its function by setting off the alarm. The DON said that there was not a device that checked function of the wander guard. In an interview with the Corporate RN on 11/28/23 at 4:00 PM she stated the facility should be check the wander guard for function with a device designed to check it's function per the facilities policy. She stated she had placed an order for the device. She stated failure to check function of the device each shift could result in elopement of the resident. In a record review of Facility Policy for Wandering and Elopements on 11/28/23 at 4:20 PM (in-part) 2. check placement every shift, and functionality daily.

Based on interview and record review, the facility failed to ensure that residents with PRN orders for psychotropic drugs were limited to 14 days for 1 of 4 residents (Resident #1) whose medication regimens were reviewed for unnecessary medications in that: Resident #1 had an order for the benzodiazepine medication Alprazolam (Xanax) 0.5 mg by mouth 1 tablet daily as needed (PRN) for anxiety, dated 10/21/2023, which did not have an end/stop date. This failure could place residents administered PRN and routinely scheduled psychotropic medications at risk of adverse side effects from prolonged use of psychotropic medications. The findings included: Record review of Resident #1's face sheet, dated 11/28/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnosis of generalized anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's care plan, last reviewed/revised on 09/08/2023 revealed the care plan I receive antianxiety medication, Buspar and Xanax for treatment of anxiety. Record review of Resident #1's Physician Orders, undated revealed an order for Alprazolam (Xanax) 0.5mg 1 tablet daily PRN for anxiety. Start date of 10/21/2023. The order did not specify a stop date. Record Review of Resident #1's Medication Administration Records dated 11/01/2023 through 11/28/2023 revealed the resident received Alprazolam (Xanax) 0.5mg PRN on 10/28/23, 11/14/23, 11/15/23, 11/24/23, and 11/25/23. Record review of physician's progress notes for the month of November 2023 did not reveal any documentation of justification for not having a stop date for Alprazolam (Xanax) PRN. In an interview on 11/29/23 at 11:30 AM, the Regional Corporate Nurse said the order for Xanax PRN should have a stop date no later than 14-days. She said a possible negative outcome would be the resident would receive medication they did not need. In an interview on 11/29/23 at 2:08 PM, the DON said there was not a stop date for the Xanax PRN as the Nurse Practitioner was charting a justification each week so it would not have to reordered every 14-days. The DON said a possible negative outcome would be the resident was using the medication for a prolonged time and they did not need it due to sedation. The DON said it was her responsibility to ensure psychotropic PRN medications are not prescribed for more than 14-days. Record Review of the facility policy Medication Orders - Stop Orders, dated 06/01/2022, revealed the following [in part]: Policy: New medication orders are subject to automatic stop orders unless the medication orders specify the number of doses or duration of medication. A time limit is included in recapped orders. Procedures: The following classes of medications, whether the order is for routine or as needed (PRN) use, are stopped automatically after an established number of days . 7. PRN psychotropic medication orders 14 days.

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured and labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (med Cart A) reviewed for proper drug storage and labeling. In medication cart A there was an opened vial of insulin belonging to Resident # 7 that was not dated when opened and was not in the original pharmacy labeled box that it was dispensed in. This failure could affect residents who receive medications in the facility and place them at risk of receiving incorrect medications or ineffective therapeutic doses related to expired medication. The findings include: An observation on [DATE] at 8:30 AM of medication cart A, revealed the top drawer contained an open, bottle of undated insulin belonging to Resident # 7. The vial was laying in the drawer with no box, dosing information or expiration date. It was labedled with the residents name and medication name. In an interview with the ADON/LVN that was charge nurse, on [DATE] at 8:30 AM she stated the vial of insulin should have the opened date on the bottle and should be stored in the original box labeled with the resident's name and directions for use. She stated failure to date the vial when opened could result in an ineffective therapeutic response for the resident . She stated she would dispose of the insulin, open a new vial, and date it as certain insulins are only good for ,d+[DATE] days after opening In an interview on [DATE] at 10:45 PM the DON revealed it was her expectation that insulin vials be dated when opened and kept in the box with the resident's name, directions for use and expiration date. Review of facility policy titled Storage of Medications revised November of 2020 revealed in part: Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the dispensing pharmacy is authorized to transfer medications between containers.

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with state and federal laws for 2 of 2 med carts ( Med Cart A and Med Cart B ). The facility failed to keep loose unidentified pills secured in their pharmacy labled packaging in medication cart A drawer . The Controlled Drug change of shift count logs were missing signatures on both medication carts. These failures could affect residents who receive medications in the facility and place them at risk of receiving incorrect medications, ineffective therapeutic doses, and drug diversion. The findings include: Medication Carts 1.An observation on 11/29/23 at 8:30 AM of the Back Hall Medication Cart A revealed the second drawer contained unidentified pills littering the bottom of the drawer. In an interview and with the ADON/ LVN charge nurse on 11/29/23 at 10:10 AM she stated it was each Nurses responsibility to see that the medication carts were clean and orderly. She stated her cart did not normally contain loose, unidentified pills. She stated she had not checked the cart for cleaning today. She stated she had not had time to clean the cart, the loose pills were due to the cart containing so many medication cards. She denied knowledge of what pills were laying in the bottom of the drawer. She stated unidentified pills laying in the med cart could result in a drug diversion, or residents not receiving the correct dosage of medication. In an interview on 11/23/23 at 10:45 AM with the DON, she revealed it was each nurse's responsibility that medication carts were kept clean. She stated it was her expectations that drugs should be stored in the original labeled packaging and that nurses be responsible for cleaning their own carts. She stated carts are checked by the pharmacy consultant during their monthly visit. 2.Record review of the Second Shift Controlled Drug Count Record revealed the facility worked 12-hour shifts. The sheets were missing signatures on the following dates and shifts in November of 2023: Cart A *11/14/23 off going nurse signature, *11/15 oncoming and off going nurse signature missing, *11/21/23 off going nurse signature missing, and *11/26/23 on coming and off going nurse signatures missing. Cart B *11/25/23 and 11/26/23 on coming and off going shifts signatures missing; on coming and off going shifts signatures missing. During an interview on 11/29/23 at 8:30 AM with the ADON who was the 7AM - 7PM charge nurse, she said staff should be signing in and out when taking possession of the medication cart and be documenting medications in the MAR when they are signed out of the Narcotic Log. She said it was the responsibility of the charge nurse to monitor the sign in sheets as well as review they are being completed. She stated nurses were to count drugs at the beginning and end of their shift with the oncoming nurse, and both shifts should sign the log signifying that they accepted the count of the narcotics as correct, and they are accepting responsibility for the contents of the cart. She stated failure to do so could result in a drug diversion. During an interview with the DON on 11/29/23 at 10:30 AM, she said staff should be signing the sign in and out narcotic log (Control Count Sheet) when they take possession of the cart. She stated it was her responsibility as the DON to be monitoring to see that it was done. She stated failure to count narcotics, could result in a drug diversion. Review of facility policy titled Storage of Medications dated revised November 2020 revealed in part: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments and under proper temperature, light and humidity controls. Drugs and biologicals are stored in the containers in which they are received. The nursing staff is responsible for maintaining medications storage and preparation areas in a clean safe and sanitary manner .At the end of each shift the nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled drug count are documented and reported to the DON immediately.

Based on record review and interview, the facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms for 35 of 36 rooms (Rooms #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36) reviewed for square footage. The facility failed to ensure multiple-bed resident rooms had the required 80 square feet of floor space per resident for rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36. This failure could place residents residing in these rooms at risk for not having adequate living space and could adversely affect residents from attaining his or her highest practicable well-being. The findings included: Review of the facility's Form 3740 Bed Classifications, completed by the Administrator and dated 11/29/2023, revealed room numbers 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36, were included in the licensed bed capacity as double occupancy rooms. Review of the prior completed Form 3762, Room Size Waiver for Facilities, dated 09/27/2022 revealed resident bedroom numbers 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36 were listed as meeting the justification criteria for a room size waiver. In an interview on 11/29/23 at 2:57 PM, the Administrator stated she wanted to continue the room size waiver for all the rooms listed on the past Form 3762.

Based on observation, interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of three residents (Resident #5) reviewed for quality of care. The facility failed to ensure skin assessments, wound care and skin treatments were provided, since Resident #5 was admitted into the facility on [DATE]. His diagnoses included skin and bone infection and toe amputation of his right foot. On 4/24/23 an open wound was discovered to his right foot. No action was taken until 4/25/23 when he was taken to the emergency room and given antibiotic treatment for an open wound to the right foot with purulent drainage. An Immediate Jeopardy (IJ) situation was identified on 5/15/2023 at 4:15 PM. While the IJ was removed on 5/17/2023 at 2:05 PM, the facility remained out of compliance at a scope and severity of isolated with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of pain, worsening of wounds, wound infection, emotional distress, harm or even death. The findings included: Record review of Resident #5's face sheet revealed a [AGE] year-old male who was admitted to the facility, on 04/17/2023, from the hospital. Resident #5 had diagnoses which included: displaced fracture of right femur; (longest, strongest bone in your body that supports your weight); unspecified open wound of right great toe, without damage to nail; acquired absence of other right toe, post second toe amputation (great right toe and second toe is missing); cellulitis of right toe (bacterial infection involving inner layers of the skin); non-pressure chronic ulcer of other part of right foot, with unspecified severity; type 2 diabetes mellitus, with foot ulcer (disease that results in high blood sugar and inadequate circulation to the feet which results in diabetic ulcers), and hypertension (high blood pressure). Record review of the Hospital Discharge notes, dated 04/15/2023, revealed the following: Active Problems Cellulitis of right toe (bacterial infection involving inner layers of the skin); Osteomyelitis of second right toe (infection of the bone); Neuropathic Ulcer limited to skin breakdown; and Neuropathic ulcer with fat layer exposed (diabetic ulcer on the foot). Record review of Resident #5's progress notes, made by the MDS/LVN, dated 04/18/2023 at 10:42 AM, revealed Integumentary Monitoring and Evaluation: Pressure Reducing Mattress, Diabetic Ulcer Monitoring and Surgical Incision Monitoring. Record review of Resident #5's facility record revealed there were no admission notes or assessments completed. There was no documentation regarding the condition of his skin and the wounds he admitted with. Record review of Resident #5's Skilled Observation notes, dated 04/18/2023, revealed all skin areas, in the observation, were left blank and the note was signed, as completed. Record review of Resident #5's care plan, dated 04/20/2023, revealed the following: Weekly Head to Toe Skin Check. There was no diabetic ulcer or wound care areas care planned. Record review of Resident #5's Skilled Observation Notes revealed there were no weekly head to toe skin checks. Record review of Resident #5's Admission MDS, dated [DATE], revealed a BIMS score of 10, which indicated the resident had moderately impaired cognition. Resident #5 had, occasional pain, with an intensity of 5, reported within the past 5 days, and no venous or arterial ulcers were noted as being present. Record review of Resident #5's therapy notes, dated 04/24/2023, revealed an open area on right lower extremity where toes were previously amputated, no dressing. The DOR notified about findings and possible need for wound care. Record review of Resident #5's clinical record, dated 04/25/2023 at 7:10 AM, revealed there were no documented skin assessments, no head-to-toe assessments, and no documented skin treatments since admission and there was no documented wound care, done on this resident, since admission. Record review of Resident #5's Wound Management revealed the resident had no wounds or skin issues identified. Record review of Resident #5's Skilled Observation Notes revealed the resident had no Braden Skin Assessments completed, since his admission to the facility, on 04/17/2023. Observation and interview, on 04/25/2023 at 7:00 AM, with Resident #5, revealed he was sitting in his wheelchair. RN A removed Resident #5's walking boot, to show the resident's foot. There were 2 toes missing, which were the great toe and the second toe. There were no bandages covering the area. There was a large open area with no scab where the second toe used to be. Resident #5 revealed he had hit his toe on the doorway 2 days after admission, which would have been 04/19/2023. He stated he had notified the DON immediately after the incident. The resident stated he had not had any type of wound care since admission into the facility. He stated RN A was working at that time, was the only nurse who had cleaned the area and kept it covered. He stated it caused pain at times, but not every day. Interview on 04/25/2023 at 7:05 AM with RN A revealed that when she was working, she provided care to the resident's foot. She stated that there were no orders, but with any resident she would make sure the area was clean, dry, and not infected. Interview with the DON, on 04/25/2023 at 7:20 AM, revealed there were no skin assessments documented for the Resident #5. The DON stated she had completed skin assessments since the resident entered the facility. The DON stated she stated she could not provide a copy of the assessments because they were only in her head. She revealed she had not had time to document the assessments due to working the floor. She revealed she knew the resident had wound issues and she had gotten behind on documentation and treatments. She stated that she did not notify the MD of the resident's skin issues and the diagnosis related to his foot. She stated she knew the resident injured his foot on the door, but she was unsure when it occurred since she had not documented it. She said when she had time, she would complete the skin care assessments, and do a wound care referral. She said that skin assessments and wound care referrals should be completed as soon as the resident admits to the facility and when the problem is identified. Interview on 04/25/2023 at 11:50 AM with the DOR revealed she was notified of Resident #5's wound issues on 04/24/2023. She reported the wounds to the DON immediately. She was notified of the wounds by the physical therapist. Interview on 04/27/2023 at 9:54 AM with the Facility's Medical Director revealed that her expectations were that the resident should receive an accurate skin assessment upon admission and weekly to reflect the resident's current condition for treatment. She stated treatments should have been performed when the resident entered the facility if there were skin issues present. She revealed that she did not know that the resident had skin issues or needed wound care orders when the resident admitted to the facility. Interview on 04/27/2023 at 11:00 AM with the DON revealed that she sent the resident out to the hospital on 04/25/2023, after concerns were made by RN A about the resident's foot. She stated that he was sent to the hospital to receive wound care orders and treatments. Interview and observation on 05/17/2023 at 2:00 PM Resident #5 revealed that he did attend the 04/28/2023 wound care appointment, and that he was now receiving wound care treatments in and out of the facility. There was a calendar posted in his room that showed his future appointments. Record review of Resident #5's Physician's Orders, dated 04/25/2023, revealed the following orders: 1) Transfer to the Hospital ER for evaluation of possible right foot wound infection with drainage and temperature 99-100F. 2) Wound Care Clinic to Evaluation and Treat wound to right foot. HX of right foot hemi-amputation and HX of PVD. Special Instructions: Daily ensure that this order is taken care of until an appointment is made with wound care. 3) Wound care Right foot hemi amputation site where an old scab had come off. Cleanse wound with NSS, pat dry, swab with Betadine solution, cover with non-adhering dressing, wrap with kelix and secure with paper tape. Q shift and PRN drainage or dislodgment. Special Instructions: Q shift and PRN drainage of dislodgement. Record review of Resident #5's ER documentation, revealed, on 04/25/2023 at 9:30 PM, Resident #5 was treated for an open wound to the right foot with purulent drainage and eschar present. The resident received 1GM IM Rocephin (antibiotic); and Augmentin (antibiotic) 875MG to be taken for 10 days. The resident received a referral for wound care. This was completed after surveyor intervention. Record review of Resident #5's Physician's Ordered Treatment Flow Sheet, dated 04/26/2023, revealed the following order: Wound treatment to Right 2nd toe amputation site: Clean with wound cleanser and gauze, apply honey and alginate or honey fiber dressing and cover with foam, secure with tape. May use super absorbent pad if draining and may wrap foot with kerlix and tape if necessary. Once A Day; 07:00 AM - 07:00 PM. Record review of Resident #5's Observation titles Facility Wound Summary Report entered and dated 04/26/2023 revealed: Surgical Incision identified on 04/17/2023 at 08:20 PM, with the most recent observation (documentation) on 04/26/2023 at 8:20 PM: Type- Surgical Location- Incision Right 2nd toe nonhealing toe amputation site. Number of days wound has been open-11. Initial size- 3 x 5 3 x 5. Current Size- 3 x 5 3 x 5. Last Wound Healing Status- Declining. Record review of Resident #5's Physician Orders dated 04/27/2023 revealed the following order: Appt: Wound Care Clinic. Friday 4-28-23 10:15 AM. Special Instructions: Eval and treatment of right foot wound. Facility to take resident to this appointment. [DX: Unspecified open wound Record review of Resident #5's Summary Wound Care Report revealed that resident attended his wound care appointment on 04/28/2023, where he received new orders and to continue treatments until healed. Review of Resident #5's Wound Care Progress Note from the 4/28/23 visit indicated he had a full thickness wound to the area where his right second toe had been amputated. There was a small amount of drainage. The wound was 2.6 cm by 2.2 cm by 0.1 cm in size. The wound was cleaned and dressed during his visit. Record review of Resident #5's Progress Notes made by RN A dated 05/02/2023 at 1:29 PM, revealed: Wound Care Evaluation from residents 4-28-23 visit and noted the following new orders: Multivitamin 1 po QD, Wound care to the right foot non healing surgical Wound: Cleanse with NSS, pat dry, apply skin prep to the peri wound, apply silvasorb gel to the wound be Q Monday/ Wed/ Friday and PRN draining or dislodgement. Resident denies pain or discomfort to his right foot. Dressing dry and intact to his right foot and he wears his protective. Dressing due to be changed per order tomorrow. Will continue to monitor. Record review of Resident #5's Progress Notes made by RN A dated 05/17/2023 at 9:03 AM, revealed: Resident left via facility staff with facility staff to go to Wound Care Center. He wore his right foot walking shoe, and his right foot dressing was dry and intact when he left. Denies pain or discomfort. Record review of Resident #5's Progress Notes made by RN A dated 05/17/2023 at 12:35 PM, revealed: Right foot has a fresh dry intact dressing, and he is wearing his sock and walking shoe. He also stated that they looked at his left foot and cleaned his left toes and put his sock back on. This was determined to be an Immediate Jeopardy (IJ) on 05/15/2023 at 4:15 PM. The Clinical Company Leader and the Administrator were notified. The Clinical Company Leader and the Administrator were provided with the IJ template on 05/15/2023 at 4:15 PM. The following Plan of Removal submitted by the facility was accepted on 05/17/2023 at 2:05 PM and included the following: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 05/15/2023. [Resident #5] received skin assessments on 05/07/2023, 05/11/2023, and 05/14/2023. [Resident #5] received wound care treatment orders on 05/02/2023. [Resident #5] is scheduled for a wound care appointment with an external provider on 05/17/2023. On 04/26/2023 [Resident #5's] information was input it into the wound management system, [Resident #5's] information was updated on 05/12/2023 to reflect the current status of the wound and on 05/13/2023 and 05/15/2023. [Resident #5's] weekly skin assessment scheduled and verified on 05/06/2023, 05/11/2023 and 05/14/2023. Action 1: Clinical Resource Nurse to audit new admissions for the previous 14 days to ensure all admission skin assessments have been completed. Missing skin assessments will be completed immediately and documented in the medical record. The Clinical Resource Nurse will monitor that admission skin assessments are completed timely. The DON will notify the MD for newly identified skin issues and to request additional clarification of treatment orders. Date: 05/16/2023 Person responsible: Clinical Resource Nurse Action 2: Clinical Resource Nurse to audit weekly skin assessments for the previous 14 days to ensure all weekly skin assessments have been completed. Missing skin assessments will be completed immediately and documented in the medical record. The Clinical Resource Nurse will monitor weekly wound documentation going forward. The CNA's will notify the charge nurse have any newly identified skin issues. The charge nurse will document the skin issue in obtain treatment orders. Date: 05/16/2023 Person responsible: Clinical Resource Nurse Action 3: Education provided to charge nurses regarding the skin system in the wound management documentation workflow. Any newly hired and or temporary (agency) charge nurses will be in-serviced prior to working the floor. Staff nurses will be educated and observed for competency. The Clinical Resource Nurse is educating the DON in on the event accident and incident process including timely completion of the event the investigation process involved and closure of the event. Date: 05/16/2023 Person responsible: Clinical Resource Nurse Action4: New admissions and weekly skin assessment will be audited, daily, (Monday through Friday), during clinical meetings by the Director of nursing/designee. Any missing assessments will be completed immediately, and findings will be documented in the medical record. [NAME] Clinical Resource Nurse will monitor the daily clinical stand-up meetings to validate discussion of skin assessments. The DON will notify the MD of newly identified skin issues and clarify and/or obtain treatment orders. Date: 05/16/2023 Person responsible: Clinical Resource Nurse POR monitoring included the following: Record review of documentation, provided by the Clinical Resource Nurse, of reviewing all current skin injuries with entries into the Wound Management Report and each skin injury had an order for treatment; performance improvement plans regarding skin system to include education, review of weekly skin assessments, skin sweeps, documentation, and action taken once skin issues identified, facility's wound management report for each resident with identified skin injuries. Record review of facility provided documentation revealed all residents had skin assessments and Ad Hoc QAPI meeting performed. Interviews on 05/17/2023 at 1:30 PM with the DON revealed she was educated on documentation on wound assessments that included admission and weekly. She revealed she had been educated on notifying the MD to facilitate orders, treatments, and notification of any changes. Interviews on 05/17/2023 at 1:00 PM with CNA B revealed they had been educated on notifying the charge nurse or DON of any skin changes or incidents. Interview on 05/17/2023 at 1:55 PM Resident #5 revealed that he has been receiving wound care treatments since his admission on 04/19/2023. Interview on 05/17/2023 at 2:05 PM Resident #8 revealed that he has been receiving wound care treatments since his admission on 04/19/2023. Observation on 05/17/2023 at 2:45 PM revealed the DON educating an RN A on wound management and documentation. The Administrator, Clinical Resource Nurse, DON, and the Clinical Company Leader were informed the Immediate Jeopardy was removed on 05/17/2023 at 2:05 PM. The facility remained out of compliance at a potential for more than minimal harm with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to have an agreement to obtain laboratory services for all residents. The facility did not have a written contract or agreement for laboratory services to meet the needs of their residents. This failure placed residents at risk of not having laboratory services conducted as ordered by the physician, which could place them at risk of unwanted medication side effect or delayed treatment of medical conditions. The findings include: In an interview on [DATE] at 2:40 PM, the DON stated the facility did not have a place to take residents to have their labs obtained and the equipment in the facility had expired. She stated it had been a couple of months since residents received their routine labs. The DON stated the facility was going to try to get a contract with someone to provide laboratory services for the residents. She said she took the order, on [DATE] for Resident #7, but did not enter it in the electronic health record, due to not having anywhere to take the labs and it not being an emergency. The DON stated routine labs for other residents had also been missed, during this time. The DON stated if a resident had a severe decline or was unresponsive, she would send them to the hospital. In an interview on [DATE] at 8:25 AM, the RN Corporate Clinical Resource Nurse stated she had started coming to the facility during [DATE]. She stated the facility had never had a contract with the local hospital to process labs. She stated the hospital would not sign a contract and there had only been a verbal agreement. The RN Corporate Clinical Resource Nurse stated the corporate office would send a contract to the hospital, and it was not signed and returned. She stated the facility nurses drew the labs which were then taken to the hospital for processing. The RN Corporate Clinical Resource Nurse stated something happened during the transition in facility administration a few months ago and the hospital refused to continue processing labs for the facility. In an interview on [DATE] at 12:00 PM, the Administrator stated that they are working to obtain a contract for lab services.

Based on interview and record review the facility failed to conduct an accurate timely assessment for 4 (Resident #1, Resident #2 and Resident #3 and Resident #4) of 8 residents reviewed for assessments. This failure could affect residents by placing them at risk of not having comprehensive or timely quarterly assessments that reflected the physical condition of the resident which is used to determine the plan of care for the resident The findings included: Resident #1 Review of Resident #1's face sheet revealed Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with primary diagnosis of Metabolic Encephalopathy (chemical imbalance in the blood that affects the brain), chronic pain (pain that is long term), hypertension (high blood pressure), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar) Morbid Obesity (more than 80-100 pounds above their ideal body weight) and Chronic Kidney Disease (long standing disease of the kidneys leading to Renal Failure). Review of Resident #1's Admission MDS assessment dated [DATE] revealed the following: Section C revealed a BIMS score of 13 (cognitively intact). Section G revealed: Bed mobility- extensive, Transfers- extensive, walk-in room- did not occur, walk in corridor- did not occur, locomotion on unit- occurred on once or twice, locomotion off unit- occurred only once or twice, dressing- extensive, toilet use- extensive and personal hygiene- extensive. Section K revealed a weight of 369 pounds. Record review on 04/27/2023 of Resident #1's Comprehensive Admission MDS dated [DATE], showed reflected the assessment had been completed on 04/27/2023. Resident #2 Review of Resident #2's face sheet on 04/27/2023 revealed Resident #2 was [AGE] year-old male who was admitted to the facility 09/30/2022 with primary diagnosis of Autistic Disorder (developmental disorder that impairs the ability to interact or communicate), Muscle wasting and atrophy (decrease and size of wasting of muscle tissue), Renal osteodystrophy-phosphate (bone disease), Muscle weakness (generalized), End stage renal disease (kidney's no longer function well enough to meet the body's demands), Cardiomegaly (heart is enlarged), Other seizures (uncontrolled electrical activity between brain cells), Lowe's syndrome (condition that affects the eyes, brain, and kidney's), Dysphagia (difficulty swallowing). Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed the following: Section C revealed a staff assessment of the BIMS score of 3 (severely impaired). Section G revealed: Bed mobility- extensive, Transfers- extensive, walk-in room- did not occur, walk in corridor- did not occur, locomotion on unit- total dependence, locomotion off unit- total dependence, dressing- total dependence, toilet use- extensive and personal hygiene- total dependence. Record review on 04/27/2023 of Resident #2's Quarterly MDS dated [DATE], showed the assessment had not been completed. Resident #3 Review of Resident #3's face sheet revealed Resident #3 was [AGE] year-old female who was admitted to the facility 08/17/2022 with primary diagnosis of Cerebral Palsy (abnormal brain development) and Dysphagia (difficulty swallowing). Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed the following: Section C revealed a staff assessment of the BIMS score of 3 (severely impaired). Section G revealed: Bed mobility- total dependence, Transfers- total dependence, walk-in room- did not occur, walk in corridor- did not occur, locomotion on unit- total dependence, locomotion off unit- total dependence, dressing- total dependence, toilet use- total dependence and personal hygiene- total dependence. Record review on 04/27/2023 of Resident #2's Quarterly MDS dated [DATE], showed the assessment had not been completed. Resident #4 Review of Resident #4's face sheet revealed Resident #4 was [AGE] year-old female who was admitted to the facility 03/19/2022 with primary diagnosis of Chronic obstructive pulmonary disease with (acute) exacerbation (Chronic Obstruction Pulmonary Disease with a sudden worsening of symptoms) and Acute and chronic respiratory failure with hypoxia (short- and long-term disease that makes it difficult to breathe on your own) Review of Resident #4's Quarterly MDS assessment dated [DATE] revealed the following: Section C revealed a BIMS score of 10 (moderately impaired). Section G revealed: Bed mobility- independent, Transfers- independent, walk-in room- independent, walk-in corridor- independent, locomotion on unit- independent, locomotion off unit- independent, dressing- limited assistance, toilet use- independent and personal hygiene- independent. Record review on 04/27/2023 of Resident #4's Quarterly MDS dated [DATE], showed the assessment had not been completed. During an interview 04/27/2023 at 4:16 PM, the MDS-LVN stated she was completing the MDS's for more than one building and had gotten behind on the assessments. She revealed it was her responsibility and that she should have completed them timely. She revealed Resident #1's Comprehensive Admission assessment should have been completed on or before 04/21/2023. She revealed Resident #2's should have been completed 90 days after the 01/06/2023 Quarterly assessment. She revealed Resident #3's should have been completed 90 days after the 01/03/2023 Quarterly assessment. She revealed Resident #4's should have been completed 90 days after the 01/06/2023 Quarterly assessment. She stated that the failure could place residents at risk for not having an accurate assessment that reflected their current needs. She revealed they used the RAI manual for guidelines on MDS's. During an interview on 04/27/2023 at 3:30 PM, the Regional RN stated that she was responsible for signing section Z of the MDS, but the MDS-LVN was responsible for setting the ARD date and completing the MDS. A policy on MDS completion and submission dated July 2017 revealed: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation 1. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Review of CMS'S RAI Version 3.0 Manual version 1.17.1 dated October 2019 revealed: The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. Nursing homes are left to determine (1) who should participate in the assessment process (2) how the assessment process is completed (3) how the assessment information is documented while remaining in compliance with the requirements of the Federal regulations and the instructions contained within this manual.